The 2020-21 Budget: Analysis of the Department of State Hospitals Budget

The 2020-21 Budget: Analysis of the Department of State Hospitals Budget Summary The Governor’s budget proposes $2.3 billion for the Department of State Hospitals (DSH) in 2020-21—an increase of $232 million (11 percent) from the revised 2019-20 level. In this report, we assess three specific DSH proposals and offer recommendations for legislative consideration. Community Care Collaborative Pilot. The Governor’s budget proposes a pilot program intended to help alleviate the rising number of incompetent to stand trial (IST) designations and referrals to the state hospital system and requests $24.6 million (General Fund) and 3 positions to implement this program in 2020-21. (The total cost of the six-year pilot is estimated to be $364.2 million General Fund.) Under this pilot, DSH would provide funding to counties for competency restoration treatment in the community, as well as incentive payments for counties to invest in strategies to reduce the level of IST designations. We recommend that the Legislature direct DSH to report back at upcoming budget hearings on issues we raise related to the efficacy and governance of this pilot. To the extent the Legislature chooses to move forward with this proposal, we recommend that it adopt legislation that (1) clarifies the target population of the pilot program, (2) includes a robust evaluation component for the pilot program, (3) strengthens fiscal oversight of the pilot, (4) requires the use of counties’ previous-year level of IST referrals as the baseline to measure progress, and (5) ensures that the funding given to counties under this pilot does not supplant funding for existing programs. Treatment Team and Primary Care Staffing. The Governor’s budget proposes several changes to the way treatment teams and primary care units are staffed at state hospitals, and requests $32 million (General Fund) and 80.9 positions to implement these changes in 2020-21. These amounts would ramp up to $64.2 million (General Fund) and 250.2 positions by 2024-25, and be ongoing thereafter at these amounts. While we recommend the Legislature approve the proposed standardization of the treatment team and primary care caseload ratios that would apply across all state hospitals, we recommend that the Legislature direct DSH to report at budget hearings on its ability to fill proposed psychiatrist positions. We also recommend that the Legislature direct DSH to report with an assessment of the degree to which nurse practitioners can be staffed in primary care units. Finally, we recommend that the Legislature approve the trauma treatment specialist positions and discharge strike teams on a pilot basis. The pilot can be used to determine whether these requested positions are effective at developing services tailored toward patients who have experienced significant trauma in their lives, or improving patient placement in community settings after discharge. Protective Services Staffing. The Governor’s budget proposes several changes to the way protective services are staffed at state hospitals, and requests $7.9 million (General Fund) and 46.3 positions to implement these changes at Napa State Hospital only. We recommend the Legislature approve the proposed standardization of protective services staffing levels, but require DSH to provide information on the cost of implementing the new staffing levels at all state hospitals, which is unknown at this time. GABRIEL PETEK LEGISLATIVE ANALYST FEBRUARY 11, 2020 analysis full gutter 2020-21 BUDGET OVERVIEW Department Provides Inpatient and Outpatient include individuals classified as incompetent to Mental Health Services to Forensic and Civil stand trial (IST), not guilty by reason of insanity, Commitments. The Department of State Hospitals mentally disordered offenders, or sexually violent (DSH) provides inpatient mental health services predators. Currently, about 90 percent of the at five state hospitals (Atascadero, Coalinga, patient population is forensic in nature. As of Metropolitan-Los Angeles, Napa, and Patton). January 14, 2020, the department had about DSH also contracts with counties to provide 1,200 patients awaiting placement, including about in-patient mental health services in additional 800 IST patients. locations (typically county jails) throughout the Operational Spending Proposed to Increase state. In addition, DSH provides outpatient by $232 Million in 2020-21. The Governor’s treatment services to patients in the community. budget proposes total expenditures of about The 2019-20 budget included resources to $2.3 billion ($2.1 billion from the General Fund) provide in-patient mental health services to about for DSH operations in 2020-21. This represents 6,200 individuals in state hospitals and roughly an increase of $232 million (11 percent) from the 400 individuals in contracted programs. The budget revised 2019-20 level. The department’s budget also included resources to provide out-patient includes increased funding for several proposals, services to around 700 individuals. Patients fall including a pilot program to reduce the number of into one of two categories: civil commitments or IST designations and referrals to the state hospital forensic commitments. Civil commitments generally system and staffing adjustments resulting from are referred to the state hospitals for treatment DSH’s Clinical Staffing Study, both of which we by counties. Forensic commitments typically are discuss in greater detail below. committed by the criminal justice system and COMMUNITY CARE COLLABORATIVE PILOT BACKGROUND (Individuals found IST facing misdemeanor charges typically receive treatment in county jails or other IST Designations and Referrals. Under state county-run programs.) Not all patients have their and federal law, all individuals who face criminal competency restored, meaning that they may reside charges must be mentally competent to help in in the DSH system longer or may be transferred to their defense. By definition, an individual who is another system to continue receiving mental health designated by the court as IST lacks the mental services. competency required to participate in court The IST Waitlist. Once DSH receives a proceedings. (Typically, the IST designation process referral for an IST patient, the patient is put on is initiated by defense attorneys reporting their a pending transfer list (commonly referred to by concerns about their clients’ mental capacity to the the department as the “IST waitlist”). Patients are judge. The judge then orders an initial evaluation removed from the waitlist when they are physically and a competency hearing.) Individuals who are transferred to a treatment program. Patients on IST and face a felony charge typically are referred the waitlist are typically housed in county jails while by a state trial court to DSH to receive competency they wait to be transferred to a DSH program, restoration treatment that, if successful, results in which is problematic for two reasons. First, due the individual returning to the court system to face to limited access to mental health treatment in the felony criminal charges levied against them. some jails, these patients’ condition can worsen 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET while they are in jail, potentially making eventual patients are being referred to DSH. The factors that restoration of competency more difficult. Second, contribute to the growing IST referral rate cannot long waitlists can result in increased court costs be addressed by competency restoration treatment and a higher risk of DSH being found in contempt alone, as competency restoration treatment only of court orders to admit patients. is provided to individuals who have already been DSH Efforts to Increase Capacity for IST designated as IST. In response to its increasing Treatment. In recent years, funding was provided IST referral rate, DSH has received funding to to DSH to increase capacity for competency implement an IST “diversion” program. We describe restoration treatment. This includes expanding the concept of diversion in the box on page 4. the number of IST treatment beds and staff within DSH Diversion Program. To address the state hospitals, as well as expanding capacity increasing number of felony IST referrals to DSH, for Jail-Based Competency Treatment (JBCT) DSH received one-time funding in 2018-19 to programs. Under the JBCT program, counties contract with counties for three years to establish provide competency restoration treatment in IST diversion programs that are intended primarily county jails to patients who do not require the to treat offenders before they are declared IST. The intensive level of inpatient treatment provided diversion programs target individuals who have in state hospitals. In addition, ongoing funding been arrested for a felony offense, have a mental was provided beginning in 2018-19 for a health condition that could render them IST, and Community-Based Restoration (CBR) program are a low public safety risk. Under this program, in Los Angeles County. Under the CBR model, courts have the authority to refer individuals who competency restoration treatment is provided meet these criteria to the county IST diversion to IST patients in county mental health facilities programs. If such individuals successfully complete outside of a jail setting. these programs, judges could drop or reduce IST Waitlist Is Now Steady, But IST Referrals their charges. This diversion program reflects the Continue to Increase. From 2013 to 2018, the narrower interpretation of diversion previously average monthly IST waitlist increased from roughly discussed. 350 patients to over 800 patients, an average annual increase of Figure 1 close to 20 percent. However, Average Monthly Felony as of 2019 it has leveled off at IST Referrals Generally Increasing around 800 individuals. This likely is due to increased capacity for 400 competency restoration treatment that has been funded in recent 350 years, such as expanding the number of JBCT beds. Despite 300 the IST waitlist leveling off, the 250 number of IST referrals to DSH (which includes referrals to 200 JBCT programs) generally has 150 increased. This trend is shown in Figure 1. 100 While funding was provided to 50 DSH to increase capacity to treat IST referrals through competency 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 restoration, this increased capacity has not kept up with IST = incompetent to stand trial. the increasing rate at which IST www.lao.ca.gov 3 analysis full gutter 2020-21 BUDGET Diversion Diversion generally narrowly refers to the process of the courts referring offenders with a mental health condition to treatment programs as an alternative to incarceration. Diversion programs often include a corresponding possibility of dropped charges should the offender complete their court-ordered treatment program. However, diversion also can have a broader interpretation—referring to the process of investing in community mental health services pre-arrest or post-release from jail, to either (1) help prevent individuals with a mental health condition from being arrested in the first place or (2) provide services so that individuals with a mental health condition are not rearrested after they are released from prison. GOVERNOR’S PROPOSAL pay $60,225 for each felony IST served by counties in a CBR treatment program. Funding would be The administration proposes a two-pronged capped at counties’ benchmark reduction goal pilot program known as the Community Care (described in the next paragraph). The funding Collaborative Pilot (CCCP) to provide funding to amount is based on a $165 per day rate, and counties for CBR treatment and incentivize counties would be increased by 3 percent each year of the to invest in strategies to reduce the overall number pilot to account for increases in local service costs. of felony IST designations and referrals to DSH. The proposal reserves $14.3 million (General Fund) This six-year pilot program would be implemented in 2020-21 for the progress payments component. in three counties that have high IST referral rates If counties treat fewer felony ISTs than the number to DSH. (The administration has not identified that has been set as their benchmark reduction which counties would participate in the pilot. We goal, any remaining funds will be rolled over into the understand that the administration is in discussions incentive payments component of the CCCP, which to identify which counties these would be.) we describe below. The pilot program is composed of three funding Incentive Payments Based on Meeting Felony components: (1) “progress payments” to counties IST Designation and Referral Benchmark for CBR treatment modeled after the CBR program Reduction Goals. The second component of in Los Angeles County that was funded by DSH in the pilot would provide incentive payments to 2018-19, (2) “incentive payments” to counties for counties for reducing felony IST designations reducing felony IST designations and referrals by and referrals based on set goals. Specifically, investing in both pre-arrest and post-release from counties’ benchmark reduction goals in felony jail strategies, and (3) application-based start-up IST designations and referrals would be set at funds (available in each year of the pilot) for either 15 percent of their total felony IST referrals in up-front CBR program costs or strategies to reduce 2018-19. The proposal reserves $7.9 million IST designations. In total, the Governor’s budget (General Fund) in 2020-21 for the incentive includes $24.6 million General Fund in 2020-21 to payments component. The benchmark reduction implement this pilot program, and the total cost to goals increase over time but would be consistently the General Fund over the six-year pilot would be measured against counties’ total 2018-19 felony $364.2 million. We describe this proposal in greater IST referrals as the baseline. We describe how detail below. counties could make progress toward these goals DSH Would Pay for CBR Treatment Through below. Progress Payments to Counties. The first Counties Would Be Required to Submit Plans component of the CCCP proposal is funding from Before Receiving Start-Up Funds. Under the DSH for CBR treatment. Specifically, DSH would CCCP, counties would be required to submit a plan 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET to DSH outlining how they plan to achieve reduction payments for designation reductions begin earlier. goals for felony IST designations and referrals. If counties meet their benchmark reduction goals The plans also would be required to outline how for felony IST designations, they will receive a counties plan to use their incentive payments to further incentive payment equal to 15 percent of invest in community mental health services, and the total amount allotted for the progress payments describe how other funding sources would be component of the pilot. used to support the pilot. The proposal reserves Governor’s Proposal Emphasizes Community $1.4 million (General Fund) in 2020-21 for start-up Mental Health and Other Diversion Strategies funds. to Prevent Further Felony ISTs. In the CCCP How Counties Could Make Progress Toward proposal, DSH argues that the most effective Benchmark Reduction Goals. Counties could way to address the increasing number of IST make progress toward their benchmark reduction designations is to invest in “upstream” county goals by treating felony ISTs in CBR programs so services (that are able to assist individuals with that they are not referred to DSH. They also could mental health conditions at risk of becoming make progress by implementing upstream efforts to a felony IST before they are arrested) or provide county services to individuals with mental “downstream” county services (that are able to health conditions before they are arrested (these connect individuals with these services when could include crisis response centers, diversion they are released from jail, so that they are not training programs for law enforcement, or mental designated as a felony IST again). DSH supports health training programs for 911 dispatchers). this strategy using evidence from its review of Finally, they could make progress by implementing felony IST arrest histories. Specifically, DSH found downstream efforts to provide county services to that in 2014-15, 45 percent of its felony ISTs had individuals with mental health conditions after they 15 or more previous arrests. It also found that in are released from jail to prevent being rearrested 2014-15, 69 percent of felony ISTs were rearrested (these could include housing assistance, ongoing and about 50 percent were convicted of new behavioral health treatment, or employment crimes. services). Comparison to Current DSH Diversion The incentive payments available to counties Program. While the existing diversion program would be “tiered,” meaning counties would not also aims to reduce IST designations, the new pilot have to fully meet their benchmark reduction proposal has some key differences from the existing goals in felony IST designations and referrals program. Under the current DSH diversion program, in order to be eligible for incentive payments. If counties agree to serve a set amount of individuals counties partially meet their benchmark reduction over three years, typically set at 20 percent to goals, they would receive a percentage of the 30 percent of counties’ total felony IST referrals to total amount available for incentive payments. As DSH in 2016-17. In addition, under the current DSH seen in Figure 2 (see next page), counties would diversion program, counties are required to divert be eligible for these partial payments starting at individuals with a mental health condition who have 25 percent of their benchmark reduction goals already been arrested before their trial. Under the for felony IST referrals, and starting at 65 percent CCCP, in contrast, incentive payments could be of their benchmark reduction goals for felony IST used to divert individuals pre-arrest or post-release designations. After counties meet each of these from jail, reflecting the broader interpretation of minimum thresholds for progress toward their diversion. The current DSH diversion program also benchmark reduction goals, the amount they could includes a requirement to drop charges if a client receive increases the closer they get to their overall completes the diversion program successfully. The benchmark reduction goals. CCCP does not include this requirement. Finally, Given reducing IST designation is more difficult the current DSH diversion program also is limited than reducing referrals to DSH (given the option to to only serving individuals with schizophrenia, treat individuals in CBR programs), the incentive schizoaffective disorder, or bipolar disorder. Under www.lao.ca.gov 5 2020-21 BUDGET the CCCP proposal, the list of eligible diagnoses is Outcomes Reporting. Under this proposal, expanded to include a broader set of mental health counties would be required to report how they conditions including post-traumatic stress disorder spent funds received through CCCP to DSH. This and major depressive disorder. would include what specific programs or services Proposal Encourages Counties to Use These the CCCP funds were used for. DSH also requests Funds to Leverage Additional Funding Sources resources to conduct evaluation of the CCCP, but for This Pilot. Under the CCCP, counties would be little detail is provided on what lessons are intended encouraged to access other funding sources (such to be learned from the pilot, or how the evaluation as Medi-Cal reimbursement) to support community framework would be structured. placement and services. Counties would be required to report which funding sources they utilize to support the CCCP to DSH. Figure 2 Tiered Incentive Payment Schedule Percent Progress Toward Benchmark Reduction Goala IST = incompetent to stand trial and DSH = Department of State Hospitals. 6 LEGISLATIVE ANALYST’S OFFICE devieceR tnemyaP evitnecnI fo egatnecreP analysis full gutter 100% 90 80 Percentage of Incentive Payment Provided for 70 Reduction to Overall Felony IST Designations 60 50 40 Percentage of Incentive 30 Payment Provided for Reduction to Overall DSH Referrals 20 10 10 20 30 40 50 60 70 80 90 100% a Goal expressed as a specified percentage reduction from 2018-19 level of total felony IST referrals. analysis full gutter 2020-21 BUDGET LAO ASSESSMENT entity with a role in overseeing community mental health funds, an area over which DSH has little experience. Proposal Raises Issues for • Coordination Issues Arising From Addition Legislative Consideration Related to of New County Actors. This proposal Efficacy and Governance potentially adds other actors to county Effectiveness of LA County Competency delivery of mental health services. The CCCP Restoration Program Is Uncertain. The CBR would require significant coordination across portion of the CCCP is modeled after the CBR multiple programs to provide upstream and program funded beginning in 2018-19 in Los downstream services for people with mental Angeles County. Considering expansion of CBR health conditions that may render them IST. treatment has merit given (1) the rate of IST These programs could be administered by designation and referral growth and (2) competency local entities other than county mental health restoration services are cheaper to provide in departments including, but not limited to, community settings than in state hospitals. However, county departments of public health, county there has not been enough time to evaluate the public guardians, or county public defenders. effectiveness of the program in Los Angeles County. This raises the possibility of coordination Consequently, expansion of this CBR program issues among multiple program efforts that may be premature, as could be basing incentive could lead to inefficiencies and poorer overall payments on the Los Angeles model. results. Increasing Community Mental Health and • Additional Funding Stream Adds to Other County Diversion Strategies Merits Complexity. The CCCP would add another Consideration . . . Given the increasing number of funding stream to the community mental felony IST designations and referrals, considering health funding system that is already methods to prevent individuals from becoming confusing. This system is composed of several IST is worthwhile. We note that the upstream different funding streams, including (1) federal and downstream services that the administration funds, (2) county realignment funds, (3) Mental describes in this proposal seem like reasonable Health Services Act (MHSA) funds, (4) state ways to provide services to individuals with mental General Fund from DHCS, and (5) additional health conditions who may be at risk of being county funds. This proposal would add designated a felony IST. funding from DSH to this system, potentially . . . But Adding Another Funding Entity for making it more complex and confusing to Community Mental Health May Create Program track the use of funds in the system. Coordination and Oversight Issues. The CCCP would add complexity to the broader community Proposal Also Raises Issues mental health system in three ways. Related to Program Structure • Addition of Another State Entity Hard to Define Target Population for Incentive Complicates Oversight. The state has Payments Component. The incentive payments long-standing issues with fiscal and component of the CCCP is meant to provide programmatic oversight of county delivery of mental health services to individuals who are at mental health services. Part of this difficulty risk of becoming IST. In practice, this population is due to the currently fragmented oversight is very difficult to identify and without more explicit system, split between the Department of criteria for determining which individuals will Health Care Services (DHCS) and the Mental receive services, the incentive payments given to Health Services Oversight and Accountability counties by DSH might be indistinguishable from Commission. This proposal creates further existing county funding sources for community fragmentation by adding DSH as a third state mental health. Counties being unable to direct www.lao.ca.gov 7 analysis full gutter 2020-21 BUDGET funding toward services for a more specific target incentive funds, different programs and practices population could dilute the effectiveness of this may be adopted on a “county-by-county” basis. pilot. This will make assessing the success of the pilot Potential Supplanting of Funding for Existing overall difficult. County Mental Health Programs. Under the CCCP, counties would be given the flexibility to LAO RECOMMENDATIONS use the incentive funding received through the pilot We find the intent of this proposal—to provide for programs that they choose. Counties could services to prevent people with mental health choose to use this funding to support existing conditions from becoming IST—to have merit. The community mental health programs that have goals amount of felony IST designations and referrals that overlap with the goals of the CCCP. There is increasing, and current DSH efforts to expand are a number of existing funding streams at the capacity for competency restoration treatment do county level that fund community mental health not directly address why people are designated programs for individuals with severe mental illness. as a felony IST in the first place. However, as These funding streams include Medi-Cal, county discussed above, we raise concerns regarding realignment funds, and MHSA funding. Given the the efficacy and governance of the CCCP that we flexibility that counties receive under this proposal, suggest the Legislature direct the administration funding received through this pilot could supplant to respond to. We offer recommendations funding for existing programs, and counties could on structural changes to the pilot should the direct existing funding sources for community Legislature decide to approve this proposal, mental health toward other purposes. If this were following further information from the administration to occur, the incentive payments might not result in that responds to the above concerns. an increase in services to prevent IST designations and referrals. Recommendations to Details on Fiscal Oversight of Spending Are Improve Program Structure if Unclear. Under this proposal, counties would be Proposal Approved in Concept required to report to DSH how they spent funds received through the CCCP. This would include There are several ways in which the Legislature the cost to treat felony ISTs, what other funding could improve the structure of the CCCP to sources were used, and what investments in address the structural concerns we raise, should upstream or downstream services were made. the Legislature approve of this budget request What systems DSH will utilize to ensure that in concept. To that end, we recommend that the counties are held accountable for their spending Legislature adopt legislation that: through this pilot is unclear. • Clarifies Definition of At-Risk-of-IST Benchmark Reduction Goals May Be Too Population. The incentives payment Difficult to Achieve. The overall trend in felony component of the CCCP is meant to provide IST designations and referrals is increasing. upstream and downstream services to DSH proposes to use counties’ level of felony individuals at risk of becoming IST. In order IST referrals in 2018-19 as the baseline year for to ensure that the funding from this pilot measuring progress. Given the underlying trend in program is directed toward that population, felony IST referrals, counties could have difficulty we recommend that the Legislature direct achieving their benchmark reduction goals in felony DSH to clarify the definition of at-risk-of-IST IST referrals in the later years of the proposal. individuals and that the definition be codified Unclear How the Pilot Will Be Evaluated. in statute. This would require DSH to review The proposal is not clear on the intended lessons referred cases for characteristics that would to be learned from this pilot program, or on how help define this population. the pilot program will be evaluated. We note that since counties are given flexibility on how to spend 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET • Establishes a Robust Evaluation under this pilot are unclear, we recommend Component of the Pilot. The proposal that the Legislature adopt legislation that does not include a framework for how to strengthens this component of the pilot. evaluate either the progress payments or This would include setting up an oversight the incentive payments components of the framework that holds counties accountable for pilot. We recommend that the Legislature their spending under the pilot. direct DSH to conduct a robust evaluation • Sets Benchmark Reduction Goals Based of both the CBR model currently being on Prior-Year’s Level of IST Referrals. implemented in Los Angeles County and the Given the potential difficulty of achieving CBR component of the CCCP. In addition, the the benchmark reduction goals for felony CCCP would give counties wide discretion in IST designations and referrals over time, the types of programs and services provided we recommend that the Legislature set to reduce the IST population, which may lead these benchmark reduction goals based on to many different types of programs being counties’ prior-year level of IST referrals. implemented. We recommend the Legislature • Establishes Non-Supplanting of Existing direct DSH to establish a robust evaluation County Funds. There is a significant strategy for the incentive payments portion possibility that the funding counties receive of this pilot as well. This would include a under this pilot would be used for existing framework for how to compare the successes programs that may utilize other sources of of different programs and how information on funding now. To ensure that the incentive the most effective programs would be shared payments that counties receive are not used among counties. to fund existing programs, we recommend • Strengthens the Fiscal Oversight that the Legislature adopt legislation that Component of County Plan Submissions. establishes a non-supplantation provision for Given that the details on how DSH would funding provided in this pilot program. provide fiscal oversight of county spending TREATMENT TEAM AND PRIMARY CARE STAFFING PROPOSAL This proposal requests $32 million General Fund Background and 80.9 positions in 2020-21, ramping up to DSH Provides Interdisciplinary Psychiatric $64.2 million General Fund and 250.2 positions in Treatment and Primary Care to Patients With 2024-25, and ongoing at that amount thereafter, for Complex Needs. DSH provides both psychiatric two separate components within DSH—treatment and medical treatment to patients with extreme teams and primary care. The proposal also includes mental illnesses who have complex needs. These changes to DSH’s supervisory structure within needs often exceed those of typical psychiatric primary care and its clinical executive structure, patients because DSH patients typically have been provides resources to implement Trauma-Informed involved in the criminal justice system. Most DSH Care, and provides resources to improve the patients also suffer from severe mental illness in patient discharge process. We provide background the form of a primary psychotic disorder, which can on these components in the following section. be resistant to typical drug therapies for such a condition. In addition, the DSH patient population is aging, which has caused increased need for medical treatment. www.lao.ca.gov 9 analysis full gutter 2020-21 BUDGET DSH Follows the Clinical Treatment Team the lowest caseload ratio of provider to patients. Approach to Provide Inpatient Psychiatric Care. Current caseload ratios are given in Figure 4. To provide psychiatric care to its patients, DSH . . . But Not Treatment or Commitment Type. utilizes a treatment method called the treatment DSH patients can have unique needs that are team approach—in which an interdisciplinary team related to the treatment they receive. For example, is assigned a caseload of patients and provides a patients who are deaf or hard of hearing require comprehensive treatment approach. This approach additional attention. DSH patients also can have is recognized as the standard of care in psychiatric unique needs that are related to their commitment hospitals. The treatment team collaborates to type. For example, patients committed as IST develop individualized treatment plans and delivery require specialized treatment that is focused on of care for each patient at DSH. Figure 3 describes restoring them to competency. Currently, the each of the positions on the treatment team. treatment team and primary care ratios do not DSH Staffs Both Physicians and Nurse reflect these factors. Practitioners for Primary Care. To provide primary DSH Clinical Staffing Study. In 2013, DSH care medical services to patients, DSH staffs both began evaluating staffing practices at its five physicians and nurse practitioners. Physicians are hospitals in a study known as the Clinical Staffing primarily responsible for all phases of medical care, Study. (This evaluation of staffing practices has and provide supervision to nurse practitioners. now been incorporated into a collaborative effort Nurse practitioners perform medical duties similar with Department of Finance to review practices to physicians, with a focus on addressing specific across DSH facilities, known as Mission-Based patient complaints related to general medical care, Review.) The department initiated the study in an so that physicians can address more complex effort to assess whether past practices and staffing medical needs. methodologies—which often differed between Current Treatment Team and Primary Care each hospital—are in need of revision, particularly Caseload Ratios Are Based on Patient Acuity, in light of a patient population that has grown Reflected in Level-of-Care Classifications . . . in terms of size, age, and the number who have Currently, the caseload ratios for both treatment been referred by the criminal justice system. The teams and primary care staff—the ratio of providers study is in the process of reviewing the hospitals’ to patients—are based on patient acuity (the forensic departments and protective services, and severity of need for mental or physical health care). the way each hospital plans and delivers treatment. This includes psychiatric acuity—which affects In 2019-20, DSH received funding and positions workload due to individual needs for individual to augment its staffing ratios within its nursing therapy or increased aggression and self-injurious services. behavior—and medical acuity—which affects As part of its review of treatment teams and workload due to individual needs for medical care. primary care, DSH examined all of its units These caseload ratios are reflected in level-of-care to determine workload categories. Workload classifications for DSH units. For example, acute categories were created based on patient treatment psychiatric units and skilled nursing facilities and commitment type. DSH then produced a house patients with the highest acuity, and have Figure 3 Department of State Hospitals Interdisciplinary Treatment Team Position Responsibilities Psychiatrist Treatment team lead, diagnostic decisions, and medication prescribing. Psychologist Treatment planning, assessment, therapy, and other specialized interventions. Clinical Social Worker Psychosocial assessment, case management, and discharge treatment. Rehabilitation Specialist Rehabilitation therapies and developing functional treatment goals. 10 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET care, as workload levels can be different for each Figure 4 of these two components. DSH then developed Current Caseload Ratios by caseload ratios specific to whether a unit is Level of Care designated as high, moderate, or low workload. Level of Care Ratioa Trauma-Informed Care. Trauma-informed care is a comprehensive approach to delivering Acute Psychiatric and Skilled Nursing Facilityb 1:15 Intermediate Care Facilityc 1:35 health care that is focused on patients who have Residential Recovery Unitsd 1:50 severe mental illness and a history of trauma. a Ratio of treatment provider to patients. DSH currently has several initiatives related to b Highest acuity. implementing trauma-informed care across its c Moderate acuity. d facilities. These include staff training programs, Lowest acuity. a pilot program to screen patients for trauma, and a statewide committee on trauma-informed model to categorize its units—based on workload care meant to steer efforts to implement categories—into ”Unit Categories” displayed in trauma-informed care in its facilities. Figure 5. DSH Patient Discharge. DSH patients have To develop new caseload ratios for the unit unique discharge needs related to their mental and categories, DSH collected data to identify major physical health needs, disabilities, and involvement factors that affect workload for its treatment in the criminal justice system. DSH currently has teams and primary care providers—including Discharge Preparation Units that work with patients patient acuity. It then classified its units into high, to maintain stability and develop skills needed to moderate, or low workload units. It classified the succeed after discharge. units separately for treatment teams and for primary Figure 5 Department of State Hospitals Clinical Staffing Study Unit Categories Unit Category Type of Patient Admissions Newly admitted patients. Discharge Preparation Patients nearing discharge. Medical Treatment Patients who are receiving medical care. Incompetent to Stand Trial Treatment Patients who are accused of a crime but must be restored to competency before their court proceedings can continue. Mentally Disordered Offender Patients who have been convicted of a violent offense connected to their Treatment severe mental disorder who are committed after completing their prison term as they have been found to pose a danger to the public if released. California Department of Corrections Patients referred for treatment from state prisons. and Rehabilitation Treatment Sexually Violent Predator Treatment Patients who have been convicted of a sex offense and are committed following their release from prison, as they have been found to have a mental disorder that makes them likely to engage in sexually violent criminal behavior. Lanterman-Petris Short Treatment Patients who have been civilly committed by counties. Multi-Commitment Treatment Various types of patients that are treated together, including mentally disordered offenders, Lanterman-Petris-Short Act patients, and individuals found not guilty by reason of insanity. Specialized Services Treatment Various patients with special needs such as those who are highly aggressive, require sex offender treatment, or are deaf. www.lao.ca.gov 11 analysis full gutter 2020-21 BUDGET Governor’s Proposal New Primary Care Caseload Ratios. Under this proposal, new primary care caseload ratios DSH proposes (1) new caseload ratios for its would be implemented using a combination of treatment team and primary care components, and the updated methodology used to develop the associated positions to meet the new caseload treatment team caseload ratios, and the California ratios (2) additional positions to implement the Department of Corrections and Rehabilitation principles of trauma-informed care, (3) additional (CDCR) methodology for staffing primary care resources to improve the patient discharge clinicians. The new primary care caseload ratios process, and (4) other staff augmentations to also would replace the old ratios based solely on address executive leadership and supervisory acuity. Based on these updated ratios, DSH is issues. This proposal requests $32 million General requesting 26.9 physician positions and no nurse Fund and 80.9 positions in 2020-21, ramping up to practitioner positions. Similarly, utilizing these two $64.2 million General Fund and 250.2 positions in components, primary care caseload ratios were set 2024-25, and ongoing at these amounts thereafter according to units designated as high, moderate, to implement these changes. or low workload. A description of the caseload New Treatment Team Caseload Ratios. level given for each unit workload type is given in Under this proposal, new treatment team caseload Figure 7. ratios would be implemented using an updated Other Staff Augmentations. The administration methodology that includes both patient acuity also proposes a number of additional staffing and the unique workload drivers associated changes outside of treatment teams and primary with treatment and commitment types. The new care. Specifically, it proposes to (1) add five Trauma treatment team caseload ratios would replace the Treatment Specialist positions to help integrate old ratios based solely on acuity, however, the trauma-informed care into the DSH culture, (2) add positions that make up the treatment team would six clinical social worker positions to establish a remain the same. Based on these updated ratios, Discharge Strike Team, to develop relationships DSH is requesting 62.6 psychiatrist positions, with community partners to help DSH establish 59.7 psychologist positions, 32 clinical social a comprehensive discharge planning program, worker positions, and 31 rehabilitation therapist (3) add six Chief Physician and Surgeon positions positions. As discussed earlier in this report, the to address alignment issues with DSH’s primary Clinical Staffing Study categorized DSH units care supervisory structure, (4) add six Medical as high, moderate, or low workload units, and Director positions with increased compensation to appropriate caseloads were developed for each address salary-related issues with DSH’s clinical of these three types of units. A description of the executive structure, and (5) create position authority caseload level given for each unit workload type is to formalize a clinical operations division, which is given in Figure 6. currently being staffed with redirected resources. Figure 6 New Treatment Team Caseload Ratios Figure 7 Unit Workload Levela Caseload Ratiob New Primary Care Caseload Ratios High workload 1:15 Unit Workload Levela Caseload Ratiob Moderate workload 1:30 Low workload 1:35c, 1:50d High workload 1:15 Moderate workload 1:30 a Workload level incorporates both patient acuity and unique workload Low workload 1:45 based on treatment and commitment type. b Ratio of treatment provider to patients. a Workload level incorporates both patient acuity and unique workload c Discharge preparation units. based on treatment and commitment type. d Sexually violent predator treatment. b Ratio of treatment provider to patients. 12 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET Methodology Reassessed Annually. Under CDCR that DSH is responsible to treat, and that this proposal, DSH will reassess the staffing recruitment of nurse practitioners is difficult. methodologies for both treatment team and primary Unclear How Effective Trauma Treatment care annually. Specialists Would Be. DSH already has several initiatives within its facilities to implement LAO Assessment trauma-informed care. These include staff training Adjusting Caseload Ratios Makes Sense. The programs, a pilot program to screen patients administration’s proposal to create uniform staffing for trauma, and a statewide committee on standards for DSH’s treatment team and primary trauma-informed care meant to steer efforts to care components across state hospitals represents implement trauma-informed care in its facilities. an important step forward. This is because the Whether the additional services provided by proposal would result in the treatment team and these proposed positions would improve the primary care portion of the DSH budget being more implementation of trauma-informed care and the accurately adjusted for the makeup of its patient outcomes therefrom is unclear. population and workload-specific certain unit Unclear How Effective Discharge Strike types. We note that utilizing CDCR’s methodology Team Would Be. DSH has existing discharge for primary care staffing makes sense due to the preparation units, which are meant to help prepare amount of forensic patients within DSH. patients for transition back to the community. The Difficult to Recruit Psychiatrists, Making proposed discharge strike team will focus more on Treatment Team Caseload Ratios Potentially establishing relationships with community partners Difficult to Meet. DSH expects to staff the to find appropriate placement. DSH notes that requested 62.6 additional psychiatrists at the end the proposed strike team also would be tasked of this proposal’s phase-in period for its treatment with identifying barriers that hinder DSH patients teams. The department has long had difficulty from finding appropriate placement in community recruiting and retaining psychiatrists, recently resources, but the proposal does not provide detail reporting that its vacancy rate for psychiatrists on how they would do so. Improving community was as high as about 40 percent. DSH has funded placement for DSH patients warrants consideration, workforce development efforts to alleviate these but it is unclear how effective the proposed difficulties, but hiring the proposed number of discharge strike team will be. psychiatrists in the five-year time frame might LAO Recommendations be unrealistic. If the Legislature approves these positions, many may go unfilled and DSH could Approve Requested Psychiatrist Positions, redirect these resources to other purposes that the But Require Department to Report Back on Legislature did not explicitly approve. Ability to Hire Psychiatrists. Given the difficulties Proposal Requests Physicians for Primary that DSH has had historically in recruiting and Care But Not Nurse Practitioners, Potentially retaining psychiatrists, DSH might use vacancies Reducing Cost-Effectiveness. Within DSH, nurse within its additional psychiatrist positions to practitioners are part of the primary care team as redirect resources to other needs. These redirected well, but the proposal does not request any nurse resources may not fit the Legislature’s priorities for practitioner positions. Having certain duties within DSH. We recommend that the Legislature enact primary care be performed by nurse practitioners provisional language to require DSH to report on its rather than physicians could be cost-effective. ability to fill these additional psychiatrist positions, DSH notes that it did not consult CDCR’s staffing and condition continued funding for the positions methodology for nurse practitioners, and that on its ability to reasonably fill vacancies. examining the need for this staffing category was Require DSH to Assess Need for Nurse beyond the scope of this study. DSH also notes Practitioners and Report Back. We find that that there have been concerns raised about staffing the increased workload needs for treatment nurse practitioner positions for patients within team and primary care units justify additional www.lao.ca.gov 13 analysis full gutter 2020-21 BUDGET staffing resources. However, this proposal does examining CDCR’s staffing methodology for nurse not request any nurse practitioner positions and practitioners may be a reasonable place to start. only requests physicians. DSH notes that there Approve Trauma-Informed Care Team on have been concerns raised about using nurse Pilot Basis and Require Evaluation. Whether the practitioners to staff care for patients within CDCR proposed Trauma Treatment Specialist positions that it is responsible for treating. We note that would be successful at improving the adoption of this does not necessarily mean that they could trauma-informed care at DSH facilities is unclear. not be staffed for other patient classifications. Whether the additional services the proposed DSH also has indicated that it is open to revisiting positions would add would improve existing efforts its need for nurse practitioners in the future. We to implement trauma-informed care within DSH also recommend that the Legislature require DSH to is unclear. Given this uncertainty, we recommend report at budget hearings on the feasibility of that the Legislature approve the proposed Trauma assessing staffing needs for nurse practitioners Treatment Specialist positions on a pilot basis, and relative to physicians in primary care units by the require evaluation on effectiveness of improved May Revision, so that the Legislature potentially adoption of trauma-informed care. could adjust the proposed staffing proposal. Should Approve Discharge Strike Team Positions on the Legislature find that DSH will have difficulty a Pilot Basis and Require Evaluation. Whether assessing that need by that time, it could choose the proposed Discharge Strike Team would be to approve this request to address the increased successful at improving patient placements is workload needs, while adopting supplemental unclear. We recommend that the Legislature report language requiring DSH’s assessment on approve the proposed strike team on a pilot basis, the issue to be submitted in conjunction with the and require evaluation on its effectiveness at Governor’s 2021-22 budget. We note that a study improving the placement of patients back into the community after discharge from DSH. PROTECTIVE SERVICES STAFFING PROPOSAL Background appointments and court hearings. A description of the key responsibilities of Support Services is given DSH Protective Services. DSH Protective in Figure 8. Services is a law enforcement agency that provides DSH Protective Services Operations Division. 24-hour police services for hospital operations. DSH’s Operations Division is responsible for the It provides security for all hospital buildings, day-to-day operations of protective services. This manages inflow and outflow of patients, and includes providing security and patrol for hospital transports patients to medical appointments and buildings. A description of the key responsibilities of court appearances. The officers within DSH utilize the Operations Division is given in Figure 9. Therapeutic Strategies and Interventions (TSI) Protective Services Staffing Levels Were when interacting with patients who have behavioral Based on Anticipated Need at the Time Units issues. TSI emphasizes less restrictive behavioral Were Set Up With Minor Adjustments Over Time. intervention techniques to manage potentially Each DSH facility has an allocation of protective violent situations. services staff. However, the level of staffing DSH Protective Services Support Services. was based on anticipated need at the time the DSH’s Support Services Division is responsible protective services were set up many years ago, for ensuring safety and security during patient and the adjustments to them have been made in movements outside of patient housing areas. This a piecemeal way in response to specific events or includes escorting patients to outside medical incidents of violence at specific hospitals. This has 14 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET resulted in staffing levels that vary across hospitals. The staffing levels Figure 8 within DSH protective services Department of State Hospitals Protective Services: also have not been adjusted for Support Services Division Key Responsibilities the increase in forensic patients at Job Duty Responsibility DSH. Main Entrance Officers operate gates, verify identities, and search DSH Clinical Staffing Study. pedestrians and vehicles. As part of DSH’s Clinical Staffing Visiting Center Officers monitor patient-visitor interactions to ensure Study (discussed earlier in this they follow guidelines, and monitor for contraband. report), DSH reviewed protective Package Center Officers use x-ray machines and metal detector wands to services staffing levels as well. For search mail. protective services, it reviewed job Transportation Officers transport patients to medical visits, court tasks specific to each post, the appearances, and to other state hospitals if transferred. number of staff required to perform these tasks, and the workload the first phase of this project. The intent is to drivers specific to these posts. This review was implement the staffing methodologies at the other conducted for both the Services Support and state hospitals in the future. Operations Divisions within DSH Protective New Methodology for Staffing Levels in Services. Services Support and Operations Division. This Overtime Concerns. DSH provides continued proposal requests resources to implement updated coverage for its posts and frequently provides that staffing levels for DSH Protective Services’ Services coverage through overtime. Napa State Hospital Support and Operations Divisions. These updated has the highest use of overtime system wide. staffing levels were developed based on the DSH Napa’s average monthly overtime is 86 percent Clinical Staffing study’s review of workload related to higher than the average monthly overtime system specific job posts. The methodology is meant to be wide. One of the reasons DSH conducted the applied to all the state hospitals. (As described later, Clinical Staffing Study is to reduce hospitals implementing the new methodology mainly requires needing to rely on overtime to cover protective additional staff at one state hospital—Napa.) services posts. New Executive Leadership Structure. Governor’s Proposal This proposal seeks to add four positions to the executive leadership structure within DSH The Governor’s budget proposes (1) new Protective Services. These consist of (1) a Chief of Protective Services staffing levels for Services Support, (2) new Figure 9 staffing levels for its Operations Division, and (3) additional Department of State Hospitals Protective Services: positions for its executive Operations Division Key Responsibilities leadership structure. In total, Job Duty Responsibilities the administration requests Admission Unit Officers conduct patient classifications, process 46.3 positions and $7.9 million property, and fingerprint patients. General Fund in 2020-21, Off-Grounds Officers provide 24-hour security to patients while they 47.8 positions and $13.4 million Custody are hospitalized at an outside medical facility. from the General Fund in 2021-22, and $12 million ongoing from the Hospital Patrol Officers provide security in patient housing units, conduct unit walkthroughs, and secure all hospital General Fund starting in 2022-23. grounds. These resources are meant to Perimeter Kiosks Officers monitor for unknown pedestrians or vehicles implement staffing level changes on hospital grounds. at Napa State Hospital only as www.lao.ca.gov 15 analysis full gutter 2020-21 BUDGET Law Enforcement to oversee protective services Unknown Cost of Implementing These at all five DSH facilities, (2) an Assistant Chief of Staffing Levels to Remaining DSH Facilities. Law Enforcement to provide support to the Chief of Given that this proposal requests funding only to Law Enforcement, (3) five Chief of Police positions implement staffing changes at Napa State Hospital, to oversee the police and fire departments at each the costs of implementing this reform across the state hospital, and (4) five Assistant Chief of Police other DSH facilities is unknown. The Legislature positions to provide support to the Chiefs of Police might want to consider what this cost would be at each state hospital. before it approves this request. Proposal Only Requests Funding to Apply LAO Recommendations New Staffing Methodology at Napa State Hospital. With the exception of augmentations Request Total Cost to Implement the to executive leadership and the off-grounds Proposed Staffing Level Across All DSH custody posts, this proposal only requests Facilities and a Time Schedule for Doing So. funding to augment staff at Napa State Hospital Given that the cost of implementing updated due to significant overtime concerns there. The staffing levels across the remaining four state administration plans to implement these new hospitals is unknown, we recommend that the staffing ratios at all five hospitals in the future. Legislature require information from DSH on the total cost to implement all phases of this proposal, LAO Assessment as well as an implementation schedule for doing Adjusting Protective Services Staffing Levels so. Based on this information, the Legislature could Makes Sense. Given the lack of a standardized consider whether this specific proposal—given its practice for staffing Protective Services job posts implications for the rest of the state hospitals— at DSH, adjusting these staffing levels based on is the best path forward. the methodology outlined in DSH’s Clinical Staffing Study is reasonable. LAO PUBLICATIONS This report was prepared by Corey Hashida, and reviewed by Mark C. Newton and Carolyn Chu. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 16 LEGISLATIVE ANALYST’S OFFICE