Marin County Grand Jury
• 2023-2024
• Agency Response
Office of the County Administrator County of Marin September 19, 2023 Matthew H. Hymel SEP 1 9 2023 County*
⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 9 findings
F1
BHRS does not currently have a one call/one door entry for all of residents who are seeking mental or behavioral health services. The website lists several phone numbers and contact points for its services, which is confusing to the public when seeking help. Response: Disagree. The Marin County Behavioral Health and Recovery Services (BHRS) website homepage (www.marinbhrs.org) prominently features a "call now" button which connects users to the Access Line (1-888-818-1115). The Access Line phone number is also listed on this page for users who are accessing the website via a computer browser without call capabilities. The website includes links to additional information for specific behavioral health issues; including children and youth services, older adult services, substance use services, and suicide prevention. All callers experiencing crisis will receive assistance by calling the Access Line or 988. While the Access Line is available to all callers for behavioral health triage, BHRS is State and Federally mandated to serve individuals who are low-income, Medi-Cal recipients, or uninsured; and who have a serious mental illness and/or substance use disorder. Privately insured individuals are more likely obtain behavioral health care from their primary care provider or via their insurance company.
Related Recommendations (1)
R1
By December 31, 2023, the Marin County Board of Supervisors should direct the County's BHRS division to develop and begin to implement a written strategic plan and operating budget detailing the enhancement, expansion, and funding of the 988 Lifeline Call Navigation Center to become the one call/one door entry for county residents who are seeking immediate help with a behavioral health crisis. This recommendation will not be implemented because it is not warranted or reasonable. BHRS has an existing contractual relationship with Buckelew Programs to support the 988 Lifeline and the County only provides a portion of the operational budget for 988. Buckelew receives additional funding from state and federal sources. BHRS is interested in a closer partnership with 988 to ensure seamless responses for individuals in a behavioral health crisis. The Grand Jury recommends 988 as a single point of entry into behavioral health services; however, it is important to note that 988 is a nationally promoted call line for people who are in a behavioral health crisis. For individuals seeking outpatient, planned behavioral health services, 988 would not be an appropriate first contact. Furthermore, if Marin were to promote 988 as a "one call/one door entry" for residents both in active crisis, and seeking help including outpatient care (e.g. in lieu of the Access Line), that would be inconsistent with national standards and messaging on 988. This would be analogous to someone calling 911 to request an outpatient medical appointment. While we agree that 988 has an important role in our system, we also recognize the need for the Access Team to serve as a primary entry point for outpatient behavioral health services. 988 is able to provide a link to the BHRS Access Team for callers who need outpatient services, but are not in a crisis.
F2
Most Marin County residents have limited or no knowledge of where to call, other than 911, for help with a mental or behavioral health crisis, and the 988 Lifeline is not widely known or used. Response: Agree. A 2023 national survey by the National Alliance on Mental Illness (NAMI) and Ipsos Polling found that 82% of Americans are not familiar with the 988 Suicide and Crisis line. As such, public awareness of the Lifeline in Marin is on par with nationwide trends. The 988 Lifeline was launched in July 2022, and since that time the Federal and State government, as well as our local 988 Operator, Buckelew Programs, have worked to publicize this resource. California State Assembly Bill 988, signed into law in September 2022, includes a five-year implementation plan that is expected to raise the profile of 988 for the public statewide, including in Marin. BHRS will continue to work with the State and Federal government and Buckelew Programs to educate the Marin public about 988 and where to get behavioral health help.
Related Recommendations (1)
R2
By December 31, 2023, the Marin County Board of Supervisors should direct the County's BHRS division to develop a new public awareness and educational outreach campaign promoting the 988 Lifeline Call Navigation Center. This recommendation has not been implemented and will be in the future. Upon launch of 988 in July of 2022, BHRS participated in community education panels and assisted with public awareness campaigns. Marin HHS has plans to do more outreach during Suicide Prevention Month in September 2023. In the current fiscal year, BHRS has budgeted approximately $55,000 for marketing of suicide prevention efforts, including high-visibility channels such as bus stop and newspaper advertisements. Of the $55,000 marketing budget, $45,000 is earmarked for a Countywide 988 outreach campaign. These funds are in addition to any advertisement or marketing tools created or leveraged by Buckelew Programs, the State of California, or national programs such as NAMI or SAMHSA. It should be noted that California Health and Human Services and federal agencies are working on 988 awareness marketing campaigns as well. Messaging and branding of 988 in Marin will need to cater to local needs and target populations, but should also be consistent with statewide and national efforts. County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023)
F3
Most calls to BHRS are not answered by a live person 24x7. Response: Partially disagree. While we agree that some non-emergency line calls are not answered live 24x7, we cannot fully agree with this finding. The report notes that the operating hours of the Access Line are County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023) Monday-Friday, 8:30am to 4:00pm, however the actual hours of operation are 8:00am to 5:00pm. The report notes that outside of these hours, "the phone line is directed to an answering service". Beyond the hours of 8:00am to 5:00pm Monday-Friday, the Access Line is staffed by behavioral health clinicians from Optum Health, the nation's largest managed behavioral health organization. Optum clinicians answer the phone, take notes about the client situation, and leave this information for Access staff to follow up during the next business day. The Access Hub is not an emergency or crisis line; it is for people seeking outpatient behavioral healthcare. If someone is in a behavioral health crisis, they should always contact 911 or 988.
Related Recommendations (1)
R3
By December 31, 2023, the Marin County Board of Supervisors should direct the County's BHRS division to create a new Behavioral Health Crisis Services department reporting directly to the division director. The new department would integrate the Access Team, the Mobile Crisis Response Team, the Crisis Stabilization Unit, and oversight of the 988 Lifeline Call Navigation Center under a single responsible and accountable management structure. This recommendation will not be implemented because it is not warranted or reasonable. The Mobile Crisis Response Team, Crisis Stabilization Unit, and Access team are part of the same Division (BHRS) within the HHS Department, which is overseen by the BHRS Director. The 988 Lifeline is a contracted service operated by Buckelew Programs, which also receives external funding from State and Federal sources. Re-organizing existing programs and structures within BHRS would require significant further exploration and outreach. BHRS has limited resources to support administrative expansion, and a new Crisis Services system within BHRS would likely require additional management and administrative staff. Additionally, best practices and trends on behavioral health policy aim to shift in the long term from from a focus on crisis response to investing in the behavioral health need continuum; and methods to reach those in need with effective treatment and strategies before crisis intervention becomes necessary. An example of this are changes in state laws which enable treatment plans before criminal court involvement, a heightened focus on prevention, early intervention and children's behavioral youth, and a push to expand availability of short and long-term residential placements to stabilize individuals more meaningfully after acute care. This focus on more seamlessly bridging the services on the behavioral health continuum – from immediate crisis care to long-term outpatient treatment - mean that a division of crisis care from other services should be further analyzed on how it would affect the flow of clients stepping down from crisis care, but who will need long-term supports.
F4
The new 988 Lifeline represents a first step toward shifting the primary response to mental and behavioral health emergencies from law enforcement, EMS, and Fire to trained behavioral health care navigators, thus reducing the burden on law enforcement, EMS and Fire so they are available for other public safety calls, and at a lower cost to the County. Response: Partially Disagree. The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) offers 24x7 call, text, and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, mental health crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support. We are in alignment with the California Health and Human Services Agency vision of "a behavioral health crisis hotline where those struggling with mental health related distress can access support and de-escalation strategies in a person-centered, non-restrictive manner." However, at this time, specific funding has not been allocated by the State for diversion of mental health calls from emergency dispatch, and this is not a factor included in federal 988 Lifeline regulations. Additionally, when a mental health crisis presents a public safety, medical, or other emergency, 988 may still route calls to 911 emergency dispatch. For calls that are not necessarily routed to 911, law enforcement may still participate in the response to a 988 crisis call, in order to ensure the physical safety of behavioral health professionals. Finally, another factor that could greatly determine whether 988 ultimately lowers public safety response costs to the County is the long- term criterion on if/when a physical response to a 988 call is required. 24x7 operation of the 988 line is required by the end of 2023 - though specific policies on response may still vary county to county.
Related Recommendations (1)
R4
By December 31, 2023, the Marin County Board of Supervisors should direct the County's BHRS division to create an organizational plan to improve its utilization and outcome reporting across the Mobile Crisis Response Team, the Crisis Stabilization Unit, the Access Team and the 988 Lifeline Navigation Call Center: 1) its sharing of that data across the units within BHRS; 2) its consolidated reporting and conclusions based on that consolidated data; and, 3) its ability to consequently make informed decisions regarding staffing, funding, program development, and new service opportunities to improve behavioral health outcomes. This recommendation requires further analysis. BHRS operates within the guidance of multiple state and federal mandates, and contracts with the State Department of Health Care Services for service delivery. New guidance under California Advancing Innovations in Medi-Cal (CalAIM) focuses on data sharing and data exchange. Additionally, state and federal programs targeting crisis response typically have unique reporting and outcome requirements for grant funds associated with various services; so a division-wide organizational plan would need to take in those requirements as well, and ideally would leverage existing data tracking. County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023) BHRS is focused on utilizing data to make informed and client-centered decisions, and is currently analyzing these mandates and implementing policy and procedure changes. HHS and BHRS are also investing heavily in technology to streamline data collection and sharing, to the extent that aggregate client data may be legally shared between divisions for the purposes of optimizing service delivery. Over the next six months, BHRS expects to conduct an analysis of the various data sharing and reporting mandates and the technological capabilities of a new electronic health record and health information exchange.
F5
BHRS's $125,000 historic annual funding of the Suicide Prevention Line has not been adjusted to reflect the expanded services provided by the Buckelew-run 988 Lifeline Navigation Call Center. Response: Disagree. In the 2023-2026 MHSA Three-Year-Plan, BHRS increased funding to Buckelew for the Suicide Prevention Lifeline to $165,000 annually. Additionally, other sources of funding have recently been made available for 988 operators and services. In 2021, the Department of Health Care County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023) Services allocated $20 million for the network of 13 Suicide Prevention Lifelines1. In 2022, the Governor signed Assembly Bill 988 into law, which includes a statewide surcharge on telephone bills that will be used to fund 988 call centers and mobile crisis teams. At the time of this response, BHRS has not yet received any funding from these sources to provide additional support to local providers.
Related Recommendations (1)
R5
By December 31, 2023, the Marin County Board of Supervisors should direct the County's BHRS division to develop a plan and operating budget to transition the Mobile Crisis Response Team to 24x7. This recommendation has not been implemented and will be in the future. Consistent with state mandates, BHRS' Mobile Crisis Response Team is working toward 24x7 operations by December 31, 2023. BOARD OF SUPERVISORS COUNTY OF MARIN PRESIDENT September 19, 2023 Stephanie Moulton-Peters 310 DISTRICT VICE PRESIDENT Honorable James T. Chou Dennis Rodoni Presiding Judge 4TH DISTRICT Marin County Superior Court 3501 Civic Center Drive 2ND VICE PRESIDENT San Rafael, CA 94903 Mary Sackett 1ST DISTRICT Dear Judge Chou: Katie Rice The Marin County Board of Supervisors' response to the FY 2021-2022 Civil 2ND DISTRICT Grand Jury Report "Marin's Behavioral Health Services: All Calls for Help Eric Lucan Need to Be Answered" (June 20, 2023) is attached. The attached document 514 DISTRICT responds to all the requests made for responses from the Board of Supervisors. Respectfully submitted, Matthew H. Hymel COUNTY ADMINISTRATOR CLERK OF THE BOARD Stephanie Molten-Peters Carla Kacmar President, Board of Supervisors ASSISTANT CLERK OF THE BOARD Marin County Civil Grand Jury CC: Marin County Civic Center 3501 Civic Center Drive Suite 329 San Rafael, CA 94903 415 473 7331 T 415 473 3645 F 415 473 6172 TTY www.marincounty.org/bos
F6
A county-wide needs/gaps assessment (broader than what the Mental Health Services Act mandates) has not been completed for several years. Response: Agree. Such an assessment is outside of the mandate of BHRS' role as a safety net provider for individuals with serious mental illnesses and substance use disorders. A comprehensive assessment of countywide behavioral health services would necessarily include services provided by health maintenance organizations, private insurance companies, and private practice behavioral health providers. It would also require access to data outside of the safety net health systems and coordination from organizations and providers who serve the 91 percent of residents who do not participate in Medi-Cal - and therefore do not share data with the County. In 2019, Marin County Public Health and the Healthy Marin Partnership produced the Community Health Assessment and, in 2022, Marin Health published the Community Health Needs Assessment in partnership with the County of Marin and the Healthy Marin Partnership. Both provide an assessment of community mental health needs as part of the larger landscape of health data. The pandemic has also both significantly raised the profile and need of mental health and changed how services are delivered - locally and nationally. An assessment today would reflect these shifted needs and access.
No recommendations for this finding
F7
Despite the HHS's Mission Statement "To promote and protect the health, well-being, self-sufficiency, and safety of all people in Marin," the large majority of the programs and funding are limited to the approximate 20 percent of Marin's population who qualify for Medi-Cal or are uninsured. Response: Agree. BHRS' mandate is to serve low-income Marin County residents who have Medi-Cal or are uninsured, and have serious mental illnesses or substance use disorders. The remainder of Marin County residents are privately insured. Although BHRS prioritizes our mandated safety net population, we do provide prevention and early intervention (PEI) and crisis services to all Marin County residents, including supporting behavioral health services and professionals in Marin's schools. In FY22/23, BHRS spent 1 Department of Health Care Services (September 3, 2021). California dedicates $20 million to support new mental health "988" crisis hotline. https://www.dhcs.ca.gov/formsandpubs/publications/oc/Documents/2021/21-06-988- Line.pdf. Accessed 07/21/2023. County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023) approximately $3.1 million on PEI services and $8.6 million on crisis services, representing approximately 14% of the overall BHRS budget. The 988 Lifeline and the Marin County Access Line (1-888-818-1115) are available to all callers, and the Older Adult Information and Assistance Line is available for older adults and persons with disabilities seeking behavioral health services, among other services offered.
No recommendations for this finding
F8
The Mobile Crisis Response Team, Crisis Stabilization Unit, Access Team, and County oversight of the 988 Lifeline Navigation Center do not report to the same department manager; thus complicating the coordination and communication between the four departments. Response: Disagree. The Mobile Crisis Response Team, Crisis Stabilization Unit, and Access Team, are within the same Division of Health and Human Services, BHRS. All three programs are overseen by the same Behavioral Health Division Director. The 988 Lifeline is a contracted service operated by Buckelew Programs, which also receives external funding from state and federal sources. All of these agencies coordinate care on a regular basis.
No recommendations for this finding
F9
The Mobile Crisis Response Team is not currently available 24x7 to respond to an urgent mental or behavioral health crisis. Response: Agree. Consistent with recent state requirements, Mobile Crisis will become a 24x7 service statewide by December 31, 2023. County of Marin Response to Grand Jury Findings and Recommendations ---- County of Marin Response to Grand Jury Report Findings and Recommendations ("Marin's Behavioral Health Services: All Calls for Help Need to Be Answered") (June 20, 2023) RESPONSE TO GRAND JURY RECOMMENDATIONS The Marin County Civil Grand Jury recommends the following:
No recommendations for this finding
* 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.