Summary

August 2013 Mental Health Services Act The State’s Oversight Has Provided Little Assurance of the Act’s Effectiveness, and Some Counties Can Improve Measurement of Their Program Performance Report 2012-122 COMMITMENT INTEGRITY LEADERSHIP The first five copies of each California State Auditor report are free. Additional copies are $3 each, payable by check or money order. You can obtain reports by contacting the California State Auditor’s Office at the following address: California State Auditor 555 Capitol Mall, Suite 300 Sacramento, California 95814 916.445.0255 or TTY 916.445.0033 OR This report is also available on our Web site at www.auditor.ca.gov. The California State Auditor is pleased to announce the availability of an online subscription service. For information on how to subscribe, visit our Web site at www.auditor.ca.gov. Alternate format reports available upon request. Permission is granted to reproduce reports. For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255. For complaints of state employee misconduct, contact the California State Auditor’s Whistleblower Hotline: 1.800.952.5665. Elaine M. Howle State Auditor Doug Cordiner Chief Deputy August 15, 2013 2012-122 The Governor of California President pro Tempore of the Senate Speaker of the Assembly State Capitol Sacramento, California 95814 Dear Governor and Legislative Leaders: As requested by the Joint Legislative Audit Committee, the California State Auditor (state auditor) presents this audit report concerning the Mental Health Services Act (MHSA). The MHSA was approved by voters in 2004 to expand existing mental health programs and services and to use innovative methods more likely to identify, mitigate, and treat mental illness. A focus of the MHSA is accountability and, initially, the MHSA assigned the responsibility of overseeing MHSA programs primarily to two state entities—the California Department of Mental Health (Mental Health) and the Mental Health Services Oversight and Accountability Commission (Accountability Commission). This report concludes that Mental Health and the Accountability Commission have provided little oversight of counties’ implementation of MHSA programs, particularly as it relates to evaluating whether these programs are effective. We expected that Mental Health and the Accountability Commission would have used a process to monitor, guide, and evaluate county implementation that built on their broad and specific MHSA oversight responsibilities and also incorporated best practices in doing so, but that is not what we found. However, looking to the future, the opportunity exists for the state entities responsible for oversight to better demonstrate the effectiveness of the MHSA. Because of the minimal oversight Mental Health and the Accountability Commission provided in the past, the State has little current assurance that the funds directed to counties—almost $7.4 billion from fiscal years 2006–07 through 2011–12—have been used effectively and appropriately. Effective late June 2012, legislation transferred most of Mental Health’s oversight role to the California Department of Health Care Services (Health Care Services). Health Care Services is moving forward with these oversight responsibilities, which includes collaborating with the Accountability Commission on its evaluation efforts, but it is still in the early stages of planning and it is too soon to tell whether its efforts will address all of our concerns. Further, we also expected that Mental Health would have taken steps to ensure counties received the guidance necessary to effectively evaluate and report on the performance of their MHSA programs, particularly given the MHSA’s focus on accountability. However, Mental Health did not provide explicit direction to the counties on how to evaluate their programs effectively, including directions for setting reasonable goals, establishing specific objectives, and gathering the data necessary to meaningfully measure program performance. Thus, it is not surprising that our review of four county departments—Los Angeles County Department of Mental Health, County of Sacramento Department of Health and Human Services, County of San Bernardino Department of Behavioral Health Administration, and Santa Clara County Mental Health Department—found that these counties used differing and inconsistent approaches to assess and report on the performance of their MHSA programs. Some counties could not effectively demonstrate through their processes that their MHSA programs are achieving the stated intent. Counties were also inconsistent in collecting data related to program goals and how completely they analyzed and reported on those data to determine if stated program goals were achieved. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor 555 Capitol Mall, Suite 300 Sacramento, CA 95814 916.445.0255 916.327.0019 fax www.auditor.ca.gov Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 v August 2013 Contents Summary 1 Introduction 7 Chapter 1 Despite the State’s Inadequate Oversight So Far, Opportunity Exists to Demonstrate the Effectiveness of the Mental Health Services Act 21 Recommendations 40 Chapter 2 Counties Should Improve Mental Health Services Act Performance Measurement and Documentation of Stakeholder Planning Efforts 43 Recommendations 59 Appendix A Mental Health Services Act Funds by County and Component Fiscal Years 2006–07 Through 2011–12 63 Appendix B Mental Health Services Act Programs for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 77 Appendix C Mental Health Services Act Client Demographics and Diagnoses for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 107 Appendix D Mental Health Services Act Revenues, Expenditures, and Prudent Reserves for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 119 Responses to the Audit Health and Human Services Agency, California Department of Health Care Services 125 California State Auditor’s Comment on the Response From the California Department of Health Care Services 133 Mental Health Services Oversight and Accountability Commission 135 California State Auditor’s Comments on the Response From the Mental Health Services Oversight and Accountability Commission 139 vi California State Auditor Report 2012-122 August 2013 California Mental Health Planning Council 141 Los Angeles County Department of Mental Health 143 California State Auditor’s Comments on the Response From the Los Angeles County Department of Mental Health 145 County of Sacramento Department of Health and Human Services 147 County of San Bernardino Department of Behavioral Health Administration 149 California State Auditor’s Comment on the Response From the County of San Bernardino Department of Behavioral Health Administration 153 Santa Clara County Mental Health Department 155 California State Auditor Report 2012-122 1 August 2013 Summary Results in Brief Audit Highlights . . . Providing effective services and treatment for those who suffer Our performance review of the Mental from mental illness or who are at risk of mental illness is an issue Health Services Act (MHSA) highlighted of great statewide and national importance. Recent statistics the following: by the U.S. Department of Health indicate that approximately » The California Department of Mental 11 million U.S. adults, or 4.8 percent of the population, had Health (Mental Health) and the serious mental illnesses in 2009. Critical incidents, such as the Mental Health Services Oversight and school shooting in Sandy Hook, point to the seriousness of these Accountability Commission (Accountability issues. Over time California has attempted to serve its mentally ill Commission) have provided little oversight population through a variety of services and programs, and in 2004 of county implementation of MHSA the voters approved Proposition 63, the Mental Health Services programs and their effectiveness. Act (MHSA), to expand on these services and to use innovative methods more likely to identify, mitigate, and treat mental illness. • We found no evidence that Mental The MHSA stresses that mental illnesses are extremely common, Health performed on-site reviews affecting almost every family in California, and that the failure to to ensure that county assertions provide timely treatment can destroy individuals and families. It about their compliance with MHSA states, “No individual or family should have to suffer inadequate requirements and use of funds or insufficient treatment due to language or cultural barriers to were accurate and proper. care. Untreated mental illness is the leading cause of disability and • None of the entities charged with suicide and imposes high costs on state and local government . . . . evaluating the effectiveness of State and county governments are forced to pay billions of dollars MHSA programs—Mental Health, each year in emergency medical care, long-term nursing home care, the Accountability Commission, or unemployment, housing, and law enforcement, including juvenile a third entity—have undertaken justice, jail and prison costs.” serious efforts to do so. The MHSA imposes a 1 percent income tax on individuals • Mental Health either did not always earning over $1 million for counties1 to use to provide mental obtain certain data or did not ensure health services to individuals severely affected by or at risk of counties reported the required data. serious mental illness. From fiscal years 2006–07 through 2011–12— the period of our review—almost $7.4 billion was directed to • The Accountability Commission did counties for their MHSA programs. The MHSA addresses a broad not adopt a framework for evaluation continuum of service needs, and its five components target different until recently—more than eight years aspects of mental health services, including intensive services in after the passage of the MHSA. the Community Services and Supports and Prevention and Early » It is too soon to tell whether the California Intervention components, and exploring creative approaches Department of Health Care Services’ to mental health services in the Innovation component. The efforts will address all of our concerns remaining two MHSA components generally focus on expanding, about the oversight of MHSA programs. educating, and training the local public mental health workforce and improving infrastructure; they are not designed to provide » Each of the four county departments we direct mental health services. reviewed used different and inconsistent approaches in assessing and reporting on their MHSA programs, and the county departments rarely developed specific objectives to assess the effectiveness of 1 County indicates a county mental health department, two or more county mental health departments acting jointly, and/or city-operated programs receiving funds per California Welfare the programs. and Institutions Code, Section 5701.5. 2 California State Auditor Report 2012-122 August 2013 A focus of the MHSA is accountability, and a significant stated purpose of the MHSA is “to ensure that all funds are expended in the most cost effective manner and services are provided in accordance with recommended best practices subject to local and state oversight to ensure accountability to taxpayers and to the public.” Initially, the MHSA assigned the responsibility of overseeing MHSA programs primarily to two state entities—the California Department of Mental Health (Mental Health) and the Mental Health Services Oversight and Accountability Commission (Accountability Commission). However, these state entities have provided little oversight of county implementation of MHSA programs and their effectiveness. We expected that Mental Health and the Accountability Commission would have used a process to monitor, guide, and evaluate county implementation that built on their broad and specific MHSA oversight responsibilities and also incorporated best practices in doing so, but that is not what we found. The opportunity exists for the state entities currently responsible for oversight to better demonstrate the effectiveness of the MHSA. Effective late June 2012, legislation transferred most of Mental Health’s oversight role to the California Department of Health Care Services (Health Care Services). Health Care Services is moving forward with these oversight responsibilities, which include collaborating with the Accountability Commission on its evaluation efforts, but this is still in the early planning stages and it is too soon to tell whether its efforts will address all of our concerns. Nevertheless, because of the minimal oversight Mental Health and the Accountability Commission provided in the past, the State has little current assurance that the funds directed to counties for MHSA programs have been used effectively and appropriately. We expected that Mental Health would base its monitoring of county MHSA programs on the provisions of the performance contract that the MHSA required Mental Health to enter into with each county. However, in fiscal year 2008–09, Mental Health stopped using the performance contract and began using an agreement that offered little specificity as to the steps a county should take to assure compliance with the MHSA. Functionally, it appears Mental Health treated the agreement as simply a means of providing MHSA funding to counties. Although the assurances within the agreement may have satisfied the minimal requirements set forth in state law, had Mental Health made better use of the agreement as a tool for holding counties accountable for their use of MHSA funds, it would have significantly bolstered the State’s oversight role. We also identified shortcomings in certain counties’ evaluation and reporting on the effectiveness of their MHSA programs. These shortcomings might have been mitigated had Mental Health chosen to use the performance contracts to improve the quality of county processes for measuring program performance. Going forward, Health Care California State Auditor Report 2012-122 3 August 2013 Services can use its performance contracts with counties to ensure that they specify program goals, identify data that are measurable and meaningfully associated with their goals, and use these data to evaluate the efficacy of their programs. The director indicated that Health Care Services intends to initiate efforts to monitor the adequacy of the counties’ administration of MHSA programs. If consistently undertaken, these efforts could address some of the issues we noted about Mental Health’s past monitoring. We also found no evidence that Mental Health conducted systematic and comprehensive monitoring to ensure that counties did, in fact, implement their state-approved MHSA plans. The limited reviews we found failed to provide assurance that all counties consistently followed MHSA requirements and spent taxpayer funds appropriately. Further, Mental Health appears to have relied on county assertions or certifications as its main assurance that a county was complying with certain MHSA requirements. As a starting point, requiring assertions or certifications is useful in informing the county of what is expected and provided Mental Health with some assurance that the county intended to comply with MHSA requirements. However, without performing on-site reviews to ensure that the county had performed as asserted, Mental Health risked that the county may have misused state funds. In addition, given that one focus of the MHSA is to ensure accountability to taxpayers and the public, we expected that the State would also evaluate the effectiveness of MHSA programs. However, the state entities given that responsibility—Mental Health, the Accountability Commission, and a third entity—have thus far not provided assurance that the MHSA is effective. Mental Health did not conduct a systematic evaluation of the effectiveness of MHSA programs during its tenure. Although it required counties to submit data concerning mental health services and the clients receiving those services, in most cases, Mental Health either failed to consistently obtain certain data or did not ensure that all counties reported the required data. Further, the Accountability Commission did not adopt a framework for evaluation until late March 2013—more than eight years after the passage of the MHSA. The Accountability Commission indicated that its efforts were initially focused on reviewing county plans for proposed MHSA programs because evaluation efforts needed to wait for the programs to mature. Although it seems reasonable that programs need time to mature before they are evaluated, the Accountability Commission began entering into ad hoc contracts related to evaluation in 2009; therefore, it seems to have judged those MHSA programs as mature enough for evaluation at that time. Further, we expected that Mental Health would have taken steps to ensure that counties received the guidance necessary to effectively evaluate and report on the performance of their MHSA programs. 4 California State Auditor Report 2012-122 August 2013 However, Mental Health did not provide explicit direction to the counties on how to evaluate their programs effectively, including directions for setting reasonable goals, establishing specific objectives, and gathering the data necessary to meaningfully measure program performance. When the responsible state entities do not provide guidance to counties for effective program evaluation, the public cannot be sure that MHSA programs are achieving their intended purposes. Thus, it is not surprising that our review of four county departments— Los Angeles County Department of Mental Health (Los Angeles), County of Sacramento Department of Health and Human Services (Sacramento), County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and Santa Clara County Mental Health Department (Santa Clara)—found that these counties used differing and inconsistent approaches to assess and report on their MHSA programs. For example, some counties could not effectively demonstrate through their processes that their MHSA programs are achieving the stated intent. Although the four reviewed counties generally included program goals in their MHSA plans, not all had communicated those goals to program providers, thereby not articulating expectations that providers demonstrate efforts to achieve those goals. Counties were also inconsistent in collecting data related to program goals and how completely they analyzed and reported on those data to determine if counties were achieving stated program goals. Moreover, we found that the four counties rarely developed specific objectives to assess the effectiveness of program services. Setting specific goals and objectives and demonstrating that programs are achieving them seems particularly relevant for the Innovation component. Media reports have reflected skepticism about counties’ Innovation programs, some of which include acupuncture and yoga. The media’s perception of Innovation programs is likely because they may include novel or creative approaches to a mental health practice that may actually be very beneficial, but because the link between the program and the mental health benefit is not clear, these programs are sometimes questioned. Assessing and reporting on program effectiveness is therefore critical to ensure that only effective programs are continued and that the taxpayers and the public are assured that MHSA funds are put to the best use. Finally, the MHSA requires counties to articulate plans for addressing the mental health needs of their communities, to include stakeholders in the community planning process, and to update the plans annually. The four counties reviewed complied with state regulations that specific groups of stakeholders and community representatives be included throughout the planning process and with community planning regulations that require staffing and training practices related to developing those plans. California State Auditor Report 2012-122 5 August 2013 However, counties did not always document in their MHSA plans and annual updates how they had circulated their draft plans to the community as required. In addition, Mental Health’s guidance to counties on plan content has been inconsistent and this may have contributed to the issues we found with county documentation. Nevertheless, failure to properly document these important steps means counties cannot point to their plans to assure their stakeholders and the broader public that they have considered feedback on their plans and developed programs that address the communities’ needs. Recommendations Health Care Services To ensure that it monitors counties to the fullest extent, including conducting the monitoring MHSA specifies as well as implementing best practices, Health Care Services should do the following: • Draft and enter into a performance contract with each county that allows for effective oversight and satisfies the intent of the MHSA, including requiring counties to demonstrate that each of their MHSA programs is meeting its respective intent. • Conduct comprehensive on-site reviews of counties’ MHSA programs, including verifying county compliance with MHSA requirements. To improve the quality of county processes for measuring program performance, Health Care Services should use its performance contracts with counties to ensure that the counties do the following: • Specify MHSA program goals in their plans and annual updates and include those same goals in contracts with program providers. • Identify meaningful data that measure the achievement of all their goals, set specific objectives, require their program providers to capture those data, and use those data to verify and report on the effectiveness of their MHSA programs. To ensure that counties have the needed guidance to implement MHSA programs, Health Care Services should collaborate with the Accountability Commission and develop and issue guidance or regulations, as appropriate, to counties on how to effectively evaluate and report on MHSA program performance. 6 California State Auditor Report 2012-122 August 2013 To ensure that Health Care Services and other responsible state entities can evaluate MHSA programs and assist the Accountability Commission in its evaluation efforts, Health Care Services should collect complete and relevant MHSA data from the counties. To help ensure county compliance with stakeholder regulations, Health Care Services should provide technical assistance to counties on the MHSA local planning process and ensure that its guidance to counties is clear and consistent with state regulations. Accountability Commission In order to fulfill its responsibilities to evaluate MHSA programs, the Accountability Commission should undertake the evaluations specified in its recently adopted framework for evaluation. Sacramento, San Bernardino, and Santa Clara Each county should review its existing MHSA contracts and by December 31, 2013, or as soon as is feasible, amend them as necessary to include plan goals. Agency Comments The three state entities and three counties to which we made recommendations—Health Care Services, the Accountability Commission, the California Mental Health Planning Council, and the counties of Sacramento, San Bernardino, and Santa Clara— agreed with our recommendations and generally agreed with the report’s conclusions. We did not make any recommendations to Los Angeles. California State Auditor Report 2012-122 7 August 2013 Introduction Background Providing effective services and treatment for those who suffer from mental illness or who are at risk of mental illness is an issue of great statewide and national importance. Recent statistics by the U.S. Department of Health indicate that approximately 11 million U.S. adults, or 4.8 percent of the population, had serious mental illnesses in 2009. Critical incidents, such as the school shooting in Sandy Hook, point to the seriousness of these issues. Over time California has attempted to serve its mentally ill population through a variety of services and programs, and in 2004 the voters approved Proposition 63, the Mental Health Services Act (MHSA), in order to expand on these services and to use innovative methods more likely to identify, mitigate, and treat mental illness. The MHSA stresses that mental illnesses are extremely common, affecting almost every family in California. Further, it states that the failure to provide timely treatment can destroy individuals and families. “No individual or family should have to suffer inadequate or insufficient treatment due to language or cultural barriers to care. Untreated mental illness is the leading cause of disability and suicide and imposes high costs on state and local government . . . . State and county governments are forced to pay billions of dollars each year in emergency medical care, long-term nursing home care, unemployment, housing, and law enforcement, including juvenile justice, jail and prison costs.” To respond to these concerns, the MHSA establishes five key purposes: “to define serious mental illness among children, adults, and seniors as a condition deserving attention; to reduce the long-term adverse impact of untreated serious mental illness on individuals, families, and state and local budgets; to expand the kinds of successful, innovative service programs for children, adults, and seniors already undertaken in California; to provide state and local funds for the purposes of the MHSA; and, finally, to ensure that all MHSA funds are expended in the most cost-effective manner and services are provided using recommended best practices subject to local and state oversight to ensure accountability to taxpayers and the public.” To support its purposes, the MHSA levies a 1 percent income tax on individuals earning more than $1 million, which is deposited into the Mental Health Services Fund (Fund) that the MHSA established. The funds must be spent to expand mental health services and cannot be used to replace existing state or county funding for mental health services. The funds primarily flow to counties2 to provide 2 County indicates a county mental health department, two or more county mental health departments acting jointly, and/or city-operated programs receiving funds per California Welfare and Institutions Code, Section 5701.5. 8 California State Auditor Report 2012-122 August 2013 services to those individuals severely affected by or at risk for serious mental illness. The California Department of Mental Health (Mental Health) was the primary state entity responsible for overseeing the implementation of the MHSA until legislation effective June 2012 transferred the majority of the MHSA duties to the California Department of Health Care Services (Health Care Services). From fiscal years 2006–07 through 2011–12, Mental Health records indicate that the MHSA provided almost $7.4 billion to counties for the provision of mental health services. MHSA Components Components of the Mental Health Services Act Community Services and Supports: Provides direct mental The MHSA provides funding for programs within health services to the severely and seriously mentally ill, such five components, as defined in the text box. as mental health treatment, cost of health care treatment, Community Services and Supports (Community and housing supports. Regulation requires counties to direct Supports) provides services to individuals with the majority of its Community Services and Supports funds serious mental illness. A significant portion of the to the Full‑Service Partnership (Partnership) service category. MHSA funds allocated to counties is designated A Partnership is a service category under which the county, for Community Supports, and regulations require in collaboration with the client and the family, when the counties to designate the biggest portion appropriate, plans for and provides the full spectrum of of their Community Supports funds to the community services. These services consist of mental health Full-Service Partnership (Partnership) service services and supports, such as peer support and crisis category. Counties must use all other Community intervention services; and non‑mental health services and Supports funds to provide general development supports, such as food, clothing, housing, and the cost of services, which are typically less extensive medical treatment. than those offered through a Partnership, for Prevention and Early Intervention: Provides services to outreach and engagement in identifying unserved mental health clients in order to help prevent mental illness individuals who qualify for mental health services from becoming severe and disabling. or to create housing for those with mental illness. Innovation: Provides services and approaches that are Community Supports programs can be funded by creative in an effort to address mental health clients’ a combination of funding sources, such as MHSA persistent issues, such as improving services for underserved funds and Medi-Cal funds. Mental Health first or unserved populations within the community. requested that counties submit initial plans for Capital Facilities and Technological Needs: Creates Community Supports programs in 2005; state law additional county infrastructure such as additional clinics requires that plans be updated at least annually. and facilities and/or development of a technological infrastructure for the mental health system, such as The Prevention and Early Intervention (Prevention) electronic health records for mental health services. component funds programs designed to prevent Workforce Education and Training: Provides training mental illnesses from becoming severe and for existing county mental health employees, outreach disabling. The MHSA requires Prevention and recruitment to increase employment in the mental programs to emphasize improving timely access health system, and financial incentives to recruit or retain to services for underserved populations and employees within the public mental health system. specifies that the programs must include outreach to members of the community and others in Sources: Mental Health Services Act, Proposition 63 of 2004; California Code of Regulations, Title 19, sections 3310, 3610, order to increase recognition of the early signs 3615, 3620, 3810; certain California Department of Mental of potentially severe and disabling mental illness. Health information notices; and other documentation. The programs must also offer access and links to medically necessary care to individuals with severe California State Auditor Report 2012-122 9 August 2013 mental illness and reduce the stigma or discrimination associated with mental illness diagnosis or with seeking mental health services. The Prevention component also calls for programs to emphasize strategies that reduce negative outcomes that may result from untreated mental illness, such as suicide, incarceration, homelessness, and prolonged suffering. Mental Health requested that counties submit their initial plans for Prevention programs in 2007. The MHSA calls for counties to spend a certain percentage of funds for Innovation programs that increase access to underserved groups, increase the quality of services, and promote interagency collaboration, among other things. In early 2009, when Mental Health issued guidelines on submitting plans for implementing the Innovation component, it acknowledged that the MHSA is less specific in its direction for this component than for the others. This component is intended to form an environment that develops new and effective practices and approaches in the field of mental health. In fact, the Mental Health guidance states that the scope of an Innovation program may include introducing a novel, creative, and/or ingenious approach to a mental health practice; as long as the program contributes to learning and maintains alignment with the MHSA, it may affect virtually any aspect of mental health practices, such as assessing a new application of a promising approach. In its guidance, Mental Health stated that Innovation programs are by nature similar to pilot or demonstration projects, are time limited, and should be assessed for effectiveness. The final two MHSA components assist counties in adding infrastructure to accommodate the increase in clients resulting from MHSA funding. The Capital Facilities and Technological Needs (Facilities) component helps fund building and technology projects. The Workforce Education and Training (Training) component provides funds to train mental health professionals to meet the increased needs arising from MHSA services, among other purposes. Beginning in fiscal year 2008–09, the MHSA capped the amount of funds that counties can spend on the Facilities and Training components. Figure 1 on the following page displays the proportions of a county’s total MHSA allocation that must be spent for each of the five components. As noted above, the allocation requirements for the Facilities and Training components changed beginning in fiscal year 2008–09, so the figure reflects two time periods. For fiscal years 2005–06 through 2007–08, the MHSA required the allocation of 10 percent of the funds to Facilities and 10 percent to Training. From fiscal year 2008–09 onward, funding for these two MHSA components was at the counties’ discretion; however, if a county chose to plan programs for the Facilities and Training components, each year Mental Health could apportion 10 California State Auditor Report 2012-122 August 2013 up to a total of 20 percent of the county’s average Community Supports allocation received over the previous five-year period to these components. Figure 1 Apportionment of Mental Health Services Act Funds to Counties July 2005–June 2008 Capital Facilities and Technological Needs—10% Workforce Education and Training—10% Innovation —5% Prevention and Community Services Early Intervention and Supports— —20% minimum 60% or remainder Community Services and Supports and Prevention and Early Intervention July 2008–June 2012 Innovation —5% Prevention and Early Intervention —20% minimum Community Services and Supports and Prevention and Early Community Services Intervention and Supports— 80% or remainder Capital Facilities and Technological Needs, Workforce Education and Training, and Prudent Reserve*—Each year a county may spend up to 20 percent of the previous five-year allocation. Sources: Mental Health Services Act and Proposition 63 of 2004. * State law requires counties to maintain a prudent reserve to ensure that service levels will continue in the event that revenues for the Mental Health Services Fund fall below recent averages. California State Auditor Report 2012-122 11 August 2013 Roles and Responsibilities Initially Mental Health was the primary state entity overseeing the MHSA. Under Proposition 63, Mental Health had the responsibility to guide and monitor counties’ implementation of the MHSA. However, beginning in March 2011, Mental Health’s3 role was reduced and subsequent changes in law effective June 2012 transferred nearly all remaining MHSA functions from Mental Health to other entities. Figure 2 on the following page shows Mental Health’s responsibilities, beginning with Proposition 63, and demonstrates how legislation enacted in 2009, 2011, and 2012 modified them. Another entity within Mental Health—the Mental Health Planning Council—was also specifically tasked with evaluating MHSA programs. Proposition 63 established the Mental Health Services Oversight and Accountability Commission (Accountability Commission) to oversee certain components of the MHSA. The Accountability Commission consists of 16 voting members either appointed by the governor or granted membership by virtue of their position within state government, such as the superintendent of public instruction. At the time it was created, the Accountability Commission acted as a division within Mental Health; however, legislative changes effective March 2009 specified that the commission is to administer its operations separately and apart from Mental Health. As with Mental Health, the Accountability Commission’s oversight authority changed over time. Legislation effective March 2011 removed the Accountability Commission’s responsibility to review and comment on counties’ plans; however, current statute requires counties to submit their plans to the Accountability Commission and for it to approve counties’ plans for their Innovation programs before the counties may spend Innovation funds. The changes in the Accountability Commission’s responsibilities over time are shown in Figure 2. MHSA Funding and State Administration The manner in which counties receive MHSA funds has also changed over the years. In the initial design, Mental Health approved funding before it went to the counties. Under Proposition 63, the State used the following process to distribute funds to counties: first, the California Department of Finance, in consultation with the Franchise Tax Board, determined the annual adjustment 3 Beginning July 2012, Health Care Services assumed Mental Health’s primary responsibilities for MHSA oversight, as Mental Health underwent a streamlining reorganization and became the California Department of State Hospitals. 12 California State Auditor Report 2012-122 August 2013 Figure 2 Mental Health Services Act Selected Roles and Responsibilities for the California Department of Mental Health and the Mental Health Services Oversight and Accountability Commission Transferred to the California Department of Health Care Services (DHCS) Added Transferred to the California State Controller’s Office (SCO) Eliminated Transferred to the Office of Statewide Health Planning and Development (OSHPD) Prop 63 AB 5xxx AB 100 AB 1467 Selected Roles and Responsibilities January 1, 2005 March 9, 2009 March 24, 2011 June 27, 2012 † Provide oversight and evaluation of county mental health programs* Administer Mental Health Services Fund Inform counties of funds available Distribute funds to counties Prepare allocation of funds to counties Enter into performance contracts Establish a Prevention and Early Intervention (Prevention) program Establish requirements for county three-year plans Approve county three-year plans Adopt regulations ‡ Provide technical assistance* Receive county revenue and expenditure reports§ Receive county performance data§ Receive quarterly progress reports§ Prepare five-year Workforce Education and Training plan Oversee and evaluate the Mental Health Services Act (MHSA) Approve Innovation programs Approve Prevention programs Issue guidelines for Innovation and Prevention program expenditures Review and comment on county three-year plans Provide technical assistance DHCS to consult with when adopting regulation Receive county revenue and expenditure reports Receive county three-year plans )htlaeH latneM( htlaeH latneM fo tnemtrapeD ainrofilaC thgisrevO secivreS htlaeH latneM noissimmoC ytilibatnuoccA dna Sources: The MHSA, Proposition 63 of 2004 (Prop 63), Assembly Bill 5 (AB 5xxx) (Chapter 20, Statutes of 2009, Third Extraordinary Session), Assembly Bill 100 (AB 100) (Chapter 5, Statutes of 2011), and Assembly Bill 1467 (AB 1467) (Chapter 23, Statutes of 2012). * This responsibility existed before passage of the MHSA, Proposition 63 of 2004. † Although not depicted in the figure, this requirement was transferred by Senate Bill 1009 (Chapter 34, Statutes of 2012), not Assembly Bill 1467. ‡ Legislation effective March 2011 removed Mental Health’s exclusive authority to adopt regulations for MHSA and instead authorized “the State,” and not just Mental Health, to adopt regulations related to the MHSA. § This responsibility was added by regulation on December 29, 2006. California State Auditor Report 2012-122 13 August 2013 amount in the Fund based on the projected amounts from the 1 percent tax. The California State Controller’s Office (State Controller’s Office) deposited the tax receipts monthly into the Fund. Next, Mental Health divided the total pool of funds among the counties, using a methodology based on factors such as the county’s total population and the population most likely to apply for services, including those defined as in poverty and uninsured. Mental Health informed each county of the total funding amount it would receive, and each county submitted an annual plan detailing how it intended to use the funds. Depending on the component the plan addressed, Mental Health or the Accountability Commission evaluated the county’s plan. Once the plan was approved, the State Controller’s Office distributed funds to the county. Figure 3 displays the original flow of MHSA funds. However, legislation effective March 2011 separated state approval of plans from a county’s receipt of MHSA funds. Figure 3 Key Steps in State Allocation and Distribution Process for Mental Health Services Act Funds Steps Effective January 2005 Through March 2011 The California The California Department of Counties submitted for Department of Finance Mental Health (Mental Health)* approval a proposed determines the total divides the total available plan for the funds amount in the Mental funds into county allocations Mental Health informed Health Services Fund. based on a methodology that them they would be considers various factors. allocated. Mental Health and the Mental Health Services Oversight and The California State Controller’s Accountability Office distributes funds to Commission the counties. (Accountability Commission)† reviewed and approved the plan. Sources: The Mental Health Services Act, Proposition 63 of 2004, and Assembly Bill 100 (Chapter 5, Statutes of 2011). * Mental Health’s functions were transferred primarily to the California Department of Health Care Services beginning in fiscal year 2012–13. † Until June 2012 state law required counties to receive approval from Mental Health with input from the Accountability Commission before receiving funds for Innovation programs. Current law allows counties to receive, but not spend, funds for Innovation programs before the Accountability Commission approves the programs. 14 California State Auditor Report 2012-122 August 2013 The MHSA also provided the State with 5 percent of all MHSA annual revenues to cover its administrative costs, including but not limited to costs associated with evaluating the effectiveness of services the counties provide. The March 2011 legislation that reduced the State’s oversight role also reduced the 5 percent to 3.5 percent.4 Although for fiscal year 2011–12 the majority of this administrative funding was budgeted for state administration to support Mental Health and the Accountability Commission, many other state entities were budgeted funds from the 3.5 percent to support mental health functions. Table 1 lists the state entities that were budgeted MHSA administrative funds in fiscal year 2011–12 and the purposes of the funding. Because of a shortage in the State’s General Fund, legislation effective March 2011 shifted more than $850 million in MHSA funds to cover General Fund obligations for other mental health programs. Among those transfers, the Legislature shifted $183.6 million to Medi-Cal Specialty Mental Health Managed Care, $98.6 million for special education pupils, and $579 million for the Early Periodic Screening, Diagnosis, and Treatment program. The effect these transfers had in the allocations to the counties for fiscal year 2011–12, the year in which they occurred, can be seen in Appendix A. Four Counties Selected for Audit The Joint Legislative Audit Committee (audit committee) directed the California State Auditor (state auditor) to review Los Angeles County and one county each from the Inland Empire, Bay Area, and Central Valley. We selected the County of Sacramento Department of Health and Human Services, the County of San Bernardino Department of Behavioral Health Administration, and the Santa Clara County Mental Health Department to review, in addition to the Los Angeles County Department of Mental Health. Figure 4 on page 16 provides key information on the counties, including total population, total MHSA funds received during fiscal years 2006–07 through 2011–12, and the year in which the counties’ initial plans were approved for implementing each of the five components. Our methodology for selecting these counties is described in Table 2 on page 17. Further information on the selected counties is available in the appendixes. Appendix B summarizes the MHSA services that the four counties planned to provide during fiscal years 2006–07 through 2011–12. Appendix C provides county demographic 4 Legislative change effective June 27, 2013, restored state administration to 5 percent. California State Auditor Report 2012-122 15 August 2013 and mental health diagnostic data by MHSA component, and Appendix D summarizes county MHSA revenues and expenditures by fiscal year and component. Table 1 Mental Health Services Act Funding Budgeted for State Administration, by State Agency Fiscal Year 2011–12 PERCENTAGE AGENCY RECEIVING FUNDS BUDGET OF TOTAL PURPOSE OF FUNDING California Department of Mental $12,339,000 43% To fund key statewide mental health projects including housing, suicide Health (Mental Health)* prevention, mitigation of stigma projects, focused data analysis, and some – Mental Health Planning Council 791,000† community-based contracts. (Planning Council) Office of Statewide Health Planning 5,895,000 20 To provide, among other things, educational loan repayments for mental and Development health professionals to encourage work in the public mental health system in positions that have been deemed difficult to fill or hard to retain. Mental Health Services Oversight 5,529,000 19 To oversee, review, and evaluate projects and programs funded by the and Accountability Commission Mental Health Services Act (MHSA), among other responsibilities. California State Controller’s Office 1,733,000‡ 6 To help support the development of a new Human Resource (State Controller’s Office) Management System, the 21st Century Project, a payroll system for use by state departments. Judicial branch 1,063,000 4 To address the increased workload relating to mental health issues in the area of prevention and early intervention for juveniles with mental health illness in the juvenile court system or at risk for involvement in the system. California Department of Health 865,000 3 To support a contract to develop and implement the interdepartmental Care Services (Health Care Services) California Mental Health Care Management Program, which serves to improve mental health care for Medi-Cal beneficiaries with a severe mental illness or a severe emotional disturbance. California Military Department 552,000 2 To support a pilot behavioral health outreach program to improve coordination between the California National Guard, local veterans’ services, and county mental health departments throughout the State. California Department of 237,000 1 To support statewide administration to inform veterans and family members Veterans Affairs about federal benefits, local mental health departments, and other services. Department of Developmental 393,000 1.5 To coordinate a statewide community-based system of mental health Services services for those with developmental disabilities. California Department of Education 125,000 .5 To support county mental health programs’ work with local education agencies, county offices of education, and special education local plan areas to provide necessary services. Financial Information Systems for 137,000‡ .5 To transform the State’s systems and workforce to operate in an integrated California (FI$CAL) financial management system environment. State agencies with accounting systems, including Mental Health, are required to provide funding to the project. Board of Governors of the California 125,000 .5 To assist in developing policies and practices that address the mental health Community Colleges needs of California community college students. Totals $28,993,000 100% Sources: Fiscal year 2011–12 Budget Act and the Mental Health Services Act Expenditure Report for Fiscal Year 2011–12. * Mental Health’s functions were transferred primarily to Health Care Services beginning in fiscal year 2012–13. † In fiscal year 2011–12, the Planning Council was a division of Mental Health, and the budget amount presented represents the portion of Mental Health’s $12.3 million budget designated for the Planning Council. ‡ The State Controller’s Office and FI$CAL receive apportionments based on amounts the California Department of Finance determines, and the amounts presented for these two entities are based on the Mental Health Services Act Expenditure Report for Fiscal Year 2011–12. 16 California State Auditor Report 2012-122 August 2013 Figure 4 Regions and Counties Identified for Audit With Key Information NO DE R L TE Sacramento County: Department of Health and Human Services SISKIYOU MODOC Region: Central Valley Population: 1,450,121 Mental Health Services Act (MHSA) funding, fiscal years 2006–07 through 2011–12: $239 million (3.2 percent of state total) SHASTA LASSEN Year component plan approved: HUMBOLDT TRINITY Community Services and Supports (CSS): 2006 Prevention and Early Intervention (PEI): 2009 TEHAMA PLUMAS Workforce Education and Training (WET): 2009 Capital Facilities and Technological Needs (Cap/Tech): 2010 GLENN BUTTE SIERRA Innovation (INN): 2011 MENDOCINO LAKE COLUSA SUTTER YUBA NEVADA PLACER San Bernardino County: EL DORADO SONOM M A ARIN NAPA C S Y O O O L N L A T O N R O A SACRAM S EN A TO N AMAD CA O L R AVERAS TUO A L L U P M IN N E E MONO D A R Po e d e g p m p i u a o i r n l n a t i m t s : i t o I e r n a n n l t a : t i o n o 2 n d f ,0 B E 8 e m 1 h ,3 p a 1 i v r 3 i e oral Health SAN FRANCISCO A C LA O M ST E A DA JOAQUIN AUS MARIPOSA M th H ro S u A g f h u n 20 d 1 in 1 g – , 1 fi 2 s : c al years 2006–07 SAN MATEO SANTA ASNTISL $352 million (4.8 percent of state total) CLARA MERCED MADERA Year component plan approved: SANTA CRUZ CSS: 2006 S B A E N NITO FRESNO INYO PEI: 2008 Santa Clara County: WET: 2008 Mental Health Department MONTEREY TULARE Cap/Tech: 2009 Region: Bay Area KINGS INN: 2010 Population: 1,837,504 MHSA funding, fiscal years 2006–07 through 2011–12: KERN SAN LUIS OBISPO $354 million (4.8 percent of state total) Year component plan approved: SAN BERNARDINO CSS: 2006 SANTA BARBARA PEI: 2009 VENTURA LOS ANGELES WET: 2009 Cap/Tech: 2009 INN: 2010 ORANGE RIVERSIDE IMPERIAL Los Angeles County: Department of Mental Health SAN DIEGO Region: The Joint Legislative Audit Committee specified that Los Angeles County be included in the California State Auditor’s review. Population: 9,962,789 MHSA funding, fiscal years 2006–07 through 2011–12: $2.2 billion (29.3 percent of state total) Year component plan approved: CSS: 2006 PEI: 2009 WET: 2009 Cap/Tech: 2009 INN: 2010 Sources: Counties’ Web sites, allocation information obtained from the California Department of Mental Health’s Web site and the California Department of State Hospitals; United States Census Bureau; state and county QuickFacts 2012; county population estimates; selected counties’ MHSA plan approval documents; and information obtained from the Web sites of the Association of Bay Area Governments, DiscoverIE.com, and the California State Library. California State Auditor Report 2012-122 17 August 2013 Scope and Methodology The audit committee directed the state auditor to conduct an audit of the MHSA, including a review of state oversight and county implementation and performance measurement of the MHSA. Table 2 outlines the audit committee’s objectives and the methods we used to address them. Table 2 Audit Objectives and the Methods Used to Address Them AUDIT OBJECTIVE METHOD 1 Review and evaluate the laws, rules, and With the assistance of legal counsel, we reviewed relevant laws, regulations, and other regulations significant to the audit objectives. background materials applicable to the Mental Health Services Act (MHSA). 2 Review and evaluate the roles and • Reviewed relevant state laws and regulations to determine the roles and responsibilities responsibilities of the California Department of each of the listed state entities as they relate to the MHSA. of Health Care Services (Health Care Services), • Interviewed key officials from each state entity to identify and determine their roles and the Mental Health Services Oversight and responsibilities as it relates to the MHSA. Accountability Commission (Accountability Commission), the Office of Statewide Health • Requested Health Care Services’ response to various questions, contained within a Planning and Development, the California State representation letter, regarding its intentions and efforts going forward as it relates to Controller’s Office, and any other state agency its recently assumed MHSA responsibilities. regarding the MHSA and the programs and activities funded by the MHSA. 3 For the most recent six-year period, determine At the time we began our audit work, we determined that our audit scope would focus whether the respective state entities identified on the most recent completed six-year period. Thus, we defined our audit period as fiscal in Item 2 are allocating, spending, and years 2006–07 through 2011–12. monitoring MHSA funding related to Innovation programs for underserved communities, Prevention and Early Intervention (Prevention) services, and Community Services and Supports (Community Supports) (primarily Full-Service Partnership) in a reasonable manner consistent with applicable laws by performing the following: a. Determine the amount of MHSA funds allocated To identify MHSA funds allocated to counties* by component for fiscal years 2006–07 by the State to counties for each component of through 2011–12, we used two data sources. For fiscal years 2006–07 through 2009–10, the MHSA. we obtained counties’ approved allocation amounts as listed on the California Department of Mental Health’s (Mental Health) Web site. However, we found that this source did not appear to consistently present complete and updated allocation information for fiscal years 2010–11 and 2011–12, which may be due to legislative changes that eliminated Mental Health’s role in reviewing counties’ three-year plans and annual updates. As a result, to identify funds allocated to counties by component for fiscal years 2010–11 and 2011–12, we obtained California State Accounting and Reporting System data from the California Department of State Hospitals. We present this information, by county, in Appendix A. b. Identify the methodology the State uses • Reviewed relevant laws, regulations, and background materials to understand to allocate funding to counties. Determine allocation requirements pertaining to the MHSA. whether improvements in the methodology • Interviewed key officials about the MHSA allocation process and methodology. are necessary to ensure the most effective allocation of the funds. • Reviewed and followed up as necessary on Health Care Services’ response to a representation letter in which we requested it describe its plans to revise the allocation methodology, what the planned revisions will accomplish, and the timeline for completing the revision. Additionally, it is important to note that despite numerous attempts to obtain the methodology from Health Care Services throughout the course of our fieldwork, it did not provide the methodology until after our closing audit conference with them, which was held in mid-June, a circumstance we describe further in Chapter 1. continued on next page . . . 18 California State Auditor Report 2012-122 August 2013 AUDIT OBJECTIVE METHOD c. Determine the oversight protocols used • Reviewed relevant laws, regulations, and background materials to understand by the respective entities to monitor the MHSA oversight requirements as they related to Mental Health, the Accountability expenditure of funds and program compliance, Commission, and the Mental Health Planning Council (Planning Council). performance, and outcomes. Determine • Interviewed key officials about MHSA oversight processes. whether any improvements should be made to these protocols. • Obtained and reviewed oversight tools used by Mental Health and the Accountability Commission to determine whether the tools satisfied the oversight requirements. • Assessed whether the oversight activities performed by Mental Health and the Accountability Commission met the requirements and intent of the MHSA. • Assessed whether the Planning Council fulfilled its statutory duties of evaluating mental health programs, including MHSA programs, by interviewing key staff and reviewing relevant documentation. • Obtained and reviewed Health Care Services’ response to a representation letter in which we inquired about its plans to perform MHSA-related oversight activities, including a timeline of the activities and their frequency, as well as whether it plans to use review tools formerly used by Mental Health. 4 For Los Angeles County and a selection of To select the three counties, in addition to Los Angeles, to include in our review, one county each from the Inland Empire, we obtained and assessed information to identify the common boundaries for the Bay Area, and Central Valley, perform the three regions: Inland Empire, Bay Area, and Central Valley. Using the MHSA allocation following on each of the MHSA components— amounts that we derived following the process described in the method column for covering the most recent six-year period: Objective 3 (a) for fiscal years 2006–07 through 2011–12, we selected the county within each of the three defined regions that received the highest amount of MHSA funds. The counties we selected for review are presented in the Introduction in Figure 4 on page 16. a. Review and assess the method each county uses • Interviewed key staff and reviewed available documentation to ascertain and assess to establish any performance measures and the process each county uses to create performance measures and outcomes for the outcomes and determine if these measures Community Supports, Prevention, and Innovation components. We excluded from and outcomes are meaningful and reasonable, our review the Workforce Education and Training and the Capital Facilities and including the methods used to establish any Technological Needs components because these components do not directly provide performance measures and outcomes for mental health services to clients. underserved and diverse communities. • To evaluate the reasonableness of counties’ measurement of their programs’ performance, we selected six to nine service provider contracts at each county, b. Evaluate the reasonableness of the methods generally based on each contract’s total dollar amount, for fiscal years 2006–07 through used to obtain and analyze data to measure 2011–12. For Los Angeles, San Bernardino, and Santa Clara, we selected three contracts performance and outcomes. each from the Community Supports, Prevention, and Innovation components, for a total of nine contracts to review at each county. For Sacramento, we selected three Community Supports and three Prevention contracts for a total of six contracts; we did not select any Innovation contracts because the county had no active Innovation services for the time period we reviewed. Mental Health issued guidance in 2009 instructing counties to choose one Prevention program to evaluate and report on in their plans. Although it is unclear whether Mental Health ever held counties accountable for this evaluation and reporting, where applicable we attempted to select this program. • We evaluated the counties’ approach to measuring their MHSA programs’ performance in four ways. First, we established whether the county defined program goals in its MHSA plans, thereby establishing objectives by which they could measure performance. Our second step determined whether counties included program goals in their provider contracts to ascertain whether counties clearly communicated program goals to providers and made providers accountable for achieving them. Third, we assessed whether counties had identified meaningful data with which to measure progress on achieving program goals (performance data). Fourth, we assessed whether counties collected and analyzed program performance data, and reported to county management and stakeholders about program performance. California State Auditor Report 2012-122 19 August 2013 AUDIT OBJECTIVE METHOD c. Identify key performance measures and Obtained a response from each county to a representation letter in which we asked outcomes achieved—including those counties various questions, and to provide supporting documentation as necessary, achieved by traditionally underserved and relating to key performance measures and outcomes achieved, as well as how the county diverse communities—such as reductions in used these data to improve its local mental health systems. Once received, we reviewed homelessness and psychiatric hospitalizations. the responses, any supporting documentation, and followed up with the counties as necessary. To determine whether the responses were reasonable, we assessed whether d. Review and assess the extent to which each they reflected the results of our testing explained in the Method column for Objectives 4a county uses performance measures and outcomes and 4b in this table. to improve the local mental health systems. e. Identify the type of services and support To identify the services offered by each of the MHSA components for the four counties we provided by each of the MHSA components reviewed, we obtained and reviewed the four selected counties’ initial three-year plans and the demographics of the populations for each of the five components as well as annual updates to those plans. Using these receiving those services. plans, for fiscal years 2006–07 through 2011–12, we developed a listing of programs and their descriptions, by component and county. Based on information we received from the counties, described in the step below, we also indicated for each program, when applicable, the age group the county specified the program would serve. This information is presented in Appendix B. To identify client demographic data for the four counties we reviewed for each of the three components that provide direct mental health services to clients— Community Supports, Prevention, and Innovation—we obtained from each county available demographics of the clients it has served including age, ethnicity, and primary language. Additionally, we obtained from each of the four counties available data related to the mental health diagnosis of the clients each has served. We classified the diagnosis data into categories based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). We present this information for fiscal years 2006–07 through 2011–12 in Appendix C. f. Determine the extent to which each county’s • For the three MHSA components that provide direct mental health services to clients— plan reflects the content of the programs and Community Services and Supports, Prevention, and Innovation—for fiscal years 2006–07 services to be delivered and their planned through 2011–12, we selected the highest-dollar contract per component per fiscal year expenditures. Further, compare each county’s to review, for a total of 33 contracts. We compared the program as described in the plan to plan to the actual delivery of services and the contract Scope of Work to ascertain whether the county was delivering the programs related expenditures. in accordance with its plan. We found no exceptions. • For fiscal years 2006–07 through 2011–12, we obtained from each of the four counties their completed Revenue and Expenditure Reports (expenditure report). For fiscal years for which the county had not completed an expenditure report, we obtained, by MHSA component, the counties’ expenditures and MHSA allocations. For each fiscal year and component, we compared counties’ revenues and expenditures. For years where expenditure reports were available, we presented the counties’ own calculations of the balance between revenues and expenditures. For years where expenditure reports were not available, we calculated this balance. We also used counties’ expenditure reports to identify contributions they made to their local prudent reserve. We present this information in Appendix D. g. Determine the degree to which each county • Reviewed relevant laws, regulations, and background materials to understand MHSA employed a stakeholder process consistent with requirements as they relate to the local planning process and counties, including the law when developing its county plan. stakeholders in this process, when developing their plans and annual updates. • For each of the four counties we reviewed, we assessed the local planning process for development of its Community Supports plan; its most recent initial component plan, which was in every case Innovation; and its most recent annual update. To perform this assessment and to determine whether counties complied with applicable state requirements, we reviewed information about the local planning process contained within each of the plans, interviewed key county staff, and obtained and assessed various documents from the counties pertaining to their adherence to local planning process requirements, such as those related to training and stakeholder engagement. continued on next page . . . 20 California State Auditor Report 2012-122 August 2013 AUDIT OBJECTIVE METHOD 5 For Los Angeles County and the three additional • Interviewed key officials to understand each county’s process for reviewing and counties selected under Item 4, select a sample approving invoices. of expenditures from each MHSA component • Documented the controls each county has in place to ensure provider invoices align covering the most recent six-year period to with contracted services. determine if the expenditures were allowable and reasonable. • Because counties often contract with providers for the provision of MHSA services, for each county we selected expenditures for contracted services for Community Supports, Prevention, and Innovation for fiscal years 2006–07 through 2011–12. We reviewed a total of 43 expenditures. We determined whether each expenditure aligned with the services as stated in the contract and with the program as described in the county’s plan. • To determine whether counties’ payroll expenditures were reasonable and appropriate, we obtained from each county payroll data listing employees who provided MHSA client services during fiscal years 2006–07 through 2011–12. We selected one employee per year in which county personnel provided MHSA client services (a total of 21 employees) and obtained their job description to determine whether that employee’s duties were reasonably related to MHSA. We found no exceptions. 6 Review and assess the method by which the • Reviewed relevant laws, regulations, and background materials to understand MHSA State collects, compiles, and reports data from requirements as they relate to state and county reporting. the counties to determine if there is a more • Identified the methods Mental Health used to collect MHSA data from the counties, efficient and comprehensive method to report including forms and databases used to store the data. Reviewed the forms to determine these data in the aggregate at the state level whether each was the most efficient and comprehensive approach. Additionally, we for analyzing the performance and outcomes interviewed former Mental Health staff as well as Health Care Services staff to determine achieved by the services resulting from if any concerns with the quality of the data may exist. the MHSA. • Reviewed evaluations the Accountability Commission contracted for and interviewed staff to determine quality of data issues and utility of evaluations. 7 Review and assess any other issues that are We identified the transition of MHSA responsibilities from Mental Health to Health Care significant to the MHSA. Services as a significant issue. We reviewed the transition plan and planning activities and interviewed staff to identify any areas of concern. We also asked Health Care Services in a representation letter to identify any outstanding issues relating to the transition. We found no reportable issues. Sources: California State Auditor’s analysis of Joint Legislative Audit Committee audit request number 2012-122, planning documents, and analysis of information and documentation identified in the column titled Method. * County indicates a county mental health department, two or more county mental health departments acting jointly, and/or city-operated programs receiving funds per California Welfare and Institutions Code, Section 5701.5. California State Auditor Report 2012-122 21 August 2013 Chapter 1 DESPITE THE STATE’S INADEQUATE OVERSIGHT SO FAR, OPPORTUNITY EXISTS TO DEMONSTRATE THE EFFECTIVENESS OF THE MENTAL HEALTH SERVICES ACT Chapter Summary The state entities initially responsible for overseeing the Mental Health Services Act (MHSA) have historically provided ineffective oversight of the counties’ implementation of MHSA programs. As a result, the State has little assurance that the counties have effectively and appropriately used the almost $7.4 billion directed to counties5 for these programs from fiscal years 2006–07 through 2011–12. One focus of the MHSA is accountability, and during this period, the task of ensuring accountability was primarily the responsibility of the California Department of Mental Health (Mental Health) and the Mental Health Services Oversight and Accountability Commission (Accountability Commission). Although each entity minimally performed the duties the MHSA specifically required, they did not fully embrace the oversight necessary to demonstrate the effectiveness of the MHSA. In particular, we expected that the responsible entities would have used an effective process to monitor, guide, and evaluate counties’ implementation of the MHSA, that they would build this process on their broad and specific MHSA oversight responsibilities, and that they would incorporate best practices; however, we found that they did not do so in the time period we reviewed. Going forward, opportunity exists for the current responsible state entities to better demonstrate the effectiveness of the MHSA. Effective late June 2012, legislation transferred most of Mental Health’s oversight role to the California Department of Health Care Services (Health Care Services). Health Care Services has reported its plans for fulfilling its MHSA responsibilities, which include providing assistance to the Accountability Commission on evaluating county MHSA programs. However, Health Care Services’ planning efforts are in the beginning stages, and the Accountability Commission has just begun to implement its recently adopted evaluation implementation plan; thus, it is too early to tell whether these efforts will fully address our concerns. 5 County indicates a county mental health department, two or more county mental health departments acting jointly, and/or city-operated programs receiving funds per California Welfare and Institutions Code, Section 5701.5. 22 California State Auditor Report 2012-122 August 2013 The Responsible State Entities Have Historically Provided Minimal MHSA Oversight, Evaluation, and Guidance As noted in the Introduction, one focus of the MHSA is accountability, and a significant stated purpose of the MHSA is “to ensure that all funds are expended in the most cost effective manner and services are provided in accordance with recommended best practices subject to local and state oversight to ensure accountability to taxpayers and to the public.” Before voter approval of the MHSA, Mental Health was responsible for overseeing mental health programs, and the MHSA specifically stated that nothing in Proposition 63 modified or reduced the existing authority or responsibility of Mental Health. In addition, the MHSA created the Accountability Commission. Over time, the oversight roles and responsibilities related to the MHSA have shifted among these two oversight entities, as shown in Figure 5.6 The period from January 2005 through March 2011 represents the initial oversight responsibilities resulting from voter approval of the MHSA. From April 2011 through June 2012, legislative changes to the roles of Mental Health and the Accountability Commission reduced the degree of state oversight. Beginning in July 2012, Health Care Services assumed primary responsibility for MHSA oversight as Mental Health underwent a streamlining reorganization to become the California Department of State Hospitals. Although Mental Health and the Under the MHSA, Mental Health and the Accountability Accountability Commission may Commission were to provide oversight of MHSA programs to have generally satisfied the MHSA’s ensure that counties gave full consideration to concerns about oversight requirements, they quality, structure of service delivery, and access to services. could have done more to ensure Although these two entities may have generally satisfied the that counties were effectively MHSA’s oversight requirements, they could have done more to implementing the MHSA. ensure that counties were effectively implementing the MHSA and that they were adequately evaluating the performance of their MHSA programs. Mental Health’s Minimalist Approach to Monitoring MHSA Programs Was Inadequate and Ineffective Originally, Mental Health had both broad mental health and MHSA-specific monitoring, oversight, and implementation responsibilities to hold counties responsible for their use of mental health funds. Before enactment of the MHSA, Mental Health was required to “conduct, sponsor, coordinate and disseminate research and evaluation” on mental health resource utilization and 6 The time frames in Figure 5 are approximate to the month to allow for ease of description. California State Auditor Report 2012-122 23 August 2013 Figure 5 The Three Phases of Oversight of the Mental Health Services Act January 2005 through March 2011 PHASE ONE (cid:127) The voter-approved Mental Health Services Act (MHSA) takes effect. (cid:127) The California Department of Mental Health (Mental Health) is required to guide counties' MHSA implementation by issuing regulations. Mental Health is required to enter into performance contracts with counties. (cid:127) Each county prepares and submits a three-year plan that must be updated at least annually and approved by Mental Health after review and comment by the Mental Health Services Oversight and Accountability Commission (Accountability Commission). (cid:127) The Accountability Commission must annually review and approve county plans for Prevention and Early Intervention (Prevention) and Innovation programs. (cid:127) Mental Health and the Accountability Commission are required to evaluate the performance of county MHSA programs. April 2011 through June 2012 PHASE TWO (cid:127) Legislative change removes Mental Health’s exclusive authority to adopt regulations for MHSA and instead authorizes “the State,” not just Mental Health, to adopt regulations related to the MHSA. (cid:127) Legislative change removes the requirement for annual review and approval of county Prevention program expenditures by the Accountability Commission and the requirement that Mental Health approve the plans after review and comment by the Accountability Commission. (cid:127) Legislative change removes express control of the Mental Health Services Fund from Mental Health and transfers it to “the State.” July 2012 through Present PHASE THREE (cid:127) Legislative change transfers Mental Health’s responsibility to guide, monitor, and evaluate the MHSA primarily to the California Department of Health Care Services (Health Care Services). (cid:127) Legislative change specifies that Health Care Services, in consultation with the Accountability Commission, is required to develop regulations, as necessary, to implement the MHSA. However, effective June 27, 2013, the Accountability Commission is required to adopt regulations for programs and expenditures related to Prevention and Innovation programs. (cid:127) Legislative change requires each county board of supervisors to approve county plans. The Accountability Commission must review and approve Innovation programs before counties may spend their allocated Innovation funds. Sources: MHSA, Proposition 63 of 2004, and amendments. Note: The time frames provided as beginning and ending periods are approximate to the month to allow for ease of description. service delivery, make technical assistance available to counties, implement a system of required performance reporting by counties, and “perform any other activities useful to improving and maintaining the quality” of community mental health programs. As originally enacted, the MHSA specifically required Mental Health 24 California State Auditor Report 2012-122 August 2013 to implement the Community Services and Supports (Community Supports) and Prevention and Early Intervention (Prevention) components of the MHSA through annual mental health services performance contracts (performance contracts) with counties. The MHSA required Mental Health Summary of County Plans and Annual Updates to review and approve county plans and annual updates, which the text box describes. Mental Upon initial implementation of each Mental Health Health could have used these performance contracts Services Act (MHSA) component, counties were required to ensure that the counties complied with their to submit a three‑year plan for MHSA programs that stated plans and annual updates by requiring the included descriptions of the proposed programs and the counties to track and report on performance community planning process used to identify and develop measures that would demonstrate their effectiveness the plan. Therefore, as required by law, counties were in meeting MHSA program goals and outcomes. to submit an annual update generally describing their progress in implementing the existing component plan(s), Based on its broad and specific responsibilities, proposals for new programs, and substantive alterations to existing programs. we expected that Mental Health would have developed and implemented an effective Sources: California Welfare and Institutions Code and guidance monitoring process for its explicit oversight issued by the California Department of Mental Health. requirements and best practices related to effective monitoring. If periodic reviews revealed that counties were not in compliance with these requirements, the State’s monitoring process would provide for enforcement action. A strong monitoring process and strong requirements help ensure that taxpayer funds are appropriately spent, that mental health services are effectively provided, and that issues of noncompliance are promptly discovered and corrected. However, we did not find a strong monitoring process in place. Mental Health Made Poor Use of County Performance Contracts, and Recent Changes to State Law Have Complicated the State’s Enforcement Mechanism We believe Mental Health should have founded its monitoring of county MHSA programs on the required performance contract. These performance contracts with each county could well have served as a mechanism for holding the county accountable for the commitments it had made to the State. State law specifies that the performance contract must include several assurances that the county can and will comply with specific legal requirements, including complying with the data reporting requirements to fulfill the information needs of the State. During fiscal year 2008–09, Mental Health switched from its original, more robust performance contract to an MHSA agreement that contained broad, general statements concerning how a county would comply with the law. The MHSA agreement offered few specifics as to what steps a county must take to assure compliance. Functionally, Mental Health appears to have treated the MHSA California State Auditor Report 2012-122 25 August 2013 agreement as a means of enabling counties to obtain MHSA funding. Although the assurance included in the MHSA agreement may have satisfied the minimal requirements set forth in state law, Mental Health could have drafted the performance contracts to require specific measurable commitments from the counties. Had Mental Health made better use of these performance contracts as a tool for holding counties accountable for their use of MHSA funds, it Going forward, Health Care Services would have significantly bolstered the State’s oversight role and can use its performance contracts might have mitigated the shortcomings we identified in selected with counties to ensure that they counties’ evaluation and reporting on the effectiveness of their specify program goals, identify MHSA programs. Going forward, Health Care Services can use its meaningful measurement of performance contracts with counties to ensure that they specify their goals, and use the resulting program goals, identify meaningful measurement of their goals, and data to evaluate the efficacy of use the resulting data to evaluate the efficacy of their programs. their programs. According to its director, Health Care Services is developing new performance contracts effective July 1, 2013. He stated that Health Care Services has included stakeholders and other state entities that have a role in the MHSA to obtain their input as to what the performance contracts should address. He also explained that once in place, the performance contracts will clearly delineate the roles and responsibilities of the counties in their local administration of the MHSA programs. In addition to Mental Health’s failure to use robust performance contracts, we are concerned because Health Care Services believes it does not have clear authority to ensure that counties comply with the terms of those performance contracts. Recent changes to state law have made the State’s ability to withhold funds from counties that it deems out of compliance with those contracts difficult. Monitoring that reveals issues requiring correction typically triggers an enforcement process to ensure that corrective action is taken and the issues are resolved. Under state law, Mental Health possessed the authority to distribute funds from the Mental Health Services Fund (Fund) and to issue administrative sanctions against counties, including withholding funds if the county did not comply with state laws and regulations. Although Mental Health retained the authority to issue administrative sanctions against counties, legislation effective March 2011 made this particular enforcement process more difficult. The legislation gave the California State Controller’s Office (State Controller’s Office) the authority to distribute the money from the Fund. As a result, Mental Health’s process to enforce MHSA requirements by withholding funds became less certain because it no longer administered the Fund. Health Care Services now faces the same challenge as it assumes MHSA oversight responsibilities. The director of Health Care Services believes that state law does not clearly define Health Care Services’ authority to withhold MHSA funds from a county if it is noncompliant with its performance contract, state law, or regulations. Health Care Services 26 California State Auditor Report 2012-122 August 2013 neither holds nor disburses funds for the MHSA to the counties; therefore, it cannot withhold MHSA funds and instead would likely have to coordinate, in terms of both authority and process, with the California Department of Finance, State Treasurer’s Office, and/or the State Controller’s Office. Although we believe that state law continues to give Health Care Services statutory authority to withhold funds from a noncompliant county, we agree that as a practical matter, its ability to exercise this authority with respect to a fund it no longer administers is unclear. Without a clear process—in this case the ability to withhold MHSA funds—the State has decreased ability to incentivize counties to quickly address and solve noncompliance that Health Care Services may identify through its monitoring activities. Mental Health Failed to Perform Comprehensive On-Site Reviews of County MHSA Programs On-site reviews are a powerful method of monitoring performance, but we found little evidence that Mental Health performed such reviews. On-site reviews would have allowed Mental Health to verify that counties had implemented MHSA programs effectively and appropriately, including meeting stated requirements. A former Mental Health manager stated that he was not aware of any on-site reviews conducted on the performance contracts. We noted one instance of Mental Health conducting a limited-scope desk review of a county and we found that Mental Health included a handful of questions in its triennial Reversion and Nonsupplant Requirements for Medi-Cal reviews pertaining specifically to the County Mental Health Services Act Funding MHSA. However, neither the desk audit nor Reversion requirement: State law specifies that any the MHSA-related questions evaluated whether unspent Mental Health Services Act (MHSA) funds allocated all counties had consistently followed to a county, other than those placed in a prudent reserve MHSA requirements and spent taxpayer in accordance with the county’s approved plan, must funds appropriately. revert to the State within certain time frames and be made available for future distribution to other counties. Funds Mental Health appears to have relied on allocated for Community Services and Supports, Innovation, assertions or certifications as assurance that a and Prevention and Early Intervention programs are subject county was complying with at least two of the to reversion after three years, whereas funds allocated for MHSA requirements. Among other things, Capital Facilities and Technological Needs and Workforce the MHSA requires unused funds to revert Education and Training may be retained by the county for to the State for future distribution (reversion up to 10 years before reversion. requirement) after specified periods of time and Nonsupplant requirement: State law requires counties requires that funds be used to expand mental to use MHSA funding to expand mental health services; health services (nonsupplant requirement). The these funds cannot be used to supplant existing state text box describes these requirements in more or county funds used by the county to provide mental detail. To monitor the reversion requirement, health services. Mental Health relied on each county to report on Source: California Welfare and Institutions Code. its annual Revenue and Expenditure Report and to certify the amount of unspent MHSA funds California State Auditor Report 2012-122 27 August 2013 that would revert to the State. Similarly, Mental Health’s approach to monitoring the nonsupplant requirement generally consisted of having a county certify in a statement in its plans and annual updates that it had not used MHSA funds to supplant existing funding for mental health services. As a starting point, requiring assertions or certifications does inform the county of what is expected and provides Mental Health with some assurance that the county intends to comply with MHSA requirements. However, without performing on-site reviews to verify that the counties have in fact complied with the MHSA nonsupplant and reversion requirements, Mental Health’s assurance was limited. Moreover, effective March 2011, the State is no longer responsible for approving county plans before the counties receive MHSA funding. It is critical that Health Care Services Currently, county boards of supervisors are tasked with reviewing take steps to monitor counties’ use and approving these documents. Therefore, it is critical that Health of MHSA funds to ensure that they Care Services take steps to monitor counties’ use of MHSA funds to are using the funds in accordance ensure that they are using the funds in accordance with applicable with applicable requirements and requirements and as the MHSA intended. as the MHSA intended. The director of Health Care Services indicated that it intends to initiate efforts to monitor the adequacy of county administration of MHSA programs. If consistently undertaken, these efforts may address some of the issues we noted about Mental Health’s monitoring. However, as noted earlier, Health Care Services is in the early planning stages of these practices; thus, it is too early to tell whether its efforts will be effective. In addition, the director explained that Health Care Services has developed a preliminary list of specific county MHSA program and fiscal requirements that it will consider reviewing, which includes the nonsupplant requirement. Health Care Services’ deputy director for Mental Health and Substance Use Disorder Services explained that Health Care Services intends to complete the program audit requirements before June 2013 so that the information may be included in the fiscal year 2013–14 protocol for its Medi-Cal Oversight Reviews, and the Audits and Investigations deputy director expects to complete the fiscal audit requirements by September 2013. However, the director noted that available staffing levels will dictate the breadth and depth of Health Care Services’ review. Mental Health Often Used Informal Guidance in Lieu of Regulations and Provided Little Guidance to Counties on How to Evaluate Program Performance Although the MHSA expressly authorized Mental Health to promulgate regulations for implementation of its requirements and for a period of time gave Mental Health emergency rule-making authority, Mental Health did not fully exercise that authority. Mental Health did not issue regulations for three of the 28 California State Auditor Report 2012-122 August 2013 five MHSA components—Prevention, Innovation, and Capital Facilities and Technological Needs (Facilities)—or for other statutory requirements. Instead, Mental Health published guidance letters it called information notices. However, to the extent some of the directives contained in these information notices were intended to be binding to the counties, these directives would not have been enforceable because they were not formally adopted as regulations. For example, state law requires counties to maintain a prudent reserve to ensure that service levels will continue if revenues for the Fund fall below recent averages. Mental Health issued an information notice “requiring” counties to establish a prudent reserve of 50 percent of their most recent allocation. Although at the time it had the authority to approve or reject county plans and annual updates based on, among other things, county establishment and maintenance of a prudent reserve, had Mental Health sought to separately enforce the 50 percent prudent reserve requirement, a court likely would have concluded that the requirement constituted an unenforceable underground regulation. Until Health Care Services exercises Until Health Care Services exercises all of the regulatory authority all of the regulatory authority vested in it under state law by promulgating regulations to fully vested in it under state law by implement the MHSA, the State will have less ability to influence promulgating regulations to fully and enforce county administration of MHSA funds, particularly implement the MHSA, the State will since the State no longer approves most elements of county plans. have less ability to influence and At the time that Mental Health issued its information notices, enforce county administration of it played a role in approving county plans, giving the State an MHSA funds. oversight mechanism to help ensure that counties appropriately implemented the MHSA. However, the State no longer has that same oversight mechanism, as only Innovation plans are now approved by the Accountability Commission, and each county’s board of supervisors approves plans for the remaining components. According to the director of Health Care Services, it will first review and revise existing regulations that it has deemed invalid due to recent legislative changes. In August 2014 it plans to develop regulations, in consultation with the Accountability Commission, for the Prevention and Innovation components of the MHSA.7 He stated that Health Care Services will continue to develop information notices as needed to provide guidance to counties on MHSA fiscal and reporting policies within its purview. He also explained that Health Care Services typically develops policies included in the information notices in consultation with the Accountability Commission and the County Mental Health Directors Association, and it considers stakeholder perspectives 7 On June 27, 2013, state law was amended to require the Accountability Commission to adopt regulations for programs and expenditures related to the Prevention and Innovation components. In its response to our report on pages 128 and 129, Health Care Services acknowledged this recent change in law and assured us that it still intends to collaborate with the Accountability Commission beginning in July 2013 to review the current MHSA regulations and develop additional regulations. California State Auditor Report 2012-122 29 August 2013 in the development process. Nevertheless, as stated earlier, to the extent the directives in these information notices constitute rules of general application and are intended to be binding, they will not be enforceable unless they are properly adopted as regulations. In addition, because one focus of the MHSA is to provide accountability to taxpayers and the public, we assumed that Mental Health would have taken steps to ensure that counties received the guidance necessary to effectively evaluate and report on the performance of their MHSA programs. However, we found scant evidence demonstrating that Mental Health had issued such guidance regarding the types of efforts counties should undertake to evaluate their MHSA programs. Mental Health issued an information notice in September 2007 directing counties to select one Prevention program for evaluation and sent another notice in January 2009 directing them to provide a final report that described, among other things, what was learned upon completion of an Innovation program. Neither of these notices provided Without state guidance on explicit direction on how counties should evaluate their programs how counties should evaluate effectively, including how to set reasonable goals, establish specific their programs effectively, objectives to attain those goals, identify and collect data relevant we found inconsistent and, at to the goals and objectives, and use those data to measure program times, inadequate approaches performance. In the absence of such guidance, it is not surprising to performance assessment that we found inconsistent and, at times, inadequate approaches to and reporting in the counties performance assessment and reporting in the counties we reviewed. we reviewed. (We describe these issues in detail in Chapter 2.) Although the Accountability Commission has indicated that it will take steps to follow up on county efforts to carry out Mental Health’s direction as previously described, without the responsible state entities providing guidance on how to evaluate program performance, the public will lack adequate assurance that MHSA programs are achieving their intended purposes. The Responsible State Entities Have Not Undertaken Serious Efforts to Evaluate the Effectiveness of MHSA Programs That Counties Have Implemented Although almost $7.4 billion in taxpayer funding was directed to mental health services and support for fiscal years 2006–07 through 2011–12, the Accountability Commission, Mental Health, and a third entity charged with evaluating MHSA programs have not provided adequate assurance to taxpayers and the public that these programs are effective. Recent efforts by the Accountability Commission have resulted in an evaluation plan, but the results remain to be seen as the implementation is not yet complete. Mental Health did not conduct a systematic evaluation of the effectiveness of MHSA programs, and although it did require counties to report extensive MHSA data, we have concerns with certain of these data, including 30 California State Auditor Report 2012-122 August 2013 their completeness, which limits the value of evaluating the MHSA using these data. Beginning June 2012 Health Care Services largely assumed Mental Health’s responsibilities to collect data and evaluate the efficacy of MHSA programs; however, its efforts to do so are in the early stages. The MHSA has, since its inception, expressly required that funds allocated for state administration include amounts sufficient to ensure adequate research and evaluation of the effectiveness of services and achievement of the outcome measures related to Community Supports—specifically care for children, adults, and seniors— and Prevention programs. As of March 2009 the Accountability Commission has the authority to obtain data and other information from state and county entities to carry out its oversight and evaluation responsibilities. The third entity charged with evaluating MHSA program effectiveness is the California Mental Health Planning Council (Planning Council), which is tasked with annually reviewing the performance of mental health programs, including MHSA-funded programs, by using performance data and existing reports. Table 3 displays the MHSA expenditures each of these entities made to carry out their administrative duties, including any funds spent on evaluation activities for fiscal years 2011–12 and 2012–13. Table 3 Expenditures of Mental Health Services Act Administrative Funds by the Three State Entities Required to Evaluate Mental Health Services Act-Funded Programs Fiscal Years 2011–12 Through 2012–13 FISCAL YEAR STATE ENTITY 2011–12 2012–13* Mental Health Services Oversight and $5,340,000 $6,925,000 Accountability Commission California Department of Mental Health (Mental Health)† 12,210,000 9,341,000 California Mental Health Planning Council 791,000‡ 770,148 (Planning Council) Sources: The Governor’s Budget for fiscal year 2013–14 and information presented for the Planning Council based on documentation provided by the California Department of State Hospitals (State Hospitals) and the California Department of Health Care Services (Health Care Services) for fiscal years 2011–12 and 2012–13, respectively. Note: The amounts displayed are representative of all Mental Health Services Act (MHSA)-related administrative expenditures for each entity, which includes any expenditures for evaluation efforts. * The amounts presented for fiscal year 2012–13 are projected. † Legislation effective June 27, 2012, transferred most of Mental Health’s MHSA responsibilities to Health Care Services. Thus, the amount presented for fiscal year 2012–13 represents projected expenditures for Health Care Services. Further, because the Planning Council was a division within Mental Health until June 2012 and now resides as a division within Health Care Services, the amounts presented for Mental Health and Health Care Services include any expenditures made, or projected to be made, by the Planning Council. ‡ According to the Planning Council, due to its transition from Mental Health to Health Care Services, neither it nor State Hospitals could provide MHSA expenditure information for fiscal year 2011–12; thus, the amount presented is its budget for that year. California State Auditor Report 2012-122 31 August 2013 Despite Its Charge to Evaluate the MHSA, the Accountability Commission Has Been Slow to Establish a Necessary Framework The Accountability Commission has been slow to develop a framework to evaluate MHSA programs. As a result, it cannot adequately demonstrate to taxpayers how implementing the MHSA has transformed county mental health systems. The Accountability Commission was established, in main part, to provide oversight. Therefore, we expected it to have created a framework for consistent evaluation. In 2008 and 2010, the Accountability Commission noted in policy papers the need for such evaluation. In fact, in the 2008 policy paper, the commission indicated that evaluation is critical for accurately depicting the extent to which counties have accomplished MHSA objectives, and it noted that large sums of taxpayer dollars have been earmarked for mental health transformation and accurate, non-biased results are required. However, it was not until late March 2013—more than eight years after the passage of the MHSA—that the Accountability Commission adopted an evaluation implementation plan8 that sets out its evaluation activities for fiscal years 2013–14 through 2017–18. The specified evaluation activities include collecting, summarizing, and publicizing client-level outcomes from counties and refining the use of previously developed indicators—such as the number of arrests and average school attendance—that measure program performance. The Accountability Commission’s executive director stated that the Although the Accountability commission initially focused on a review of county plans for proposed Commission’s purpose in providing MHSA programs, as evaluation efforts needed to wait for those oversight has not changed since programs to mature. In addition, the Accountability Commission did voter approval of the MHSA in 2004, not believe its responsibility to evaluate was clear until the legislative it did not believe its responsibility to changes made in 2009. However, the Accountability Commission’s evaluate was made clear until 2009. purpose in providing oversight has not changed since voter approval of the MHSA in 2004. Although it seems reasonable that programs need time to mature before they are evaluated, the Accountability Commission began entering into contracts related to evaluation in 2009 and we assume it had judged some MHSA programs mature enough for evaluation at that time. Further, the executive director noted that the implementation plan provides a framework for evaluating the MHSA as well as the broader community-based public mental health system. However, she acknowledged that the implementation of the framework has begun but it is not complete. We do not believe that developing an evaluation framework necessarily depends on those programs producing data. A framework is an approach to effectively and regularly review data that an entity collects. Ideally, an evaluation framework should be developed as programs are 8 The Accountability Commission adopted the implementation plan to execute a master evaluation plan. 32 California State Auditor Report 2012-122 August 2013 being implemented so program operators can collect and maintain information for use in evaluations. Even so, the Accountability Commission has had significant amounts of information about counties’ programs and desired outcomes upon which to base its evaluations because it reviews the counties’ plans. The Accountability Commission’s approach to funding its evaluation efforts also appears skewed. As shown in Table 4, since fiscal year 2009–10, its expenditures have grown significantly— reaching nearly $7 million in fiscal year 2012–13—yet, they are disproportionate to the amount the Accountability Commission reported spending on evaluation in the same year, almost $1.3 million. According to the executive director, the Accountability Commission began receiving funding earmarked for evaluation in fiscal year 2009–10 after requesting such funding. She explained that the commission funds evaluations either through such appropriations or by using funds remaining at fiscal year-end. However, given that one of the commission’s primary purposes is to evaluate, we question whether it needs an additional specific appropriation for this purpose. Table 4 Expenditures by the Mental Health Services Oversight and Accountability Commission and Amounts Dedicated to Evaluation Fiscal Years 2005–06 Through 2012–13 (In Thousands) AMOUNT DEDICATED FISCAL YEAR EXPENDITURE TO EVALUATION 2005–06 $707 $0 2006–07 1,480 0 2007–08 3,323 0 2008–09 4,089 0 2009–10 4,089 250 2010–11 4,538 1,894 2011–12 5,340 2,116 2012–13 6,925* 1,285 Totals $30,491 $5,545 Sources: Governor’s budgets for fiscal years 2012–13 and 2013–14, Budget Act amounts for authorized expenditures, and other information provided by the Mental Health Services Oversight and Accountability Commission (Accountability Commission), as well as the California State Auditor’s review of Accountability Commission contract amounts related to Mental Health Services Act evaluation. Note: According to the chief deputy of the Accountability Commission, before fiscal year 2011–12, the commission’s budget preparation, management, and documents were handled by the California Department of Mental Health (Mental Health). The chief deputy explained that, in becoming independent, the Accountability Commission was unable to obtain or reconstruct expenditure information on prior-year budgets with any degree of reliability. He stated that the uncertainty is so great, the California Department of Finance accepts the Accountability Commission declaring its expenditure information before fiscal year 2010–11 as “not available;” nevertheless, the chief deputy provided Budget Act amounts for authorized expenditures and positions for fiscal years 2005–06 through 2009–10. * The amount presented for fiscal year 2012–13 is projected. California State Auditor Report 2012-122 33 August 2013 We are even more concerned that in its implementation plan for fiscal year 2012–13, the Summary of the Mental Health Services Accountability Commission states that without an Oversight and Accountability Commission’s augmentation to its funding and staffing, it will only Completed Contracted Mental Health be able to complete roughly half of the evaluation Services Act-Related Evaluations activities called for in the plan. Such a statement is surprising for two reasons. First, legislation effective Access study: The contractor was to analyze disparities March 2011 removed from the Accountability in service access and delivery at the county level, Commission’s duties the likely time-consuming including creation of detailed maps containing analyses review of county plans and approval of certain of mental health services. The contractor was to work with three counties to implement procedures and component plans, meaning that it could commit methodologies to track mental health service delivery more of its existing resources to evaluation efforts. and utilization in order to reduce disparities in the Second, as Table 4 indicates, the Accountability delivery of services, improve access to care, and to deliver Commission’s expenditures for fiscal year 2011–12 care in a more cost‑effective manner. The contractor increased by more than $800,000 following the was to provide recommendations on how to develop a legislative reduction of its duties and it reported mental health tracking system in California. The Mental dedicating more than $220,000 to evaluation than Health Services Oversight and Accountability Commission in the previous fiscal year. The executive director (Accountability Commission) stated that the final deliverable informed us that the Accountability Commission for this contract was provided in November 2011. intends to review all county plans although that is Prevention and Early Intervention (Prevention) study: not explicit in state law, it will also approve The contractor was to review, summarize, and synthesize counties’ Innovation plans as state law requires. existing Prevention evaluations, reports, and studies with Nevertheless, evaluation of MHSA programs a particular focus on the impact of the component on is a primary purpose of the Accountability respective outcomes. The contractor was also to determine Commission, and its belief that it needs additional Prevention program data elements that counties and their specific funds to support its evaluation efforts providers are tracking, and report on counties’ intended causes us to question whether the commission outcomes and outcome measures based on the contractor’s is properly prioritizing its resources. analysis of the Prevention plans. Study was final as of August 2011. The Accountability Commission has contracted Full-Service Partnership study: The contractor was to for certain evaluations related to the MHSA, but determine the statewide and county‑specific per person it has been slow to maximize use of the information annual cost average, by specified age group, of Full‑Service from those evaluations. From July 2009 through Partnership services; the impact specific Community June 2012, the Accountability Commission Services and Supports programs have had on selected client outcomes; the impact of the Mental Health Services Act on contracted for six studies;9 as of May 2013, client outcomes, using the input from clients, their families, three were complete. The three contracted and personal caregivers; and identify recommended data studies focused on disparities in access to elements that are needed for comprehensive evaluation care (access study), outcomes of Prevention but that are not available in the data sets currently in use by programs (Prevention study), and Full-Service the California Department of Mental Health or the counties. Partnership (Parternship) costs and the impact Study was final as of April 2013. of the MHSA on client outcomes (Partnership Sources: California State Auditor’s review of the scope of work study). The text box provides a summarized for the three Accountability Commission contracts. description of each contract. 9 Mental Health entered into a contract in July 2009, but because the deliverable from that contract was due to the Accountability Commission, we consider it an Accountability Commission contract. 34 California State Auditor Report 2012-122 August 2013 The Accountability Commission has had an Evaluation Committee since 2008, and since 2010, this committee has been charged with ensuring that information from evaluative efforts and reports is used and usable for continuous improvement relating to the MHSA. Given this responsibility, we expected that the Accountability Commission would have used the evaluation study findings to improve the MHSA. The final Partnership study was submitted in April 2013, and according to the Accountability Commission’s chief legal counsel, because the report was only recently finished (May 2013), neither The Evaluation Committee did the Evaluation Committee nor the Accountability Commission has not specifically review all the reviewed the report. We also found that the Evaluation Committee did deliverables of either the access not specifically review all the deliverables of either the access study or study or the final report for the the final report for the Prevention study, based on interviews with the Prevention study, yet both of those chief legal counsel and a review of Evaluation Committee agendas and studies have been final for more minutes. Both of those studies have been final for more than 18 months. than 18 months. The chief legal counsel stated that until 2013, the focus of the Evaluation Committee has been prioritizing and recommending new evaluations to undertake, not reviewing or analyzing completed evaluations. We question this approach, however, because focusing on new evaluations de-emphasizes the Evaluation Committee’s charge to ensure that information from completed evaluations is used and usable for continuous improvement to MHSA programs. Additionally, in a report dated March 2013, a contractor noted that the Accountability Commission needs to devote more attention to using evaluation information. According to the executive director of the Accountability Commission, the access study led the Accountability Commission to incorporate the use of several surveys, including a mental health survey administered by the University of California, Los Angeles, in its implementation plan. She also stated that the Prevention study’s findings helped to guide and inform the scope of work for the larger-scale statewide Prevention evaluation that the Accountability Commission contracted for in June 2012. However, since the access study was completed in November 2011 and the Accountability Commission has not yet completed the steps outlined in the implementation plan, its actions do not adequately demonstrate a timely or effective use of the evaluation study findings. Furthermore, the Accountability Commission’s use of the Prevention study’s findings to help inform the scope of work for another evaluation contract does not indicate that the findings have been fully used to continuously improve the MHSA. There Is No Indication That Mental Health Conducted Systematic MHSA Evaluations Given its responsibilities and funding, we expected that Mental Health would have conducted regular evaluations of statewide performance of MHSA programs. However, beyond collecting California State Auditor Report 2012-122 35 August 2013 large amounts of data (see next section), we found no evidence that Mental Health conducted systematic evaluations. We did identify an evaluation that Mental Health had jointly funded with the California Health Care Foundation, of certain Community Supports programs, specifically Full-Service Partnership programs, through 2008 and 2009, but this type of review does not constitute a systematic evaluation. The 2012 legislation that transferred most of Mental Health’s remaining responsibilities to Health Care Services added requirements that Health Care Services and the Accountability Commission, in conjunction with other stakeholder groups, create a comprehensive plan for the coordinated evaluation of client outcomes. According to a branch chief within the Mental Health Services Division, beyond creating this required plan and working collaboratively with the Accountability Commission by providing data and information as necessary to support its current evaluation efforts, Health Care Services has no intention of conducting a separate statewide evaluation of MHSA programs. Further, Until the Accountability the branch chief indicated that the master evaluation plan the Commission’s master evaluation Accountability Commission developed satisfies this requirement and implementation plans for a comprehensive joint plan. Nevertheless, until the master address the concerns we raise in evaluation and implementation plans address the concerns we raise this chapter, we believe efforts to in this chapter, we believe efforts to evaluate the effectiveness of evaluate the effectiveness of MHSA MHSA programs will fall short. programs will fall short. Mental Health Required Counties to Report Extensive MHSA Data, but the Data Are Incomplete and of Limited Value in Measuring MHSA Program Effectiveness From December 2006 until its recent reorganization, Mental Health required counties to submit information related to the provision of mental health services and the clients receiving those services. However, in nearly all cases, Mental Health either failed to consistently obtain certain data or did not ensure that all counties reported required data. Mental Health’s inaction likely hindered any meaningful evaluation of the data to identify the effectiveness of certain aspects of the MHSA. Table 5 on the following page details the type of data counties are required to submit, both during Mental Health’s administration of the MHSA and currently; the frequency of counties’ submission of the required data; and any concerns we noted in our review of the type and completeness of the data collected. 36 California State Auditor Report 2012-122 August 2013 Table 5 Reporting Instruments and Data That Counties Are Required to Submit and Identified Concerns REPORTING INSTRUMENTS AND DATA SUMMARY OF INFORMATION CAPTURED FREQUENCY SUMMARY OF IDENTIFIED CONCERNS Client and Includes client demographics, such as age No later than Based on available information as of March 2013 Service and ethnicity, diagnosis, and description 60 days after the provided by the California Department of Health Care Information of services provided for all mental health end of the month in Services (Health Care Services), the data are incomplete data clients. These data are captured in the Client which the services as not all counties have reported as required. and Service Information System. were provided Consumer Includes clients and/or families’ perceptions Semiannually, Based on available documentation, the survey was Perception of quality and results of services provided. 90 days after not consistently administered and the data are, Semi-Annual collection therefore, incomplete and anecdotal. Survey Full-Service For clients that have a Full-Service Partnership At the start of According to Health Care Services staff, who formerly Partnership (Partnership) agreement with the county, a Partnership worked for the California Department of Mental Health data data collected includes residential status, agreement, (Mental Health), the data are incomplete as not all employment status, financial support quarterly, and when counties have reported as required. services, health status, substance abuse a key event occurs issues, and emergency interventions. such as loss of This information is captured in the employment Full-Service Partnership Data Collection and Reporting System. Cost Report As part of the annual cost and financial Annually According to documentation provided by Health Care reporting, the county must submit Services, as of December 2012, 16 counties—including information on revenue, distribution, and Los Angeles—had not yet filed their cost reports for expenditures for Mental Health Services Act fiscal year 2010–11, which were due in October 2012. (MHSA) programs. Thus, the data may be incomplete as not all counties have reported as required. MHSA Includes a report of MHSA administration Annually None noted. Revenue and expenditures, MHSA program expenditures, Expenditure and MHSA funds received during the Report fiscal year. Quarterly Includes a count of clients planned to be No later than • Tracks clients participating in Community Services Progress Report served and actually served. 60 days following and Supports, but not Prevention and Early the end of Intervention and Innovation. each quarter • Data are incomplete as not all counties have reported as required. Sources: MHSA, Proposition 63 of 2004, associated regulations, Mental Health information notices, information provided by Health Care Services, and the California State Auditor’s analysis of reporting instruments and data captured. Perhaps the most problematic aspect of the information Mental Health collected from the counties is the significant gaps in the data that we and former Mental Health staff identified. These gaps likely would limit the value of any evaluation Mental Health, or others, performed or may perform using those data. As shown in Table 5, counties submit data including client demographics, diagnosis, residential status, and employment status, which are entered into two systems formerly administered by Mental Health and currently administered by Health Care Services: the Full-Service Partnership Data Collection and Reporting System (partnership system) and the Client and Service Information System (client service system). California State Auditor Report 2012-122 37 August 2013 According to the fiscal branch chief, seven counties have never Health Care Services stated submitted the required Partnership data. According to a research that seven counties have analyst formerly with Mental Health and now with Health never submitted the required Care Services, who is responsible for the systems, the counties Partnership data—the counties experienced data processing issues that Mental Health never experienced data processing issues resolved. He explained that Mental Health never monitored that Mental Health never resolved. whether counties submitted the required data or verified the data’s accuracy. The research analyst’s statements call into question the completeness and usefulness of the data. Similarly, the quality of the data maintained in the client service system is also flawed. As of March 2013, based on documentation Health Care Services provided, 43 counties were late in submitting their data and four of these were more than a year late. Additionally, based on information and documentation Health Care Services provided, data collected by way of the progress reports and consumer perception surveys were incomplete. These reporting instruments are described in Table 5. For instance, the progress report captured only data pertaining to Community Supports programs—the first MHSA component to be implemented— and omitted the Prevention and Innovation components. Mental Health failed to update the progress report to capture data related to these two components’ programs, which were rolled out after Community Supports. Finally, Mental Health cancelled one of the semiannual surveys in 2009 citing numerous factors and logistical barriers, and former Mental Health staff could not demonstrate that survey data from one of the two surveys required in both 2010 and 2011 were submitted. Based on our review of the guidance issued to the counties, Mental Health also cancelled one of the two required surveys in 2012, citing similar reasons for doing so. Furthermore, these surveys are based on anecdotal information, not on data that could be measured or trended to evaluate program success. Lacking meaningful and complete data, the State is hindered in its ability to report on the success of MHSA programs and to assure taxpayers that their funds are not being wasted. The director of Health Care Services stated that information technology (IT) staff are currently dedicated specifically to addressing technical issues with the partnership and client services systems, including problems with uploading data, error code translation, and other issues. In addition, Health Care Services has temporarily redirected an IT staff person to actively work with program staff and counties to resolve all known system issues. The director reported that Health Care Services will be working with the Accountability Commission over the next year to improve the system by addressing statewide system issues and data quality. 38 California State Auditor Report 2012-122 August 2013 The Planning Council Has Not Fulfilled Its MHSA Responsibility Finally, state law requires a third entity—the Planning Council—to annually “review the performance of mental health programs based on performance outcome data and other reports,” and state law makes it clear that MHSA programs must be included. (The text box describes the Planning California Mental Health Planning Council Council.) However, despite receiving MHSA funding to perform evaluations, the Planning The California Mental Health Planning Council (Planning Council has yet to fulfill its MHSA responsibilities. Council) comprises 40 members whose purpose is For its fiscal year 2011–12 operations—as depicted to advocate for individuals with serious mental illness, to in Table 3 on page 30—the Planning Council provide oversight and accountability for the public mental reported a budget of $791,000, and MHSA funds health system, to advise the governor and the Legislature on priority issues, and to participate in statewide planning. made up roughly 60 percent of that. When asked At the end of June 2012, state law transferred responsibilities how the Planning Council fulfilled its MHSA relating to the Planning Council from the California requirement, the executive officer pointed us to a Department of Mental Health to the California Department report titled California Mental Health Planning of Health Care Services (Health Care Services). The Planning Council Accomplishments, 2008–2010 Council, according to the Health Care Services Web site, (accomplishments report). For the section holds quarterly meetings in different sections of California applicable to the MHSA, the accomplishments to allow maximum participation. Membership must include report cites a Mental Health Board Workbook eight representatives from various state departments Project (workbook) and describes the workbook as and appointees from various mental health constituency a tool to facilitate uniform reporting to the organizations. State law requires at least one‑half of Planning Council by local mental health boards on the members to be persons with mental disabilities, family members of persons with mental disabilities, and their analyses of their local performance data. representatives of organizations advocating on behalf However, the accomplishments report did not of persons with mental disabilities. indicate whether any data collection or evaluations occurred. Sources: California Welfare and Institutions Code, meeting minutes provided by the Planning Council, and Health Care Services’ Web site. The Planning Council’s executive officer attributed the workbook to her predecessor, stating that there are no associated records of what was done with the workbook or any county submissions based on the workbook, but that the Planning Council was in the process of designing a new workbook in consultation with county mental health boards. She also provided a draft revision of the accomplishments report extending through fiscal year 2012–13. However, the draft accomplishments report did not include actions satisfying the Planning Council’s responsibilities related to the MHSA. Members of the Planning Council stated that the Planning Council reviewed the performance of certain MHSA programs by receiving information counties submitted and through presentations and other materials. However, because it did not document the results of its review of this information, we question whether the Planning Council met its statutory responsibility in this area. The executive officer stated that the Planning Council does not have resources to perform raw data analysis and until very recently there were almost no reports on MHSA programs, creating a lack of material with which to work. Reviewing the performance California State Auditor Report 2012-122 39 August 2013 of MHSA programs is critical to determining whether the MHSA is fulfilling its stated intents and purposes, yet the Planning Council, like the other entities charged with evaluating these programs, is not fulfilling its responsibility. Counties’ MHSA Funding Allocations May Not Be Appropriate Another area of concern is the methodology used to determine the factors governing the MHSA funding to allocate to counties. A lack of substantive updates to the factors calls into question the propriety of the methodology. Mental Health was tasked with creating a method to divide among the counties Summary of Factors the California Department annual tax revenues remitted to the Fund. Available of Mental Health Included in the Mental Health documentation shows that Mental Health’s Services Act Allocation Methodology methodology identified several factors and weighted them to derive each county’s share (see text box). State law required the California Department of Mental Mental Health outlined that methodology in a Health (Mental Health) to divide the available amount document issued to counties in June 2005. of Mental Health Services Act funds among the counties According to a Health Care Services memorandum, for any particular year and to give greater weight to Mental Health last applied the methodology significantly underserved counties or populations. Mental Health developed a formula, including the following in fiscal year 2009–10. In subsequent years through weighted factors: fiscal year 2012–13, allocations were based on the ratio of the county’s allocation to the total allocation 1. The need for mental health services in each county based for all counties for fiscal year 2009–10. However, it on the following: appears Mental Health has not updated the factors a. The county’s total population. since 2008 and therefore has not accounted for b. Population most likely to apply for services, which counties’ prevalence of mental illnesses, poverty represents the sum of: rates, or populations. Thus, a county with a sharp rise in the prevalence of mental illnesses may still • The poverty population. receive the same proportion of MHSA funds that it • The uninsured population. did for fiscal year 2009–10. Of further concern, based on available documentation, Mental Health • Population most likely to access services, which represents the prevalence of mental developed its methodology in 2005, at the time that illness among different age groups and ethnic it implemented the Community Supports populations of poverty households. component, and does not appear to have altered that methodology when it implemented the 2. Adjustments to the need for mental health services in remaining four components. Consequently, to each county based on the following: the extent that changes such as in county population a. The cost of being self‑sufficient. or the introduction of new MHSA components b. The available resources provided in fiscal year 2004–05, warrants modification of the allocation formula, such as funding sources, including the State’s General MHSA allocations to counties may not be Fund managed care allocations. appropriate to meet changing county needs. 3. An additional minimum planning estimate for each county, to provide small counties with a base level During the course of our audit, we made repeated of funding. requests of Health Care Services for documents and information regarding the allocation methodology, Sources: Welfare and Institutions Code and Mental Health’s but its officials did not comply with our requests. Letter No. 05-02, issued June 1, 2005. At our audit closing conference in mid-June 2013, 40 California State Auditor Report 2012-122 August 2013 Health Care Services officials in attendance again indicated that there was no such documentation. However, Health Care Services did provide a copy of a letter sent to the California Department of Finance dated June 2012 outlining how the factors comprising the methodology were weighted and applied to compute the counties’ MHSA allocations for fiscal years 2009–10 through 2012–13. Although the director has stated that Health Care Services will revise its methodology, currently no changes are planned until MHSA funding exceeds peak levels, i.e., the highest amount of taxes remitted to the fund in a single year, which occurred in fiscal year 2009–10, to ensure that adjustments to the methodology that might lower the amount a particular county receives will not result in a county being unable to fund existing MHSA obligations. The director stated that Health Care Services intends to review the existing factors to determine how updating them would affect MHSA allocations. Because responsibility for developing an allocation methodology now resides with Health Care Services, we believe it is imperative that it either update Mental Health’s allocation methodology as necessary or create a new allocation methodology altogether to ensure that counties’ MHSA allocations are appropriate and reasonable. Until Health Care Services can fully support the reasonableness of the allocation methodology, questions will remain as to whether the counties’ allocations are commensurate with their need for mental health services. Recommendations Legislature To ensure that Health Care Services can withhold MHSA funds from counties that fail to comply with MHSA requirements, the Legislature should enact legislation that clarifies Health Care Services’ statutory authority to direct the State Controller’s Office to withhold such funds from a noncompliant county. Health Care Services To ensure that it monitors counties to the fullest extent as the MHSA specifies and that it implements best practices, Health Care Services should do the following: • Draft and enter into a performance contract with each county that contains sufficient assurances for effective oversight and furthers the intent of the MHSA, including demonstration that each of the county’s MHSA programs are meeting the MHSA’s intent. California State Auditor Report 2012-122 41 August 2013 • Conduct comprehensive on-site reviews of county MHSA programs, including verifying county compliance with MHSA requirements. To ensure that counties have the needed guidance to implement and evaluate their MHSA programs, Health Care Services should do the following: • Coordinate with the Accountability Commission and issue guidance or regulations, as appropriate, for Facilities programs and for other MHSA requirements, such as a prudent reserve. • Commence this regulatory process no later than January 2014. • Collaborate with the Accountability Commission to develop and issue guidance or regulations, as appropriate, to counties on how to effectively evaluate and report on the performance of their MHSA programs. To ensure that Health Care Services and other state entities can evaluate MHSA programs and assist the Accountability Commission in its efforts, Health Care Services should do the following: • Collect complete and relevant MHSA data from the counties. • Resolve all known technical issues with the partnership and client services systems and provide adequate and expert resources to manage the systems going forward. Health Care Services should, as soon as is feasible, revise or create a reasonable and justifiable allocation methodology to ensure that counties are appropriately funded based on their identified needs for mental health services. Health Care Services should ensure that it reviews the methodology regularly and updates it as necessary so that the factors and their weighting are appropriate. Accountability Commission To ensure that counties have needed guidance to implement and evaluate MHSA programs, the Accountability Commission should do the following: • Issue regulations, as appropriate, for Prevention and Innovation programs. • Commence the regulatory process no later than January 2014. 42 California State Auditor Report 2012-122 August 2013 To fulfill its charge to evaluate MHSA programs, the Accountability Commission should undertake the evaluations specified in its implementation plan. To ensure that it can fulfill its evaluation responsibilities, the Accountability Commission should examine its prioritization of resources as it pertains to performing all necessary evaluations. To report on the progress of MHSA programs and support continuous improvement, the Accountability Commission should fully use the results of its evaluations to demonstrate to taxpayers and counties the successes and challenges of these programs. Planning Council The Planning Council should do the following: • Take steps to ensure that it annually reviews the overall effectiveness of MHSA programs in accordance with state law. • Document and make public the reviews that it performs of MHSA programs to demonstrate that it is performing all required reviews. California State Auditor Report 2012-122 43 August 2013 Chapter 2 COUNTIES SHOULD IMPROVE MENTAL HEALTH SERVICES ACT PERFORMANCE MEASUREMENT AND DOCUMENTATION OF STAKEHOLDER PLANNING EFFORTS Chapter Summary The four county departments we reviewed—Los Angeles County Department of Mental Health (Los Angeles), County of Sacramento Department of Health and Human Services (Sacramento), County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and Santa Clara County Mental Health Department (Santa Clara)—differed in their approaches to assessing and reporting on their Mental Health Services Act (MHSA) programs. We noted that the counties varied in establishing meaningful goals for these programs and in implementing reasonable practices to evaluate their attainment of those goals.10 For example, some counties did not consistently include program goals from their initial plans in their contracts with program providers. As a result, some counties could not demonstrate that they had communicated with providers the importance of pursuing and tracking performance in meeting goals. Counties also varied in collecting and analyzing data to determine the achievement of program goals and in how completely they reported program outcomes. In the absence of explicit evaluation requirements and specific state guidance as discussed in Chapter 1, these differences are not surprising. All counties we reviewed complied with state regulations requiring the inclusion of specific stakeholders and community representatives throughout the MHSA planning process. However, we found instances in which counties did not comply with regulations requiring them to document or describe certain aspects of the public review process so they were unable to assure stakeholders or the public that their MHSA programs were prepared based on the broadest possible input from the communities and people those programs are intended to serve. Finally, we found that counties have generally taken steps to ensure that the payments they made to external contractors were for appropriate MHSA services. Counties Develop Plans That Summarize MHSA Programs The MHSA requires each county to lay out in a written plan the programs it will offer to address the mental health needs of its community. Figure 6 on page 45 illustrates the plan development 10 County plans sometimes refer to goals as “outcomes,” but we reserve the term outcomes for what programs have actually accomplished. 44 California State Auditor Report 2012-122 August 2013 and approval cycle in effect from January 2005 through March 2011.11 The figure shows that the process was iterative: once plans were approved, counties were to provide annual updates on those plans. The counties generally developed their plans for each Mental Health Services Act Component of the five MHSA components over time: Community Rollout Dates Services and Supports (Community Supports), Workforce Education and Training (Training), 2005: Community Services and Supports Prevention and Early Intervention (Prevention), 2007: Workforce Education and Training Capital Facilities and Technological Needs (Facilities), and Innovation. In a staggered rollout process from 2007: Prevention and Early Intervention 2005 through 2009, Mental Health issued guidelines to 2008: Capital Facilities and Technological Needs the counties for each MHSA component (see text box). 2009: Innovation The counties’ plans contain program descriptions and Sources: California Department of Mental Health information typically list program goals. For example, a program notices dated August 2005, July 2007, September 2007, March 2008, and January 2009. goal might be to reduce isolation in seniors or to assist homeless adults diagnosed with mental illness in accessing services. A county can generally include as many programs as it deems necessary, although realistically it can only fund so many programs with its annual MHSA allocation. Appendix B demonstrates the breadth and depth of the programs of the four reviewed counties. For example, Los Angeles’ plans list 68 programs across the five MHSA components. Because program goals are generally included in the draft plan, stakeholders and county officials can review the goals as part of the local planning process. To understand whether a program is meeting its stated goals, a county should identify the data needed to make that determination. For example, to understand whether the county’s senior population has reduced feelings of isolation as a result of its program, the county may develop and administer a survey of its program participants. However, the data to measure goals have generally not been stated in these plans. We found that counties often contract with service providers to deliver the programs outlined in their plans, and those contracts should specify providers’ responsibilities in collecting data for county evaluation of their programs, but again they have not always done so. Opportunity Exists for the Four Counties We Reviewed to Improve Their Performance Measurement Processes The clear intent of the MHSA is to ensure that services are provided in accordance with best practices in programs that are subject to local and state oversight so as to ensure accountability to taxpayers and the public. However, we found little evidence demonstrating that Mental Health 11 Effective March 2011 part of the process depicted in Figure 6 changed. Mental Health no longer reviewed and approved county plans, that role was transferred to each county’s board of supervisors, except for Innovation programs, which are reviewed and approved by the Mental Health Services Oversight and Accountability Commission. California State Auditor Report 2012-122 45 August 2013 Figure 6 Summary of the Mental Health Services Act Annual Planning, Review, Approval, and Implementation Process Fiscal Year 2006–07 Through March 2011 DESIGN THE PLAN CONTENTS IMPLEMENTATION With the input of local stakeholders, including individuals with severe mental illness, providers of services, and law enforcement and education agencies, the After approval of an initial component county designs the content of its plan. For initial component plans, based on our plan or a portion of that plan, Mental review of certain counties’ plans, this process involves identifying community Health Services Act (MHSA) funds are needs and drafting strategies to address those needs. For annual updates, the distributed to the county through its process focuses on implementation and service activities across components, MHSA agreement with the State. The as well as changes to existing programs or proposing new programs. county then generally proceeds with implementing its approved programs and providing services. Following approval of an annual update, the county continues services and/or 1 implementing approved changes to MHSA-funded programs. DEVELOP PLAN Based on stakeholder input from the 5 community and with the assistance 2 of formalized internal stakeholder groups or committees, the county decides on the programs/content to APPROVAL include and develops its draft of the plan or update for local review. Having submitted its plan, the county awaits review and approval 4 by the California Department of 3 Mental Health (Mental Health), after review and comment by the Mental Health Services Oversight and Accountability Commission LOCAL REVIEW PROCESS (Accountability Commission).* According to guidance issued by Mental Health, if additional County prepares and The county mental The county submits the adopted plan circulates the draft health board conducts to the State for review. County must information was needed from plan for review and a public hearing on the document (in the submitted plan) the counties on any portion of the plan, public comment for plan at the close of following: description of the methods it would not withhold approval on at least 30 days to the 30-day comment used to circulate the draft plan, the other acceptable portions of the representatives of period for further public hearing, summary and analysis plan; therefore, the approval process stakeholder interests comment, revisions, of any substantive recommendations, could be incremental. and any interested party and board adoption. and a description of any substantive who has requested a changes made to the draft plan copy of the plan. the county circulated for A B C public comment. Sources: California Welfare and Institutions Code and associated regulations, county MHSA plans and annual updates, and county provider contracts. * Effective March 2011 Mental Health’s review role ceased. Subsequent legislation requires counties’ boards of supervisors to approve county plans. The Accountability Commission must review and approve Innovation programs. had issued guidance to counties regarding the specific steps they should take to evaluate the performance of their MHSA programs, and our review of the four counties’ evaluation efforts revealed differing and inconsistent approaches to assessing and reporting on that performance, potentially hindering statewide efforts to 46 California State Auditor Report 2012-122 August 2013 evaluate the effectiveness of MHSA programs. Further, effective March 2011, the State is no longer statutorily required to review and approve county plans, with the exception of those relating to It is imperative for counties to use Innovation. Currently, county boards of supervisors are tasked with performance data as they make reviewing and approving these documents. Thus, moving forward, it decisions about which programs will become imperative for counties to use performance data as they to approve. make decisions about which programs to approve. Effective measurement of program performance depends on setting program goals, communicating them to program providers, and effectively collecting, measuring, and analyzing meaningful data. We evaluated the reviewed counties’ approaches to measuring their MHSA programs’ performance in four ways. First, we established whether they defined program goals in their MHSA plans, thereby establishing objectives by which they could measure performance. Because counties commonly contracted with providers to deliver mental health services, we next determined whether they included program goals in those contracts and made providers accountable for achieving them. Third, we assessed whether counties had identified meaningful data for measuring progress on achieving the program goals. Finally, we assessed whether counties collected and analyzed those data and reported the results. To identify programs to review, we selected six to nine provider contracts, largely based on their total dollar amounts, from fiscal years 2006–07 through 2011–12 for each county we reviewed. For Los Angeles, San Bernardino, and Santa Clara, we selected three contracts each from the Community Supports, Prevention, and Innovation components for a total of nine contracts per county. For Sacramento, we selected three Community Supports and three Prevention contracts, for a total of six contracts; we did not select Innovation contracts because Sacramento stated it had no active Innovation services for the period under review.12 The MHSA components for Training and Facilities are not designed to provide mental health services, so we did not include them. By Not Consistently Including MHSA Plan Goals in Contracts With Their Providers, Counties Cannot Ensure That the Providers Are Aware of Those Goals or Are Held Accountable for Achieving Them The counties we reviewed generally stated goals for their MHSA programs in their plans and annual updates. Because the plans are the county’s official description of the manner in which its 12 For fiscal year 2010–11, Sacramento included an Innovation program in its plan; the program is described in Appendix B. In fiscal years 2010–11 and 2011–12, Appendix D reflects that Sacramento made expenditures for Innovation. The fiscal year 2010–11 expenditures were for planning and the fiscal year 2011–12 expenditures were for a contracted entity that administered the Innovation program. However, as noted above, the county stated it was not providing Innovation services to mental health consumers in either fiscal year 2010–11 or 2011–12. California State Auditor Report 2012-122 47 August 2013 programs will fulfill the intent of the MHSA, it is important that the plans contain goals for each MHSA program the county designs. The plans of Los Angeles and Sacramento listed goals for each program we reviewed. For example, the description of a Los Angeles Community Supports program stated that the county embraces reducing incarceration in jails and juvenile halls as well as institutionalization. However, our review of plans from San Bernardino and Santa Clara found an instance in each plan in which the county did not clearly identify the goals for a program; thus, these counties have not made clear what those programs are intended to achieve, calling into question whether the programs will fulfill the intent of the MHSA. Moreover, although the counties’ plans contained program goals, they rarely developed specific objectives that would allow them to assess the effectiveness of the program in achieving the stated goals. We also found that three of the four counties failed to include the plan’s goals in their contracts with program providers. Los Angeles effectively used its contracting process with program providers to communicate all program goals for which they were responsible. However, the other three counties did not. • San Bernardino did not include all program goals in six of the nine provider contracts we reviewed. For example, the contract establishing the county’s Coalition Against Sexual Exploitation program did not contain all the program goals identified in the county plan, such as increasing the understanding of the impact of sexual exploitation, the risk factors, and the means to develop rapport and initiate effective identification and collaborative intervention and treatment. • Santa Clara included the services it planned to provide in the three contracts we reviewed for its Community Supports programs but did not include the actual program goals listed in its plan. • Although Sacramento included goals in the six contracts we reviewed, the content of three of those contracts was not always consistent with the goals stated in the county plans. For a Community Supports program, the county plan stated a goal of using bilingual, culturally competent staff, with a minimum of 20 percent of those staff being mental health services clients, family members, and caregivers. However, the program provider’s contract did not state this goal. Without ensuring that the contracts include all the applicable programs’ goals, counties cannot be certain that providers are aware of the programs’ objectives, that they are achieving the programs’ intent, or that providers can be held accountable for attaining the programs’ goals. 48 California State Auditor Report 2012-122 August 2013 Without Meaningful Data, Some Counties Are Hindered in Measuring Whether Their Programs’ Goals Were Achieved Counties and their contract providers often identified meaningful data and ways to measure goal achievement. However, the counties we reviewed varied in how effectively they identified such data. Some counties reported strong practices for using specific goals and identifying the needed data. Los Angeles and Sacramento both reported taking steps to identify the appropriate data to measure and to ensure that providers were aware of the need to collect those data. However, San Bernardino and Santa Clara typically used ad hoc approaches that were not always sufficient in identifying meaningful data. Because these counties cannot reasonably measure whether their MHSA programs accomplished their identified goals, they are less able to ensure that they are providing effective mental health services to their communities. Generally, Los Angeles and Sacramento effectively identified meaningful data that would allow them to measure their programs’ effectiveness. For its Full-Service Partnership (Partnership) programs, Los Angeles expanded upon existing data collection instruments that it required providers to use. These expanded data elements include detailed information about clients’ living arrangements, such as whether clients and provider staff believe the change in the living arrangement was positive or negative. A Sacramento Prevention program that aims to reduce bullying in local schools identified improved student perceptions of school safety as a program goal. To capture data on that goal, the program used detailed pre- and post-survey instruments administered to students at school sites where the program was conducted. More than half of the contracts However, more than half of the contracts we reviewed for we reviewed for San Bernardino San Bernardino and Santa Clara did not identify meaningful data and Santa Clara did not identify for measuring their programs’ effectiveness. Eight of the nine contracts meaningful data for measuring San Bernardino executed lacked requirements for collecting and their programs’ effectiveness. providing information suitable for measuring goal achievement. Further, San Bernardino lacked a process to identify meaningful data to measure its progress in achieving goals. For example, the county gave the providers of all three Innovation programs we reviewed templates to summarize program performance, but the templates did not specify what data the providers should capture. One way in which the county could better ensure that it identifies meaningful data is to strengthen the inclusion of desired goals in its contracts; San Bernardino’s chief of research and analytics indicated that the county was reviewing its Community Supports provider contracts for this purpose. In addition, the managers of its Prevention and Innovation programs indicated that the county was continuing to improve its evaluation efforts of those programs and that, beginning July 2013, it will be implementing some standard evaluation tools. California State Auditor Report 2012-122 49 August 2013 In five of the nine program provider contracts we reviewed, Santa Clara did not always identify the data to collect to determine goal achievement, and it did not have processes in place for its Community Supports and Prevention programs for that purpose. For example, in one Prevention program we reviewed, the county developed a program that includes making books available for young children in doctors’ offices as a screening tool for identifying early indications of developmental delays and providing key linkages to certain county mental health services. However, based on the required reporting, the county could not determine whether the program met the goal of increasing early detection of developmental delays. The director of Santa Clara’s family and children’s services division indicated that as of April 2013 the county was in the contract renewal process and was reviewing all of its contracts and making modifications to ensure that the contracts include data and outcome requirements. The counties also rarely developed specific, well-defined, and measurable objectives that would allow them to assess the effectiveness of program services. Without such specific objectives, counties are Without specific, well-defined and not able to demonstrate their programs’ actual success. We assessed measurable objectives, counties both plans and contracts prepared by each county to determine are not able to demonstrate their whether those documents contained specific measurable objectives. programs’ actual success. Although Sacramento’s Community Supports plan included one such objective, all other plans we reviewed across all four counties did not. Of the 33 contracts we reviewed, only three Sacramento contracts and one Los Angeles contract contained specific objectives. A Sacramento Community Supports program contract to develop permanent housing units contained the specific objective that 80 percent of clients would obtain housing within 120 days of enrolling in the program. However, neither the Santa Clara nor San Bernardino contracts we reviewed contained specific objectives. Although one of San Bernardino’s providers stated its progress in meeting objectives in an annual report, all the goals these objectives were derived from except one differed from those in the county’s plan; however, in one instance the specific objectives the provider reported on did address a program goal listed in the county’s plan. Setting specific objectives, assessing programs for meeting those objectives, and reporting on the results seems especially relevant to the Innovation component. Media reports reflect skepticism about counties’ Innovation programs, some of which include acupuncture and yoga, perhaps because Innovation programs may include novel, creative, and/or ingenious approaches to a mental health practice and at times the link between the program and mental health is not obvious. Counties have been advised that Innovation programs are efforts to learn about promising approaches to treating and preventing mental illness and that the programs are similar to pilot or demonstration projects, are time limited, and should be assessed for effectiveness. Assessing and reporting on the effectiveness of 50 California State Auditor Report 2012-122 August 2013 Innovation programs are critical to ensuring that only effective programs are continued and to assuring taxpayers and the public that MHSA funds are put to the best use. Not All Counties Analyzed and Reported on Data, Hindering Their Ability to Assess and Communicate Whether They Were Meeting Program Goals Quality data collection, analysis, The quality of data collection, analysis, and reporting related to program and reporting processes related to goals differed among counties and across their MHSA components. program goals are central to effective Such processes are central to effective performance measurement because performance measurement. they allow counties to demonstrate their programs’ effectiveness. When the processes are flawed or incomplete, the counties and their respective communities cannot measure the difference that MHSA programs are making in the lives of community members with mental health illnesses. Los Angeles was generally effective in its collection and analysis of data related to program goals. For example, for its Community Supports programs, the county formulated reports using data that providers entered directly into an online database created by the county and referred to as the Outcomes Measures Application. It then shared these reports, including detailed data on living arrangements and mental health, with internal and external stakeholders. Los Angeles also provided analysis of its Community Supports and Prevention programs’ outcomes in its fiscal year 2012–13 annual update. For example, the county reported on its Community Supports program goal of reduced incarceration by stating that it achieved a 26 percent decrease in the number of older adult clients who were incarcerated in fiscal year 2010–11, along with a 36 percent decrease in the number of days those clients were incarcerated. Nevertheless, Los Angeles, like the other counties reviewed, generally lacked specific targeted objectives that were well defined and measurable and that quantified what program success is. Therefore, even though its report of these decreases for two measures related to incarceration may indicate successful achievement, if its targeted objectives had been decreases of 50 percent and 75 percent, respectively, it would not indicate a successful attainment of the stated goal. Although Sacramento consistently collected, analyzed, and often reported on data related to the three Community Supports programs we reviewed, it did not always do so for its Prevention programs. In two of the three Prevention programs we reviewed, the county failed to collect data that its contracts required providers to submit. For example, one Prevention contract required the provider to measure clients’ awareness of suicide risk before and after participating in the program, but the county did not request the data in the report template it distributed to the provider. As a result, the provider never submitted the data to the county. The county’s division of behavioral health’s program planner confirmed the oversight and stated that the county is amending the template to collect the data in the future. California State Auditor Report 2012-122 51 August 2013 San Bernardino also often failed to collect meaningful data, which affected its ability to adequately analyze and report on program goals. Specifically, it did not collect data on goals identified for contracts we reviewed for its Innovation programs, for one of the contracts we reviewed for a Prevention program, and for some of the goals identified for each of the three contracts we reviewed for its Community Supports programs. This failure to collect data may be due to San Bernardino’s insufficient identification of meaningful data, as described earlier. Santa Clara also did not collect relevant data on some goals identified for its Prevention and Community Supports programs we reviewed, although it did appear to have processes in place to properly analyze and report on its Innovation programs. Specifically, Santa Clara did not collect sufficient data for three Community Supports and two Prevention program contracts, preventing it from sufficiently analyzing and reporting on any of these programs’ accomplishments. In contrast, for the three Innovation program contracts we reviewed, Santa Clara did collect meaningful data on the goals and prepared reports on the performance. For its Innovation program, Adults with Autism and Co-occurring Mental Health Disorders, one goal is to understand the effectiveness of a new diagnosis tool; Santa Clara has an evaluation plan for the program that resulted in detailed monthly reports that noted a higher rate of diagnosing autism using the tool. In addition, for its Innovation programs and based on information provided by the county, it established learning advisory committees that are charged with refining project design, assessing progress, and evaluating results. Consequently, Santa Clara appears to have processes in place to analyze and report on the performance of its Innovation programs. Counties Described Program Outcomes and Efforts to Use Data to Improve MHSA Services, but Our Review Suggests That These Outcomes and Efforts Are Incomplete For the four counties we reviewed, the Joint Legislative Audit Committee (audit committee) asked us to identify key outcomes achieved, including those achieved for traditionally underserved and diverse communities, such as reductions in homelessness and psychiatric hospitalizations.13 Further, the audit committee asked us to review and assess the extent to which each county uses outcomes to improve the local mental health systems. To address these objectives, we asked the four counties to respond with documentation to 13 The audit committee asked us to identify key performance measures—as well as outcomes achieved—as part of its audit request. However, during the course of our field work and based on counties’ responses to our inquiries, we learned that the terms performance measures and outcomes were generally used interchangeably. Thus, for the purposes of our report, we have chosen to use the term outcomes to describe what programs actually achieved with respect to their goals. 52 California State Auditor Report 2012-122 August 2013 questions relating to data they view as key to evaluating their MHSA programs, any key outcomes achieved, and ways they have used those outcomes to improve services. Although the state entities charged with oversight and evaluation of MHSA programs have not provided specific performance measurement directions, counties’ use of data to measure a program’s achievement of Based on some of the counties’ goals and whether they produced specified outcomes would responses to our questions, we allow counties and the public to assess the success of MHSA concluded that the counties’ efforts programs. However, based on some of the counties’ responses to to evaluate and improve their our questions, we concluded that the counties’ efforts to evaluate MHSA programs are incomplete. and improve their MHSA programs are incomplete. The level of detail present in Los Angeles’ response and our conclusions regarding its generally strong efforts to measure program performance document that county’s efforts to use outcome data to improve services. The detailed Los Angeles report addressed data collection and outcomes across all of its MHSA components, and the director of the Los Angeles Department of Mental Health called out specific outcomes the county achieved, such as a 71 percent reduction in days spent homeless for adult Partnership clients. This outcome works toward satisfying the county’s Partnership program goal that clients experience positive housing outcomes. According to the director, Los Angeles frequently uses performance measures and outcomes for improving MHSA programs and services. In one instance, the director explained a county review found that older adult Partnership clients with certain disorders were the most costly to treat; in response, the county is bringing in an expert on these specific disorders to train provider staff on best treatment practices. The review provided other specific past and planned efforts to use outcomes for program improvement, including efforts aimed at further improving practices for measuring outcomes. Sacramento’s response was less detailed than our review of its program performance measurement processes led us to expect. The former acting director of Sacramento County’s Department of Health and Human Services provided limited data on outcomes achieved and was not specific in reporting on the ways the county used outcomes to improve programs. Among the outcomes she reported was a 58 percent decrease in mental health-related emergency room visits by Partnership clients. She also listed only one outcome for one of the county’s Prevention programs and noted that the shortage of reportable outcomes data stemmed from both the nature of the programs and limited resources. However, she acknowledged that as resources become available in the future, measures and outcomes will be reported. In addition, the outcomes she did report were generally taken from documents focusing on fiscal years 2007–08 through 2009–10. Our review established that the county has no more recent Community Supports outcomes California State Auditor Report 2012-122 53 August 2013 of this kind. However, the former acting director stated that the county is developing additional reports on Partnership program outcomes for fiscal years 2010–11 and 2011–12. Finally, in contrast to the other three counties’ responses, she reported that Sacramento only intermittently used performance outcomes and measures to improve the county’s services. As an example, the county increased the capacity of its Partnership programs because of the positive outcomes in those programs. Although the former acting director acknowledged limitations on the county’s collection of outcome data, we believe its ability in this area was likely also hampered by the county not always including goals in its program provider contracts or collecting all data the contracts specified—issues described previously. San Bernardino’s director of the Department of Behavioral Health Administration (Behavioral Health director) identified performance measures that the county states are key for evaluating MHSA programs or services and described the ways in which it used the performance measures and outcomes to improve its programs. As an example of the county’s success, she pointed to an outcome from a Community Supports program that targeted older adults, stating that 82 percent of clients maintained or improved their mental health functions based on a tool the county used to assess overall psychological, social, and occupational functions for people 18 and older. She also identified a Community Supports program for which data showed a population of underserved juvenile justice clients whose demographics included bilingual clients, and clients with incidences of substance abuse and problems with truancy. As a result of these data, San Bernardino hired an additional bilingual staff member to provide services to bilingual clients, rolled out new services relating to substance abuse treatment, and expanded supportive services to assist youth with transportation to and from school, among other things. The director of Santa Clara’s Mental Health Department (Mental Health director) noted that 88 percent of individuals to whom the county provided care come from underserved and diverse populations as one example of its success in increasing access to care for these populations. The Mental Health director also indicated that the county began providing childcare resources as a result of data it collected indicating that parents were cancelling or not appearing at scheduled appointments; outcome data subsequently indicated a significant increase in parent participation. Although both San Bernardino’s Behavioral Health director and Santa Clara’s Mental Health director stated that their counties frequently made use of collected data to measure program performance and resulting outcomes to improve their programs, our review found issues with the performance measurement processes these counties used. Therefore, even though the counties reported specific program 54 California State Auditor Report 2012-122 August 2013 outcomes and the use of those outcomes to improve their mental health delivery systems, our review shows that this level of reporting may not be representative of their MHSA programs. Issues May Exist With County Collection and Reporting of Data That Affect Statewide Evaluation As described in Chapter 1, evaluating the effectiveness of MHSA programs is a state-level responsibility, and the State’s evaluation should reasonably be able to rely on the counties’ data on program outcomes and goal achievement. However, the Accountability Commission has reported issues with county data collection In a July 2010 report, one of the and reporting. In a July 2010 report, one of its contractors noted Accountability Commission’s disparate evaluation efforts of MHSA activities, pointing out that contractors noted disparate although nearly all counties the contractor had interviewed or evaluation efforts of MHSA surveyed were evaluating one or more MHSA components, each activities and in two other evaluation effort represented a unique method for understanding reports published in May and what was working and what was not. The report also pointed out December 2011, the same contractor that several universities and other research partners were engaged noted limitations of the data. in independent research related to MHSA-funded activities. The report concluded that although each evaluation effort provides some benefit, it also increases the complexity of a statewide evaluation effort that seeks to build on existing efforts, avoid duplicative data collection requests, and ensure that data collection is consistent. In two other reports published in May and December 2011, the same contractor noted limitations of the data. Generally, both reports reviewed, summarized, and synthesized existing evaluations. The May report focused on Community Supports programs and reported that fully understanding the impact of Community Supports on client outcomes—such as living situations or employment—across counties was hampered by inconsistent collection and reporting of data. Specifically, the May report indicated that counties did not always report client outcomes by age group or other important demographics, including ethnicity and gender; they did not reveal their data sources, such as self-reported or clinician rating; and they did not consistently report on the same measures for assessing client outcomes. The December report provided a summary and synthesis of existing evaluations and studies on the impact of MHSA on nine MHSA values—including client and family involvement and engagement, and integration of mental health services with substance abuse services and primary care—and the report found that sufficient information or evidence was not available to assess the impact that the MHSA has had on those nine values. The report attributed its findings, in part, to the tendency of counties to focus their evaluation efforts on client-level outcomes rather than a broader set of outcomes that include the family, program, and community. As a result, both the limited California State Auditor Report 2012-122 55 August 2013 quantity and quality of information hampered the contractor’s ability to summarize and come to definitive conclusions about the impact of the MHSA on MHSA values across counties. These reports, as well as the July 2010 report, underscore the inconsistent These reports suggest the need for quality of data or information collected and reported that we found broader, standardized collection in our review of four counties. Further, they suggest the need for and measurement practices, even broader, standardized collection and measurement practices, even as individual counties pursue the as individual counties pursue the specific goals of their programs. specific goals of their programs. Counties Generally Complied With Regulations Governing the MHSA Planning Process, Including Stakeholder Involvement, but They Can Improve Some Documentation Practices To determine whether the four counties complied with regulations governing stakeholder involvement in the MHSA planning process, we reviewed their processes for developing, reviewing, and submitting their plans and updates. We chose for review the counties’ planning processes for the first MHSA component they rolled out— Community Supports—as well as the component they had most recently rolled out—Innovation—and we reviewed their most recent annual updates. Counties complied with regulations that require including specific types of stakeholders and representatives throughout the planning process. The plans generally indicated they had used similar structures to govern the stakeholder process and that stakeholder work groups provided program ideas and concepts to central groups or committees that included the stakeholders and county representatives responsible for overseeing the planning process and development of the draft plan. For example, in its Community Supports plan, Sacramento used a steering committee, four task forces, and several work groups. The four task forces each formed stakeholder work groups to complete assessments of the priority needs of targeted populations and to suggest programs and strategies to meet those needs. Each task force also reviewed program components and prioritized recommendations before sending the recommendations to the steering committee, which oversaw the MHSA planning process and included clients and family members. Further, counties documented that they included the required stakeholders in the planning processes we reviewed. The membership of both stakeholder workgroups and central groups or committees generally included not only clients and their family members but also representatives from community advocacy groups, public service agencies, and organizations. For example, during its Innovation planning process, Los Angeles stakeholder delegates included representatives from client networks and coalitions, faith-based organizations, law enforcement and education agencies, and specific ethnic and cultural communities. 56 California State Auditor Report 2012-122 August 2013 The counties we reviewed also implemented staffing and training practices consistent with community planning regulations. To support MHSA planning, the four counties designated positions responsible for overall administration of planning—typically an MHSA coordinator—and for engaging specific communities such as unserved and underserved populations. In addition, based on interviews with county staff and available examples of training-related materials, including attendance rosters, we found that all four counties offered training to staff and stakeholders. We found that the county plans However, we found that the county plans we reviewed reflected we reviewed reflected certain certain inconsistencies between the counties’ documentation of inconsistencies between the their planning processes and the documentation requirements counties’ documentation of contained in the regulations. Since December 2006 regulations their planning processes and the have required that a county’s plans and annual updates must documentation requirements explain how the county complied with requirements related to the contained in the regulations. community planning process, including stakeholder participation. Figure 6 on page 45 describes the general process involved in a county’s community planning process, including the local review process. All four counties we reviewed included a standardized form that attested to their compliance, but they did not describe how they complied. The requirement to describe stakeholder involvement in plan review is important because it helps ensure that a county’s MHSA services were vetted by the community, including individuals the MHSA programs are meant to serve, and that the county was responsive to the community’s feedback. Those same December 2006 regulations require the county to document certain aspects of its local review process as part of its plans and annual updates. For example, the county must describe the methods it used to circulate its draft component plan or annual update for public comment, yet the counties we reviewed did not always submit a complete description of these methods with their component plan or update. The four counties’ Innovation component plans stated only the dates during which the draft plan had been posted for public review and provided no further detail of how the counties circulated the drafts. This was also the case with Sacramento’s fiscal year 2012–13 annual update. These descriptions seemed particularly incomplete since we noted detailed descriptions in other plans we reviewed, such as translating plan summaries into multiple languages, distributing draft plans to local libraries, and responding to phone and e-mail requests for copies of the drafts. Los Angeles, Sacramento, and Santa Clara responded to our questions by stating they undertook methods to circulate the plans that were not outlined in their plans. San Bernardino did not state that it had undertaken additional methods, but it acknowledged that the plan needed clarification to be fully in line with the requirement. California State Auditor Report 2012-122 57 August 2013 The reasons underlying the inconsistencies vary. Between fiscal years 2005–06 and 2010–11, Mental Health issued guidelines to counties for preparing component plans and annual updates. These guidelines, however, did not always fully align with the regulations pertaining to the planning process. Specifically, Mental Health’s Community Supports component plan guidelines—issued in August 2005 and before these regulations were in effect—explicitly required counties to provide information or documentation of the local review process, such as how the county circulated the draft plan for public review. However, Mental Health’s Innovation component plan guidelines do not mention this requirement. Similarly, Mental Health omitted a requirement related to obtaining stakeholder input from the standardized form counties use to certify their compliance with requirements. As a result, the form did not specifically ask counties to explain how they complied with Despite the inadequate guidance the given regulation. Despite the inadequate guidance from Mental from Mental Health, counties were Health in these instances, counties were still required to comply still required to comply with the with the applicable regulations. applicable regulations. The four counties we reviewed generally maintained that although they are confident their planning processes are complete, they could have done more to document these processes in their plans and thus comply with the regulations. Santa Clara’s MHSA coordinator confirmed that the county’s plans did not include the specific language that regulations required but stated that the county followed the guidance from Mental Health. The deputy director of San Bernardino’s program support services stated that although the county maintains that it met the requirements of the process and that its MHSA plans document that process, the language in the plan should have been clearer to fully align with regulations. Similarly, Sacramento’s MHSA program manager indicated that although their plans lacked the explicit content that regulations require, the county strives to circulate its plans, documents the feedback it receives, and complies with other planning requirements. The MHSA program manager also stated that the county plans to review the draft content of its fiscal year 2013–14 annual update to ensure that the final version includes specifics on how the county met these requirements. The deputy director of Los Angeles’ program support bureau stated that the standardized form Los Angeles used to assert compliance with certain planning requirements for its fiscal year 2012–13 annual update—which makes the same statements about compliance as the form Mental Health required counties to complete—was used by all counties and vetted by certain state entities involved in overseeing the MHSA. As evidence of Los Angeles’ compliance with regulations, the deputy director also provided a flyer about the Innovation review process. However, Los Angeles did not describe the flyer, including how it was distributed to the public, in its submitted plan, and thus it does not fulfill the regulation’s requirement. Although each 58 California State Auditor Report 2012-122 August 2013 county expressed confidence that its planning process is strong, failure to comply with required documentation of the planning process means counties cannot always point to their official plans to assure their stakeholders or the public that their plans for MHSA programs are prepared with the broadest possible input. Counties’ Review of Provider Invoices and Contract Oversight Helps to Ensure That Payments to Providers Are for Contracted Services The four counties have a common Our review showed that the four counties have a common control control in place that helps ensure in place that helps ensure that payments to providers are for payments to providers are for programs that the county contracts for and that are specified contracted programs. in their plans. Counties often contract with providers to deliver mental health programs in lieu of using county-operated clinics. Based on interviews with county staff and our review of available documentation, we noted that each county has an invoice review and approval process in place for ensuring that providers’ requests for payment are appropriate. For example, in Sacramento the fiscal services division receives a provider’s monthly invoice and forwards it to program staff to review each expenditure and compare it to the provider’s contract. If the expenditure aligns with the contract, staff approve the invoice for payment. For the Community Supports, Prevention, and Innovation components, we reviewed a total of 43 invoices selected from the four counties covering fiscal years 2006–07 through 2011–12, and we found that the respective county had reviewed and approved each invoice. Contract oversight provides the counties with valuable insights about their providers’ performance, including the types of services rendered and whether the programs reflect the county’s plan. Based on interviews and our review of available documentation, the four counties appear to perform oversight activities that help ensure that providers are requesting payment only for those services they deliver in accordance with their contracts and the counties’ plans. For example, three of the four counties we reviewed use contract monitors. Generally, these staff function as liaisons between the counties and the providers and perform site visits, among other responsibilities. All four counties also had quality assurance review programs in place. For example, Los Angeles has two levels of quality assurance reviews that, according to the compliance officer of the Compliance Program and Audit Services division, are scheduled to include all providers of mental health programs the county offers, including providers of MHSA programs. These quality assurance reviews typically include examining a provider’s expenditures, client charts, services delivered, and the provider’s internal controls to ensure compliance with the county’s program requirements. California State Auditor Report 2012-122 59 August 2013 Generally, program provider contracts and program descriptions in the county plans supported county expenditures. However, we questioned two invoices Santa Clara paid. For the period covering May 2007 through June 2008, Santa Clara entered into a contract with a provider who offered transitional housing unit beds—i.e., sleeping arrangements—for clients on a daily basis; the services were part of Santa Clara’s Community Supports plan. The invoice totaled over $7,600 but provided no support for the services the contractor claimed. The invoice listed the total number of beds the contractor claimed were occupied during the month multiplied by the daily rate charged per bed. Although the county’s contract with the provider required the provider to maintain detailed records about services provided, including admissions lists, it did not specifically require detailed invoice support. Without support, such as an admissions list, to demonstrate the number of clients requiring beds on any given day, the county has little assurance that it is paying for MHSA services that were actually provided. In addition, we reviewed an invoice for over $58,000 from a program provider that was contracted to deliver early detection, prevention, and intervention services to adolescents and transition-age youth as part of Santa Clara’s Prevention plan. However, the invoice included more than $19,000 for services that were not a part of the provider’s contract. According to the director of the family and children’s services division, the invoiced services were mistakenly left out of the provider’s contract. In May 2013 the county executed a contract amendment allowing for the previously paid services. Although the contract has been corrected, the county modified it only because we brought the discrepancy to the county’s attention, almost a year after the county paid its provider for services the provider was not authorized to supply. Recommendations California Department of Health Care Services To improve the quality of county processes for measuring program performance, the California Department of Health Care Services (Health Care Services) should use its performance contracts with counties to ensure that they do the following: • Specify MHSA program goals in their plans and annual updates and include those same goals in their contracts with program providers. 60 California State Auditor Report 2012-122 August 2013 • Identify meaningful data to measure the achievement of all their goals, set specific objectives, and require their program providers to capture those data so they can use the data to verify and report the effectiveness of their MHSA programs. Health Care Services should develop standardized data collection guidelines or regulations, as appropriate, that will address inconsistencies in the data that counties report to the State. In developing these guidelines or regulations, Health Care Services should consult with the Accountability Commission to ensure that data collected reasonably fulfill statewide evaluation purposes. To help ensure county compliance with stakeholder regulations, Health Care Services should provide technical assistance to counties on the MHSA local planning review process and ensure that its guidance to counties is clear and consistent with state regulations. Santa Clara Santa Clara should do the following: • Review its existing MHSA contracts and by December 31, 2013, or as soon as is feasible, amend them as necessary to include plan goals. • Ensure that all MHSA invoices are adequately supported with information that demonstrates that MHSA services were provided. Sacramento Sacramento should review its existing MHSA contracts and by December 31, 2013, or as soon as is feasible, amend them as necessary to include plan goals. San Bernardino San Bernardino should review its existing MHSA contracts and by December 31, 2013, or as soon as is feasible, amend them as necessary to include plan goals. California State Auditor Report 2012-122 61 August 2013 We conducted this audit under the authority vested in the California State Auditor by Section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the scope section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor Date: August 15, 2013 Staff: Laura G. Kearney, Project Manager Sharon L. Fuller, CPA Christopher P. Bellows Nathan Briley, JD, MPP Mark Reinardy, MPP Erin Satterwhite, MBA Legal Counsel: Stephanie Ramirez-Ridgeway, Sr. Staff Counsel For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255. 62 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 63 August 2013 Appendix A Mental Health Services Act Funds by County and Component Fiscal Years 2006–07 Through 2011–12 The Joint Legislative Audit Committee directed the California State Auditor to determine the amount of Mental Health Services Act (MHSA) funds that the State allocated to the counties for each MHSA component for the past six fiscal years. Table A shows county allocation amounts from the California Department of Mental Health’s (Mental Health) Web site for fiscal years 2006–07 through 2009–10 and California State Accounting and Reporting System (CALSTARS) expenditure data obtained from the California Department of State Hospitals (State Hospitals) for fiscal years 2010–11 and 2011–12. Effective June 27, 2012, the State streamlined and reorganized Mental Health, which became State Hospitals. The California Department of Health Care Services, State Hospitals, and the California Department of Social Services now perform duties that Mental Health once performed. As Table A shows, the amount of funds allocated or spent varied widely among counties and fiscal years. Funding in fiscal year 2011–12 was the lowest in the past five fiscal years corresponding with the Legislature directing more than $850 million to other mental health programs. Because Mental Health implemented the five MHSA components over time, it did not allocate funds for each component in every fiscal year. We did not determine the accuracy or completeness of the amounts listed in the table. Table A Unaudited Mental Health Services Act Funds by County and by Component Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Alameda CSS $11,145,798 $33,067,500 $22,863,600 $31,914,400 $56,956,441 $26,276,200 $182,223,939 PEI – 4,301,000 10,366,400 13,902,800 15,557,864 7,081,300 51,209,364 INN – – 2,543,800 2,543,800 6,825,900 1,742,400 13,655,900 CAPTECH – 12,327,100 3,873,200 – 16,200,300 – 32,400,600 WET 3,645,000 3,911,700 1,800,000 – – 1,800,000 11,156,700 Totals $14,790,798 $53,607,300 $41,447,000 $48,361,000 $95,540,505 $36,899,900 $290,646,503 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 64 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Alpine CSS $254,927 $358,300 $622,600 $872,600 $751,314 $718,400 $3,578,141 PEI – 100,000 150,200 250,200 319,500 126,500 946,400 INN – – 62,000 62,000 232,600 44,500 401,100 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 450,000 – 900,000 Totals $479,927 $1,283,300 $1,023,300 $1,184,800 $2,541,914 $889,400 $7,402,641 Amador CSS $531,570 $1,355,900 $1,298,300 $1,648,300 $2,074,619 $1,357,100 $8,265,789 PEI – 100,000 227,600* 327,600* 732,300* 199,700* 1,587,200 INN – – 115,200 115,200 367,400 80,000 677,800 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 416,200 – 866,200 Totals $756,570 $2,280,900 $1,829,600 $2,091,100 $4,379,019 $1,636,800 $12,973,989 Berkeley City† CSS $896,084 $3,466,100 $1,893,500 $2,687,100 $4,131,965 $2,212,400 $15,287,149 PEI – 370,300 897,600 1,207,700 1,605,605 614,500 4,695,705 INN – – 214,800 214,800 685,200 147,700 1,262,500 CAPTECH – 1,089,700 342,400 – 1,432,100 – 2,864,200 WET 313,800 343,100 – – 656,900 – 1,313,800 Totals $1,209,884 $5,269,200 $3,348,300 $4,109,600 $8,511,770 $2,974,600 $25,423,354 Butte CSS $1,999,624 $5,818,700 $3,984,300 $5,340,000 $4,649,400 $4,396,600 $26,188,624 PEI – 639,300 1,545,000* 2,074,800* 1,883,600* 1,274,700* 7,417,400 INN – – 418,100 418,100 1,326,200 285,000 2,447,400 CAPTECH – 1,849,700 581,200 – 742,061 – 3,172,961 WET 541,800 587,100 – – – – 1,128,900 Totals $2,541,424 $8,894,800 $6,528,600 $7,832,900 $8,601,261 $5,956,300 $40,355,285 Calaveras CSS $609,442 $1,614,800 $1,404,300 $1,754,300 $1,960,526 $1,444,400 $8,787,768 PEI – 121,100 292,300* 403,300* 417,100* 247,200* 1,481,000 INN – – 126,400 126,400 400,300 86,500 739,600 CAPTECH – 600,000 188,500 – 408,500 – 1,197,000 WET 225,000 225,000 – – – – 450,000 Totals $834,442 $2,560,900 $2,011,500 $2,284,000 $3,186,426 $1,778,100 $12,655,368 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 65 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Colusa CSS $430,973 $1,006,200 $1,159,500 $1,509,500 $1,314,300 $1,242,900 $6,663,373 PEI – 100,000 153,100* 253,100* 225,500* 154,400* 886,100 INN – – 101,500 101,500 327,100 72,000 602,100 CAPTECH – 600,000 188,500 – 325,559 – 1,114,059 WET 225,000 225,000 – – – – 450,000 Totals $655,973 $1,931,200 $1,602,600 $1,864,100 $2,192,459 $1,469,300 $9,715,632 Contra Costa CSS $7,192,809 $20,989,700 $14,657,600 $20,347,300 $17,715,700 $16,752,600 $97,655,709 PEI – 2,686,300 6,489,100* 8,712,300* 5,154,800 8,104,400* 31,146,900 INN – – 1,616,400 1,616,400 3,689,672 1,106,800 8,029,272 CAPTECH – 7,778,300 2,443,900 – 6,022,200 – 16,244,400 WET 2,276,500 2,461,500 – – – – 4,738,000 Totals $9,469,309 $33,915,800 $25,207,000 $30,676,000 $32,582,372 $25,963,800 $157,814,281 Del Norte CSS $475,514 $1,187,400 $1,224,500 $1,574,500 $1,370,935 $1,296,400 $7,129,249 PEI – 100,000 187,000 287,000 596,200 148,600 1,318,800 INN – – 108,100 108,100 400,500 75,800 692,500 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 416,200 – 866,200 Totals $700,514 $2,112,400 $1,708,100 $1,969,600 $3,572,335 $1,520,800 $11,583,749 El Dorado CSS $1,437,533 $5,180,200 $2,853,700 $3,744,800 $4,476,340 $3,083,200 $20,775,773 PEI – 331,770 1,036,700* 1,385,000* 2,636,699* 850,500* 6,240,669 INN – – 292,000 292,000 923,500 198,100 1,705,600 CAPTECH – 1,235,800 388,300 – 1,624,100 – 3,248,200 WET 365,300 389,700 – – 389,700 – 1,144,700 Totals $1,802,833 $7,137,470 $4,570,700 $5,421,800 $10,050,339 $4,131,800 $33,114,942 Fresno CSS $8,042,129 $22,362,500 $15,958,200 $22,217,000 $19,343,600 $18,292,000 $106,215,429 PEI – 2,721,000 6,722,800* 9,168,400* 8,400,200* 5,649,900* 32,662,300 INN – – 1,739,800 1,739,800 5,552,100 1,198,500 10,230,200 CAPTECH – 8,406,100 2,641,200 – 8,022,449 – 19,069,749 WET 2,306,000 2,679,800 – – – – 4,985,800 Totals $10,348,129 $36,169,400 $27,062,000 $33,125,200 $41,318,349 $25,140,400 $173,163,478 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 66 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Glenn CSS $486,119 $1,189,200 $1,234,500 $1,584,500 $1,379,600 $1,304,600 $7,178,519 PEI – 100,000 188,500* 288,500* 261,900* 175,500* 1,014,400 INN – – 108,700 108,700 348,300 76,200 641,900 CAPTECH – 600,000 188,500 – – – 788,500 WET 225,000 225,000 1,800,000 – – 1,800,000 4,050,000 Totals $711,119 $2,114,200 $3,520,200 $1,981,700 $1,989,800 $3,356,300 $13,673,319 Humboldt CSS $1,294,231 $4,405,400 $2,553,400 $3,340,600 $2,908,500 $3,439,460 $17,941,591 PEI – 370,200 892,700* 1,200,200* 1,087,600* 47,940* 3,598,640 INN – – 258,700 258,700 430,700 175,800 1,123,900 CAPTECH – 1,068,100 335,600 – – – 1,403,700 WET 313,700 337,200 – – – – 650,900 Totals $1,607,931 $6,180,900 $4,040,400 $4,799,500 $4,426,800 $3,663,200 $24,718,731 Imperial CSS $1,716,012 $5,475,500 $3,408,200 $4,576,900 $3,985,000 $3,768,400 $22,930,012 PEI – 503,600 1,249,900* 1,706,600* 2,607,876* 1,052,500* 7,120,476 INN – – 353,200 353,200 1,123,400 242,200 2,072,000 CAPTECH – 1,568,900 492,900 – 2,061,800 – 4,123,600 WET 426,800 503,000 – – 929,800 – 1,859,600 Totals $2,142,812 $8,051,000 $5,504,200 $6,636,700 $10,707,876 $5,063,100 $38,105,688 Inyo CSS $373,705 $730,600 $783,600 $1,033,600 $1,380,500 $851,000 $5,153,005 PEI – 100,000 152,100 252,100 153,700 128,400 786,300 INN – – 72,800 72,800 234,500 51,400 431,500 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 416,200 – 866,200 Totals $598,705 $1,655,600 $1,197,000 $1,358,500 $2,973,400 $1,030,800 $8,814,005 Kern CSS $7,048,579 $19,040,100 $13,868,500 $19,210,900 $16,726,300 $15,817,000 $91,711,379 PEI – 2,333,700 5,764,300* 7,851,800* 14,982,431* 4,838,700* 35,770,931 INN – – 1,503,100 1,503,100 2,539,100 1,034,300 6,579,600 CAPTECH – 7,165,600 2,251,400 – 6,006,056 – 15,423,056 WET 1,977,700 2,297,000 – – 50 – 4,274,750 Totals $9,026,279 $30,836,400 $23,387,300 $28,565,800 $40,253,937 $21,690,000 $153,759,716 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 67 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Kings CSS $1,511,485 $4,674,600 $2,936,100 $3,870,700 $7,763,463 $3,186,900 $23,943,248 PEI – 367,924 1,024,200 1,389,300 2,933,300 705,500 6,420,224 INN – – 298,300 298,300 945,900 203,500 1,746,000 CAPTECH – 1,254,300 394,100 – 1,648,400 – 3,296,800 WET 353,600 402,400 – – 403,000 – 1,159,000 Totals $1,865,085 $6,699,224 $4,652,700 $5,558,300 $13,694,063 $4,095,900 $36,565,272 Lake CSS $760,035 $2,162,400 $1,615,300 $1,985,000 $2,300,502 $1,634,300 $10,457,537 PEI – 178,400 427,300* 571,900* 927,548* 350,900* 2,456,048 INN – – 150,000 150,000 546,300 100,900 947,200 CAPTECH – 600,000 188,500 – 613,500 – 1,402,000 WET 225,000 225,000 – – 416,250 – 866,250 Totals $985,035 $3,165,800 $2,381,100 $2,706,900 $4,804,100 $2,086,100 $16,129,035 Lassen CSS $479,453 $1,187,500 $1,228,100 $1,578,100 $1,430,600 $1,299,300 $7,203,053 PEI – 100,000 186,000 286,000 148,400 148,000 868,400 INN – – 108,200 108,200 400,900 75,900 693,200 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 450,000 – 900,000 Totals $704,453 $2,112,500 $1,710,800 $1,972,300 $3,218,400 $1,523,200 $11,241,653 Los Angeles CSS $90,691,911 $260,220,300 $180,588,300 $255,155,500 $319,091,506 $210,077,200 $1,315,824,717 PEI – 34,001,800 82,273,100* 110,567,500* 122,608,254* 67,946,000* 417,396,654 INN – – 20,294,900 20,294,900 50,730,032 13,909,700 105,229,532 CAPTECH – 98,053,039 33,479,200 – 88,232,464 – 219,764,703 WET 34,667,140 31,370,800 1,800,000 – 37,868,778 1,800,000 107,506,718 Totals $125,359,051 $423,645,939 $318,435,500 $386,017,900 $618,531,034 $293,732,900 $2,165,722,324 Madera CSS $1,514,515 $5,173,200 $3,020,000 $4,037,700 $3,515,500 $3,324,400 $20,585,315 PEI – 438,900 1,087,300* 1,485,000* 1,411,400* 915,500* 5,338,100 INN – – 311,100 311,100 522,300 213,200 1,357,700 CAPTECH – 1,367,200 429,600 – 1,796,800 – 3,593,600 WET 371,900 435,700 – – – – 807,600 Totals $1,886,415 $7,415,000 $4,848,000 $5,833,800 $7,246,000 $4,453,100 $31,682,315 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 68 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Marin CSS $1,727,527 $6,189,900 $3,711,600 $5,124,500 $5,067,750 $4,219,100 $26,040,377 PEI – 632,800 1,543,200* 2,095,200* 1,906,100* 1,288,600* 7,465,900 INN – – 402,000 402,000 1,481,800 276,100 2,561,900 CAPTECH – 1,893,900 595,100 – 1,085,740 – 3,574,740 WET 536,300 596,900 – – 130,200 – 1,263,400 Totals $2,263,827 $9,313,500 $6,251,900 $7,621,700 $9,671,590 $5,783,800 $40,906,317 Mariposa CSS $380,977 $748,200 $792,600 $1,042,600 $1,166,284 $858,500 $4,989,161 PEI – 100,000 152,200 252,200 379,000 128,500 1,011,900 INN – – 73,400 73,400 236,400 51,800 435,000 CAPTECH – 600,000 188,500 – – – 788,500 WET 225,000 225,000 – – – – 450,000 Totals $605,977 $1,673,200 $1,206,700 $1,368,200 $1,781,684 $1,038,800 $7,674,561 Mendocino CSS $926,687 $3,137,200 $1,851,400 $2,361,000 $2,645,881 $1,943,800 $12,865,968 PEI – 150,000 587,600* 786,700* 1,713,266* 482,900* 3,720,466 INN – – 181,400 181,400 663,000 122,700 1,148,500 CAPTECH – 704,500 221,400 – 925,900 – 1,851,800 WET 225,000 225,000 – – – – 450,000 Totals $1,151,687 $4,216,700 $2,841,800 $3,329,100 $5,984,047 $2,549,400 $20,036,734 Merced CSS $2,534,123 $6,692,200 $4,971,600 $6,737,600 $3,833,833 $5,547,300 $30,316,656 PEI – 769,500 1,902,600* 2,592,700* 2,377,400* 1,598,100* 9,240,300 INN – – 522,700 522,700 1,663,400 358,600 3,067,400 CAPTECH – 2,385,600 749,600 – 394,620 – 3,529,820 WET 652,000 760,000 – – – – 1,412,000 Totals $3,186,123 $10,607,300 $8,146,500 $9,853,000 $8,269,253 $7,504,000 $47,566,176 Modoc CSS $321,891 $556,400 $712,000 $962,000 $1,114,405 $792,100 $4,458,796 PEI – 100,000 151,200* 251,200* 245,945* 152,500* 900,845 INN – – 68,000 68,000 253,900 48,300 438,200 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – – – 450,000 Totals $546,891 $1,481,400 $1,119,700 $1,281,200 $2,402,750 $992,900 $7,824,841 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 69 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Mono CSS $356,737 $669,800 $759,900 $909,900 $1,081,775 $831,500 $4,609,612 PEI – 100,000 151,700 251,700 208,750 128,000 840,150 INN – – 71,200 71,200 204,800 50,400 397,600 CAPTECH – 600,000 188,500 100,000 53,772 – 942,272 WET 225,000 225,000 – – – – 450,000 Totals $581,737 $1,594,800 $1,171,300 $1,332,800 $1,549,097 $1,009,900 $7,239,634 Monterey CSS $3,885,218 $10,515,500 $7,765,900 $10,576,700 $9,208,800 $8,708,200 $50,660,318 PEI – 1,357,700 3,264,100* 4,362,400* 3,952,300* 2,678,600* 15,615,100 INN – – 837,400 837,400 1,402,400 571,200 3,648,400 CAPTECH – 3,882,200 1,219,800 – – – 5,102,000 WET 1,150,600 1,225,200 – – – – 2,375,800 Totals $5,035,818 $16,980,600 $13,087,200 $15,776,500 $14,563,500 $11,958,000 $77,401,618 Napa CSS $1,136,972 $3,840,200 $2,343,900 $3,107,500 $2,901,700 $2,558,500 $15,888,772 PEI – 346,100 842,600* 1,141,000* 2,378,800* 1,064,900* 5,773,400 INN – – 240,500 240,500 762,900 164,100 1,408,000 CAPTECH – 1,031,000 323,900 – 1,100,856 – 2,455,756 WET 293,300 324,900 – – 574,200 – 1,192,400 Totals $1,430,272 $5,542,200 $3,750,900 $4,489,000 $7,718,456 $3,787,500 $26,718,328 Nevada CSS $1,012,437 $3,367,287 $2,058,300 $2,598,300 $3,011,875 $2,139,300 $14,187,499 PEI – 262,600 627,700 838,600 693,450 427,900 2,850,250 INN – – 199,100 199,100 359,213 134,300 891,713 CAPTECH – 745,100 234,100 – 30 – 979,230 WET 225,000 232,000 – – – – 457,000 Totals $1,237,437 $4,606,987 $3,119,200 $3,636,000 $4,064,568 $2,701,500 $19,365,692 Orange CSS $25,757,558 $70,799,600 $52,212,700 $72,573,400 $63,187,200 $59,752,100 $344,282,558 PEI – 9,755,200 23,561,700* 31,517,400* 28,637,000* 19,367,400* 112,838,700 INN – – 5,787,600 5,787,600 18,410,300 3,958,900 33,944,400 CAPTECH – 28,308,300 8,894,500 – 15,559,675 – 52,762,475 WET 8,267,200 8,948,100 – – – – 17,215,300 Totals $34,024,758 $117,811,200 $90,456,500 $109,878,400 $125,794,175 $83,078,400 $561,043,433 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 70 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Placer CSS $2,284,145 $6,479,900 $4,593,100 $6,249,400 $6,776,853 $4,888,035 $31,271,433 PEI – 701,400 1,769,300* 2,416,500* 3,505,525* 1,494,900* 9,887,625 INN – – 483,800 483,800 1,541,300 589,865 3,098,765 CAPTECH – 2,276,500 715,300 – 1,943,002 – 4,934,802 WET 594,400 735,700 1,800,000 – 710,005 1,800,000 5,640,105 Totals $2,878,545 $10,193,500 $9,361,500 $9,149,700 $14,476,685 $8,772,800 $54,832,730 Plumas CSS $392,188 $886,900 $1,039,000 $1,458,000 $1,197,900 $1,200,400 $6,174,388 PEI – 100,000 152,100 252,100 149,500 128,400 782,100 INN – – 98,000 98,000 365,500 69,800 631,300 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 69,000 – 71,500 – 590,500 Totals $617,188 $1,811,900 $1,546,600 $1,808,100 $2,572,900 $1,398,600 $9,755,288 Riverside CSS $16,878,027 $43,990,700 $33,610,600 $47,117,200 $51,294,200 $38,793,200 $231,683,927 PEI – 5,612,500 14,190,600* 19,468,200* 26,816,452* 12,040,800* 78,128,552 INN – – 3,673,500 3,673,500 11,519,251 2,539,300 21,405,551 CAPTECH – 18,358,100 5,768,100 – 17,826,200 – 41,952,400 WET 4,756,400 5,941,900 – – 30 – 10,698,330 Totals $21,634,427 $73,903,200 $57,242,800 $70,258,900 $107,456,133 $53,373,300 $383,868,760 Sacramento CSS $10,021,351 $31,272,200 $19,822,329 $27,976,100 $33,141,107 $23,754,100 $145,987,187 PEI – 3,630,500 8,969,700* 12,246,700* 21,657,600* 7,546,300* 54,050,800 INN – – 2,267,300 2,267,300 8,379,100 1,565,200 14,478,900 CAPTECH – 11,242,700 4,174,871 875,000 1,797,290 – 18,089,861 WET 3,076,700 3,574,100 – – – – 6,650,800 Totals $13,098,051 $49,719,500 $35,234,200 $43,365,100 $64,975,097 $32,865,600 $239,257,548 San Benito CSS $737,007 $2,056,100 $1,580,000 $1,930,000 $2,329,200 $1,589,000 $10,221,307 PEI – 166,300 398,700 531,600 282,075 270,800 1,649,475 INN – – 145,000 145,000 455,200 97,400 842,600 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – – – 450,000 Totals $962,007 $3,047,400 $2,312,200 $2,606,600 $3,854,975 $1,957,200 $14,740,382 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 71 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL San Bernardino CSS $17,340,108 $45,307,600 $34,194,700 $47,400,100 $41,393,300 $39,143,000 $224,778,808 PEI – 5,936,400 14,610,400* 19,825,800* 18,150,610* 12,213,200* 70,736,410 INN – – 3,737,900 3,737,900 6,311,400 2,570,200 16,357,400 CAPTECH – 18,162,500 5,706,700 – 1,819,498 – 25,688,698 WET 5,030,900 5,780,200 1,800,000 142,000 – 1,800,000 14,553,100 Totals $22,371,008 $75,186,700 $60,049,700 $71,105,800 $67,674,808 $55,726,400 $352,114,416 San Diego CSS $25,671,808 $72,951,300 $52,232,700 $73,166,800 $68,058,657 $60,240,700 $352,321,965 PEI – 9,733,400 23,625,400* 31,805,200* 31,185,555* 19,554,300* 115,903,855 INN – – 5,816,200 5,816,200 12,260,950 3,991,400 27,884,750 CAPTECH – 28,417,800 8,928,900 – 34,358,758 – 71,705,458 WET 8,248,700 9,062,100 – – 40 – 17,310,840 Totals $33,920,508 $120,164,600 $90,603,200 $110,788,200 $145,863,960 $83,786,400 $585,126,868 San Francisco CSS $5,386,299 $17,873,300 $11,570,900 $16,467,000 $16,454,050 $13,557,900 $81,309,449 PEI – 2,269,600 5,445,300* 7,358,500 11,585,019* 3,758,400* 30,416,819 INN – – 1,313,800 1,313,800 4,200,900 904,300 7,732,800 CAPTECH – 6,313,100 1,983,600 – 6,148,350 – 14,445,050 WET 1,923,400 2,026,600 – – 1,172,159 – 5,122,159 Totals $7,309,699 $28,482,600 $20,313,600 $25,139,300 $39,560,478 $18,220,600 $139,026,277 San Joaquin CSS $5,645,671 $15,207,900 $11,097,800 $15,292,600 $15,347,167 $12,591,000 $75,182,138 PEI – 1,865,100 4,575,900 6,214,900 4,337,500 3,156,600 20,150,000 INN – – 1,197,800 1,197,800 3,816,200 822,700 7,034,500 CAPTECH – 5,673,500 1,782,600 – 7,456,100 – 14,912,200 WET 1,580,600 1,796,700 – – – – 3,377,300 Totals $7,226,271 $24,543,200 $18,654,100 $22,705,300 $30,956,967 $16,570,300 $120,656,138 San Luis Obispo CSS $2,317,778 $6,906,700 $4,167,425 $5,901,550 $5,100,150 $5,101,800 $29,495,403 PEI – 760,000 1,832,100* 2,451,000* 2,224,000* 1,505,600* 8,772,700 INN – – 487,300 487,300 1,545,200 331,900 2,851,700 CAPTECH – 2,168,000 1,126,675 294,950 294,950 – 3,884,575 WET 644,100 692,400 – – – – 1,336,500 Totals $2,961,878 $10,527,100 $7,613,500 $9,134,800 $9,164,300 $6,939,300 $46,340,878 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 72 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL San Mateo CSS $5,022,392 $15,083,100 $10,472,300 $14,546,300 $12,665,000 $11,976,500 $69,765,592 PEI – 1,989,300 4,749,800* 6,341,600* 10,494,687* 5,847,400* 29,422,787 INN – – 1,163,000 1,163,000 4,279,100 794,700 7,399,800 CAPTECH – 5,539,300 1,740,400 – 1,992,724 – 9,272,424 WET 1,685,900 1,751,700 – – 1,717,340 – 5,154,940 Totals $6,708,292 $24,363,400 $18,125,500 $22,050,900 $31,148,851 $18,618,600 $121,015,543 Santa Barbara CSS $3,853,402 $11,527,900 $7,582,206 $10,474,700 $9,120,002 $8,624,200 $51,182,410 PEI – 1,346,800 3,236,300* 4,321,500* 6,813,610* 2,653,400* 18,371,610 INN – – 829,800 829,800 2,948,600 565,700 5,173,900 CAPTECH – 3,830,200 1,203,400 – – – 5,033,600 WET 1,141,400 1,213,700 115,294 – 1,328,994 – 3,799,388 Totals $4,994,802 $17,918,600 $12,967,000 $15,626,000 $20,211,206 $11,843,300 $83,560,908 Santa Clara CSS $13,521,652 $39,490,800 $28,814,300 $38,732,100 $48,528,816 $33,536,100 $202,623,768 PEI – 5,663,100 13,664,300* 18,321,000* 37,640,067* 11,254,700* 86,543,167 INN – – 3,263,200 3,263,200 11,720,900 2,238,600 20,485,900 CAPTECH – 16,205,300 5,091,700 – 9,459,000 – 30,756,000 WET 4,799,400 5,171,300 – 2,000,000 2,000,000 – 13,970,700 Totals $18,321,052 $66,530,500 $50,833,500 $62,316,300 $109,348,783 $47,029,400 $354,379,535 Santa Cruz CSS $2,393,226 $6,876,300 $4,902,500 $6,660,600 $7,414,350 $5,483,900 $33,730,876 PEI – 857,400 2,049,400* 2,736,300* 3,902,394* 1,678,400* 11,223,894 INN – – 527,600 527,600 1,674,100 359,500 3,088,800 CAPTECH – 2,394,000 752,200 – 3,146,200 – 6,292,400 WET 726,600 758,000 – – – – 1,484,600 Totals $3,119,826 $10,885,700 $8,231,700 $9,924,500 $16,137,044 $7,521,800 $55,820,570 Shasta CSS $1,712,376 $5,998,200 $3,362,700 $4,464,700 $3,887,301 $3,676,000 $23,101,277 PEI – 508,500 1,233,800 1,664,400 1,160,400 847,000 5,414,100 INN – – 346,800 346,800 1,099,800 236,500 2,029,900 CAPTECH – 1,501,000 471,600 – 1,972,600 – 3,945,200 WET 431,000 472,600 – – – – 903,600 Totals $2,143,376 $8,480,300 $5,414,900 $6,475,900 $8,120,101 $4,759,500 $35,394,077 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 73 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Sierra CSS $271,896 $405,200 $644,800 $894,800 $1,155,424 $736,700 $4,108,820 PEI – 100,000 150,400 250,400 326,633 126,700 954,133 INN – – 63,500 63,500 237,900 45,400 410,300 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 31,590 – 481,590 Totals $496,896 $1,330,200 $1,047,200 $1,208,700 $2,540,047 $908,800 $7,531,843 Siskiyou CSS $588,535 $1,533,500 $1,374,300 $1,724,300 $1,957,175 $1,419,700 $8,597,510 PEI – 112,300 265,900* 369,600* 891,900* 225,600* 1,865,300 INN – – 122,800 122,800 451,000 84,400 781,000 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 416,200 – 866,200 Totals $813,535 $2,470,800 $1,951,500 $2,216,700 $4,504,775 $1,729,700 $13,687,010 Solano CSS $3,258,606 $9,382,600 $6,642,100 $9,143,000 $7,960,501 $7,527,700 $43,914,507 PEI – 1,138,100 2,776,700* 3,753,900* 2,618,800* 3,111,800* 13,399,300 INN – – 718,900 718,900 1,390,050 493,000 3,320,850 CAPTECH – 3,165,123 1,073,800 – 3,681,923 – 7,920,846 WET 1,216,877 1,076,500 – – (252,377) – 2,041,000 Totals $4,475,483 $14,762,323 $11,211,500 $13,615,800 $15,398,897 $11,132,500 $70,596,503 Sonoma CSS $3,741,594 $11,152,000 $7,518,500 $10,235,200 $11,812,783 $8,426,900 $52,886,977 PEI – 1,340,200 3,198,500* 4,260,000* 9,306,300* 2,612,600* 20,717,600 INN – – 813,300 813,300 2,986,900 553,900 5,167,400 CAPTECH – 3,741,900 1,175,700 – 4,120,361 – 9,037,961 WET 1,135,800 1,180,000 – – 2,145,400 – 4,461,200 Totals $4,877,394 $17,414,100 $12,706,000 $15,308,500 $30,371,744 $11,593,400 $92,271,138 Stanislaus CSS $4,293,970 $14,335,000 $8,502,900 $11,684,900 $10,173,700 $9,620,600 $58,611,070 PEI – 1,414,500 3,475,800* 4,719,300* 4,314,900* 2,906,400* 16,830,900 INN – – 914,400 914,400 2,912,500 627,800 5,369,100 CAPTECH – 4,327,200 1,359,600 – 5,686,800 – 11,373,600 WET 1,198,800 1,369,300 – – – – 2,568,100 Totals $5,492,770 $21,446,000 $14,252,700 $17,318,600 $23,087,900 $13,154,800 $94,752,770 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training continued on next page . . . INN = Innovation 74 California State Auditor Report 2012-122 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Sutter-Yuba CSS $1,761,564 $5,196,400 $3,568,300 $4,510,900 $5,043,253 $3,714,000 $23,794,417 PEI – 447,900 1,076,200* 1,444,500* 2,434,400* 1,036,800* 6,439,800 INN – – 344,500 344,500 1,258,600 232,900 2,180,500 CAPTECH – 1,343,200 422,100 – 1,765,300 – 3,530,600 WET 450,000 450,000 – – 900,000 – 1,800,000 Totals $2,211,564 $7,437,500 $5,411,100 $6,299,900 $11,401,553 $4,983,700 $37,745,317 Tehama CSS $716,402 $2,652,700 $1,555,100 $1,929,300 $1,679,800 $1,588,500 $10,121,802 PEI – 162,900 404,400 550,600 823,100 278,900 2,219,900 INN – – 144,500 144,500 527,700 97,800 914,500 CAPTECH – 600,000 188,500 – 788,500 – 1,577,000 WET 225,000 225,000 – – 450,000 – 900,000 Totals $941,402 $3,640,600 $2,292,500 $2,624,400 $4,269,100 $1,965,200 $15,733,202 Tri City† CSS $1,907,890 $5,976,200 $3,721,400 $4,989,000 $2,362,389 $4,107,700 $23,064,579 PEI – 702,900 1,621,200 2,116,400 2,975,582 1,086,600 8,502,682 INN – – 402,600 402,600 1,472,300 271,500 2,549,000 CAPTECH – 2,059,600 647,100 – 2,706,700 – 5,413,400 WET 595,800 548,200 – – 1,144,000 – 2,288,000 Totals $2,503,690 $9,286,900 $6,392,300 $7,508,000 $10,660,971 $5,465,800 $41,817,661 Trinity CSS $355,222 $648,900 $755,600 $1,005,600 $127,725 $827,900 $3,720,947 PEI – 100,000 151,600 251,600* 1,091,975* 152,900* 1,748,075 INN – – 70,900 70,900 194,200 50,200 386,200 CAPTECH – 600,000 188,500 – 500 – 789,000 WET 225,000 225,000 – – 140,000 – 590,000 Totals $580,222 $1,573,900 $1,166,600 $1,328,100 $1,554,400 $1,031,000 $7,234,222 Tulare CSS $4,105,199 $11,056,200 $7,577,700 $11,085,300 $10,399,375 $9,126,900 $53,350,674 PEI – 1,322,300 3,259,800 4,435,000 2,012,425 2,250,300 13,279,825 INN – – 865,300 865,300 3,189,300 594,400 5,514,300 CAPTECH – 4,060,300 1,775,700 – 5,336,000 – 11,172,000 WET 1,120,600 1,293,900 – – 2,246,400 – 4,660,900 Totals $5,225,799 $17,732,700 $13,478,500 $16,385,600 $23,183,500 $11,971,600 $87,977,699 CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation California State Auditor Report 2012-122 75 August 2013 FISCAL YEAR COUNTY/ COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 TOTAL Tuolumne CSS $693,980 $1,959,500 $1,520,700 $1,870,700 $2,122,475 $1,540,300 $9,707,655 PEI – 151,000 357,800 475,300 313,050 242,900 1,540,050 INN – – 138,200 138,200 469,650 93,400 839,450 CAPTECH – 600,000 188,500 – 372,047 – 1,160,547 WET 225,000 225,000 – – – – 450,000 Totals $918,980 $2,935,500 $2,205,200 $2,484,200 $3,277,222 $1,876,600 $13,697,702 Ventura CSS $6,810,115 $18,815,700 $11,671,400 $18,726,100 $26,904,863 $15,417,800 $98,345,978 PEI – 2,414,300 5,853,700* 7,849,800* 13,676,217* 4,826,700* 34,620,717 INN – – 1,483,000 1,483,000 5,085,650 1,014,000 9,065,650 CAPTECH – 7,091,300 4,174,700 – 4,213,527 – 15,479,527 WET 2,046,000 2,240,500 – – 2,575,830 – 6,862,330 Totals $8,856,115 $30,561,800 $23,182,800 $28,058,900 $52,456,087 $21,258,500 $164,374,202 Yolo CSS $1,838,123 $6,225,800 $3,692,900 $4,975,000 $9,786,617 $4,096,100 $30,614,540 PEI – 570,700 1,407,100* 1,908,100* 3,180,183* 1,175,900* 8,241,983 INN – – 386,700 386,700 1,422,400 264,700 2,460,500 CAPTECH – 1,730,800 543,800 – 1,696,975 – 3,971,575 WET 483,700 558,800 – – 577,625 – 1,620,125 Totals $2,321,823 $9,086,100 $6,030,500 $7,269,800 $16,663,800 $5,536,700 $46,908,723 Statewide CSS $320,453,101 $918,430,987 $644,124,260 $896,588,050 $982,640,247 $741,431,795 $4,503,668,440 PEI – 114,756,594 278,600,000 376,000,000 469,648,647 232,062,340 1,471,067,581 INN – – 71,000,000 71,000,000 197,705,668 48,957,265 388,662,933 CAPTECH – 343,115,862 114,091,446 1,269,950 280,725,187 – 739,202,445 WET 106,070,717 110,000,300 9,184,294 2,142,000 60,892,214 9,000,000 297,064,525 Totals $426,523,818 $1,486,303,743 $1,117,000,000 $1,347,000,000 $1,991,611,963 $1,031,451,400‡ $7,381,256,524 Sources: Unaudited county allocations published by the California Department of Mental Health on its Web site for fiscal years 2006–07 through 2009–10 and California State Accounting and Reporting System expenditure data for fiscal years 2010–11 through 2011–12. * For fiscal years 2008–09 through 2011–12, Prevention and Early Intervention (Prevention) funds include amounts the State used to conduct statewide Prevention programs. † County indicates a county mental health department, two or more county mental health departments acting jointly, and/or city-operated programs receiving funds per California Welfare and Institutions Code, Section 5701.5. ‡ Legislation was passed in March 2011 directing more than $850 million in Mental Health Services Act funds to other mental health programs in fiscal year 2011–12. The reduction in funds in fiscal year 2011–12 appears to correspond with this change in legislation. CSS = Community Services and Supports CAPTECH = Capital Facilities and Technological Needs PEI = Prevention and Early Intervention WET = Workforce Education and Training INN = Innovation 76 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 77 August 2013 Appendix B Mental Health Services Act Programs for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 The Joint Legislative Audit Committee directed the California State Auditor to identify the type of services and supports that counties provided through each of their Mental Health Services Act (MHSA) components, covering the most recent six-year period. We reviewed four county departments: Los Angeles County Department of Mental Health, County of Sacramento Department of Health and Human Services, County of San Bernardino Department of Behavioral Health Administration, and Santa Clara County Mental Health Department. Tables B.1 through B.4 on the following pages list by component the names of the counties’ planned MHSA programs with a brief description of each. The programs listed are those that appeared in the counties’ plans for fiscal years 2006–07 through 2011–12. Each table also indicates the age group the county targeted with its planned programs for the Community Services and Supports, Prevention and Early Intervention, and Innovation programs. Because the MHSA components of Workforce Education and Training and Capital Facilities and Technological Needs are not designed to provide mental health services directly to clients, counties typically did not specify target age groups for these components. Table B.1 Los Angeles County Department of Mental Health: Mental Health Services Act Planned Programs/Actions by Component Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Children’s Full-Service County works with individuals Partnership and families to provide all (Partnership) necessary and appropriate       l services and supports to assist the individual/family in achieving the goals identified. Family Support Provides access to mental health Services services such as individual psychotherapy, couples/group therapy, and crisis intervention       l for parents/families of seriously emotionally disturbed children who are enrolled in Partnership services. continued on next page . . . 78 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Children’s Integrated Provides training to enhance Mental Health/ the ability of mental health Co-Occurring professionals to identify,    l Disorders assess, and engage individuals experiencing substance abuse and/or co-occurring disorders. Children’s Respite Care Provides support services to relieve eligible parents and/or caregivers from ongoing stress     l that results from providing constant care to a seriously emotionally disturbed child. Children’s Performs evidence-based Field-Capable direct interventions to address Clinical Services the needs of children who are     l seriously emotionally disturbed and/or severely and persistently mentally ill. Transition-Age Provides intensive mental Youth Full-Service health services and supports Partnership to high-need and high-risk severely emotionally disturbed transition-age youth who       l are transitioning out of the child welfare system or are at risk of becoming homeless or leaving long-term institutional care. Transition-Age Youth Provides entry points to the Drop-In Centers mental health system for homeless youth or youth in unstable living conditions.       l Provides “low-demand, high-tolerance” environments offering temporary safety and basic services. Transition-Age Youth Includes three activities: Housing Services housing specialists to assist in securing housing, enhanced emergency shelter program to provide temporary shelter,       l and project-based operating subsidies to provide subsidies to transition-age youth for securing permanent housing. Transition-Age Youth Teams of parent/peer advocates, Probation Camp clinicians, health staff, and Services others provide on-site treatment       l and support services at probation camps. California State Auditor Report 2012-122 79 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Transition-Age Youth Provides field-capable services for Field-Capable Clinical seriously emotionally disturbed Services and/or severely and persistently mentally ill transition-age youth. The services are evidence-based     l direct interventions and may serve to transition youth from Partnership programs to lower levels of service. Adult Full-Service Provides “whatever it takes” to Partnerships assist individuals with housing, employment, education, and       l integrated treatment for those with co-occurring mental health and substance abuse disorders. Wellness/ Funds centers that provide Client-Run Centers self-help services and an opportunity for clients in advanced stages of recovery       l to address both physical and mental health needs and to focus on increasing self-reliance and community integration. Adult Institutions Helps clients from acute for Mental Disease inpatient and institutional Step-Down Facility settings be safely maintained       l in the community with mental health services. Adult Housing Provides housing services Services for homeless individuals and families and those living in institutional settings. Housing specialists provide housing       l placement services for a safe and nonthreatening environment for chronically homeless individuals with mental health issues. Adult Services— Addresses the needs of individuals Jail Transition and in collaboration with the judicial Linkage Services system by providing identification,       l outreach, support, advocacy, linkage, and interagency collaboration in the courtroom. Adult Field-Capable Enables providers to reach Clinical Services unserved, underserved, or inappropriately served     l individuals who will not or cannot access mental health services in traditional settings. continued on next page . . . 80 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Older Adult Provides services for older Full-Service adults with a serious mental Partnership illness who are in need of intensive mental health services       l and who have experienced a reduction in personal or community functioning. Older Adult Develops an infrastructure of Transformation older adult services through Design Team work on data collection, outcome       l measures, performance-based contracting, and more. Older Adult Directly responds to and Field-Capable addresses the needs of unserved Clinical Services and underserved older adults by providing screening, assessment, linkage, medication support, and       l case management. Assists older adults who are severely mentally ill, isolated, self-neglecting, abused, and/or homeless. Older Adult Service Provides training to service Extender Program extenders who are peers in recovery, family members, or       l other individuals interested in providing field-capable clinical services to older adults. Older Adult Training Addresses training needs Program of existing mental health professionals, service extenders,       l and community partners, including specialized training for staff. Alternative Crisis Includes the following five areas Services of services: urgent care centers designed to reduce unnecessary and lengthy involuntary inpatient treatment; countywide resource management, including centralized administrative       l l l l and clinical management functions; residential and bridging services; enriched residential services providing on-site mental health services; and services to reduce homelessness. California State Auditor Report 2012-122 81 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Planning, Outreach, Implements strategies to and Engagement increase awareness of the Mental Health Services Act (MHSA) among unserved, underserved, and inappropriately served       l* l* l* l* populations, including outreach to the homeless and development of the County Department of Mental Health’s Division of Empowerment and Advocacy. Service Area Funds persons who work to link Navigators needed services to members       l* l* l* l* of the community. Teams are age-group specific. Prevention and Early Intervention q Early Start Suicide Contains several suicide Prevention prevention components, including increasing the capacity and quality of the suicide prevention hotline; increasing public awareness     l l l l efforts; providing training; providing support groups; and offering activities targeted toward diverse and at-risk populations. Early Start School Implements a school threat Mental Health assessment response team Initiative to identify at-risk students,     l l l l and provides services in all Los Angeles service areas. Early Start Anti-Stigma Implements client-focused and Discrimination strategies, family support and education, and broader     l l l l community advocacy strategies to reduce stigma and discrimination in communities. School-Based Services Provides several interventions to build resiliency in children, identify as early as possible children and    l l youth who have risk factors, and provide on-site services to address nonacademic problems. Family Education and Provides interventions to build Support Services competencies, capacity, and resilience in parents, family    l l l l members, and other caregivers. Concentrates on parental skill building in a variety of settings. At-Risk Family Services Provides training and assistance to families of children at risk for out-of-home placements, builds skills for families with difficult    l l l l children, and provides support to families with histories that place them at risk. continued on next page . . . 82 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Trauma Recovery Provides short-term crisis Services counseling to clients, family, and staff affected by a traumatic event,    l l l l and provides intensive services to trauma-exposed youth. Primary Care and Develops mental health services Behavioral Health within primary care clinics, Services and helps prevent patients at    l l l l clinics from developing severe behavioral health issues. Early Care Includes three components for and Support for transition-age youth: building Transition-Age Youth resiliency and increasing protective factors, addressing    l l l depressive disorders, and minimizing impact for youth who may be in the early stages of mental illness. Juvenile Justice Builds resiliency and protective Services factors among youth and children exposed to risk factors, promotes coping and life skills, and    l l l identifies mental health issues among youth in the juvenile justice system as early as possible. Early Care and Support Establishes the means to identify for Older Adults and link older adults who need treatment but are reluctant, are hidden, or are unknown; to    l l l prevent and alleviate depressive disorders; and to provide brief mental health treatment for older adults. Improving Access Builds resiliency and increases for Underserved protective factors among Populations non-English-speaking or limited-English-speaking and other underserved populations,    l l l l identifies at-risk individuals, and provides culturally and linguistically appropriate mental health services. American Indian Builds resiliency and increases Project protective factors among children, youth, and their families; addresses stressful forces in children’s and    l l l l youth’s lives; and identifies as early as possible children and youth who have risk factors. California State Auditor Report 2012-122 83 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Innovation q Integrated Clinic Provides integrated care in a large, Model complex urban environment specifically targeting the most vulnerable populations and integrating primary care sites with mental health services. The    † † † † program focuses on individuals eligible for specialty mental health services who could benefit from primary health and/or substance abuse services. Integrated Mobile Provides integrated care in a Health Team Model geographically widespread, complex urban environment, managing it under one agency    † † † † and increasing access to services by leveraging multiple funding sources. Community-Designed Provides integrated care in a Integrated Service diverse urban environment Management Model by differentiating specific needs and approaches for five underrepresented ethnic communities, focusing on    † † † † community self-direction for integrated service delivery. Peers are integrated into the mix of formal and nontraditional providers. Integrated Peer-Run Provides peer-run integrated Model services and peer-run crisis houses to expand the potential of peer-run services. Peer-run    † † † † integrated services management addresses physical health, mental health, and substance abuse issues. Workforce Education and Training q Workforce Education Funds staffing for the planning and Training and development of the county     NA NA NA NA Coordination workforce plan. County of Los Angeles Funds a committee to guide and Oversight Committee support the implementation of   NA NA NA NA the county plan. Transformation Provides a training program Academy aimed at improving the skills Without Walls of the mental health workforce.     NA NA NA NA Includes standard curricula and incorporates coaching and mentoring. continued on next page . . . 84 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Recovery-Oriented Immerses supervisors in the Supervision Trainings basic tenets of the MHSA, provides them with updated information on issues related   NA NA NA NA to recovery and wellness, and teaches them how to integrate clients and family members into the mental health workforce. Interpreter Training Offers training in phases: trains Program interpreters for mental health settings, trains mental health     NA NA NA NA providers in how best to use interpreters, and offers technical assistance and follow-up support. Training for Offers training on symptomatology Community Partners and on how to access health services to community partners,     NA NA NA NA including law enforcement, probation departments, and child protective services. Intensive Mental Offers training for entry-level Health Recovery professionals who represent the Specialist Training linguistic and cultural diversity Program of those receiving services.     NA NA NA NA Efforts are also made to recruit and match trainees with ideal field placement. Expand Employment Increases training and and Professional employment of clients in the Advancement public mental health system Opportunities and decreases barriers to     NA NA NA NA for Consumers in employment. Specifically the Public Mental targets older adults and Health System transition-age youth. Expand Employment Helps develop skills needed to and Professional perform community outreach, Advancement advocacy, and leadership Opportunities for duties, with a focus on teaching Parent Advocates, participants how to navigate    NA NA NA NA Child Advocates, systems including mental health, and Caregivers in schools, regional centers, and the Public Mental child protective services. Targets Health System parents, child advocates, and caregivers of children. Expand Employment Trains family members of clients and Professional to develop or augment skills Advancement related to community outreach, Opportunities for advocacy, and leadership,    NA NA NA NA Family Member and decreases barriers Advocates in the to employment. Public Mental Health System California State Auditor Report 2012-122 85 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Mental Health Develops a group of advisors Career Advisors who will work with newly entering and/or existing mental    NA NA NA NA health staff to help them as they enter and remain in the mental health workforce. High School Through Expands academic programs University Mental to promote mental health Health Pathways careers to high school, community college, and    NA NA NA NA university students, especially in communities or areas of the county where ethnically diverse populations reside. Market Research and Establishes a collaboration Advertising Strategy with an academic institution, for Recruitment research institute, or think tank of Professionals in to conduct market research and     NA NA NA NA the Public Mental formulate advertising strategies Health System to identify ways of attracting and targeting new professionals into the public mental health field. Partnership with Works with educational Educational institutions currently producing, Institutions to or that may in the future Increase the Number produce, mental health     NA NA NA NA of Mental Health professionals in key high-need Professionals in disciplines to expand capacity the Public Mental for developing additional mental Health System health professionals. Recovery-Oriented Works with degree-granting Internship institutions providing Development recovery-oriented classroom instruction to develop    NA NA NA NA relationships with nontraditional providers, and works with existing providers to increase the number of internships available. Tuition Provides up to $5,000 per Reimbursement year for tuition expenses for Program individuals interested in entering    NA NA NA NA or enhancing skills for the mental health field who meet certain criteria. Associate and Targets individuals currently Bachelor Degree working in public mental 20/20 and/or health who are interested in 10/30 Program advancing in their career by obtaining an associate- or a   NA NA NA NA bachelor-level degree. Program pays for a portion of their salaries to allow students to meet academic responsibilities. continued on next page . . . 86 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Stipend Programs Seeks to expand the number for Psychologists, of psychologists, masters in Masters of Social social work, marriage and family Work, Masters of therapists, psychiatric nurse Family Therapy, practitioners, and psychiatric     NA NA NA NA Psychiatric Nurse technicians in the county Practitioners, by offering stipends in the and Psychiatric programs that will represent Technicians underserved ethnic groups. Loan Forgiveness Explores loan forgiveness to Program programs that complement existing programs and meet the need for a linguistically and    NA NA NA NA culturally competent workforce based on geographic, cultural, and linguistic needs. Capital Facilities and Technological Needs q Integrated Behavioral Provides clinicians direct access Health Information to current client clinical records System regardless of where each client was seen previously in the network, including medication    NA NA NA NA history, recent assessments, treatment plans, and clinical notes. It also provides an improved means of measuring and reporting MHSA outcomes. Contract Provider Provides contract providers with Technology Project a means to pursue technology improvements in support of MHSA activities. Distributes MHSA   NA NA NA NA information technology funds to more than 125 contract providers to pursue predetermined technological projects. Consumer/Family Promotes client/family growth Access to Computer and autonomy, provides Resources Project basic computer skills training to clients allowing them to   NA NA NA NA effectively use computer resources available to them and provides appropriate access to technical assistance resources. Personal Health Develops written and online Record Awareness awareness and educational and Education materials with the target   NA NA NA NA audiences of client/family and mental health services provider. Data Warehouse Based on the implementation Redesign Project of electronic health records, prepares the county to store new clinical, administrative,   NA NA NA NA and financial data sources as well as establishes resources for warehousing legacy data. California State Auditor Report 2012-122 87 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM/ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Capital Facilities and Technological Needs q Telepsychiatry Hires a consultant to identify Feasibility Study and opportunities for a variety Recommendation of telepsychiatry projects, Project research the possible benefits of widespread and systematic  NA NA NA NA adoption of telepsychiatry, and make recommendations regarding the value of implementing telepsychiatry. Telepsychiatry Extends functionality of Implementation the existing telepsychiatry Project pilot to meet the MHSA information technology goal of  NA NA NA NA modernizing and transforming clinical and administrative information systems. Sources: MHSA component plans and annual updates prepared by the Los Angeles County Department of Mental Health. NA = Not applicable. Workforce Education and Training and Capital Facilities and Technological Needs generally include efforts that focus on expanding, educating, and training the local public mental health workforce and improving infrastructure. Because programs within these components are not designed to provide direct mental health services, no age group is targeted.  = Program appears in a plan applicable for the fiscal year. l = County plan indicated that program targeted this age group. * The county’s plans did not specify an age group this program served; based on the program description, it reasonably serves all age groups. † The county’s Innovation component plan did not identify specific age groups for this program. We, therefore, could not determine which discrete age groups the program targeted. 88 California State Auditor Report 2012-122 August 2013 Table B.2 County of Sacramento Department of Health and Human Services: Mental Health Services Act Services Planned Programs/Actions by Component Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR AGE GROUP TARGETED PROGRAM/ TRANSITION‑AGE OLDER ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Transitional Provides community-based services Community for those leaving or at risk of entering Opportunities acute care settings and who are       l l l for Recovery and not linked to ongoing mental Engagement health services. (TCORE) Sierra Elder Provides specialized geriatric Wellness* psychiatric support, multidisciplinary mental health assessments, treatment, and intensive case management services for individuals       l l with multiple co-occurring mental health, physical health, and/or substance abuse and social service needs requiring intensive case management services. Permanent Consists of three components: Supportive (1) offers same-day access to services Housing such as mental health assessments Program and medication, and limited temporary housing; (2) provides short-term housing and focuses on rapid access to permanent housing and       l l l l Full-Service Partnership (Partnership) level of services for moderate and episodic intensive-level service needs; and (3) provides permanent supportive housing and a Partnership level of mental health services. Transcultural Addresses the mental health Wellness Center needs of the Asian/Pacific Islander community, taking into account the cultural and religious beliefs       l l l l and values, traditional and natural healing practices, and ceremonies this community recognizes. Wellness and Consists of three components: Recovery Center (1) two community-based, multi-service centers that provide a supportive environment offering choice and self-directed guidance for recovery and transition into community life; (2) peer support services for individuals linked to       l l l l the TCORE clinics serving adults; and (3) program promoting and advocating for client involvement in the mental health system through a wide array of services and supports including advocacy, system navigation, training, support groups, and psycho-educational groups. California State Auditor Report 2012-122 89 August 2013 FISCAL YEAR AGE GROUP TARGETED PROGRAM/ TRANSITION‑AGE OLDER ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Adult Full-Service Contains two components serving Partnership adults with persistent and significant mental illness. Services include case management, benefits acquisition, crisis response, intervention and stabilization, medication    l l l evaluation and support, and effective ongoing specialty mental health services. Supports include housing, employment, education, and transportation. Juvenile Justice Provides screenings, assessments, Diversion and and intensive mental health Treatment services and Partnership supports    l l Program to eligible youth and their families involved in the juvenile justice system. Prevention and Early Intervention q Suicide Consists of five components focusing Prevention on suicide prevention and education: Program (1) a 24-hour telephone crisis line, (2) brief individual and group bereavement counseling services, (3) support groups and services designed to encourage healing for those coping with a loss by suicide,    l l l l (4) services designed to reduce isolation and decrease the risk of suicide, and (5) field-based flexible services to community members experiencing a crisis. Services include assessment, support services, and linkage to ongoing services and supports. Strengthening Contains five components: (1) provides Families Program behavioral consultations to preschools and early care learning environments designed to increase teacher awareness about the meaning of behavior; (2) provides health exams, assessments, referrals, and treatment services for children from birth to 5 years old who are placed into protective custody; (3) trains school staff to educate others on anti-bullying   l l l l strategies; (4) implements prevention approaches for youth age 6 to 18 and families to improve social skills, increase protective factors, prevent youth violence, and reduce or eliminate family conflict; and (5) independent living program expanded to non-foster, homeless, and lesbian, gay, bisexual, transgender, and questioning youth age 16 to 25 to gain life skills. continued on next page . . . 90 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED PROGRAM/ TRANSITION‑AGE OLDER ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Integrated Health Consists of two components: and Wellness (1) provides assessment, early Program identification, and treatment of the onset of psychosis and (2) serves adults demonstrating early signs of   l l l l isolation and depression through socialization opportunities, skill-building groups, transportation services, and collaboration with health care providers. Mental Health Increases awareness about Promotion mental health issues and reduces Project stigma and discrimination toward   l l l l individuals and families living with mental illness. Innovation q Respite Establishes a collaborative to learn Partnership whether a partnership with a Collaborative community-based organization can, among other things, lead to new   l l l l partnerships that can help address crisis and other mental health issues in Sacramento. Workforce Education and Training q Workforce Facilitate the implementation of Staffing Support Workforce Education and Training     NA NA NA NA efforts across the county. System Training Expands training capacity of mental Continuum health staff, system partners,     NA NA NA NA consumers, and family members. Office of Seeks to develop entry and Consumer and employment opportunities to     NA NA NA NA Family Member address occupational shortages. Employment High School Introduces mental health career     NA NA NA NA Training information to high school students. Psychiatric Places medical residents and fellows Residents and in mental health settings with     NA NA NA NA Fellowships dedicated supervision. Multidisciplinary Seeks to increase the number of Seminar psychiatrists and other practitioners working in community mental     NA NA NA NA health that are trained in specific service models. Consumer Provides clients and family members Leadership the opportunity to receive stipends Stipends for leadership or educational opportunities that increase     NA NA NA NA knowledge, build skills, and further advocacy for clients on mental health issues. California State Auditor Report 2012-122 91 August 2013 FISCAL YEAR AGE GROUP TARGETED PROGRAM/ TRANSITION‑AGE OLDER ACTION TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Stipends for Establishes a fund to allow Individuals, individuals to apply for stipends Especially to participate in educational Consumers and opportunities that will lead to Family Members, employment in Sacramento County’s     NA NA NA NA for Education mental health system. Programs to Enter the Mental Health Field Capital Facilities and Technological Needs q Technological Consists of five phases to build Needs Project infrastructure to meet Sacramento County’s goals in its Community Services and Supports plan and to    NA NA NA NA achieve the federal objectives of meaningful use of electronic health records to improve client care. Sources: Mental Health Services Act component plans and annual updates prepared by the County of Sacramento Department of Health and Human Services. NA = Not applicable. Workforce Education and Training and Capital Facilities and Technological Needs generally include efforts that focus on expanding, educating, and training the local public mental health workforce and improving infrastructure. Because programs within these components are not designed to provide direct mental health services, no age group is targeted.  = Program appears in a plan applicable for the fiscal year. l = County plan indicated that program targeted this age group. * In fiscal year 2006–07, this program was titled Older Adult Intensive Services Program. 92 California State Auditor Report 2012-122 August 2013 Table B.3 County of San Bernardino Department of Behavioral Health Administration: Mental Health Services Act Planned Programs by Component Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Comprehensive Coordinate and access an array Child and of county services for children Family Support who are challenged with System emotional disturbances. Uses evidence-based practices and includes case management, flexible       l l funding, family focus treatment, service coordination, child care, co-occurring treatment, psychiatric services, family advocacy, and parent partnerships. Integrated Provides mental health services to New Family children age 13 to 17 in custody Opportunities and post-custody juvenile     l detention. Services seek to reduce out-of-home placements. One Stop Provides integrated mental health Transition-Age services to individuals age 16 to Youth Center 25 at a drop-in center. Clients receive mental health services as well as short-term residential and educational/vocational services       l to help transition-age youth become independent, stay out of the hospital or a higher level of care, reduce involvement in the criminal justice system, and reduce homelessness. Consumer- Includes an independent program Operated Peer using clients hired as mental Support System health specialists. Services include peer education and advocacy,       l employment support, and life skills development classes. Also expands existing clubhouse services to underserved adults. Forensic Consists of three programs that Integrated all target severely and persistently Mental Health mentally ill individuals involved Services with the criminal justice system. The programs are the forensic assertive       l community treatment program, the supervised treatment after release program, and the crisis intervention training program. California State Auditor Report 2012-122 93 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Assertive Provides support services 24 hours a Community day to clients who are frequent users Treatment Team of acute psychiatric hospitalization for High Users or are caught in the arrest cycle for       l l l of Arrowhead minor crimes. The program includes Regional Center peer support, clinical interventions, Behavioral housing, and employment services. Health Hospital Crisis Walk-In Redesigns and expands current Center walk-in clinics to provide urgent mental health services. Provides       l l l l integrated substance abuse treatment services for dually diagnosed clients. Psychiatric Triage Creates a preliminary psychiatric Diversion Team screening program to better use at Arrowhead mental health resources and reduce       l l l Regional unnecessary hospitalizations. Medical Center Community Combines the previously approved Crisis Response child’s crisis response team Team and adult crisis response team, creating a community crisis     l l l l response team, a seamless program that melds crisis intervention with outreach and education. Homeless Provides case management services Intensive Case and linkage to community and Management county resources for mentally ill     l l l and Outreach adults who are homeless or at risk of homelessness, incarceration, or hospitalization. Alliance for An alliance of organizations, Behavioral private practitioners, and county and Emotional departments that provide a variety     l l l l Treatment of services to the mentally ill in the Big Bear Lake area. System Develops Full-Service Partnership Transformation (Partnership) teams providing for Engaging outpatient mental health and Partners in medication support services,  l Uplifting community crisis intervention and People case management services, and integrated treatment support. Circle of Care: Provides mental health treatment System and case management services Development to older adults age 60 and       l over to assist them in remaining independent and active in their communities. continued on next page . . . 94 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Circle of Care: Provides a mobile crisis team Mobile that provides services to older Outreach and adults who are isolated in their       l l Intensive Case homes, homeless, or in crisis. Also Management establishes a Partnership system of care initially in the High Desert. Improving Purchases multiple software Information applications, such as electronic Systems health records and geographic information system applications,   l l l l designed to better track the success of the Mental Health Services Act (MHSA) implementation. Department Provides a comprehensive staff Training development program to train all Program staff and clients who are hired or   l l l l participate in client activities in leadership roles. Cultural Provides a comprehensive cultural Competence competence program to better Program serve an ethnically and linguistically   l l l l diverse population and eliminate disparities in access to services. Housing and Provides housing and employment Employment support services according to the   l l l Program appropriate level of care. Capital San Bernardino County is requesting Purchases $4,033,800 to be used for capital purchases for all 10 programs to be funded and implemented under the MHSA. Capital purchases include purchases such as cars, copiers,  * * * * computers, furniture, and office rents that are required tools to operate the programs requested in the county’s three-year Community Services and Supports plan. Prevention and Early Intervention q Student Minimizes the barriers to learning Assistance and supports students in developing Program academic and personal success by training educators to identify     l l l students in need of additional interventions. Additionally, provides early intervention and counseling services. Resilience Promotes resilience in Promotion in African-American children in order African-American to mediate the development of Children post-traumatic stress disorders, mood disorders, anxiety disorders,     l l substance abuse, and psychotic disorders. The program consists of a 12-week intensive program followed by weekly counseling and mentoring. California State Auditor Report 2012-122 95 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Preschool Targets children (and their families) Project in Head Start programs who are displaying aggressive behavior or who have suffered traumatic loss. Includes programs to identify     l l l l children needing referrals for more intensive mental health services, and provides direct services to children and their caregivers. Family Resource Attempts to reduce stigma and Center discrimination by providing a variety of prevention and early intervention services in a natural community     l l l l setting. Each center implements programs that are culturally specific and community relevant. Native American Provides culturally specific Resource prevention and early intervention     l l l l Center services to Native Americans. National Provides classes throughout Curriculum the county in order to provide and Training early intervention for children Institutes at risk of school failure and/or     l l l Crossroads juvenile justice involvement. In Education addition, the program promotes Classes communication between youth and family members. Promotores Trains identified community leaders de Salud to become personal contacts or liaisons to mental health services and programs within     l l l l the community. The goal of the program is to reduce stigma and make information regarding mental health resources more accessible. Older Adult Addresses needs of older adults by Community providing a mobile resource unit, Services wellness services, home safety     l l Program programs, and suicide prevention through peer-to-peer counseling. Child and Youth A collaborative effort with the Connection San Bernardino County Department of Children’s Services to screen children placed in foster care for     l l l l mental health issues. Also provides funds for a mentoring specialist and a mental health liaison to the public defender’s office. Nurse Family An evidence-based home visitation Partnership/ program in which nurses link     l l LIFT families with needed health, mental health, and human social services. continued on next page . . . 96 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Active Duty and Provides in-home psychosocial Family Support assessments for returning military personnel and their families and     l l l provides prevention activities for children and families while a family member is deployed. Community Targets transition-age youth and Wholeness and adults and their families suffering Enrichment early onset of mild mental health Project issues and identifies residents     l l l l suffering from mild to moderate mental issues that can be addressed before hospitalization or incarceration. Innovation q On-Line Diverse Creates pages on social networking Community sites such as Facebook and Twitter to Experiences disseminate news and information about mental health resources and   l l l l increase connectivity. Also provides computer training to transition-age youth at community centers to aid access to online resources. Coalition An interagency approach that Against Sexual includes government agencies, Exploitation community organizations, parents, and other caretakers to develop a comprehensive model   l l of interventions and services to address the issue of sexual exploitation of diverse children and youth. Community Adapts existing trauma training to Resiliency a community-based model, offering Model training to diverse community members who in turn offer   l l l l education and skills presentations to at-risk and underserved groups in their communities. Holistic Campus Creates a center that offers culturally appropriate and community-based mental health services for diverse and underserved populations outside of a clinical setting. Potential   l l l l offerings include acupuncture, sweat lodges, pet therapy, yoga, and healing circles. Actual offerings are determined by a community advisory board. California State Auditor Report 2012-122 97 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Innovation q Interagency Creates an interagency Youth team to explore and test the Resiliency Team implementation of innovative approaches that empower youth and their resource providers in the process of enhancing connections   * * * * by resolving issues of grief and loss, resolving issues relating to exposure to violence, building coping skills, and assisting resource providers in navigating systems and services. Transition-Age Creates a youth hostel to allow Youth transition-age youth to access Behavioral peer-run services and linkages to Health Hostel the mental health system. Focuses on two groups of underserved  l transition-age youth: former foster youth/wards; and lesbian, gay, bisexual, transgender, and questioning youth. Workforce Education and Training q Expand Existing Provides clients and family Training members, all levels of the diverse Program workforce, and contract agencies with education and training needed      NA NA NA NA to advance the vision and business strategy adopted by the county, as well as fundamental MHSA concepts. Training to Provides access for county Support the staff, contract agencies, and Fundamental clients and family members to      NA NA NA NA Concepts of training on wellness, recovery, the MHSA and discovery models as well as evidence-based practices. Development Develops processes to ensure that of Core staff receive training in topics central      NA NA NA NA Competencies to their duties, and that the content of those trainings has been vetted. Outreach In collaboration with California State to High University, San Bernardino, develop School, Adult a career pathway from high school Education, through graduation from university Community for careers in the mental health College, and system. Also, develops agreements Regional with adult schools throughout      NA NA NA NA Occupational the county to provide federally Program mandated vocational training at Students county facilities and collaborate with other community colleges to develop certificate programs for careers in mental health. Leadership Develops leaders from existing Development staff, begins succession planning for      NA NA NA NA Program future county leadership, and builds leadership into supervisory training. continued on next page . . . 98 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Peer and Family Expand the number and locations Advocate of trainings for the Peer and Family Workforce Advocate Certificate program from      NA NA NA NA Support the city to the county. Initiatives Expand Existing Increases internships within the Internship Department of Behavioral Health as Program well as coordinates intern programs      NA NA NA NA with contract agencies, thereby increasing the pool of potential future employees. Psychiatric Establishes a psychiatric residency Residency program through the Arrowhead Program Regional Medical Center with      NA NA NA NA specializations in child or geriatric psychiatry, public mental health, or multidisciplinary psychiatry. Scholarship Creates a scholarship program that Program helps current county employees      NA NA NA NA continue their education in the mental health field. Increase Works to obtain federal designation Eligibility for four additional county areas as for Federal areas with a shortage of mental      NA NA NA NA Workforce health professionals, which would Funding then open up additional federal funding opportunities. Capital Facilities and Technological Needs q One-Stop Converts a former medical Center/Crisis facility into a one-stop center for Residential transition-age youth. The center  NA NA NA NA Program provides access to care and houses a crisis residential program. Integrated Incorporates multiple technology Information projects, such as a Charon-Vax Systems server upgrade and improvements Infrastructure to data warehouse and electronic   NA NA NA NA record keeping, with the intent of creating an integrated information systems infrastructure. Integrated Develops, in conjunction with other Healthcare county agencies, an integrated Project health care facility that combines  NA NA NA NA medical and behavioral health services to address the whole person. Sources: MHSA plans and annual updates prepared by the County of San Bernardino Department of Behavioral Health Administration. NA = Not applicable. Workforce Education and Training and Capital Facilities and Technological Needs generally include efforts that focus on expanding, educating, and training the local public mental health workforce and improving infrastructure. Because programs within these components are not designed to provide direct mental health services, no age group is targeted.  = Program appears in a plan applicable for the fiscal year. l = County plan indicated that program targeted this age group. * Program description in county’s plan did not contain specific age groups. We, therefore, could not determine which discrete age groups the program targeted. California State Auditor Report 2012-122 99 August 2013 Table B.4 Santa Clara County Mental Health Department: Mental Health Services Act Planned Programs by Component Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Child and Provides a comprehensive Family System program for youth age 0 to 15 Improvement/ that combines critical core       l Full-Service services within a wraparound Partnerships* model that incorporates age-appropriate elements. Young Child Creates a program, in cooperation System of Care with First Five Santa Clara and the Development Infant and Toddler Mental Health Collaborative, that addresses the       l full-service needs of children under the age of 6 in Santa Clara County who are experiencing significant mental health challenges. Child and Creates a strategic effort to improve Family System the current Child and Family Improvement/ Behavioral Health outpatient system Behavioral through the research, design, and Health implementation of systemwide       l Recovery level-of-care screening, assessment, Services* and practice guidelines that incorporate core transformation principles and support selected evidence-based practices. Transition-Age Combines critical core services and Youth System wraparound services designed of Care for transition-age youth using Development/ a model called the Transition to       l Full-Service Independence Process System. Partnerships (Partnership)† Transition-Age Creates a strategic effort to improve Youth the current outpatient transition-age Behavioral youth system through the research, Health Services design, and implementation of Outpatient systemwide level-of-care screening,       l System assessment, and practice guidelines Redesign† that incorporate core transformation principles and support selected evidenced-based practices. Transition-Age Establishes a 24-hour drop-in Youth System center for transition-age youth of Care/Crisis that provides a safe place in a and Drop-In nonstigmatizing environment with       l Services and access to mental health, other basic Supports† services, and crisis intervention during the day. continued on next page . . . 100 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Transition-Age Establishes a specialized Youth System recovery-through-education of Care program through a partnership Development/ with a local community college,       l Education the California Department of Partnership† Mental Health, the California Department of Rehabilitation and potential employers. Adult System Establishes a Partnership program Development/ that provides all necessary services Full-Service and supports that assist the client       l Partnerships‡ in achieving his or her personal recovery goals. Adult System Establishes a strategic effort to Development/ shift the current mental health Behavioral outpatient system to a behavioral Health health model, including stakeholder Recovery involvement and embracing a       l Services— wellness and recovery model. Outpatient System Redesign‡ Adult Criminal Addresses the mental health needs Justice System of individuals with concurrent Development mental health and substance abuse       l problems who are also involved in the criminal justice system. Adult System Establishes urgent care and Development mobile crisis support services /Urgent Care near the Santa Clara County and Crisis Valley Medical Center Emergency Support‡ Psychiatric Service. These will       l respond to individuals who are in immediate need of medication management, crisis intervention, and linkage to community-based outpatient services. Adult System Hires program managers for Development/ Consumer Affairs and Family Consumer Support and Education to increase and Family the engagement of family,       l Self Help‡ significant others, and peers in supporting the individualized wellness and recovery plan for each client. Older Adult Establishes a Partnership program System of Care for individuals over the age of Development/ 60 who are seriously mentally ill. Full-Service Clients receive necessary services       l Partnerships§ and supports that assist them in achieving their personal recovery goals. California State Auditor Report 2012-122 101 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Community Services and Supports q Older Adult Represents a strategic effort to System of Care shift the current mental health Development/ outpatient system to a behavioral Behavioral health model, including stakeholder       l Health involvement and embracing a Recovery wellness and recovery model. Services§ Older Adult Creates a mobile assessment and System of Care outreach team to provide for the Development/ mental health needs of older adults       l Mobile who are physically, linguistically, or Assessment culturally isolated. and Outreach§ Older Adult Provides counseling support and System of Care education to older adults, their Development/ families, and care providers on aging       l Family and and mental health issues. Caregiver Support§ Housing Options Provides permanent supportive and       l Initiative transitional housing. Community Hires program managers for Family Consumer Affairs and Family OutreachII Relations who will help the       l county move toward a more consumer-centered model of mental health recovery services. Behavioral Creates a partnership with a local and Primary primary care provider to address       l Health Care a need for better access to basic Partnership health care for mental health clients. Behavioral Creates a partnership with local Health Learning community colleges to provide Partnership/ support for mental health clients Education to obtain their high school diploma       l Employment, and continue their education in Self-Sufficiency community colleges or universities. Recovery ServicesII Behavioral Creates a training center for Health Learning stakeholders that include technical Partnership support, training, and consultation       l to ensure ongoing education in various healing practices. Adult System Develops specialized services of Care to assist refugees in Santa Clara Development/ County. Services will include Regional psychiatric and psycho-social Survivors assessment and treatment, linkage       l of Torture to medical services, family support Treatment and education, and linkage to self-help through the Refugee and Immigrant Forum Ethnic Community Advisory Committee. continued on next page . . . 102 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Community Reduces disparities in access to Engagement mental health interventions among and Capacity underserved cultural populations Building for due to sigma, discrimination, Reducing and lack of knowledge about Stigma and mental health services. This    l l l l Discrimination goal is accomplished through four strategies: expanding outreach and engagement, enhancing mental health literacy, identifying programs to reduce stigma and discrimination, and building community capacity. Strengthening Prevents or intervenes early in the Families and development of emotional and Children behavioral problems in young children by providing parents with outcome-based parenting strategies, support services, and access to screenings to    l l identify developmental delays. In conjunction with other agencies, these strategies establish a foundational network of prevention and early intervention services to underserved cultural populations. Prevention Implements a continuum of services and Early targeting individuals experiencing Interventions an at-risk mental state or first onset. for Individuals The services attempt to detect and Experiencing treat serious mental illness early Onset of through community education,    l l l l Serious targeted multicultural outreach, Psychiatric community-based interventions, Illness with multifamily support groups, Psychotic peer-support services, supported Features employment, and education and social services navigation. Primary Care/ Provides a continuum of services Behavioral targeting adults and older Health adults experiencing the onset Integration of psychiatric illness. Some key for Adults and strategies for this project will Older Adults focus on improved coordination between primary care services and mental health services;    l l l improved capacity of primary care providers to identify, prevent, and treat mental health problems; improved mental health and social functioning of those with serious mental illness; and creating programs to prevent suicide. California State Auditor Report 2012-122 103 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Prevention and Early Intervention q Suicide Implements the five strategies Prevention of the county’s suicide plan including coordinated suicide intervention programs and services, a community education and information campaign, improved  l l l l media coverage and public dialogue, policy and governance advocacy to promote change, and it establishes robust data collection and monitoring to evaluate prevention efforts. Innovation q Early Childhood Creates online screening tools in Universal primary health care settings in order Screening to better detect mental illness in   l l Project children, especially those speaking only Spanish. Peer-Run Develops a model to expand the Transition-Age leadership capacity of transition-age Youth youth partners in the delivery of   l Innovation services in 24-hour care setting to improve access and outcomes for high-risk residents. Adults with Determines whether a specialized Autism and assessment instrument will help Co-Occurring clinicians more accurately diagnose  l l Mental Health co-occurring mental health Disorders disorders in adults with autism. Older Adults Increases quality of services for isolated older adults from underserved cultural and ethnic groups through a 12-week   l interactive activity in which the older adult is elicited to reminisce, capture, and express his or her life story. Multi-Cultural Increases access to underserved Center and inappropriately served ethnic communities by creating a multicultural center where members of all ethnic communities can   # # # # find a sense of cultural resonance, belonging, and support. Services are designed and delivered by peer and family partners. Transitional Creates a collaborative support Mental Health group between the mental Services for health department, faith-based   # # # # Newly Released organizations, and service providers County Inmates for newly released inmates with mental health issues. continued on next page . . . 104 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Innovation q Mental Collects data on all suicide or mental Health/Law health-related calls in the city of Enforcement San Jose and creates a response   # # # # Post-Crisis team that will follow up on all Intervention incidents within 24 hours. Interactive Video Establishes a process whereby clients Simulator and family members, especially Training those from ethnic communities, can directly impart their perspectives and needs as they collaborate as equal partners in the creation of a training   ** ** ** ** delivery system for law enforcement. The program also seeks to create a series of interactive video scenarios and lesson plans that impact the way law enforcement responds to mental health crisis situations. Workforce Education and Training q Workforce Hires staff to implement the Education county’s Workforce Education and    NA NA NA NA and Training Training plan. Coordination Promising Expands a training program for staff, Practice-Based contract staff, and stakeholders that Training in addresses child, adolescent, and Adult Recovery family treatment models. Principles    NA NA NA NA and Child, Adolescent and Family Service Models Improved Expands training for all staff to Services & improve services to ethnic and Outreach to cultural populations including    NA NA NA NA Unserved and marginalized populations. Underserved Populations Welcoming Develops and implements training, Consumers workshops, and consultations that and Family create an environment that welcomes Members consumers and family members as    NA NA NA NA contributing members of the public health system, thereby reducing barriers to accepting and welcoming consumers into the workforce. Workforce Builds on the collaboration between Education the Mental Health Department and and Training key system partners to develop Collaboration and share training and education    NA NA NA NA With Key programs so consumers and family System Partners members receive more effective integrated services. California State Auditor Report 2012-122 105 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Workforce Education and Training q Comprehensive Develops a career pathway Mental Health model for consumers and Career Pathway family members that leads to Model participants becoming eligible    NA NA NA NA for part- and full-time permanent positions with the county or community-based organizations. Stipends and Provides financial support to Incentives to attract and enable clients, family, Support Mental and community partners to enroll Health Career in a full range of educational    NA NA NA NA Pathway programs that are prerequisites for employment and advancement in public mental health. Capital Facilities and Technological Needs q Electronic Health Provides a comprehensive electronic Record medical record for consumers that can be shared in a secure and    NA NA NA NA integrated environment across service providers. Enterprise Creates a single data repository Wide Data for all Mental Health Department   NA NA NA NA Warehouse service, administrative, financial, and provider information. Consumer Portal Provides additional services for and Web site consumers and their families by Redesign enhancing the current Mental   NA NA NA NA Initiative Health Department Web site and developing a secure client portal. Consumer Sets up supervised computer Learning labs and provides basic personal Centers computer skills training to clients   NA NA NA NA in Mental Health Services Act recovery programs and living in the community. Bed and Housing Creates a database that allows Database operators of inpatient/residential Exchange mental health facilities to post their open beds whenever they become available so that case managers,   NA NA NA NA clinicians, and others authorized to act on behalf of Mental Health Department clients can quickly see what is available in housing and/or beds. County Health Creates a system that provides Record secure, real-time combined Integration countywide client health records that can be accessed across various service-providing agencies and provide a collaborative,  NA NA NA NA cross-agency view of registered clients’ demographic, services and care, medications, physical health services, insurance, employment, housing, and other information. continued on next page . . . 106 California State Auditor Report 2012-122 August 2013 FISCAL YEAR AGE GROUP TARGETED TRANSITION‑AGE OLDER PROGRAM TITLE DESCRIPTION 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 CHILD YOUTH ADULT ADULT Capital Facilities and Technological Needs q Medi-Plex Redesigns and reconstructs space Health Center for children and transition-age (Facility youth that is large enough to  NA NA NA NA Renovation) accommodate both and offer privacy and space for each group. Downtown Renovates a portion of a building Mental Health that will be used for a self-help  NA NA NA NA Renovation center providing outpatient services and training. Sources: Mental Health Services Act plans and annual updates prepared by the Santa Clara County Mental Health Department. NA = Not applicable. Workforce Education and Training and Capital Facilities and Technological Needs generally include efforts that focus on expanding, educating, and training the local public mental health workforce and improving infrastructure. Because programs within these components are not designed to provide direct mental health services, no age group is targeted.  = Program appears in a plan applicable for the fiscal year. l = County plan indicated that program targeted this age group. * Program combined into Child and Family System Improvement in fiscal year 2008–09. † Program combined into Transition-Age Youth System of Care Development in fiscal year 2008–09. ‡ Program combined into Adult System Development in fiscal year 2008–09. § Program combined into Older Adult System of Care Development in fiscal year 2008–09. II Program combined into Behavioral Health Learning Partnership/Education Employment, Self-Sufficiency Recovery Services in fiscal year 2008–09. # The county’s Innovation component plan did not identify specific age groups for the program. We, therefore, could not determine which discrete age groups the program targeted. ** This program is not designed to provide mental health services; rather, the purpose of the program is to create and present an effective mental health training delivery system for field law enforcement officers by adapting an existing technology in a new and innovative manner. California State Auditor Report 2012-122 107 August 2013 Appendix C Mental Health Services Act Client Demographics and Diagnoses for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 The Joint Legislative Audit Committee directed the California State Auditor to identify the demographics of the populations receiving services funded by the Mental Health Services Act (MHSA) in each of the four counties we reviewed. To provide additional information about the population receiving MHSA services, where available we obtained from each of the four counties mental health diagnoses of their clients. We did not confirm the accuracy or completeness of the demographic or diagnostic data the counties provided. County Client Demographics We reviewed four county departments: Los Angeles County Department of Mental Health (Los Angeles), County of Sacramento Department of Health and Human Services (Sacramento), County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and Santa Clara County Mental Health Department (Santa Clara). Tables C.1 through C.4 beginning on page 109 summarize client demographic data for those departments for the Community Services and Supports (Community Supports), Prevention and Early Intervention (Prevention), and Innovation (Innovation) components by fiscal year. If a county could not provide data for a given component for the audit period, which we established as fiscal years 2006–07 through 2011–12, we did not display data for that component. For example, Table C.2 does not include demographic data for clients receiving Innovation services because Sacramento had not provided Innovation services as of fiscal year 2011–12.14 The tables do not include the Workforce Education and Training and Capital Facilities and Technological Needs components because these components do not provide direct services to clients. We identified three state-defined demographic categories to use for this review: age, ethnicity, and primary language. The tables include the age group demographic because age group is a main focus of MHSA program design. Regulations define four age groups: children and youth, from birth, or age 0, 14 For fiscal year 2010–11, Sacramento included an Innovation program in its plan; the program is described in Appendix B. In fiscal years 2010–11 and 2011–12, Appendix D reflects that Sacramento made expenditures for Innovation. The fiscal year 2010–11 expenditures were for planning and the fiscal year 2011–12 expenditures were for a contract entity administering the Innovation program. However, as noted above, the county stated it was not providing Innovation services to mental health consumers in either fiscal year 2010–11 or 2011–12. 108 California State Auditor Report 2012-122 August 2013 through age 17 and certain disabled individuals age 18 and over; transition-age youth, age 16 to 25; adults, age 18 through 59; and older adults, age 60 and older. To prevent unnecessary duplication of client counts, we requested that the counties provide information in non-overlapping age categories: children and youth, age 0-15; transition-age youth, age 16-25; adults, age 26-59; and older adults, age 60 and over. Also included are the ethnicity and primary language demographics because state regulations name both as contributing to a determination of being underserved, and the underserved are a focus of the MHSA. We limited the display of the primary language data that counties provided to the five most commonly reported primary languages for each county. For each county at least 95 percent of all clients who identified with a primary language, excluding those identified with “Other” or “Unknown,” identified with one of the five most commonly reported languages. Counties vary in the relative ethnic and linguistic makeup of their MHSA clients. For instance, tables C.1 and C.4 show that Hispanics and Latinos make up a significant number of MHSA clients in both Los Angeles and Santa Clara counties, respectively. Spanish and Vietnamese were common non-English primary languages among all counties’ MHSA clients, although Los Angeles, Sacramento, San Bernardino, and Santa Clara counties reported Armenian, Russian, Farsi, and Chinese, respectively, as other major primary languages. County Client Diagnoses Tables C.5, C.6, and C.7 beginning on page 114 provide client diagnoses by fiscal year and county for the Community Supports, Prevention, and Innovation components, respectively. Not all counties tracked client diagnoses across these three components or for each year in our audit period. In some cases, this was because the counties had not yet implemented programs for a specific component, such as Innovation. To allow for comparison among counties, we summarized county-provided diagnoses into broader classifications as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). According to the American Psychiatric Association, the DSM-IV is the standard classification of mental disorders used by mental health professionals in the United States. Each classification includes examples of the disorders that make up the classification. California State Auditor Report 2012-122 109 August 2013 1.C elbaT tnenopmoC tcA secivreS htlaeH latneM yb egaugnaL yramirP dna ,yticinhtE ,puorG egA rof stnuoC tneilC htlaeH latneM fo tnemtrapeD ytnuoC selegnA soL 21–1102 hguorhT 70–6002 sraeY lacsiF NOITAVONNI NOITNEVRETNI YLRAE DNA NOITNEVERP STROPPUS DNA SECIVRES YTINUMMOC RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF 21–1102 21–1102 11–0102 01–9002 21–1102 11–0102 01–9002 90–8002 80–7002 70–6002 1 987,23 259,52 433,2 985,21 652,31 106,11 512,3 994,2 929 )51-0( htuoY dna nerdlihC 71 767,31 828,01 679,1 770,41 154,31 374,11 614,5 966,3 963,1 )52-61( htuoY egA-noitisnarT *puorG egA 222 612,51 578,8 709,3 798,16 073,06 143,35 698,52 275,71 399,7 )95-62( tludA 43 565,1 527 043 596,01 431,01 150,9 547,4 481,3 501,1 )+06( tludA redlO 29 785,31 736,01 335,2 406,62 651,62 746,32 642,31 182,9 682,4 naciremA-nacirfA 91 972 302 16 555 085 045 991 731 53 evitaN naciremA 01 536,1 501,1 903 868,5 589,5 436,5 719,2 623,2 155,1 rednalsI cfiicaP/naisA yticinhtE 06 087,53 761,62 726,3 077,63 164,53 499,92 099,11 729,7 620,3 cinapsiH 31 870,2 533,1 382 141,4 786,3 742,3 073,1 590,1 725 rehtO 08 484,8 808,5 407,1 233,32 333,32 489,02 918,8 247,5 978,1 etihW 11 603 091 37 970,1 288 988 441 48 32 nainemrA 2 79 48 7 059 469 879 867 297 137 naidobmaC 402 055,44 159,23 725,6 141,37 956,17 209,26 804,92 637,91 438,7 hsilgnE yramirP 51 278 436 762 604,3 134,3 732,3 104,1 130,1 625 rehtO †egaugnaL 63 033,51 298,01 705,1 933,61 947,51 038,31 126,5 948,3 646,1 hsinapS 6 306 454 411 717,1 108,1 905,1 067 706 722 detropeR toN/nwonknU – 58 74 22 836 617 107 244 604 713 esemanteiV .)selegnA soL( htlaeH latneM fo tnemtrapeD ytnuoC selegnA soL eht yb dedivorp noitamrofni detiduanU :ecruoS htuoy ega-noitisnart ,revo dna 81 ega slaudividni delbasid niatrec dna 71 hguorht 0 ega htuoy dna nerdlihc sa spuorg ega eht senfied tcA secivreS htlaeH latneM eht ot gnitaler snoitalugeR fo edoC ainrofilaC * .revo dna 06 ega tluda redlo dna ,95 ot 81 ega tluda ,52 ot 61 ega ”.rehtO“ yrogetac eht ni segaugnal rehto lla denibmoc eW .21–1102 hguorht 70–6002 sraey lacsfi rof selegnA soL yb dedivorp atad ni segaugnal detroper ylnommoc tsom evfi eht stsil egaugnaL yramirP † 110 California State Auditor Report 2012-122 August 2013 2.C elbaT egaugnaL yramirP dna ,yticinhtE ,puorG egA rof stnuoC tneilC secivreS namuH dna htlaeH fo tnemtrapeD otnemarcaS fo ytnuoC tnenopmoC tcA secivreS htlaeH latneM yb 21–1102 hguorhT 80–7002 sraeY lacsiF NOITNEVRETNI YLRAE DNA NOITNEVERP STROPPUS DNA SECIVRES YTINUMMOC RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF 21–1102 11–0102 01–9002 21–1102 11–0102 01–9002 90–8002 80–7002 939,2 074,2 380,1 082 832 351 711 56 )51-0( htuoY dna nerdlihC 296,3 785,1 695,2 551,1 829 975 453 841 )52-61( htuoY egA-noitisnarT 491,6 271,8 575,9 295,7 367,6 195,4 769,1 655 )95-62( tludA *puorG egA 129,5 744 363,1 038 848 435 113 811 )+06( tludA redlO 629,62 433,6 051 285 786 927,1 312 11 nwonknU 120,1 023 304,1 489,1 596,1 850,1 894 661 naciremA-nacirfA 774 761 105 669 029 327 992 941 naisA 105,1 264 292,1 871,1 269 645 022 011 cinapsiH 015 281 850,1 19 29 64 52 36 itluM 652 98 221 691 361 06 15 5 evitaN yticinhtE 011 7 198 843 323 962 612 91 rehtO 811 29 – 67 66 74 24 11 rednalsI cfiicaP 605,32 831,4 455,3 040,1 260,1 311,2 372 82 nwonknU 371,81 355,31 649,5 065,4 971,4 427,2 833,1 743 etihW 794,24 508,81 767,41 046,8 275,7 347,4 334,2 367 hsilgnE 23 2 – 482 662 512 87 72 gnomH 819 54 – 124 384 654 411 63 rehtO 723 6 – 57 57 97 92 3 naissuR †egaugnaL yramirP 108 68 – 191 071 591 77 21 hsinapS 680,1 46 – 107 267 667,1 081 03 nwonknU 11 2 – 721 631 231 15 72 esemanteiV .)otnemarcaS( secivreS namuH dna htlaeH fo tnemtrapeD otnemarcaS fo ytnuoC eht yb dedivorp noitamrofni detiduanU :ecruoS htuoy ega-noitisnart ,revo dna 81 ega slaudividni delbasid niatrec dna 71 hguorht 0 ega htuoy dna nerdlihc sa spuorg ega eht senfied tcA secivreS htlaeH latneM eht ot gnitaler snoitalugeR fo edoC ainrofilaC * .revo dna 06 ega tluda redlo dna ,95 ot 81 ega tluda ,52 ot 61 ega ”.rehtO“ yrogetac eht ni segaugnal rehto lla denibmoc eW .21–1102 hguorht 80–7002 sraey lacsfi rof otnemarcaS yb dedivorp atad ni segaugnal detroper ylnommoc tsom evfi eht stsil egaugnaL yramirP † California State Auditor Report 2012-122 111 August 2013 3.C elbaT egaugnaL yramirP dna ,yticinhtE ,puorG egA rof stnuoC tneilC noitartsinimdA htlaeH laroivaheB fo tnemtrapeD onidranreB naS fo ytnuoC tnenopmoC tcA secivreS htlaeH latneM yb 21–1102 hguorhT 70–6002 sraeY lacsiF NOITAVONNI NOITNEVRETNI YLRAE DNA NOITNEVERP STROPPUS DNA SECIVRES YTINUMMOC RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF 21–1102 11–0102 21–1102 11–0102 01–9002 90–8002 21–1102 11–0102 01–9002 90–8002 80–7002 70–6002 151,1 5 688,401 991,91 757,61 664 678,1 500,2 791,2 389,1 165 28 )51-0( htuoY dna nerdlihC 702,1 21 315,91 322,41 374,2 712 711,3 365,3 029,3 794,2 070,1 185 )52-61( htuoY egA-noitisnarT egA 436,3 – 702,04 416,21 626,5 72 607,6 522,7 409,6 423,4 422,2 177,1 )95-62( tludA *puorG 359 – 875,21 249,4 175,5 1 395 775 275 783 612 87 )+06( tludA redlO 260,1 – – – – – – – 4 – – – nwonknU 907 21 583,71 116,5 821,4 411 280,2 571,2 752,2 654,1 216 254 naciremA-nacirfA 899 – 885,9 540,1 650,1 8 632 332 132 621 95 55 rednalsI cfiicaP/naisA 236,3 3 046,37 940,61 800,21 583 ‡876,3 ‡831,4 ‡352,4 ‡419,2 ‡412,1 ‡977 onitaL/cinapsiH †yticinhtE 352 – 289,7 128 651 2 721 231 821 39 05 52 naciremA evitaN 398 – 289,81 436,9 878,1 34 951,3 707,3 900,4 095,2 801,1 267 rehtO 225,1 2 083,24 942,51 102,11 951 886,6 321,7 279,6 629,4 242,2 812,1 naisacuaC/etihW 351,4 71 151,131 797,02 783,11 623,21 253,21 044,8 566,3 091,2 hsilgnE – – 022 – 1 – 3 2 – – israF – – 927 – – – 3 – – – niradnaM 33 – 241,2 041,2 IIAN IIAN 032 942 492 441 46 29 rehtO §eg y a r u a g m n i a rP L 314,1 – 401,71 027,1 614 554 555 233 631 621 hsinapS 804,2 – 932,5 004,3 842 923 973 862 302 301 nwonknU – – 08 31 01 11 11 5 3 1 esemanteiV .)onidranreB naS( noitartsinimdA htlaeH laroivaheB fo tnemtrapeD onidranreB naS fo ytnuoC eht yb dedivorp noitamrofni detiduanU :ecruoS ega htuoy ega-noitisnart ,revo dna 81 ega slaudividni delbasid niatrec dna 71 hguorht 0 ega htuoy dna nerdlihc sa spuorg ega eht senfied tcA secivreS htlaeH latneM eht ot gnitaler snoitalugeR fo edoC ainrofilaC * .revo dna 06 ega tluda redlo dna ,95 ot 81 ega tluda ,52 ot 61 ,onipiliF ,esenihC ,naidobmaC ,naidnI naisA ,rednalsI cfiicaP/naisA ,naisaremA fo desopmoc si rednalsI cfiicaP/naisA .seirogetac xis otni atad eht denibmoc eW .atad yticinhte deliated dedivorp onidranreB naS † naciremA evitaN .cinapsiH dna ,naciR atsoC ,nacinimoD ,nabuC ,naciremA lartneC ,naebbiraC fo desopmoc si cinapsiH .evitaN naiiawaH dna ,esemanteiV ,naomaS ,naitoaL ,naeroK ,esenapaJ ,gnomH ,nainamauG .elpitluM dna ,rehtO/nwonknU ,etihW-noN rehtO ,barA fo desopmoc si rehtO .nainemrA dna ,nailatI ,etihW sedulcni etihW .naciremA evitaN dna naksalA evitaN fo desopmoc si ”.rehtO“ yrogetac eht ni dedulcni osla era stneilc esoht hguohtla ,nigiro cinapsiH fo snosrep sedulcni sihT ‡ ”.rehtO“ yrogetac eht ni segaugnal rehto lla denibmoc eW .21–1102 hguorht 70–6002 sraey lacsfi rof onidranreB naS yb dedivorp atad ni segaugnal detroper ylnommoc tsom evfi eht stsil egaugnaL yramirP § .raey siht rof noitamrofni egaugnal yramirp noitnevretnI ylraE dna noitneverP edivorp ton did onidranreB naS sa elbaliava toN = AN II 112 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 113 August 2013 4.C elbaT tnenopmoC tcA secivreS htlaeH latneM yb egaugnaL yramirP dna ,yticinhtE ,puorG egA rof stnuoC tneilC tnemtrapeD htlaeH latneM ytnuoC aralC atnaS 21–1102 hguorhT 70–6002 sraeY lacsiF DNA NOITNEVERP NOITAVONNI NOITNEVRETNI YLRAE STROPPUS DNA SECIVRES YTINUMMOC RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF RAEY LACSIF 21–1102 21–1102 11–0102 21–1102 11–0102 01–9002 90–8002 80–7002 70–6002 24 – 6 950,7 151,6 341,5 596,4 659,3 408,3 )51-0( htuoY dna nerdlihC 461 62 8 553,2 391,2 120,2 157,1 734,1 912,1 )52-61( htuoY egA-noitisnarT 944 – 3 701,6 537,5 925,5 994,5 330,5 949,4 )95-62( tludA *puorG egA 71 – – 540,1 720,1 869 979 709 088 )+06( tludA redlO 721 – – – – – – – – nwonknU 842 8 – 243,1 052,1 502,1 321,1 469 219 naciremA-nacirfA 331 1 – 322 312 612 202 051 731 naidnI naciremA 743 1 – 979,1 700,2 819,1 488,1 928,1 298,1 rednalsI cfiicaP/naisA 594 01 9 220,7 369,5 899,4 406,4 997,3 172,3 onitaL yticinhtE 5 – 2 54 43 52 91 11 31 dexiM 46 – 1 925 415 024 164 134 924 rehtO 861 2 – 547 555 594 154 773 714 nwonknU 262 4 5 186,4 075,4 483,4 081,4 277,3 187,3 etihW 41 – – 781 632 332 542 252 572 naidobmaC 079 32 – 75 36 76 36 36 76 esenihC 32 – 01 899,21 630,21 040,11 143,01 389,8 486,8 hsilgnE yramirP 274 3 5 744 564 344 724 604 704 rehtO †egaugnaL 1 – 2 041,2 036,1 512,1 681,1 789 347 hsinapS 13 – – 055 155 855 655 035 915 esemanteiV 8 – – 781 521 501 601 211 751 nwonknU .)aralC atnaS( tnemtrapeD htlaeH latneM ytnuoC aralC atnaS eht yb dedivorp noitamrofni detiduanU :ecruoS htuoy ega-noitisnart ,revo dna 81 ega slaudividni delbasid niatrec dna 71 hguorht 0 ega htuoy dna nerdlihc sa spuorg ega eht senfied tcA secivreS htlaeH latneM eht ot gnitaler snoitalugeR fo edoC ainrofilaC * .revo dna 06 ega tluda redlo dna ,95 ot 81 ega tluda ,52 ot 61 ega ”.rehtO“ yrogetac eht ni segaugnal rehto lla denibmoc eW .21–1102 hguorht 70–6002 sraey lacsfi rof aralC atnaS yb dedivorp atad ni segaugnal detroper ylnommoc tsom evfi eht stsil egaugnaL yramirP † 114 California State Auditor Report 2012-122 August 2013 Table C.5 Community Services and Supports Client Counts by Mental Health Diagnosis and County Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR 2006–07 FISCAL YEAR 2007–08 FISCAL YEAR 2008–09 FISCAL YEAR 2009–10 FISCAL YEAR 2010–11 FISCAL YEAR 2011–12 MENTAL HEALTH DIAGNOSIS* DESCRIPTION SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS Adjustment disorders Includes adjustment disorders with 143 NA† 28 699 404 19 143 764 507 40 399 936 1,580 46 415 1,079 2,212 58 407 1,380 2,304 78 396 1,689 depression and with anxiety. Anxiety disorders Includes disorders such as panic disorders, obsessive-compulsive disorder, 807 NA† 57 988 1,662 12 246 1,122 2,125 52 591 1,369 5,202 75 818 1,448 6,254 95 790 1,728 6,935 102 785 1,906 and agoraphobia. Delirium, dementia, and amnestic Includes delirium, dementia, and disorders NA‡ NA† NA‡ 5 NA‡ 2 NA‡ 12 NA‡ – NA‡ 8 NA‡ 2 NA‡ 13 NA‡ 1 NA‡ 11 NA‡ 1 NA‡ 19 and other cognitive disorders such as amnestic disorders. Disorders usually first diagnosed in Includes disorders such as mental infancy, childhood, or adolescence retardation, attention-deficit, and disruptive 647 NA† 72 1,712 1,555 30 233 1,927 2,006 42 914 2,388 7,166 43 1,068 2,845 7,846 84 1,105 3,450 7,856 134 1,071 3,947 behavior disorders. Mood disorders Includes depressive and bipolar disorders. 5,668 NA† 1,499 3,841 14,013 257 2,544 3,773 continued . . . 20,878 334 5,294 4,292 45,520 691 8,291 4,357 51,612 687 7,868 4,504 53,140 695 7,145 4,665 Personality disorders Includes disorders such as borderline personality disorder, narcissistic personality 2 NA† – 11 5 – 1 12 19 7 1 17 64 24 – 13 54 27 2 18 46 30 1 21 disorder, and paranoid personality disorder. Schizophrenia and other Includes disorders such as schizophrenia, 3,812 NA† 810 3,185 8,198 145 826 3,261 12,011 190 1,882 3,335 22,758 623 2,750 3,425 25,111 591 2,903 3,536 24,981 596 2,675 3,823 psychotic disorders delusional disorder, and psychotic disorders. Somatoform disorders Includes somatoform disorder and disorders 2 NA† – 6 5 NA‡ – 5 8 NA‡ 1 3 33 NA‡ 2 2 71 NA‡ 3 4 71 NA‡ 1 5 such as pain disorder and hypochondriasis. Substance-related disorders Includes disorders such as alcohol-related, amphetamine-related, and 107 NA† 36 NA‡ 265 3 60 NA‡ 415 6 46 NA‡ 617 1 32 NA‡ 647 18 30 NA‡ 640 20 26 NA‡ cocaine-related disorders. Other Includes disorders counties diagnose irregularly such as dissociative disorders, 87 NA† 10 118 247 4 18 124 422 7 63 131 714 8 221 172 818 15 262 153 764 13 192 146 sexual and gender identity disorders, eating disorders, and sleep disorders. None/unknown Includes clients who left services before being diagnosed, those whom counties determined not to have a Diagnostic and Statistical 29 NA† NA‡ 287 153 18 NA‡ 333 150 3 NA‡ 445 392 9 NA‡ 307 588 1 NA‡ 322 532 10 NA‡ 345 Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder, and clients reported as having an unknown diagnosis. Sources: Unaudited diagnosis data provided by the Los Angeles County Department of Mental Health (Los Angeles), the County of Sacramento Department of Health and Human Services (Sacramento), the County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and the Santa Clara County Mental Health Department (Santa Clara). NA = Not applicable. * Mental health diagnosis based on classifications from the DSM-IV. † Sacramento did not provide client counts for Community Services and Supports programs; the county stated it implemented those programs in fiscal year 2007–08. ‡ The county did not provide client counts for this mental health diagnosis. California State Auditor Report 2012-122 115 August 2013 Table C.5 Community Services and Supports Client Counts by Mental Health Diagnosis and County Fiscal Years 2006–07 Through 2011–12 FISCAL YEAR 2006–07 FISCAL YEAR 2007–08 FISCAL YEAR 2008–09 FISCAL YEAR 2009–10 FISCAL YEAR 2010–11 FISCAL YEAR 2011–12 MENTAL HEALTH DIAGNOSIS* DESCRIPTION SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS Adjustment disorders Includes adjustment disorders with 143 NA† 28 699 404 19 143 764 507 40 399 936 1,580 46 415 1,079 2,212 58 407 1,380 2,304 78 396 1,689 depression and with anxiety. Anxiety disorders Includes disorders such as panic disorders, obsessive-compulsive disorder, 807 NA† 57 988 1,662 12 246 1,122 2,125 52 591 1,369 5,202 75 818 1,448 6,254 95 790 1,728 6,935 102 785 1,906 and agoraphobia. Delirium, dementia, and amnestic Includes delirium, dementia, and disorders NA‡ NA† NA‡ 5 NA‡ 2 NA‡ 12 NA‡ – NA‡ 8 NA‡ 2 NA‡ 13 NA‡ 1 NA‡ 11 NA‡ 1 NA‡ 19 and other cognitive disorders such as amnestic disorders. Disorders usually first diagnosed in Includes disorders such as mental infancy, childhood, or adolescence retardation, attention-deficit, and disruptive 647 NA† 72 1,712 1,555 30 233 1,927 2,006 42 914 2,388 7,166 43 1,068 2,845 7,846 84 1,105 3,450 7,856 134 1,071 3,947 behavior disorders. Mood disorders Includes depressive and bipolar disorders. 5,668 NA† 1,499 3,841 14,013 257 2,544 3,773 . . . continued 20,878 334 5,294 4,292 45,520 691 8,291 4,357 51,612 687 7,868 4,504 53,140 695 7,145 4,665 Personality disorders Includes disorders such as borderline personality disorder, narcissistic personality 2 NA† – 11 5 – 1 12 19 7 1 17 64 24 – 13 54 27 2 18 46 30 1 21 disorder, and paranoid personality disorder. Schizophrenia and other Includes disorders such as schizophrenia, 3,812 NA† 810 3,185 8,198 145 826 3,261 12,011 190 1,882 3,335 22,758 623 2,750 3,425 25,111 591 2,903 3,536 24,981 596 2,675 3,823 psychotic disorders delusional disorder, and psychotic disorders. Somatoform disorders Includes somatoform disorder and disorders 2 NA† – 6 5 NA‡ – 5 8 NA‡ 1 3 33 NA‡ 2 2 71 NA‡ 3 4 71 NA‡ 1 5 such as pain disorder and hypochondriasis. Substance-related disorders Includes disorders such as alcohol-related, amphetamine-related, and 107 NA† 36 NA‡ 265 3 60 NA‡ 415 6 46 NA‡ 617 1 32 NA‡ 647 18 30 NA‡ 640 20 26 NA‡ cocaine-related disorders. Other Includes disorders counties diagnose irregularly such as dissociative disorders, 87 NA† 10 118 247 4 18 124 422 7 63 131 714 8 221 172 818 15 262 153 764 13 192 146 sexual and gender identity disorders, eating disorders, and sleep disorders. None/unknown Includes clients who left services before being diagnosed, those whom counties determined not to have a Diagnostic and Statistical 29 NA† NA‡ 287 153 18 NA‡ 333 150 3 NA‡ 445 392 9 NA‡ 307 588 1 NA‡ 322 532 10 NA‡ 345 Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder, and clients reported as having an unknown diagnosis. Sources: Unaudited diagnosis data provided by the Los Angeles County Department of Mental Health (Los Angeles), the County of Sacramento Department of Health and Human Services (Sacramento), the County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and the Santa Clara County Mental Health Department (Santa Clara). NA = Not applicable. * Mental health diagnosis based on classifications from the DSM-IV. † Sacramento did not provide client counts for Community Services and Supports programs; the county stated it implemented those programs in fiscal year 2007–08. ‡ The county did not provide client counts for this mental health diagnosis. 116 California State Auditor Report 2012-122 August 2013 6.C elbaT ytnuoC dna sisongaiD htlaeH latneM yb stnuoC tneilC noitnevretnI ylraE dna noitneverP 21–1102 hguorhT 90–8002 sraeY lacsiF 21–1102 RAEY LACSIF 11–0102 RAEY LACSIF 01–9002 RAEY LACSIF 90–8002 RAEY LACSIF NOITPIRCSED *SISONGAID HTLAEH LATNEM ARALC ATNAS ONIDRANREB NAS OTNEMARCAS SELEGNA SOL ARALC ATNAS ONIDRANREB NAS OTNEMARCAS SELEGNA SOL ARALC ATNAS ONIDRANREB NAS OTNEMARCAS SELEGNA SOL ARALC ATNAS ONIDRANREB NAS OTNEMARCAS SELEGNA SOL 701 691 1 106,4 2 17 ‡AN 267,2 §AN 33 ‡AN 192 §AN 61 ‡AN †AN dna noisserped htiw sredrosid tnemtsujda sedulcnI sredrosid tnemtsujdA .yteixna htiw 751 69 3 215,8 4 94 ‡AN 277,5 §AN 27 ‡AN 365 §AN 71 ‡AN †AN ,sredrosid cinap sa hcus sredrosid sedulcnI sredrosid yteixnA .aibohparoga dna ,redrosid evislupmoc-evissesbo – IIAN – IIAN – IIAN ‡AN IIAN §AN IIAN ‡AN IIAN §AN IIAN ‡AN †AN sa hcus sredrosid dna ,aitnemed ,muiriled sedulcnI citsenma dna ,aitnemed ,muirileD .sredrosid citsenma sredrosid evitingoc rehto dna 21 011 3 592,51 2 43 ‡AN 500,21 §AN 92 ‡AN 559 §AN 1 ‡AN †AN ,noitadrater latnem sa hcus sredrosid sedulcnI ni desongaid tsrfi yllausu sredrosiD .sredrosid roivaheb evitpursid dna ,ticfied-noitnetta ecnecseloda ro ,doohdlihc ,ycnafni 223 68 7 138,62 3 86 ‡AN 713,91 §AN 371 ‡AN 949,4 §AN 33 ‡AN †AN .sredrosid ralopib dna evisserped sedulcnI sredrosid dooM ytilanosrep enilredrob sa hcus sredrosid sedulcnI sredrosid ytilanosreP 2 – – 2 – – ‡AN 1 §AN – ‡AN – §AN – ‡AN †AN dna ,redrosid ytilanosrep citsissicran ,redrosid .redrosid ytilanosrep dionarap 52 2 17 463,4 4 – ‡AN 535,3 §AN 71 ‡AN 135,1 §AN 8 ‡AN †AN lanoisuled ,ainerhpozihcs sa hcus sredrosid sedulcnI rehto dna ainerhpozihcS .sredrosid citohcysp dna ,redrosid sredrosid citohcysp – 2 – 42 – – ‡AN 71 §AN – ‡AN 3 §AN – ‡AN †AN sa hcus sredrosid dna redrosid mrofotamos sedulcnI sredrosid mrofotamoS .sisairdnohcopyh dna redrosid niap IIAN 7 1 961 IIAN 3 ‡AN 211 §AN 1 ‡AN 44 §AN 2 ‡AN †AN ,detaler-lohocla sa hcus sredrosid sedulcnI sredrosid detaler-ecnatsbuS .sredrosid detaler-eniacoc dna ,detaler-enimatehpma hcus ylralugerri esongaid seitnuoc sredrosid sedulcnI rehtO 6 605 – 193 2 18 ‡AN 313 §AN 82 ‡AN 49 §AN – ‡AN †AN ytitnedi redneg dna lauxes ,sredrosid evitaicossid sa .sredrosid peels dna ,sredrosid gnitae ,sredrosid gnieb erofeb secivres tfel ohw stneilc sedulcnI nwonknu/enoN ot ton denimreted seitnuoc mohw esoht ,desongaid 14 IIAN – 356,1 – IIAN ‡AN 224,1 §AN IIAN ‡AN 78 §AN IIAN ‡AN †AN latneM fo launaM lacitsitatS dna citsongaiD a evah dna redrosid )VI-MSD( noitidE htruoF ,sredrosiD .sisongaid nwonknu na gnivah sa detroper stneilc fo ytnuoC eht ,)otnemarcaS( secivreS namuH dna htlaeH fo tnemtrapeD otnemarcaS fo ytnuoC eht ,)selegnA soL( htlaeH latneM fo tnemtrapeD ytnuoC selegnA soL eht yb dedivorp atad sisongaid detiduanU :secruoS .)aralC atnaS( tnemtrapeD htlaeH latneM ytnuoC aralC atnaS eht dna ,)onidranreB naS( noitartsinimdA htlaeH laroivaheB fo tnemtrapeD onidranreB naS .elbacilppa toN = AN .VI-MSD eht morf snoitacfiissalc no desab sisongaid htlaeh latneM * .01–9002 raey lacsfi ni smargorp esoht nageb ti detats ytnuoc eht ;smargorp )noitneverP( noitnevretnI ylraE dna noitneverP rof stnuoc tneilc edivorp ton did selegnA soL † .21–1102 raey lacsfi ni gninnigeb margorp eno dekcart ti detats ytnuoc eht ;smargorp noitneverP rof stnuoc tneilc edivorp ton did otnemarcaS ‡ .11–0102 raey lacsfi ni smargorp esoht detnemelpmi ti detats ytnuoc eht ;smargorp noitneverP rof stnuoc tneilc edivorp ton did aralC atnaS § .sisongaid htlaeh latnem siht rof stnuoc tneilc edivorp ton did ytnuoc ehT II California State Auditor Report 2012-122 117 August 2013 Table C.7 Innovation Client Counts by Mental Health Diagnosis and County Fiscal Year 2011–12 FISCAL YEAR 2011–12 MENTAL HEALTH DIAGNOSIS* DESCRIPTION SELEGNA SOL OTNEMARCAS ONIDRANREB NAS ARALC ATNAS Adjustment disorders Includes adjustment disorders with depression and with anxiety. 13 NA† NA§ 1 Anxiety disorders Includes disorders such as panic disorders, obsessive-compulsive 21 NA† NA§ 8 disorder, and agoraphobia. Delirium, dementia, and amnestic and Includes delirium, dementia, and disorders such as NA‡ NA† NA§ – other cognitive disorders amnestic disorders. Disorders usually first diagnosed in Includes disorders such as mental retardation, attention-deficit 2 NA† NA§ 1 infancy, childhood, or adolescence and disruptive behavior disorders. Mood disorders Includes depressive and bipolar disorders. 194 NA† NA§ 12 Personality disorders Includes disorders such as borderline personality disorder, – NA† NA§ – narcissistic personality disorder, and paranoid personality disorder. Schizophrenia and other Includes disorders such as schizophrenia, delusional disorder, and 41 NA† NA§ 2 psychotic disorders psychotic disorders. Somatoform disorders Includes somatoform disorders and disorders such as pain disorder 1 NA† NA§ – and hypochondriasis. Substance-related disorders Includes disorders such as alcohol-related, amphetamine-related, 1 NA† NA§ NA‡ and cocaine-related disorders. Other Includes disorders counties diagnose irregularly.II 1 NA† NA§ – None/unknown Includes clients who left services before being diagnosed, those whom counties determined not to have a Diagnostic and – NA† NA§ 2 Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder, and clients reported as having an unknown diagnosis. Sources: Unaudited diagnosis data provided by the Los Angeles County Department of Mental Health (Los Angeles), the County of Sacramento Department of Health and Human Services (Sacramento), the County of San Bernardino Department of Behavioral Health Administration (San Bernardino), and the Santa Clara County Mental Health Department (Santa Clara). NA = Not applicable. * Mental health diagnosis based on classifications from the DSM-IV. † Sacramento did not provide client counts for Innovation programs; the county stated it did not offer services through Innovation programs until fiscal year 2012–13. ‡ The county did not provide client counts for this mental health diagnosis. § San Bernardino did not provide client counts for Innovation programs; the county stated it does not collect data in a usable format pending a software implementation. II Los Angeles reported one client with an unspecified disorder affecting a medical condition. 118 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 119 August 2013 Appendix D Mental Health Services Act Revenues, Expenditures, and Prudent Reserves for the Four Counties Reviewed Fiscal Years 2006–07 Through 2011–12 The Joint Legislative Audit Committee directed the California State Auditor to compare counties’ Mental Health Services Act (MHSA) planned expenditures to their actual expenditures for the last six fiscal years, which we established as 2006–07 through 2011–12. We reviewed four county departments: Los Angeles County Department of Mental Health, County of Sacramento Department of Health and Human Services, County of San Bernardino Department of Behavioral Health Administration, and Santa Clara County Mental Health Department. Tables D.1 through D.4 on the following pages summarize their revenues and expenditures using data obtained from the annual Revenue and Expenditure Report (RER) each county submitted to Mental Health. The RER ranged from fiscal years 2006–07 through 2010–11. In order to present MHSA revenues for years for which a county had not yet prepared an RER, we used the allocation amounts presented in Appendix A; for county expenditures, we obtained county accounting information. We did not confirm the accuracy or completeness of the counties’ RERs or the accounting information they provided. Tables D.1, D.2, D.3, and D.4 generally show that, in total, the counties had growing positive ending balances in the earlier years of the time frame and that these peaked in fiscal year 2010–11. To ensure that program service levels continue in the event of an MHSA revenue shortfall, counties are required to establish and maintain a prudent reserve. Tables D.1 through D.4 show the MHSA funds each county contributed to its prudent reserve as expenditures; the tables also summarize these funds in a stand-alone section. Because we obtained county contributions to the prudent reserve from the counties’ RERs, we could not identify the amounts counties may have dedicated to their prudent reserves in fiscal years for which RERs were not available. Also, the stand-alone tables summarizing prudent reserve do not reflect funds the counties may have spent from these reserves. All expenditures are reflected in tables D.1 through D.4. 120 California State Auditor Report 2012-122 August 2013 Table D.1 Los Angeles County Department of Mental Health: Mental Health Services Act Revenues and Expenditures by Component Fiscal Years 2006–07 Through 2011–12 Revenues and Expenditures by Component FISCAL YEAR COMPONENT 2006–07* 2007–08* 2008–09* 2009–10* 2010–11† 2011–12† Community Services and Supports Unspent funds available $69,580,600 $119,546,820 $128,669,270 $5,806,002 $34,791,908 $113,731,605 Revenues 107,787,977 158,076,638 182,714,073 260,798,561 319,091,506‡ 210,077,200 Expenditures 57,821,757 148,954,188 177,999,591 231,812,655 240,151,809 249,898,868 Contributions to prudent reserveII – – 127,577,750 – – – Ending balance 119,546,820 128,669,270 5,806,002 34,791,908 113,731,605 73,909,937 Prevention and Early Intervention Unspent funds available $– $– $6,220,352 $100,461,486 $143,979,291 $216,594,237 Revenues – 7,074,500 97,522,000 87,648,558 122,608,254 67,946,000 Expenditures – 854,148 3,280,866 10,983,101 49,993,308 81,599,995 Contributions to prudent reserveII – – – 33,147,652 – – Ending balance – 6,220,352 100,461,486 143,979,291 216,594,237 202,940,242 Innovation Unspent funds available $– $– $– $20,294,900 $40,006,830 $89,687,855 Revenues – – 20,294,900 20,294,900 50,730,032 13,909,700 Expenditures – – – 582,970 1,049,007 4,983,293 Ending balance – – 20,294,900 40,006,830 89,687,855 98,614,262 Workforce Education and Training Unspent funds available $– $– $814,730 $20,981,138 $54,014,046 $87,956,208 Revenues – 2,450,146 27,519,016 37,268,778 37,868,778 1,800,000 Expenditures – 1,635,416 7,352,608 4,235,870 3,926,616 3,472,844 Ending balance – 814,730 20,981,138 54,014,046 87,956,208 86,283,364 Capital Facilities and Technological Needs Unspent funds available $– $– $– $43,359,775 $70,204,026 $152,913,733 Revenues – – 43,359,775 28,576,585 88,232,464 – Expenditures – – – 1,732,334 5,522,757 14,322,812 Ending balance – – 43,359,775 70,204,026 152,913,733 138,590,921 Total ending balances $119,546,820 $135,704,352 $190,903,301 $342,996,101 $660,883,638 $600,338,726 Mental Health Services Act Funds Dedicated to Local Prudent Reserve COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11II 2011–12II TOTAL Community Services and Supports $– $– $127,577,750 $– $– $– $127,577,750 Prevention and Early Intervention – – – 33,147,652 – – 33,147,652 Totals $– $– $127,577,750 $33,147,652 $– $– $160,725,402 Sources: Unaudited county Revenue and Expenditure Reports (RERs), unaudited internal county accounting data, and Appendix A allocation data. * For fiscal years 2006–07 through 2009–10, revenues and expenditures are from the county’s unaudited RERs. According to the director of finance for the county’s Mental Health Department, revenues reflect cash received for the respective fiscal year and interest earned on those amounts. † For fiscal years 2010–11 and 2011–12, revenues are based on state-allocated amounts the California Department of Mental Health reported and include some funds the county assigned to a Joint Powers Authority and, therefore, were not administered locally (see Appendix A). Expenditures are based on unaudited county accounting reports. ‡ According to the director of finance for the county’s Mental Health Department, Community Services and Supports revenue for fiscal year 2010–11 was $210 million. Revenues are based on state-allocated amounts the California Department of Mental Health reported and are unaudited. II The Mental Health Services Act requires a prudent reserve to ensure that the county can continue to provide Community Services and Supports and Prevention and Early Intervention programs to its current clients. The amounts shown are from the county’s RERs and these documents were limited to fiscal years 2006–07 through 2009–10; thus, there may be contributions to the prudent reserve the table does not reflect. California State Auditor Report 2012-122 121 August 2013 Table D.2 County of Sacramento Department of Health and Human Services: Mental Health Services Act Revenues and Expenditures by Component Fiscal Years 2006–07 Through 2011–12 Revenues and Expenditures by Component FISCAL YEAR COMPONENT 2006–07* 2007–08* 2008–09* 2009–10† 2010–11† 2011–12† Community Services and Supports‡ Unspent funds available $1,231,301 $7,052,900 $11,285,593 $17,521,544 $15,366,689 $16,945,386 Revenues 13,769,665 16,507,375 30,857,863 27,976,100 33,141,107 23,754,100 Expenditures 7,948,066 9,622,947 15,501,500 30,130,955 31,562,410 24,661,208 Contributions to prudent reserve§ – 2,651,735 9,120,412 – – – Ending balance 7,052,900 11,285,593 17,521,544 15,366,689 16,945,386 16,038,278 Prevention and Early Intervention Unspent funds available $– $– $– $1,232,942 $12,536,187 $30,703,357 Revenues – – 1,529,164 12,246,700 21,657,600 7,546,300 Expenditures – – 296,222 943,455 3,490,430 8,565,608 Contributions to prudent reserve§ – – – – – – Ending balance – – 1,232,942 12,536,187 30,703,357 29,684,049 InnovationII Unspent funds available $– $– $– $– $2,267,300 $10,504,242 Revenues – – – 2,267,300 8,379,100 1,565,200 Expenditures – – – – 142,158 4,152,581 Ending balance – – – 2,267,300 10,504,242 7,916,861 Workforce Education and Training Unspent funds available $– $– $– $402,178 $203,096 $(130,108) Revenues – – 439,649 – – – Expenditures – – 37,471 199,082 333,204 517,939 Ending balance – – 402,178 203,096 (130,108) (648,047) Capital Facilities and Technological Needs Unspent funds available $– $– $– $9,431 $884,431 $390,718 Revenues – – 642,371 875,000 1,797,290 – Expenditures – – 632,940 – 2,291,003 2,110,071 Ending balance – – 9,431 884,431 390,718 (1,719,353) Total ending balances $7,052,900 $11,285,593 $19,166,095 $31,257,703 $58,413,595 $51,271,788 continued on next page . . . 122 California State Auditor Report 2012-122 August 2013 Mental Health Services Act Funds Dedicated to Local Prudent Reserve FISCAL YEAR COMPONENT 2006–07 2007–08 2008–09 2009–10§ 2010–11§ 2011–12§ TOTAL Community Services and Supports $– $2,651,735 $9,120,412 $– $– $– $11,772,147 Prevention and Early Intervention – – – – – – – Totals $– $2,651,735 $9,120,412 $– $– $– $11,772,147 Sources: Unaudited county Revenue and Expenditure Reports (RERs), unaudited internal county accounting data, and Appendix A allocation data. * For fiscal years 2006–07 through 2008–09, revenues and expenditures are from the county’s unaudited RERs. Revenues reflect deposits from state-allocated amounts and interest earned on those amounts. † For fiscal years 2009–10 through 2011–12, revenues are based on state-allocated amounts the California Department of Mental Health reported and include some funds the county assigned to a Joint Powers Authority and, therefore, were not administered locally (see Appendix A). Expenditures are based on unaudited county accounting reports. ‡ Because of the nature of its accounting systems, Sacramento’s Community Services and Supports expenditure totals for fiscal years 2009–10 and 2010–11 include amounts that may later be reimbursed by non-MHSA funds. As a result, Community Services and Supports total expenditures for those years may be overstated. § The Mental Health Services Act requires a prudent reserve to ensure that the county can continue to provide Community Services and Supports and Prevention and Early Intervention programs to its current clients. The amounts shown are from the county’s RERs and these documents were limited to fiscal years 2006–07 through 2008–09; thus, there may be contributions to the prudent reserve the table does not reflect. II For fiscal year 2010–11, Sacramento included an Innovation program in its plan; the program is described in Appendix B. In fiscal years 2010–11 and 2011–12, Appendix D reflects that Sacramento made expenditures for Innovation. The fiscal year 2010–11 expenditures are for planning and the fiscal year 2011–12 expenditures are for a contracted entity administering the Innovation program. However, the county stated it was not providing Innovation services to mental health consumers in either fiscal year 2010–11 or 2011–12. California State Auditor Report 2012-122 123 August 2013 Table D.3 County of San Bernardino Department of Behavioral Health Administration: Mental Health Services Act Revenues and Expenditures by Component Fiscal Years 2006–07 Through 2011–12 Revenues and Expenditures by Component FISCAL YEAR COMPONENT 2006–07* 2007–08* 2008–09* 2009–10* 2010–11* 2011–12† Community Services and Supports Unspent funds available $4,826,566 $22,658,065 $16,898,180‡ $14,213,315 $5,375,467 $14,528,329 Revenues 23,182,869 32,231,436 36,781,333 37,664,269 52,343,415 39,143,000 Expenditures 5,351,370 25,957,042 39,466,198 41,394,678 43,190,553 52,268,360 Contributions to prudent reserve§ – 11,989,911 – 5,107,439 – – Ending balance 22,658,065 16,942,548 14,213,315 5,375,467 14,528,329 1,402,969 Prevention and Early Intervention Unspent funds available $– $– $676,619 $15,324,917 $14,521,032 $20,666,822 Revenues – 881,387 17,511,603 13,628,096 16,407,441 12,213,200 Expenditures – 204,768 2,863,305 9,376,968 10,261,651 13,199,134 Contributions to prudent reserve§ – – – 5,055,013 – – Ending balance – 676,619 15,324,917 14,521,032 20,666,822 19,680,888 Innovation Unspent funds available $– $– $– $(6,167) $6,467,016 $12,837,468 Revenues – – – 6,794,246 7,110,599 2,570,200 Expenditures – – 6,167 321,063 740,147 5,979,698 Ending balance – – (6,167) 6,467,016 12,837,468 9,427,970 Workforce Education and Training Unspent funds available $– $– $130,654 $10,893,797 $9,730,507 $8,548,314 Revenues – 754,600 11,856,500 204,765 120,145 1,800,000 Expenditures – 623,946 1,093,357 1,368,055 1,302,338 1,993,020 Ending balance – 130,654 10,893,797 9,730,507 8,548,314 8,355,294 Capital Facilities and Technological Needs Unspent funds available $– $– $– $– $21,554,836 $19,589,365 Revenues – – – 22,179,502 1,953,323 – Expenditures – – – 624,666 3,918,794 1,474,804 Ending balance – – – 21,554,836 19,589,365 18,114,561 Total ending balances $22,658,065 $17,749,821 $40,425,862 $57,648,858 $76,170,298 $56,981,682 Mental Health Services Act Funds Dedicated to Local Prudent Reserve COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12§ TOTAL Community Services and Supports $– $11,989,911 $– $5,107,439 $– $– $17,097,350 Prevention and Early Intervention – – – 5,055,013 – – 5,055,013 Totals $– $11,989,911 $– $10,162,452 $– $– $22,152,363 Sources: Unaudited county Revenue and Expenditure Reports (RERs), unaudited internal county accounting data, and Appendix A allocation data. * For fiscal years 2006–07 through 2010–11, revenues and expenditures are from the county’s unaudited RERs. Revenues reflect deposits from state-allocated amounts and interest earned on those amounts. † For fiscal year 2011–12, revenues are based on state-allocated amounts the California Department of Mental Health reported and include some funds the county assigned to a Joint Powers Authority and therefore were not administered locally (see Appendix A). Expenditures are based on unaudited county accounting reports. ‡ The unspent funds available as noted on the county’s RER for fiscal year 2008–09 differed from the reported ending balance for fiscal year 2007–08 by over $44,000. The table reflects the difference. § The MHSA requires a prudent reserve to ensure that the county can continue to provide Community Services and Supports and Prevention and Early Intervention programs to its current clients. The amounts shown are from the county’s RERs and these documents were limited to fiscal years 2006–07 through 2010–11; thus, there may be contributions to the prudent reserve the table does not reflect. 124 California State Auditor Report 2012-122 August 2013 Table D.4 Santa Clara County Mental Health Department: Mental Health Services Act Revenues and Expenditures by Component Fiscal Years 2006–07 Through 2011–12 Revenues and Expenditures by Component FISCAL YEAR COMPONENT 2006–07* 2007–08* 2008–09* 2009–10* 2010–11† 2011–12† Community Services and Supports Unspent funds available $541,443 $17,502,332 $22,209,300 $21,513,979 $21,213,304 $35,842,965 Revenues 20,253,043 29,209,374 29,578,237 37,295,274 48,528,816 33,536,100 Expenditures 3,292,154 16,362,683 30,273,558 31,139,949 33,899,155 31,590,232 Contributions to prudent reserve‡ – 8,139,723 – 6,456,000 – – Ending balance 17,502,332 22,209,300 21,513,979 21,213,304 35,842,965 37,788,833 Prevention and Early Intervention Unspent funds available $– $– $1,122,314 $790,434 $3,793,491 $35,344,648 Revenues – 1,216,607 24,604 11,677,300 37,640,067 11,254,700 Expenditures – 94,293 356,484 3,974,243 6,088,910 11,127,713 Contributions to prudent reserve‡ – – – 4,700,000 – – Ending balance – 1,122,314 790,434 3,793,491 35,344,648 35,471,635 Innovation Unspent funds available $– $– $– $– $240,772 $11,543,088 Revenues – – – 310,919 11,720,900 2,238,600 Expenditures – – – 70,147 418,584 2,553,459 Ending balance – – – 240,772 11,543,088 11,228,229 Workforce Education and Training Unspent funds available $– $– $695,073 $245,310 $7,921,404 $7,232,081 Revenues – 743,304 18,419 9,294,049 2,000,000 – Expenditures – 48,231 468,182 1,617,955 2,689,323 1,851,704 Ending balance – 695,073 245,310 7,921,404 7,232,081 5,380,377 Capital Facilities and Technological Needs Unspent funds available $– $– $– $– $11,772,188 $19,488,405 Revenues – – – 11,888,212 9,459,000 – Expenditures – – – 116,024 1,742,783 2,517,915 Ending balance – – – 11,772,188 19,488,405 16,970,490 Total ending balances $17,502,332 $24,026,687 $22,549,723 $44,941,159 $109,451,187 $106,839,564 Mental Health Services Act Funds Dedicated to Local Prudent Reserve COMPONENT 2006–07 2007–08 2008–09 2009–10 2010–11‡ 2011–12‡ TOTAL Community Services and Supports $– $8,139,723 $– $6,456,000 $– $– $14,595,723 Prevention and Early Intervention – – – 4,700,000 – – 4,700,000 Totals $– $8,139,723 $– $11,156,000 $– $– $19,295,723 Sources: Unaudited county Revenue and Expenditure Reports (RERs), unaudited internal county accounting data, and Appendix A allocation data. * For fiscal years 2006–07 through 2009–10, revenues and expenditures are from the county’s unaudited RERs. Revenues reflect deposits from state-allocated amounts and interest earned on those amounts. † For fiscal years 2010–11 and 2011–12, revenues are based on state-allocated amounts the California Department of Mental Health reported and include some funds the county assigned to a Joint Powers Authority and therefore were not administered locally (see Appendix A). Expenditures are based on unaudited county accounting reports. ‡ The Mental Health Services Act requires a prudent reserve to ensure that the county can continue to provide Community Services and Supports and Prevention and Early Intervention programs to its current clients. The amounts shown are from the county’s RERs and these documents were limited to fiscal years 2006–07 through 2009–10; thus, there may be contributions to the prudent reserve the table does not reflect. California State Auditor Report 2012-122 125 August 2013 * * California State Auditor’s comment appears on page 133. 126 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 127 August 2013 128 California State Auditor Report 2012-122 August 2013 1 California State Auditor Report 2012-122 129 August 2013 130 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 131 August 2013 132 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 133 August 2013 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES To provide clarity and perspective, we are commenting on the California Department of Health Care Services’ (Health Care Services) response to our audit. The number below corresponds to the number we have placed in the margin of Health Care Services’ response. Health Care Services correctly indicated in its response that the 1 Mental Health Services Oversight and Accountability Commission (Accountability Commission) is now responsible for developing regulations for Prevention and Early Intervention and Innovation programs and that Health Care Services continues to have responsibility for developing regulations for Capital Facilities and Technological Needs (Facilities) programs. As a result, we modified the recommendation on page 41 to clarify that Health Care Services should coordinate with the Accountability Commission and issue regulations, as appropriate, for Facilities programs and other Mental Health Services Act requirements. 134 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 135 August 2013 * * California State Auditor’s comments begin on page 139. 136 California State Auditor Report 2012-122 August 2013 1 California State Auditor Report 2012-122 137 August 2013 2 2 2 2 138 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 139 August 2013 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE MENTAL HEALTH SERVICES OVERSIGHT AND ACCOUNTABILITY COMMISSION To provide clarity and perspective, we are commenting on the Mental Health Services Oversight and Accountability Commission’s (Accountability Commission) response to our audit. The numbers below correspond to the numbers we have placed in the margin of the Accountability Commission’s response. We disagree with the Accountability Commission’s assertion that 1 it was first statutorily authorized to evaluate the Mental Health Services Act (MHSA) in 2009. Although the Legislature expressly added evaluation to the list of the Accountability Commission’s enumerated authorized activities in 2009, the Accountability Commission was established in 2004 by Proposition 63 to “oversee” the MHSA. Moreover, the California Department of Mental Health was required to allocate administrative funds, including funds specifically for the purpose of evaluation, to the Accountability Commission, among others. Accordingly, we believe that the Accountability Commission was charged with evaluating MHSA programs before 2009, and we located an Accountability Commission document dated April 2008 that supports that contention. Specifically, before the 2009 amendment expressly authorizing it to evaluate MHSA programs, the commission adopted a proposal that stated the Accountability Commission had an overarching responsibility for oversight and accountability and should be a lead entity for evaluating the extent to which the MHSA’s objectives have been accomplished. The Accountability Commission states that evaluation is 2 one of many of its statutory functions and, though it is one of seven strategies adopted to oversee the MHSA programs, it is not its sole priority. We never recommended that evaluations be its sole priority. Rather, as we state on page 42, we recommended that the Accountability Commission examine its prioritization of resources as it pertains to ensuring it is performing all necessary evaluations. We do believe, however, that for an entity established to oversee the accountability of MHSA programs, that evaluations to ensure those programs are achieving their intended outcomes and goals should be a top priority. We believe the recommendation to the Accountability Commission to prioritize its resources for evaluation is warranted and supported by the report’s conclusions. The recommendation is based on our discussion and information in Table 4 on pages 32 and 33 where we summarize the Accountability Commission’s expenditures and 140 California State Auditor Report 2012-122 August 2013 amounts dedicated to evaluation. Table 4 includes the additional funds totaling $1.295 million that the Accountability Commission highlights in its response that it prioritized for evaluations in fiscal years 2010–11 through 2012–13. As we describe on page 33 in the report, with its reduction in duties following legislative change in March 2011, it seems reasonable that the Accountability Commission would have more of its existing resources to commit to evaluation efforts. The Accountability Commission maintains that its budget for fiscal year 2012–13 increased by $1.6 million to support specific organizations and that using these resources for evaluation would be improper. While we do not disagree, this does not explain why the amount it dedicated to evaluation in fiscal year 2012–13 decreased from the previous fiscal year as shown in Table 4. Specifically, when we reduce its fiscal year 2012–13 expenditures by the $1.6 million, the resulting amount is roughly equal to the Accountability Commission’s expenditures for fiscal year 2011–12. Yet, as shown in Table 4, the amount it dedicated to evaluation decreased by roughly $800,000, from approximately $2.1 million in fiscal year 2011–12 to nearly $1.3 million in fiscal year 2012–13. California State Auditor Report 2012-122 141 August 2013 142 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 143 August 2013 * 1 2 3 * California State Auditor’s comments appear on page 145. 144 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 145 August 2013 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH To provide clarity and perspective, we are commenting on the Los Angeles County Department of Mental Health’s (Los Angeles) response to our audit. The numbers below correspond to the numbers we have placed in the margin of Los Angeles’ response. Los Angeles is concerned with our use of the word “approve” rather 1 than “adopt.” Under state law, county boards of supervisors are required to adopt county plans. However, because the plans are developed as a result of an ongoing stakeholder process and then acted upon by boards of supervisors, we used the word “approve” so that our readers would understand that those boards only act on what is presented to them after counties engage in the stakeholder process. The word “adopt” means “to accept formally and put into effect.” Since “accept” is defined as, among other things “to give admittance or approval,” we believe using the word “approve” accurately reflects the adoption of county plans as required by law. We have included Los Angeles’ perspective in a footnote to 2 Table D.1 on page 120. Audit evidence obtained from the California Department of State 3 Hospitals supports the fiscal year 2010–11 Community Services and Supports revenue figure reflected in Table D.1. Nevertheless, we added a footnote to the table to present Los Angeles’ perspective on the revenue amounts. Also, as we state in Appendix D on page 119 and again in Table D.1 on page 120 the figures are unaudited. 146 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 147 August 2013 148 California State Auditor Report 2012-122 August 2013 Sacramento County – Response to Draft Audit Report 2012-122, titled “Mental Health Services Act: [redacted], and Select Counties Can Improve Measurement of Their Program Performance” Sacramento County Recommendation: Sacramento County should review its existing MHSA contracts and by December 31, 2013, or as soon as feasible,amend them as necessary to include plan goals. The Sacramento County Division of Behavioral Health Services (Division) is committed to addressing the recommendations contained in the audit report. To this end, the Division will conduct a complete review of the goals stated in the Mental Health Services Act (MHSA) plans as compared with the goals captured in the contracts for MHSA-funded programming. The Division will begin the internal review process immediately. Necessary revisions to contract scopes identified through the review process will be addressed with contracted service providers. These revisions will require review and approval by counsel/administration for both County and the provider agencies. Contracting authority is granted by the local Board of Supervisors. Due to the volume of contracts potentially impacted, the Division anticipates completion of this entire process with updated scopes capturing the plan goals prepared for inclusion in MHSA-funded contracts by June 30, 2014. The Division looks forward to reading the audit report in its entirety upon release. California State Auditor Report 2012-122 149 August 2013 * 1 * California State Auditor’s comment appears on page 153. 150 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 151 August 2013 COUNTY OF SAN BERNARDINO RESPONSE TO MENTAL HEALTH SERVICES ACT: [REDACTED], AND SELECT COUNTIES CAN IMPROVE MEASUREMENT OF THEIR PROGRAM PERFORMANCE REPORT July 17, 2013 This management response to the audit report received on July 11, 2013, is provided by the Department of Behavioral Health on behalf of the County of San Bernardino. RECOMMENDATION: San Bernardino County should review its existing MHSA contracts and by December 31, 2013, amend them as necessary to include plan goals. RESPONSE The Department of Behavioral Health (DBH) includes plan goals in its Mental Health Services Act (MHSA) 1 contract language, and goals are monitored on an ongoing basis. DBH has more than 60 MHSA contracts, and in the possible absence of specific contract language or collection of 1 certain data favored by the audit, it should be not assumed or inferred that program goals are not being set, monitored, and accomplished, or that meaningful services are not being provided to the community. The department uses various performance measures to evaluate MHSA-funded programs and services. 1 Continued monitoring provides the information necessary to make modifications, as needed, to ensure the efficiency and effectiveness of mental health services. The County of San Bernardino remains committed to continuous improvement, including developing/refining its approaches for evaluation of performance outcomes. DBH understands the value of this audit and the opportunity it offers to further enhance its programs and services to community members impacted by mental illness, and to continue to adhere to the spirit of MHSA. Action Steps and Time Frame DBH will review its existing MHSA contracts and amend as necessary. 152 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 153 August 2013 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE COUNTY OF SAN BERNARDINO DEPARTMENT OF BEHAVIORAL HEALTH ADMINISTRATION To provide clarity and perspective, we are commenting on the County of San Bernardino Department of Behavioral Health Administration’s (San Bernardino) response to our audit. The number below corresponds to the number we have placed in the margin of San Bernardino’s response. San Bernardino has mischaracterized the information in the audit 1 report. On pages 47 through 53 we discuss what we found in our review of county plans and nine San Bernardino provider contracts and our concerns with the plans and contracts including program goals, etc. In summary, we identified the following concerns regarding San Bernardino’s plans and the nine contracts: • San Bernardino did not always state goals for its programs in its county plans. (See page 47.) • For six contracts, San Bernardino did not include all program goals as stated in the county plans. (See page 47.) • Eight contracts lacked requirements for collecting and providing information suitable for measuring the attainment of program goals. (See page 48.) • None of the nine contracts contained specific objectives— meaning objectives that were well defined and measurable. (See page 49.) • San Bernardino typically used ad-hoc approaches that were not always sufficient in identifying meaningful data to measure progress in meeting its programs’ goals. Moreover, it often failed to collect meaningful data, which affected San Bernardino’s ability to adequately analyze and report on whether program goals are being achieved. (See pages 48 and 51.) • Even though San Bernardino reported to us specific program outcomes and the use of those outcomes to improve its mental health delivery systems, our review shows that this reporting may not be representative of the county’s MHSA programs. (See page 53.) 154 California State Auditor Report 2012-122 August 2013 Blank page inserted for reproduction purposes only. California State Auditor Report 2012-122 155 August 2013 156 California State Auditor Report 2012-122 August 2013 California State Auditor Report 2012-122 157 August 2013 cc: Members of the Legislature Office of the Lieutenant Governor Little Hoover Commission Department of Finance Attorney General State Controller State Treasurer Legislative Analyst Senate Office of Research California Research Bureau Capitol Press