A Promise Kept Health Care for Low-Income Families

Note: Missing finding numbers detected: F31, F32, F33, F34, F35, F36, F37, F38, F39, F40, F41, F42, F43, F52, F53, F54, F55, F56, F57, F58, F59

Conclusions 51

• CL1 Page 4
  The County made a sincere effort to qualify as a demonstration site. Consolidation and Simplification 2000-2001 Grand Jury Recommendation 2: The Board of Supervisors should direct the Health Services Agency (HSA) to develop a plan for incremental consolidation and eligibility simplification of categorical health plans. • This plan should be based on prepaid capitation payments and a local public commission should govern its operations. • Eligibility requirements should be simplified and extended to a term of at least one year. • Eligibility should be based on family income, rather than assets, and tied to federally designated poverty guidelines. • The entire family, not individual members, should be designated as the beneficiary for health service coverage. • The Central Coast Alliance for Health and its principles of practice should be used as a model for the administration of other categorical health programs. • The Board of Supervisors should urge the state to engage an independent non- governmental entity with credentials in the healthcare field to monitor the demonstration and track its impacts on both program costs and clinical outcomes. The Medical Information Management System should facilitate this tracking. County Response: This recommendation had not yet been implemented, but will be implemented in the future. 2007-2008 Grand Jury Findings
• CL2 Page 4
  While the County has pursued a goal of consolidating categorical health plans and simplifying eligibility requirements, there is no published plan or public commission in place to oversee it. Response from the County: DISAGREES. The Public Health Commission is charged with overseeing the operation of preventative health programs, medical clinics and medical programs, which includes review of eligibility requirements and categorical health plans.
• CL3 Page 5
  Eligibility requirements for health plans have not been simplified in any significant way, but the County has structured resources to guide applicants through the maze of health services and health insurance programs that are offered by non-profits and various government agencies.
• CL4 Page 5
  Santa Cruz County now uses One-e-App, a web-based system for connecting families with a range of publicly funded health and social service programs. Applicants, usually with the help of Certified Application Assistants or county eligibility workers, enter their personal information to learn about and apply for programs that best meet their family's needs. System administrators, supervisors, and case management staff, can run reports and determine eligibility.
• CL5 Page 5
  Santa Cruz County Health Care Outreach Coalition expands access to health care coverage for uninsured county residents, promotes awareness of government- funded health insurance programs and conducts outreach to schools, community-based organizations, businesses, faith-based organizations, childcare providers, and the general community.
• CL6 Page 5
  The Benefits Call Center was established in 2000 to provide an easily accessible source of information for Medi-Cal recipients and to ensure that recipients complete all program requirements to maintain their coverage.
• CL7 Page 5
  There is no new program, or expansion of an existing program, to extend health care to entire families instead of just individual members. California’s Medicare system, Medi-Cal, is governed by federal rules because it is mainly funded by the federal government. Medi-Cal has not acted to extend health care coverage to low-income families.
• CL8 Page 5
  In 2008, Medicare’s Hospital Insurance Trust Fund (HI) is scheduled to pay out more in hospital benefits and other expenditures than it receives in taxes and other dedicated revenues. Growing annual deficits are projected to exhaust HI reserves in
• CL9 Page 5
  Private health care providers, both physicians and dentists, have been recruited to treat patients who can’t afford to pay. They do this without remuneration as a community service.
• CL10 Page 5
  In order to simplify access to categorical health programs, the 2000-2001 Grand Jury recommended using the Central Coast Alliance for Health as a model for administering them. Health Services Agency determined it would accomplish the same goal to make those programs part of the Alliance where possible.
• CL11 Page 5
  Some Grand Jury recommendations hinged on the county becoming a demonstration site for the integrated provision of local health services subsidized by state and federal governments. This did not happen as explained in Demonstration Site Finding 1.
• CL12 Page 6
  Since the most pressing concern today is from where the money will come to maintain Medicare and Medicaid services for those who qualify under today’s system, extending it to include low-income families is not being discussed.
• CL13 Page 6
  Santa Cruz County public, non-profit, and for-profit medical resources have worked together to make health care more accessible to low-income families.
• CL14 Page 7
  Because Healthy Families is a state and federally funded health plan, Santa Cruz County cannot change the eligibility requirements for the program.
• CL15 Page 7
  The 2000-2001 report recommended, “Coverage should be maintained during short periods of seasonal unemployment.” But, in fact, qualifying seasonal workers are covered while unemployed. They risk losing coverage when employed because their income may exceed guidelines. That issue has not been addressed by Medi-Cal or any county agency.
• CL16 Page 7
  A public/private partnership exists in the county to provide affordable access to health care for low-income individuals and families.
• CL17 Page 9
  While low reimbursement rates for medical providers inhibit the delivery of adequate health care to Medi-Cal and Healthy Families beneficiaries, county residents must depend on state and federal entities to resolve the problem. Coalition for Health Care Outreach 2000-2001 Grand Jury Recommendation 5: The Coalition for Health Care Outreach should be supported in the budget of the Health Services Agency upon expiration of the Packard Foundation grant. County Response: This recommendation is being implemented. 2007-2008 Grand Jury Findings
• CL18 Page 9
  In June of 2001 the Packard Foundation grant expired. In 2007-2008, funding for the Coalition for Health Care Outreach (Coalition) came from two sources, First 5 California (First 5) and Medi-Cal Administrative Activities.
• CL19 Page 9
  The budget for fiscal year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive the additional $103,000 from Medi-Cal Administrative Activities.
• CL20 Page 9
  The County works as a middleman for both sources of Coalition funding. Medi-Cal Administrative Activities
• CL21 Page 9
  During the month of September, the Coalition completes a “time survey” to establish the annual cost of outreach activities in excess of what First 5 already pays. The federal government agency Medi-Cal Administrative Activities is billed that excess cost. The turnaround for payment is generally about three years.
• CL22 Page 9
  The County supports various organizations associated with the Coalition throughout the year and receives the money from Medi-Cal Administrative Activities. Many variables determine what work is being done and how it is being claimed. On average, the Coalition received approximately 75 percent of what they predicted in their budget from Medi-Cal Administrative Activities. The County then funds the remaining budget. First 5 California
• CL23 Page 10
  The State of California retains 20 percent of the money First 5 receives, and 80 percent is distributed to the 58 counties throughout California based on the number of children born in the county. Santa Cruz receives approximately $2,700,000 annually.
• CL24 Page 10
  First 5 has three established goals: healthy children, children learning and ready for school, and healthy families. Allowing for local decision-making, the First 5 Santa Cruz County Commission determines how to distribute funds based on a three-year strategic plan and annual contracts. Money provided to the Coalition by First Five has been designated as outreach funds.
• CL25 Page 10
  First 5 reimburses the County for payments made to community agencies for contracted services.
• CL26 Page 10
  In the fall of 2008, First 5 will create a new three-year strategic plan. This may or may not result in continued funds for the Coalition for Health Care Outreach.
• CL27 Page 10
  Since the Packard Foundation grant expired, the Coalition for Health Care Outreach has secured funds to continue successful operation in Santa Cruz County.
• CL28 Page 11
  Clinic operations are no longer confined to daytime hours. The three clinics each offer some lunchtime and/or evening hours. All offer Saturday appointments as well.
• CL29 Page 11
  The inconsistencies of the posted clinic hours confuse and possibly inconvenience patients.
• CL30 Page 13
  Services are limited by the lack of funding, and there are still unserved and under- served people in the county.
• CL31 Page 13
  More dental care is offered to low-income individuals and families now than was offered when the 2000-2001 Grand Jury investigated, but there is still a significant part of the county population that is not being served.
• CL32 Page 13
  Low-income families and individuals of Santa Cruz County are receiving excellent care from two quality agencies and several private dentists.
• CL33 Page 14
  Despite decreasing resources, the County has significantly reduced the number of uninsured residents during the past seven years.
• CL34 Page 15
  The Mental Health and Substance Abuse Services (Division), a division of the Santa Cruz County Health Services Agency, works with and through many groups to offer a wide range of mental health care services including emergency shelter, transitional housing, supported housing, dual diagnosis treatment, crisis intervention, case management, and peer support. Other services available to clients are assessment, counseling, medication support, and referrals. Spanish translation is offered, as is an Appeal Resolution Process for anyone who is denied assistance. The following is a partial list of these resources. Adult residential treatment is offered at • Transition House, 10 beds • Paloma House, 12 beds • Pioneer House, eight beds • Opal Cliffs, 15 beds • El Dorado Center, 16 beds • Darwin House, 15 beds • Front St., Inc., 11 beds • River Street Shelter, 20 beds reserved for people referred by County Mental Health Outpatient treatment and/or social rehabilitation are available at • North County Mental Health Center • South County Clinic • Community Support Services • Dominican Hospital Behavioral Health • Pioneer House Dual Diagnosis Day Program • Community Connection Academy • Front Street Day Rehabilitation Program Self help resources include • Mental Health Client Action Network • Mariposa Activity Center • Community Connection Mental Health Resource Center and Career Services • Community Support Services Community Organizers Program Ongoing services for the protection of low-income mentally ill residents include • Advocacy, Inc. (Patient Rights) • Public Guardian’s Office
• CL35 Page 16
  It is hard to retain staff; therefore, continual training programs are necessary. Many new employees come from the Cabrillo College Health Science/Community Health programs.
• CL36 Page 16
  Various federal, state, county and private agencies fund mental health treatment in our county. Mental health has made effective use of these grants and programs. Some of these sources (known as funding streams) are designated for specific and limited uses. Clients often present with a variety of issues and staff sometimes has difficulty matching funds to the specific needs of the client. Services offered to individuals and families will be further restricted by potential state and county budget cuts in the coming year.
• CL37 Page 16
  Training in cultural sensitivity is emphasized and employees are trained within their department as well as by outside resources.
• CL38 Page 16
  Some families have difficulty acknowledging the existence of a mental health problem. This can be a cultural issue or a matter of pride. Successful mental health outreach and education programs have worked as a part of the network of general health services.
• CL39 Page 16
  Access to services is difficult for South County residents because most service sites are located in Santa Cruz. Public transit offers only a few routes and limited hours of operation. The Division is attempting to expand county services and to create more partnerships with community agencies in South County.
• CL40 Page 16
  The Division works with Senior Network Services but does not yet have an early intervention program for seniors.
• CL41 Page 16
  Among the ongoing concerns of the Division is the ever-present worry of patients exhibiting unexpected antisocial behavior.
• CL42 Page 16
  The County’s mental health program is active and in good hands and is continually adapting to the changing needs of the community.
• CL43 Page 16
  The Division works well, has effective coordination with many nonprofit organizations in the county, and maintains a constant effort for structural improvement.
• CL44 Page 16
  Financing mental health programs is a continual struggle. Clients sometimes have problems finding appropriate services because they do not meet the funding requirements. Mental health staff strive to find creative ways to match client needs in spite of restrictions placed on various funding sources.
• CL45 Page 16
  The Division recognizes cultural issues in treating county mental health patients. This perspective is important to ensure the effective delivery of services because cultural issues may make that more difficult, such as when families feel embarrassed by a member with a mental illness and may not acknowledge it as a legitimate health problem.
• CL46 Page 16
  Effective programs have been developed that recognize the importance of family relationships. Both children and adults are treated. Establishing more peer counseling is a priority.
• CL47 Page 17
  A comprehensive approach is the most pressing need in the system. Along with counseling and medication, affordable housing, tenured living spaces, and job development are all necessary for proper treatment.
• CL48 Page 21
  While all “safety net clinics” are not geared toward families, they are putting forth their best efforts to meet the various needs of the uninsured and Medi-Cal patients in Santa Cruz County.
• CL49 Page 21
  Santa Cruz County needs to recruit more specialists and internists because of the increase in the number of elderly patients with complex health problems.
• CL50 Page 22
  The Health Services Agency is able to recruit adequate medical staff and negotiate appropriate wage and benefit packages under very difficult circumstances.
• CL51 Page 22
  The County has found innovative ways to meet the medical needs of low-income residents through grants and creative staffing. Anticipated budget cuts threaten this tenuous balance, but the Grand Jury believes that the County is going to be able to continue to provide a basic level of staffing to meet the minimal needs of low-income residents.

Commendations 33

• CM1 Page 6
  The Human Services Department and the Health Services Agency are to be commended for ongoing focus on the delivery of adequate health care services to Santa Cruz County residents. Health Insurance Coverage 2000-2001 Grand Jury Recommendation 3: The Healthy Families Program should include parents in its coverage. Premiums should be set at more affordable levels in order to accelerate enrollment of families without insurance. Coverage should be maintained during short periods of seasonal unemployment. The Central Coast Alliance for Health should approach local employers to continue premium payments for families during short periods of seasonal unemployment to keep insurance coverage from lapsing. It should continue to expand the participation of specialists in its programs. County Response: This recommendation has been implemented. 2007-2008 Grand Jury Findings
• CM2 Page 6
  The Healthy Families Program does not include parents in its coverage. Healthy Families insurance premiums vary depending on the health plan selected. Families receive a discounted premium if they select the local Community Provider Plan, which is the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The Alliance’s maximum monthly premium for a family with three or more children is $36 (or $108 per quarter).
• CM3 Page 6
  Recent local funding contributions to the Healthy Kids program, which came primarily from Sutter Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children off the waiting list and into enrollment.
• CM4 Page 6
  Seasonal unemployment only affects the eligibility of adults in a family receiving Medi-Cal. The Alliance reports that their Medi-Cal membership fluctuates by about five percent each year according to the growing season and migration of Medi-Cal recipients out of the area. Typically, a seasonal employee becomes eligible for Medi- Cal when the work season ends or slows down because the worker’s income decreases. When an individual’s work hours increase again, Medi-Cal eligibility could be lost due to the corresponding increase in income. Thus, an individual may qualify during periods of little work or unemployment but no longer qualify for Medi- Cal when working full-time.
• CM5 Page 7
  Medi-Cal has no provision for continued eligibility if an adult no longer meets the criteria. However, children can maintain Medi-Cal eligibility for 12 months even if the adults in the family are terminated due to an increase in income or assets.
• CM6 Page 7
  Although families pay no premiums for the Medi-Cal program, there are premiums associated with the Healthy Families and Healthy Kids programs. However, regardless of changes in family income, once a child is deemed eligible for Healthy Families or Healthy Kids, that child remains eligible for 12 months unless he or she becomes eligible for no-cost Medi-Cal, is covered by other health insurance, or turns
• CM7 Page 7
  In 2000, the Santa Cruz County population was 255,602. In 2007, the population increased slightly to an estimated 264,125 (3.3 percent). But the supply of health care specialists for Alliance programs has increased by almost 30 percent since that year. In 2000, the Alliance had an average of 499 specialists available to serve Santa Cruz County residents. As of March 2008, 697 specialists are available.
• CM8 Page 7
  The Alliance collaborates with over 60 community coalitions and organizations to promote its programs, including the Santa Cruz County Human Services Department. It also promotes health care resources to the public at events, such as farmers’ markets, health fairs, community block parties, and other festivals. In addition, the Alliance publishes a provider bulletin in which providers are urged to encourage their Healthy Families and Healthy Kids patients to stay enrolled and thereby continue their health care coverage.
• CM9 Page 7
  Children also lose Healthy Kids eligibility and coverage when they move out of Santa Cruz County.
• CM10 Page 8
  It is admirable and impressive that Central Coast Alliance for Health has been able to expand local coverage to improve low-income families’ access to health care at a time when statewide reform has failed to gain traction. Increased Reimbursement Levels 2000-2001 Grand Jury Recommendation 4: In order to assure that appropriate care is provided at the least costly level, the outpatient services of local hospitals need to be reimbursed at a higher percent of reasonable costs. The same is true for on-call private physicians who provide care to indigent patients in need of admission to the hospital. The level of reimbursements to private health service providers must be set at a reasonable percent of costs to assure retention of physicians and hospitals participating in Medi-Cal and Healthy Families Program. Rates should be subject to annual negotiation.
• CM11 Page 9
  Since Medi-Cal and Healthy Families reimbursement rates are set by state and federal government agencies, the County of Santa Cruz has no authority to revise them.
• CM12 Page 9
  Congressman Sam Farr, the California Medical Association (CMA), and others have called the reimbursement fee schedules for county doctors inequitable and continue to work to require that the U.S. Department of Health and Human Services fix a system viewed as unfair to local qualified participants.
• CM13 Page 14
  The Grand Jury commends both Dientes Community Dental Care and Salud Para La Gente for providing excellent dental care to low-income residents of Santa Cruz County.
• CM14 Page 14
  Dientes and Salud are to be commended for combining Medicare, Medi-Cal, and county funding with grants and other resources to meet the dental care needs of a significant portion of low-income families and individuals.
• CM15 Page 14
  Since the 2000-2001 Grand Jury report, dental care services available to low-income families and individuals have expanded significantly. Health Services Agency and the Board of Supervisors are to be commended for assisting with this expansion. Expanded Health Insurance Coverage 2000-2001 Grand Jury Recommendation 8: The County should continue to collaborate with community health organizations, local employers and organized labor to expand the numbers of individuals and working families covered by health insurance which includes mental health and dental benefits. County Response: This Recommendation has been and will continue to be implemented. 2007-2008 Grand Jury Findings In 2000, the United Way Community Assessment Project estimated that:
• CM16 Page 14
  Seventeen percent of county residents had no health insurance. That figure dropped to 11 percent in 2007, a decrease of 35 percent in uninsured individuals.
• CM17 Page 14
  One-third of the county residents who could not access health care when they needed it attributed that problem to lack of insurance. The percentage dropped to 18.6 percent in 2007, a decrease of 44 percent.
• CM18 Page 14
  Thirty percent of the county’s low-income families had no health insurance. That estimate dropped to 22 percent in 2007.
• CM19 Page 17
  The County is to be commended for developing and supporting vibrant mental health programs managed by experienced and dedicated staffs. The programs are dynamic and flexible enough to keep up with the demands of clients and changing methods of treatment. Clinic Reconfiguration 2000-2001 Grand Jury Recommendation 10: County clinics should be reconfigured to family-oriented primary and preventive care, backed by clinical specialties and case- managed group therapy for persons at high risk or suffering chronic and recurring illness. These measures will require the recruitment of full-time county physicians and allied practitioners. County Response: This recommendation is being implemented. 2007-2008 Grand Jury Findings
• CM20 Page 18
  In the County of Santa Cruz, “safety net clinics,” (i.e., county or nonprofit clinics), take patients that are uninsured regardless of their ability to pay.
• CM21 Page 18
  Current public and non-profit clinics, as a whole, have not been reconfigured to family-oriented and preventative care, but rather each clinic has an area or multiple areas of concentration which are listed below. Santa Cruz Clinics Santa Cruz Women’s Health • Primary Care for Women and Children • Family Planning • Health Benefits Advocacy • Illness Prevention and Health Promotion • Gynecology and Prenatal Care • Pediatrics • Acupuncture, Chiropractic, Naturopathy Westside Health Center (Planned Parenthood) • Primary Care Services • Family Planning • Health Benefits Advocacy • Illness Prevention and Health Promotion • Obstetrics and Gynecology • Pediatrics • Abortion Services Emeline Clinic • Primary Care Services • Walk-in Immunizations • Health Benefits Advocacy • Pediatrics • Child Health and Disability Prevention • Orthopedics • Family Planning • Laboratory, Radiology, and Pharmacy Coral Street Clinic • Urgent Care and Primary Care • Integrated Case Management • Mental Health and Substance Abuse • Health Benefits Advocacy • Counseling Beach Flats Clinic • Primary Care Services • Women’s Health • Pediatrics • Family Planning • Dental Care • HIV Testing • Obstetrics and Gynecology Dientes Community Dental Care • Emergency Dental Care • Full Range of Dental Services • Oral Health Advocacy Dominican Pediatric Clinic • Pediatric Services Elderday Adult Day Health (Salud Para La Gente) • Adult Day Health Watsonville Clinics Salud Para La Gente • Primary Care Services • Family Planning • Dental Care • Eye Clinic / Optometry • Health Prevention and Promotion • Health Benefits Agency • Pediatrics • Obstetrics and Gynecology Diabetes Health Center • Diabetes Self-Management • Medical Nutrition Therapy • Group Classes • Insulin Training • Glucometer Training Clinica del Valle Del Pajaro • Primary Care Services • Dental Care • Family Planning • Women’s Health • Pediatrics • Child Health and Disability Prevention • Obstetrics and Gynecology
• CM22 Page 20
  Santa Cruz Women’s Health and Planned Parenthood specialize in women’s health, family care, and reproductive health.
• CM23 Page 20
  Specialists are available when necessary, usually through Sutter Maternity & Surgery Center, which provides some free services to the community.
• CM24 Page 20
  The County of Santa Cruz currently employs 20 full-time doctors: five primary care physicians (including two pediatricians), and 15 psychiatrists, four of which are bilingual.
• CM25 Page 20
  The recruitment of allied health practitioners and full-time county physicians is often a challenge. Response from the County: AGREES. The Health Services Agency and the Personnel Department have developed a number of successful initiatives to increase the County’s ability to recruit for various classes of health practitioners and physicians.
• CM26 Page 20
  The high cost of housing in Santa Cruz County makes recruiting primary care physicians difficult.
• CM27 Page 20
  Psychiatry has only one vacant position, and nurse practitioner positions are filled through a “feeder program” from San Jose State University.
• CM28 Page 21
  The Grand Jury commends Sutter Maternity & Surgery Center for providing the services of medical specialists to those in need. Medical Staff Recruitment and Salaries 2000-2001 Grand Jury Recommendation 11: In the recruitment of health care professionals, salary surveys conducted in nearby agricultural counties are no longer pertinent to this County. In the next round of County salary negotiations, surveys should be conducted that use counties more comparable to the emerging characteristics of Santa Cruz County. County Response: The County has utilized the nine-County comparison for over thirty years, and this long-term base of information is useful in evaluating salaries. The nine- County comparison is used as a guide along with other information such as the Consumer Price Index, turnover statistics, recruitment and retention rates, the relationship between positions within the County, changes in classifications, and operational changes. Other jurisdictions are also surveyed, as appropriate. 2007-2008 Grand Jury Findings
• CM29 Page 21
  Currently Santa Cruz County uses eight nearby counties in salary surveys: Monterey, Santa Clara, Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to Santa Cruz than the nine counties formerly used in that they are not strictly agricultural and have living costs comparable to Santa Cruz.
• CM30 Page 21
  Recruiting and retaining physicians and other medical professionals is uniquely difficult in Santa Cruz County because it is labeled by Medicare as a rural county. The Medicare reimbursement rate is the same as Butte, Imperial and other counties with a much lower cost of living.
• CM31 Page 21
  The county health programs must compete with Dominican and Sutter for physicians and other medical professionals. Hospitals are in a unique position to pay higher salaries as their Medicare reimbursements are based on actual costs. A national Medicare study released in 2007 shows hospitals in Santa Cruz County have the highest labor costs in the country, which local health officials say means higher medical costs and insurance premiums for patients. This situation creates a difficult challenge when it comes to recruiting medical professionals.
• CM32 Page 22
  Salaries and working conditions for physicians and other medical professionals employed by the County are negotiated with the respective unions.
• CM33 Page 22
  The Grand Jury commends the Health Services Agency for the innovative way it has succeeded in providing quality health care to county low-income residents despite financial limitations.