Mental Health Services Act Transforming Mental Health in Santa Clara County A Presentation to Community Health Partners

1. Mental Health Services ActTransforming Mental Health in Santa Clara CountyA Presentation to Community Health PartnershipApril 28, 2006 Nancy Peña, Ph.D., Director Department of Mental Health

2. Objectives • Santa Clara County Mental Health Services • Local MHSA Planning • Current Primary Care Interface Initiatives • Future Opportunities for Integrated Service

3. SCC Health System

4. Santa Clara CountyMental Health System SCVHHS Mental Health Department • Administers specialty mental health services to Medi-Cal beneficiaries carved out from Medi-Cal managed care (60% of services; est. 6% penetration) • Provides service to uninsured poor (40% of services) • Funded through local county general fund, state realignment, federal Medicaid revenues • Serves 18,000 children, adults and seniors each year (approximately 10,000 ongoing persistently ill children and adults)

5. Santa Clara CountyMental Health System • Services include emergency, hospital, case management, outpatient, day services and residential services through multiple county-operated and 27 contracted agencies • Ethnic specific programs established for Latino, Asian, African American, Native American and Eastern European populations • Services provided in institutions (jail, juvenile hall, ranches & children’s shelter)

6. SCC Mental Health FY06 Funding - $190.5 M

7. Santa Clara CountyMental Health System • Call Center screens 100 calls per day; 30% meet criteria for specialty services • Emergency Psychiatric Services (EPS) evaluates 30-35 per day with 20% requiring hospitalization • Average 70 adult and 10 youth patients hospitalized in VMC and Bay Area private hospitals

8. Santa Clara CountyMental Health System • 600-700 LPS Conserved requiring intensive residential and case management support, with 230 currently in locked residential settings • Another 200 severely mentally ill served in unlocked intensive residential programs • 34 in long-term state hospital care • Several hundred state hospital penal code commitments from criminal justice system funded through that system

9. The Mental Health Services Act

10. MHSA (aka Proposition 63) • 1% tax on taxable personal income over $1 million to be deposited into a Mental Health Services Fund (MHSF) in State Treasury • Administered by State Department of Mental Health • Oversight by 16-Member Accountability Commission • Distributed to Counties Via Current State-County Contract • $300 Est. Million in FY05; $700 Million Est. in FY06 • Phased in approach to implementation, beginning with Planning and Expanded Service components • Counties currently submitting first component funding requests

11. MHSA Components The MHSA outlines six components to build a better mental health system. SDMH requires an extensive stakeholder process to guide policies and programs: • Community Program Planning (underway) • Services and Supports (underway) • Capital (buildings) and Information Technology • Education and Training (human resources) • Prevention and Early Intervention • Innovation

12. Current Situation in California • Estimates (Year 2000) - over 1,000,000 living at or below 200% of poverty in California are in need of treatment (FY02 expenditures $3.1 Billion) • Public system provides services to estimated 460,000 • System would need to more than double capacity to meet needs of those who rely on public services • MHSA est. $700 Million in new revenue in FY06 with 55% to direct service expansion • Estimates are Initial full year will increase direct services statewide by 15%

13. MHSA in Perspective • SCC annual share $13.4 Million for Community Services and Supports (CSS) or 7% of current budget • Funding for future components undetermined • Local budget crisis will continue into FY07

14. DMH Vision Statement: • Consumer and Family Participation and Involvement • Recovery Oriented and Evidenced Based Service Programs • Community Partnerships • Cultural Competence • Outcomes and Accountability • Integrated Services

15. The Opportunity • Will not achieve transformation without strong leadership and vision at the local level. That leadership must: • Engage local consumers and families, system partners, providers, and advocates • Establish a collective purpose and system-wide enthusiasm and desire for change • Provide a clear and understandable framework for the planning process • Provide opportunities for subjective and deep dialog as well as access to objective data and information

16. The Local Planning Process • Broad based community involvement process • Extensive inreach and outreach brought voice of 10,000 through surveys and meetings • Open monthly forums to engage, inform, gather input, educate • Four clear phases of planning • Ethnic Community Advisory Committees established to provide ongoing input to system

17. Planning Phases • Engagement and Commitment • Invite Stakeholder Involvement • Share Intent and Vision • Lay Out Planning Landscape • Learning and Assessment • Learn Current System • Learn Needs of Consumers, Stakeholders, Community • Learn Best Practice Strategies to Meet Needs • Prioritization and Planning • Establish Local Mission, Values & Transformation Objectives • Prioritize Local Needs • Select Most Effective Strategies to Meet Local Needs • Implementation • Obtain State Approval • Select Local Providers • Initiate, Monitor and Evaluate Services

18. Community Stakeholder Meetings • High energy meetings to create forward momentum in collecting consumer voice • Emphasis on being the voice for others • Commitment by County providers to engage and sustain consumer, family and community voice • Constant “bringing home” of mental illness to personal experience of policy makers, providers, planners, community members

19. Community Stakeholder Meetings • Constant reminder “It’s not the money, it’s the change!” • Planning emphasis on selecting “catalyst strategies” rather than “gap fillers” • Solicitation of “long haul” commitment • Illustration of disparities through qualitative and quantitative means: voice and data

20. The Process • Paper surveys • Posters in waiting areas and clinics • Focus groups • Conversation groups • Ethnic Community Advisory Committees • Presentations to wide range of stakeholder groups and system partners

21. The Process • Work Groups for five age groups • Children 0 –5 • Children 6-15 • Transition Age Youth 16 – 25 • Adults 26 – 59 • Older Adults 60 • Strategy Teams for detailed research and design covering 13 distinct populations of mental health clients

22. The Process • Stakeholder Leadership Committee to: • Review & Input to Development of Plan • Facilitate Stakeholder Involvement • Educate Community • Advise Board of Supervisors

23. Santa Clara County Approach • Visual Models of System Components • Public Health View of Need • “Across the Lifespan” Perspective • Quality of Life Domains • Ecology Systems Model • Human Connectedness Emphasis

24. The Approach • Establish System Structure and Stakeholder Involvement Perspective System Policy and Management System Performance:Expectations & Results Stakeholders Provider Performance: Expectations & Results Provider Services Individual & Family Client Level Outcomes: Expectations & Results

25. Public HealthLifespan Approach • Determine and Prioritize Local Mental Health Needs Across Lifespan Current Public MH System Intervention Unmet Need Citizens in need Early Intervention Prevention All Citizens Across Lifespan

26. Common Quality of Life Goals for All • Health and emotional well being • Safe and permanent living situations • Supportive social network • Meaningful school, work, daily activities • Free from trouble or causing harm to others • Safe from harm from environment or others

27. Quality of Life Domains Thriving With Mental Illness Low Need Emotional Well Being SA Remission Good Health Housed Adult Connected Senior Child at Home Employed Adult Active Senior Child in School Adult out of Jail Safe Senior Child out of Trouble Safe From Harm or Harming in Community Meaningful School, Work Activity Stable Home, Family, Social Relations Health & Well Being Emotional Suffering SA Abuse Poor Health Homeless Adult Isolated Senior Removed Child Jobless Adult Inactive Senior School Failing Child Jailed Adult Victimized Senior Delinquent Child Hi Need Failing With Untreated and Under-treated Mental Illness

28. Ecological and Human Connectedness Models as a Context for Effective Interventions Tertiary Ecology Secondary Ecology Primary Ecology Relationships: Heart Blood Guide Spiritual

29. The Approach • Provide an accountability paradigm to demonstrate process quality and favorable outcomes What Are We Trying to Change? Who Do We Serve? What Practices Do We Employ and Why? How Do We Insure Quality of Practices? How Do We Measure Results? What Results Do We Achieve?

30. Plan Requirements The Three-Year CSS Plan 1 2 3 4 Identify Specific Populations for Focus Identify Community Concerns for All Ages Determine Unmet Need Identify strategies to Meet Need

31. Most Frequently Noted Concerns • Across all Age Groups • In trouble with the law, incarceration • Concurrent substance abuse • Abuse, neglect, violence, trauma • Sadness, depression, loneliness, isolation • Poverty, homelessness, inadequate housing • Failing school & jobs, meaningless activities • Concurrent medical problems • Institutionalization, hospitalization • Problems with family and peers

32. Disparities in Unmet Need • Latino, Asian and American Indian underserved among all ages • Latino, African American and American Indian over-represented in CJS, un-housed, and foster care with greater need (prevalence) and less served • Refugee, immigrant and monolingual greater need and less served • LGBTQ greater need and less served • Developmentally disabled greater need and less served

33. Focal PopulationsDefined Per Requirements Children • Zero to Five Years High Risk • Foster Care Youth • Juvenile Justice Involved Youth • Underserved Seriously Emotionally Disturbed Transition Age Youth • First Time Psychosis • Sixteen to 25 Years Aging Out of Child Systems Adults • Jail Involved/Homeless/Dual Diagnosed SMI • Underserved/Un-served SMI Older Adults • High Risk/Homebound SMI Seniors

34. CSS Plan • Full range of strategies established for each focal population • Priority first phase incorporated into 23 work plans to address critical concerns of 9 focal populations • Full service partnerships, evidenced based practice throughout system, redesigned access, self help, peer support and family support • Housing, urgent care, youth crisis and college-based service, primary care interface improvement

35. Current Primary Care and Mental Health Initiatives

36. Valley Homeless Healthcare Program • DHHS Health Resources and Services Admin (HSRA) three-year (FY04-FY06) grant for homeless healthcare services, $500K-$650K per year • Administered through VMC Ambulatory Care Health Services • Integrated medical, substance abuse and mental health services to vulnerable homeless consumers who do not successfully utilize traditional health services

37. Valley Homeless Healthcare Program • Multiple sites, including homeless shelters, mobile clinics, specialty methadone clinic, FQHC sites • 15 member staff - 2 internists, psychiatrist, nurse practitioner, social work, psychology interns, and nursing staff; administered through VMC Ambulatory Care Health Services; collaborates with homeless service providers • Serves 3,000 – 4,000 hard to serve per year

38. New Directions Frequent Users Program • Frequent Users Statewide Initiative and Health Trust funded 3-year grant, hosted by Hospital Council of Northern California • Administered through VMC • Targeted to frequent ER users with 8+ visits, with goals of reducing ER and inpatient use and increasing quality of life • Provides intensive case management service to needed medical, substance abuse, mental health, housing and employment service

39. New Directions Frequent Users Program • Staffed with 4 social worker case managers, physician and psychiatrist consultants • Low staff to client caseload (1:15); 157 enrolled in first two years; collaborates with Valley Homeless Healthcare Program, Mental Health, Alcohol and Drug service • Results: Year 1 Year 2 • ED visits  31%  64% • ED costs  18%  47% • inpatient costs  68%  12% • outpatient costs  55%  71%

40. Moorpark ClinicPsychiatry Consult Program • VMC funded psychiatrist placed in primary care clinic with 50 physicians and 1500 patients • Treats patients with mild to moderate anxiety and depressive disorders, substance abuse, bipolar illness • Most frequent diagnoses anxiety and depression • Provides consultation, medication evaluation and initial treatment, crisis evaluation, “curbside consults”, resident training • 7% referred to specialty MHD services

41. Center for Learning and Achievement • Comprehensive pediatric (0-17) multidisciplinary assessment clinic • Funded through First Five and county general fund • Provides developmental assessments, diagnostic evaluations and referrals to community services

42. Future Opportunities for Integration

43. Effective Strategies • Standardized behavioral health screening & referral • “Embedded” primary care psychiatric consultants • Warm line consultation • Primary care behavioral health guidelines • Information campaign • Peer and paraprofessional “navigators” • Popular education, e.g., Mayfair Teatro • Specialty multi-disciplinary service • Care coordination and care management protocols

44. Ongoing Challenges • Continue to welcome and engage underserved community to process • Keep those who are not funded engaged in transformation • Integrate new components into local planning and oversight structure

45. Ongoing Challenges • Maintain communication with all stakeholders on implementation progress • Carry stakeholders through budget crisis with continued inspiration for change • Honor and support those who continue to work at warp speed, with no relief in sight!

46. Contact Info Nancy Pena, Ph.D., Director, MHD, 408-885-5783 Bruce Copley, Deputy Director, MHD 408-885-5773 Tiffany Ho, M.D., Medical Director, 408-885-5770 Maria Fuentes, Ethnic Services Manager, 408-885-5770 Sheila Yuter, MHSA Coordinator, 408-885-3885 Santa Clara County MHD Website www.sccmhd.org State Dept. Mental Health website www.dmh.ca.gov