Memo from Vice President Ellenberg and Supervisor Lee on mental health and substance abuse August 2022
Board of Supervisors, August 30, 2022
Memo on Item 10 - Under advisement from May 3, 2022 (item no. 29): Receive report from the Behavioral Health Services Department relating to a follow-up report on mental health and substance use as a public health crisis.
To: President Mike Wasserman, Supervisors Chavez and Simitian
CC: Dr Jeff Smith
From: Vice President Susan Ellenberg, Supervisor Otto Lee
Esteemed Colleagues:
In January, 2022, we were grateful to secure your unanimous support to declare mental illness and substance use disorders a public health crisis in Santa Clara County. We know you share our urgency to better serve the residents of County of Santa Clara when they are in crisis. Each of you has championed aspects of this important work and together we strive continuously to do better by our community.
The purpose of this memo is to secure your agreement to hold our Administration accountable in specific, measurable ways to act with greater urgency to implement direction already approved by this or previous Boards of Supervisors. Please see a brief discussion of the items below, each of which is followed by a proposed charge we hope will be rolled into an addendum to the CEO’s goals that we can use to evaluate performance and effectiveness.
1. It has been seven years since the BOS directed administration to develop an acute inpatient facility to treat children, adolescents and adults. Sup. Simitian has championed this facility to fill a critical need for children and their families. Despite the allocation of funds, issuance of debt and development of plans, the County has not successfully issued a contract to begin construction. CHARGE: Secure a contractor and execute an agreement in the next 90 days to construct the facility with a projected operational date no later than January 1, 2025
2. Numerous reports to the BOS have shown is a critical lack of step-down beds for patients leaving acute inpatient hospitalizations, locked sub-acute beds (IMDs/SNFs), jail or otherwise in need of intensive services. In the absence of these beds, patients occupy space needed for more acute patients, may remain in settings inappropriate for their own recovery, and cost the County additional dollars for higher levels of treatment. In the worst-case scenarios these patients may be unhoused and lost to care if not able to be placed appropriately. The BOS has approved a couple of projects to address a portion of this shortage:
a. Renovations for 650 S. Bascom were funded in the budget approved in June 2021 to provide 28 beds for unlocked highly supported step-down care. While permit issuance by City of San Jose caused a five-month delay, in the August 2022 report to the Health and Hospital Committee staff projected opening the facility not until April 2023 – nearly two years after funds were authorized by this board. This estimate does not include additional time needed for licensing which may extend until July 2023. Charge: Accelerate renovations to open 650 S. Bascom within 90 days.
b. A vendor in the East Bay has been in negotiations with County staff for more than twelve months to provide a similar level of “super board and care” residential treatment to individuals with high needs who are ready to step down from locked facilities. These beds are reportedly immediately available to provide treatment. Approximately 20 beds have been discussed as a target for County of Santa Clara clients. Charge: bring a contract and funding proposal to the Board of Supervisors for adult residential facility beds within 90 days.
c. Staff reports indicate that over 200 locked subacute beds are needed to serve County of Santa Clara residents. The public bed tracker requested by FGOC members Sups. Lee and Chavez show all local IMD, SNF and MHRC beds are full on an ongoing basis. This lack of capacity results in people staying longer in acute inpatient care or in jail that could be released for competency restoration. On May 3, 2022, this Board unanimously approved direction to proceed with pre-construction planning for a County owned IMD, and designated $1M for this purpose in the FY22-23 budget. To date no timeline or indication of any planning for this facility has been presented to the BOS, despite its centrality in the discussion of behavioral health system needs at the August 30th Board meeting. Administration has indicated this will need to be embedded in the VMC facility master plan with no clear timeline to return to the Board with this information. Charge: Present a plan, timeline, and funding plan for development of a County owned IMD at a public meeting of the Board of Supervisors within 90 days.
3. There is broad agreement that workforce shortages are at an all-time high across the behavioral health system in County of Santa Clara and beyond. While efforts have been implemented to adjust contract rates for partners and offer incentives to attract some classifications of County employees, more needs to be done to alleviate immediate workforce gaps and build a pipeline for future behavioral health system workers at all levels from peer providers to psychiatrists. Some restricted funds exist to support this work, but the need exceeds those grants and warrants general fund investment if federal or state dollars are insufficient:
a. The California Mental Health Services Authority (CalMHSA) grants provided an opportunity for the County to invite applicants in mental health clinical training programs to receive tuition assistance or loan repayment funds of $10,000 per qualified student in exchange for two years of public service. 29 more qualified applicants submitted requests than were available with State grant funds. Rather than identify the additional $290,000 from other sources or request Board authority to spend from the $4M special program fund for behavioral health, these students were not accepted. This choice represents a clear lack of urgency and an unwillingness to invest County resources in our workforce. Charge: Bring an action to the Board within 90 days with options to fund all qualified applicants from the prior round of submissions and a timeline and recommended resources for regular (at least annual) rounds of applications and funding utilizing state grants if available, or County funds if not available.
b. Per the department vacancy report submitted to the Board during the Budget process, approximately 1 in 8 positions are currently vacant in the Behavioral Health Services Department. From the pace of progress across initiatives it appears that the department does not have sufficient capacity to provide core services and meet increased levels of need, including in reporting and planning to this Board. Gaps in FAF, TSS, Procurement or other areas may hinder timely implementation of behavioral health system tasks including those outlined above. Charge: Bring a supplemental staffing plan to the Board of Supervisors at a public meeting within 90 days to assure Board approved and state required programs are implemented. This may include diversion of staff in a DSW model, increase of extra help utilization, prioritization of recruitments by ESA or any other mechanism available to the CEO.
4. County staff recommended the addition of 15 adult and 5 youth “social detox” beds to support withdrawal from drugs and entry into residential or outpatient treatment programs. These services are estimated to support 700 residents per year to enter recovery. These services were approved as part of the budget in June 2022, however recent staff reports indicate that the procurement and planning timeline will not allow services to begin until July 1, 2023. Charge: accelerate procurement of adult detox beds or amend existing contracts to add capacity within 90 days.
5. Some community providers continue to report that individuals with complex medical conditions or other risk factors need a higher level of “medical detox”. Sup. Chavez has repeatedly asked for a plan to provide this level of service. Most recently an off agenda (see attachment) published on May 16th outlined the levels of care without any recommendation or path forward to meet the gap for this service. The follow up off-agenda on July 18th indicates that all needs can be handled through the VMC emergency departments and inpatient services but offers no path to connect substance use service providers that identify patients with higher needs into these supports in a manner that expedites and coordinates care. Charge: bring options for implementation of a medical detox unit or program to a meeting of the Board of Supervisors for consideration within 90 days.
6. Past audits have identified, and contracted providers continue to report, challenges spending down their contracted funds. In fact, the report to the Board on Behavioral Health finances (Item 11 at tomorrow’s meeting) shows over $102M in fund balance in MHSA (not including the MHSA prudent reserve) and an additional $128M in fund balance in 2011 Mental Health Realignment. Whether this is an issue of workforce availability, contract flexibility, outreach processes or any other number of systemic challenges, the fact remains that available funds are not being translated into services for residents. The Board has asked numerous times for information on how these funds should/could be spent. Administration must identify solutions to apply resources to meet community need. Charge: bring recommendations forward to address these barriers to spending with clear solutions at a meeting of the FGOC committee within 90 days.
7. CalAIM opens new avenues for benefits including enhanced care management and community supports (ECM and CS) to people with serious mental illness that may include housing stabilization resources, transportation and medication management. These services were available as of July 1, 2022 but it appears no mechanisms of referral or authorization of services have been established between the County and Santa Clara Family Health Plan and Anthem to allow for reimbursement of these benefits to flow. This leaves funds on the table the County is not utilizing for care that is being provided (case management) and does not link residents eligible for housing supports to those new resources. While CalAIM is undoubtedly complex and emerging with state and managed care guidance, the primary barrier at this stage appears to be negotiation of roles and contractual issues between the County and the plans. Charge: establish any necessary agreements, protocols or workflows so that County clients begin receiving ECM and CS benefits and that the County begins receiving reimbursement for those services within 90 days.
We have confidence in our Behavioral Health Services Department to execute on work assigned and to maximize their impact with resources and staffing allotted to their work. Our concern lies primarily with our perceived lack of urgency by the Administration to follow through on Board authorized and funded initiatives, unacceptably long implementation timelines for initiating new facilities or services, and hesitancy to propose strategies that might require general fund investment despite alignment with stated strategic priorities of the behavioral health system. We certainly acknowledge that the long-term solutions to a complex and shifting behavioral health system will likely require further analysis and planning, the specific items detailed above have been authorized by the board, charged to the CEO, and are within his power and resources to implement.
We look forward to conversation with our colleagues and with Dr. Smith and hope to secure support for the charges listed above. Thank you all for your partnership and commitment to the health of our residents.
Respectfully,
Susan and Otto
Attachments:
- Report to the Health and Hospital Committee from the Facilities and Fleet Department, Santa Clara Valley Medical Center (SCVMC), and the Office of the County Executive relating to the Child and Adolescent Psychiatric Facility/BHSC on the SCVMC campus. August 24, 2022.
- Report to the Health and Hospital Committee from the Facilities and Fleet Department relating to use of Don Lowe Pavilion and Barbara Arons Pavilion on Santa Clara Valley Medical Center Bascom Campus. (Referral from April 19, 2022, Item No. 98 and June 28, 2022, Item No. 27). August 24, 2022.
- Report to the Health and Hospital Committee from the Facilities and Fleet Department relating to tenant improvements for 650 S. Bascom Avenue, San Jose. (Referral from May 17, 2022, Item No.15) August 24, 2022.
- Off-Agenda Report Back on Medically Supervised Detoxification, Issued May 16, 2022.
- Off-Agenda Report on Algorithm to Access Medical Detoxification and Expansion, Issued July 18, 2022.
- Report to the Santa Clara County Board of Supervisors relating to financial resources for expanding behavioral health system capacity.