Sacramento County Grand Jury • 2014-2015 • Agency Response
Response to: City of Sacramento Fire Department Handling of Narcotics

Mental Health Crisis Intervention Services. . . Sacramento County's Shameful Legacy of Neglect*

Published: September 15, 2015 23 pages
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Findings and Recommendations 7 findings

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Sacramento County has abdicated the provision of crisis services for the mentally ill. The current mental health crisis services in Sacramento County are inadequate, anti- therapeutic, costly and dangerous. <b>Board of Supervisors Response:</b> Sacramento County disagrees partially with this finding. Sacramento County disagrees with the Grand Jury's finding that the County "has abdicated the provision of crises services for the mentally ill." The 2011 and 2014 Mental Health Plan Triennial program reviews for specialty mental health services conducted by the California Department of Mental Health and the California Department of Health Care Services, respectively, found Sacramento County to be meeting its responsibilities for crisis and hospitalization services. The County disagrees that current mental health crisis services are anti-therapeutic and dangerous. Crisis services, whether accessed by residents at hospital emergency rooms (ERs), inpatient hospitals or other community service settings, are not dangerous or anti-therapeutic and are staffed by appropriately certified professional staff in appropriately licensed and certified healthcare settings. Medical clearance requirements and screening for specific mental health crisis services depend on level of acuity. The County agrees that inpatient psychiatric services are costly and that there is an inadequate array of alternatives to this expensive service in our community. Recognizing these gaps, Sacramento County has taken numerous steps to improve its system. In September 2012, the Mental Health Treatment Center (MHTC) redesigned and reopened an Intake Stabilization Unit. This unit coordinates care for all hospitals' referrals, directing individuals to available psychiatric hospital beds as well as admitting them to the 23-hour crisis stabilization service when appropriate. Going forward, based on extensive collaborative work with the Mental Health Improvement Coalition as well as the Mental Health Board and the Mental Health Services Act (MHSA) Steering Committee, the County has committed to make improvements to its crisis and hospital service options: Development of four Crisis Residential Programs to expand capacity by 60 residential treatment beds outside a hospital setting; Two mobile crisis teams in operation starting April 15, 2015; Mental health navigator program to be implemented third quarter 2015; Planned increase of at least one psychiatric health facility (15 Medi-Cal-reimbursable • inpatient hospital beds) within the current fiscal year; Expansion of outpatient service capacity, serving 150 additional persons with highest- • intensity service, including housing support as needed; Step-by-step increase in use of MHTC Intake and Stabilization Unit for direct admission • from the community, including direct access by the mobile treatment teams, already begun. Budgeted staff increases will support additional expedited access by navigators, and then law enforcement, to be implemented stepwise as the new residential beds Response To The 2014-15 Grand Jury Final Report become operational, so that exit capacity from the crisis unit is sufficient to ensure that the 23-hour regulatory time limit is not violated for this facility.
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Adopt this report as Sacramento County's response to findings and recommendations contained in the 2014-15 Grand Jury Final Report. 2. Direct the Clerk of the Board to forward a copy of this report to the Presiding Judge of the Superior Court no later than September 16, 2015. Measures/Evaluation Not applicable. <b>Fiscal Impact</b> Departments contributing to this report absorbed incurred costs within their respective budgets. <b>BACKGROUND</b> Each year the Sacramento County Grand Jury concludes its work and releases its Final Report, typically the last week in June. The report, which can address a variety of activities, functions, and responsibilities of government, typically contains findings and recommendations with a response specifically directed to the Presiding Judge of the Superior Court. Response To The 2014-15 Grand Jury Final Report The form of the County's responses as required by Penal Code section 933.05 is as follows: As to each Grand Jury finding, the responding person or entity shall indicate one of the following: 1. The respondent agrees with the finding. 2. The respondent disagrees wholly or partially with the finding in which case the response shall specify the portion of the finding that is disputed and shall include an explanation of the reasons. As to each Grand Jury recommendation, the responding person or entity shall report one of the following actions: 1. The recommendation has been implemented, with a summary regarding the implemented action. 2. The recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation. 3. The recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a timeframe for the matter to be prepared for discussion by the officer or head of the agency or department being investigated or reviewed, including the governing body of the public agency when applicable. This timeframe shall not exceed six months from the date of the publication of the Grand Jury report. 4. The recommendation will not be implemented because it is not warranted or is not reasonable, with an explanation. If a finding or recommendation of the grand jury addresses budgetary or personnel matters of a county agency or department headed by an elected officer, both the agency or department head and the board of supervisors shall respond if requested by the grand jury, but the response of the board of supervisors shall address only those budgetary or personnel matters over which it has some decision making authority. The response of the elected agency or department head shall address all aspects of the findings or recommendations affecting his or her agency or department. County Counsel was consulted regarding the response requirements and confirmed that there are no additional requirements beyond those specified above. The level of detail to include in the responses is at the discretion of the Board. <b>DISCUSSION</b> The 2014-15 Grand Jury Final Report contained two reports on issues pertaining directly to the County. The reports, "Mental Health Crisis Intervention Services. . . Sacramento County's Shameful Legacy of Neglect" and "The Ralph M. Brown Act. . . Not to be Taken Lightly" required county responses from the Director of the Department of Health and Human Services and the Board of Supervisors. While the Grand Jury only asked the County to respond to specific findings and recommendations related to the two reports, we are following the penal code requirements and responding to all. Response To The 2014-15 Grand Jury Final Report 1. Mental Health Crisis Intervention Services. . . Sacramento County's Shameful Legacy of Neglect
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Sacramento County's decision to close the Crisis Stabilization Unit to adult patients and to eliminate 50 beds from the Sacramento County Mental Health Treatment Center, as well as subsequent program decisions, has had widespread negative fiscal impacts. Board of Supervisors Response: Sacramento County disagrees with this finding to the extent that the fiscal impacts listed in the Grand Jury report are a result of many factors and not just the 2009 reduction in access to the Crisis Stabilization Unit and the conversion of 50 beds at the Treatment Center to outpatient beds. Many subsequent program decisions that built outpatient capacity in this community have redirected the trajectory of mental illness for thousands of residents. The high cost of inpatient hospital beds, including existing Federal exclusions for reimbursement for care in facilities with more than 16 beds, has for many years prevented the County from redirecting funding and investing in outpatient and residential treatment options that are much more therapeutically appropriate in many cases. The absence of sufficient appropriate treatment options in the community is the key factor in the high cost of providing crisis services in Sacramento. In response, many of the County's program decisions have grown the community-based prevention and outpatient system of care through the Mental Health Services Act, resulting in a variety of intensive programmatic alternatives to inpatient care for adults with mental illness. The responses to Recommendations 3, 4, 6, 7 provide a few of many examples of program decisions that demonstrate the County's commitment to services in the least restrictive environment. It is also important to acknowledge the very real consequences to patients of the over-crowding that led to the County's loss of certification (2000-2003) when its crisis unit failed to comply with the regulation that limits stays to less than 24 hours in the crisis unit. The old way of providing access to crisis services did not provide prompt access to appropriate treatment, and it proved to be unsustainable. In fact, the County's commitment to operationalize four residential crisis programs, serving 60 additional individuals at any time, plus an additional 16-bed inpatient psychiatric facility, will have a substantial impact on many of the concerns raised in this report, including emergency rooms, law enforcement, and prompt access for patients to appropriate care. By providing increased discharge alternatives, it will enable the County's crisis stabilization unit to provide increased access to more clients without jeopardizing its certification. The County believes that this is the financially and programmatically sound solution, and all of the stakeholders who have been participating in the planning of this approach are united in supporting it. Response To The 2014-15 Grand Jury Final Report
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Establish a fully functional and available 23-hour intake and evaluation crisis unit (Crisis Stabilization Unit) or similar urgent care model. Board of Supervisors Response: The County agrees with the recommendation and is in the process of implementing it, as demonstrated by steps taken since 2012 to increase and restore access to its crisis stabilization unit. In September, 2012 the County expanded 23 hour crisis stabilization services allowing for an increase of admissions compared to what was in place from 2009 to 2012. The service is referred to as the Intake Stabilization Unit (ISU). A merger and cross training of children's and adult clinicians formed an integrated crisis stabilization service team allowing for round the clock 24/7 telephone screening and processing of 5150 referrals. In FY 2013-14, 1,804 adults were transferred to the Mental Health Treatment Center (MHTC) from local emergency rooms allowing for a comprehensive mental health assessment, crisis stabilization services, aftercare Response To The 2014-15 Grand Jury Final Report hospitalization, and/or other services. Additionally, another 744 individuals were either directly admitted to the MHTC inpatient unit or directly diverted for services to one of the contracted PHF beds managed by the ISU. Example includes forensic clients treated at the MHTC. In April 2015, the County funded and implemented two operational mobile crisis teams that have direct access to the crisis unit, so that persons in crisis evaluated by these mobile teams do not go to the local ER unless a medical condition requires such action. In June 2015, the Board of Supervisors approved 18 positions for the MHTC to continue the process to restore access to the Crisis Stabilization Unit (CSU) to the 2009 level: direct admission by law enforcement, other system partners, and adults seeking crisis services. This will further reduce the number of persons in crisis using emergency rooms. The County is also working to develop other programming that is essential for sustaining a fully functioning CSU. This includes an expansion of its Full Service Partnership (FSP) intensive community based outpatient programs, where 24/7 crisis response is part of the treatment model; development of Crisis Residential Program beds; the addition of Psychiatric Health Facility (PHF) beds; and, purchase of sub-acute and forensic treatment beds.
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Sacramento County's shift of responsibility for crisis services has overwhelmed community hospital emergency rooms. <b>Board of Supervisors Response:</b> Sacramento County disagrees partially with this finding. The County acknowledges that decisions about the use of the MHTC crisis stabilization unit presented emergency departments with significant challenges. As detailed in our response to Finding 1, the County has made significant commitments and investments to provide material relief by getting individuals needing mental health treatment to appropriate treatment more promptly than is the current practice in the community. The County disagrees that its decisions are the sole contributing factor to the increased use of emergency rooms by people in mental health crisis. The Grand Jury's finding does not address other relevant pressures on emergency departments, such as the impact of staffing decisions at emergency rooms or the increasing numbers of uninsured individuals presenting at emergency rooms for basic primary healthcare.
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Develop, expand and support outpatient programs that respond to and mitigate mental health crises before they escalate. <b>Board of Supervisors Response:</b> The County agrees with the recommendation and is in the process of implementing it, as demonstrated by the County's investment in programs over the past several years. Some examples below illustrate the County's effort in this area: Since 2009, the County's Department of Health and Human Services (DHHS) has funded seven Full Service Partnerships (FSPs); a service model that provides a comprehensive array of services and supports to address the needs of clients with complex, intensive service needs to prevent escalation to crisis service levels. These community based outpatient programs provide intensive services including 24/7 crisis response. There are plans to open an eighth FSP in FY 2015-16 that focuses on Transition Age Youth. From 2007-2010, DHHS implemented several programs that contribute to mitigating mental health crises before they escalate. Two Wellness and Recovery Centers were opened, one in 2007 and another in 2009, for individuals to access a variety of resources, groups, and supports. The Transitional Community Opportunities for Recovery and Engagement (TCORE) Program opened in 2007. TCORE provides flexible, responsive outpatient services to difficult-to-engage clients and/or clients with noted barriers to services. A Peer Partner program was added to the County-operated clinic to also expand available types of services and supports. Between 2009 and 2011, DHHS implemented Prevention and Early Intervention (PEI) and Innovation projects funded by Mental Health Service Act (MHSA) component funding. These projects respond to crises before they escalate and provide a variety of referrals and supports, as well as proactive response to community need in this area. Response To The 2014-15 Grand Jury Final Report In FY 2009-10, DHHS provided funding to WellSpace Health to provide a 24-hour suicide ٠ prevention and crisis line for callers of all ages at risk of suicide. A variety of warm lines and other cultural specific interventions have been created as part of prevention programs. In FY 2010-11, DHHS funded nine community-based programs through PEI-Suicide • Prevention resources. This project, known as "Supporting Community Connections" (SCC), includes a network of eight community-based agencies working collaboratively to provide support services to mitigate against mental health crises of people in targeted underserved high risk communities. In FY 2011-12, DHHS created a Community Support Team (CST) to work with Crossroads ٠ Vocational Services to provide flexible, field-based services to community members experiencing a crisis. Services include assessment, support and linkage to on-going services and support. In 2011, DHHS implemented the five-year Respite Partnership Collaborative Project, funded ٠ by Mental Health Services Act (MHSA) Innovation Component funding. The project has funded eleven mental health respite programs for individuals at risk of or experiencing a mental health crisis. The MHSA Steering Committee has expressed support for sustainable MHSA funding for respite programs demonstrating success and impact. In 2015, Community Care Teams, funded through MHSA, were implemented at the Regional • Support Teams as components to existing programs to create additional service capacity and flexibility of response.
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Sacramento County's use of inpatient hospitals is dysfunctional and currently too expensive. <b>Board of Supervisors Response:</b> Sacramento County disagrees partially with this finding. In many cases, inpatient hospitalization is needed and effective for many patients, when clinically appropriate. However, the County also acknowledges that the absence of sufficient alternative community-based treatment options results in some over-utilization of inpatient care. It is certainly absorbing a disproportionate share of the resources that might otherwise be invested in building out such alternatives. While it is correct that inpatient hospital bed care is expensive, there are numerous factors that account for this cost, such as the Federal payment exclusion for hospitals over 16 beds (IMD Exclusion). Our response to Recommendation 10 explains in more detail the cost structures that affect the rates that the County is paying for inpatient hospitalization. Sacramento County has made significant efforts in the last four years to reduce dependence on psychiatric hospitals with more than 16 beds and has increased its programming with local MediCal-reimbursable Psychiatric Health Facilities (PHFs). Two have been in operation since 2010 and 2012 and another is planned for Fiscal Year 2015-16. The County agrees that inpatient hospitalization currently absorbs an unnecessary and disproportionate portion of the mental health services budget. Prior to the Affordable Care Act (ACA), care provided in these psychiatric facilities was considered "charity care" by the psychiatric hospitals. An unintended consequence of individuals becoming MediCal eligible under ACA was a dramatic increase in psychiatric hospitalization costs to the County. Ideally, the County would be making these investments in intensive outpatient treatment, residential treatment, supportive housing, and other therapeutic multi-level alternatives to psychiatric hospitalization. Response To The 2014-15 Grand Jury Final Report
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Expand mobile crisis programs. <b>Board of Supervisors Response:</b> The County agrees with the recommendation and is in the process of implementing it, as demonstrated by steps already taken to fund and implement programs. Using a 2013 Investment in Mental Health Wellness Act (SB82) grant and Mental Health Services Act (MHSA) funding, two Mobile Crisis Support Teams (MCSTs) were implemented in April 2015. The MCSTs provide timely crisis intervention and assessment when an individual experiencing a mental health crisis comes to the attention of law enforcement. The crisis response, support, and linkage to services continue until the client is stabilized and appropriate community resource linkages are established. These teams collaborate with other mental health programs, providers, and partners to utilize a full array of resources to coordinate services. The MCSTs are included in "roll call" where law enforcement officers meet for daily briefings and announcements.
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Sacramento County's shift of responsibility for crisis services has adversely impacted area law enforcement agencies. <b>Board of Supervisors Response:</b> Sacramento County disagrees partially with this finding. The County disagrees that it has shifted its responsibility for crisis services. The 2011 and 2014 Mental Health Plan Triennial program reviews for specialty mental health services conducted by the California Department of Mental Health and the California Department of Health Care Services, respectively, found Sacramento County to be meeting its responsibilities for crisis and hospitalization services. Based on collaboration and frequent communication with law enforcement officials, the County agrees that law enforcement officers are spending considerable time in hospital emergency rooms while emergency department personnel and staff at the County's crisis stabilization unit consult in an effort to access appropriate treatment options for patients. However, there are many factors that may contribute to this beyond reduced direct access to the MHTC. The County cannot address the hospital and non-county law enforcement policies that require them to wait in that setting. The current practice of Sheriff personnel, when transporting an individual who meets the criteria for a 5150 involuntary hold to a hospital, is to fill out the paperwork and then leave the individual in the hospital triage process. If the individual is non-compliant, the practice is to stay until the person is accepted by the hospital. The time commitment becomes more complex if the originally compliant individual walks away or becomes non-compliant. The Sheriff Department supports County plans to facilitate more prompt access to appropriate treatment, including the use of mobile crisis teams, navigators at the jail and at hospital emergency departments, and establishment of a law enforcement hotline to the County's crisis stabilization unit, all of which will reduce the need for long wait times in emergency departments. The County also notes that prison/correctional realignment has brought more pressures on law enforcement and correctional systems. Factors such as this contribute to the challenges facing law enforcement. The County is committed to improving mental health services and has invested in numerous program initiatives that we expect will significantly reduce time spent waiting in emergency departments while medical personnel seek appropriate treatment for persons coping with mental health crises. The County has already implemented direct access to the MHTC crisis stabilization unit for patients served by joint clinician/law enforcement mobile crisis teams. Planning is underway for expedited access to the MHTC crisis stabilization unit, implemented in a stepwise fashion as residential treatment beds become operational, so that the crisis unit has sufficient discharge alternatives to meet regulatory requirements limiting stays to less than 24 hours. The County's plan for prompt access to appropriate treatment will have a significant impact on time that officers currently spend in emergency rooms, providing more options for expedited access to treatment than were available to clients in the past, even when the crisis stabilization unit was open for walk-ins and drop-offs. Response To The 2014-15 Grand Jury Final Report
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Assure continuation of CIT (Crisis Intervention Training) opportunities for law enforcement by exploring all available funding options. <b>Board of Supervisors Response:</b> The County agrees with this recommendation and is in the process of implementing it, as evidenced by the production of a mental health training education program provided to Sacramento City Police Department (SPD) and Citrus Heights Police officers and supervisors. Individuals with lived experience of mental illness shared their interactions with Law Response To The 2014-15 Grand Jury Final Report Enforcement to demonstrate both what was helpful and what could be done differently. In 2012, partners updated the training so that it now meets the Police Officer Standards and Training (POST) certification requirements. In 2011 Sacramento County Sherriff's Department requested that the training be part of their 2012-13 and 2013-2014 Advanced Officer Training (APT) schedule. Over 114 training sessions were provided to all deputies and Sheriff Office staff (18 for Sacramento Police Department, 3 for Citrus Heights, 92 for Sacramento Sheriff's Department). There is a Sacramento County Regional Crisis Intervention Team (CIT) that currently provides additional 8 hour and 24 hour training in partnership with several law enforcement agencies. Funded by a Homeland Security grant, this program is in place through May 2016. The Division of Behavioral Health Services (DBHS) participates in the development of the curriculum. As partners in this project, DBHS is committed to its success and sustainability and will explore all possible funding options.
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Sacramento County's relationship with hospital providers and law enforcement is strained or conflictual. <b>Board of Supervisors Response:</b> Sacramento County disagrees partially with this finding. The County acknowledges that changes to the mental health crisis system have placed pressures on all sectors of the system and that disagreement over priorities and decisions from all sectors has challenged relationships. However, the Grand Jury finding does not take into account the outstanding work devoted to system wide problem-solving among County staff, the hospitals, emergency responders, law enforcement, and consumers that has taken place in the past year. County officials have been committed participants in several collaborative forums, including the Mental Health Improvement Coalition led by hospital providers and work groups with law enforcement officials on services and policies to serve homeless populations, training, and mobile crisis team initiatives with law enforcement. The energy and creativity brought to these efforts by County officials has been recognized by community partners. For example, at the County's Recommended Budget hearings on June 16, 2015, a hospital official representing the Mental Health Improvement Coalition commended the County's mental health services rebalancing plan and expressed support for the work of County officials and program personnel, calling them "incredible partners" and commending their "leadership, creativity, brave decision-making" that led to "stellar results" that would take "Sacramento County from a place of opportunity to being one of the best-practice counties throughout the State." It is important to note that community relationships include not only those with hospital officials and law enforcement, but also advocacy organizations, consumers, and families who are critical stakeholders in our policies and programs. The County has also strengthened its relationships with these community constituents, as evidenced by multiple years of regular meetings of the Mental Health Board and the Mental Health Services Act Steering Committee and subcommittees, ensuring that all parts of the community participate in program planning decisions.
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Expand crisis residential services, both acute and non-acute. <b>Board of Supervisors Response:</b> The County agrees with this recommendation and is in the process of implementing it. In this regard, the County has actively pursued every opportunity for competitive capital funding grants through the 2013 Investment in Mental Health Wellness Act (SB82). To date, Sacramento County has secured $6.9 million ($1.2 million in Round 2 and $5.7 million in Round 3) in capital facility funding administered by the California Health Facilities Financing Authority (CHFFA) to implement four crisis residential programs totaling 60 short-term residential treatment beds. This capital funding is being matched with treatment services funded through behavioral health realignment and Mental Health Services Act (MHSA) funding. Crisis Residential Program beds are eligible for Medi-Cal Federal reimbursement and help clients develop coping skills to overcome crises and live in the community. This program is in contrast to inpatient hospital beds that provide only inpatient stabilization care and are not eligible for Medi-Cal reimbursement due to size of facility. While one crisis residential program will be generic - no specific program focus - three will have specific programmatic focus responding to identified gaps in the behavioral health crisis response continuum with a goal of improving client flow from crisis to outpatient services. One Rapid Turnaround Step-Down Crisis Residential Program focused on individuals with a crisis presenting at emergency departments (EDs). This program will provide short-term services and supports to mitigate the immediate mental health crisis in a supportive environment with a primary focus on clients already engaged with outpatient treatment providers. One Co-Occurring Disorders Crisis Residential Program focused on diversion from EDs with an emphasis on individuals with a co-occurring substance use disorder who are experiencing an immediate mental health crisis. There will also be some capacity for community provider referrals to prevent inappropriate and unnecessary psychiatric hospitalizations or ED visits. Response To The 2014-15 Grand Jury Final Report One Family/Community Focused Crisis Residential Program focused on individuals referred • from community providers as well as EDs. This program will also provide access for step-up from community providers to address a crisis before requiring presentation at an ED.
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Sacramento County's use of long-term, non-acute 24-hour care utilization is inadequate, costly and fails to utilize more appropriate alternatives. Board of Supervisors Response: Sacramento County disagrees partially with this finding. The County disagrees that it fails to utilize more appropriate alternatives. Since the inception of the Mental Health Services Act (MHSA), Sacramento County has been a leader in the creation of Full Service Partnerships (FSPs) for adults with serious mental illness to create intensive-outpatient alternatives for their care. These are excellent alternatives to long-term, non-acute 24-hour services. In FY 2014-15, 1,474 individuals with serious mental illness received services in these intensive outpatient Each individual in an FSP has benefitted from this intensive, individualized, programs. community-based approach, which includes housing supports, as needed. In FY 15-16, the County is expanding these FSPs to immediately serve an additional 150 individuals, with plans for additional capacity. Response To The 2014-15 Grand Jury Final Report Sacramento County agrees that the availability of long-term, non-acute 24-hour care is inadequate in Sacramento, though it should be noted that this situation is not unique to Sacramento County. The conversion of many private operators long-term, non-acute 24 hour care programs to other types of care that have better reimbursement structures has reduced capacity over the last ten years in Sacramento County and elsewhere. Sacramento has the additional challenge that existing local facilities are utilized heavily by other counties.
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Maximize reimbursable services utilizing funding sources including Prop 63 (MHSA), S.B. 82 (Mental Health Wellness Act), and Medi-Cal. Board of Supervisors Response: The County agrees with the recommendation and has taken the following actions to implement it: Sacramento County has invested $16 million in housing for homeless people living with • severe mental illness. These local funds have leveraged over $130 million of Federal, State and local housing dollars to finance hundreds of apartments, of which 161 are currently dedicated to MHSA tenants. As a result of efforts to date, approximately 660 households (about 760 homeless persons living with mental illness) are housed with over $9 million in treatment services attached to these Permanent Supported Housing programs. In Sacramento, there are seven fully operational MHSA-funded Full Services Partnership (FSP) programs serving over 1,600 clients annually. Each of these FSPs leverages Medi-Cal funding for associated treatment. Wellness and Recovery Centers, Transitional Community Opportunities for Recovery and Engagement (TCORE) Program, and Adult Psychiatric Support Services (APSS) Clinics maximize Medi-Cal, Prop 63, and community resources in different ways with private and public partners. Through the MHSA Innovation Component, the County has funded 11 new mental health respite programs in the Sacramento community for individuals at-risk of or experiencing a mental health crisis. Prevention programs include a variety of suicide prevention projects. Early Intervention is also included at the UCD EDAPT (Early Diagnosis and Preventative Treatment). This program is a nationally recognized service model, receiving National Institute of Mental Health grant support as well as funding from the Substance Abuse Mental Health Services Administration (SAMHSA). These federal resources complement the local Medi-Cal and MHSA investment. Using SB 82 grant awards, the County is adding 60 crisis residential beds, two Mobile Crisis Support Teams, and twenty-one triage navigators to the Sacramento system of care. These grant awards will be leveraged with MHSA, Realignment, SAMHSA, and Medi-Cal. Response To The 2014-15 Grand Jury Final Report

* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.