Being There: Making a Commitment to Mental Health

Little Hoover Commission •••••• Richard R. Terzian To Promote Economy and Efficiency Chairman Michael E. Alpert* Vice Chairman The Little Hoover Conunission, formally kno\\n as the Milton Marks Bill Campbell "Little Hoover" Conunission on California State Government ASJembIYmember Organization and Economy, is an independent state oversight agency. Carl D. Covitz By statute, the Conunission is a biIYJrtisan ooard composed of five public Daniel W. Hancock members appointed by the Governor, four public members appointed by the Legislature, t\\O Senators and t\\O Assemblymembers. Sally Havice AssembIYmember I n creating the Conunission in 1962, the Legislature declared its purpose: Charles S. Poochigian .. .to secure assistance for the Governor and itself in promoting economy, efficient:) ana Senator improved servim in the transaction ift he public business in the various departments, agencies and instrumentalities f!lthe executive branch oft he state government, and in H. Eric Schockman* making the operation qla ll state departments, agencies and instrumentalities, and all J olm Vasconcellos expenditures ifp ublic funds, more directlY responsive to the wishes if the people as Senator expressed ry their elected representatives. .. Scan Walsh* The Conunission fulfills this charge by listening to the public, consulting with the experts and conferring with the wise. In the course of its StanleyR. Zax investigations, the Conunission typically empanels advisory conunittees, conducts public hearings and visits government operations in action. Stanley M. Zimmerman *S erved on stucfy sub((}mmittee Its conclusions are submitted to the Governor and the Legislature for their consideration. Recommendations often take the form of legislation, The Commission has one vacancy which the Conunission supports through the legislative process. Commission Staff ++++++ James P. Mayer Executive Dim.tor NancyM. Lyons Depu!J Executive Diredor TobyEvMg Projed Manager Contacting the Commission and Copies ofR eports Chloe Bullard All correspondence should be addressed to the Commission at: Research AnalYst .:. 925 L St., Suite 805, Sacramento CA 95814 Cindy Wren .:. E-mail: little.hoover@lhc.ca.gov Research AnalYst .:. Telephone: (916)445-2125 Fax: (916)322-7709 .:. Worldwide Web: www.lhc.ca.gov Rachel Orkand Intern Additional copies of this report may be purchased for $5 per copy. The report is available from the Commission's Web site. State of CAlifornia LITTLE HOOVER COMMISSION November 20, 2000 The Honorable Gray Davis Governor of California The Honorable John Burton The Honorable James Brulte President pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Robert Hertzberg The Honorable Scott Baugh Speaker of the Assembly Assembly Minority Leader and members of the Assembly Dear Governor and Members of the Legislature: Just over a year ago the Commission began to study the quality and availability of mental health services for California's adults. We discovered something that sets mental health policies apart from others: Despite programs and promises, California explicitly rations care to only those with the most extreme needs - and even then we tum people away. California's mental health policy lacks something fundamental: a clear commitment to provide mental health services to people who need assistance. The goal of mental health reform should be that simple - ensuring that all Californians who need mental health services receive care. The Commission also discovered that we spend billions of dollars dealing with the consequences of untreated mental illness - rather than spending that money wisely on adequate services. We pay for jail space and court costs that we incur because mental health clients do not receive care and treatment. We pay for redevelopment and struggle to revitalize our inner cities, but we pretend we cannot do anything to keep people with mental health needs from sleeping in the doorways of downtown homes and businesses. We have, in effect, criminalized mental illness. State law instructs counties to tum away those in need because funding is limited. But law enforcement is expected to respond to every call, to keep every peace, and to ensure everyone's safety. Absent adequate mental health services, the cop has become the clinician. The jail has become the crisis center. There is, of course, a moral imperative for caring for those who cannot care for themselves, and on that basis alone we should change our policies. But there is also a fiscal imperative to mental health reform. The public and private sectors share the costs of failed policies: lost productivity and business, lower property values and quality of life, and increased costs of criminal justice, public health and safety programs. To curb these uncontrolled costs we must develop policies that proactively help people maintain their functionality - to keep their jobs and homes, their ambition and independence. Ensuring that everyone receives care would require a substantial up front expenditure. It also may take years to build the public support and to build the system capacity to provide services. Still, this investment has been shown to yield a positive return: including lower criminal justice costs and healthy business districts, and more importantly a renewed hope for Californians who are too often viewed as a liability rather than an asset. Moreover, as with the physical health care system, the value of quality mental health care is shared throughout our communities. Providing quality care therefore is a community responsibility. The State must create the foundations for stable, successful private sector mental health coverage and nurture the expansion of the private market. With a strong private system in place, the public system can be the safety net for those without private coverage. California has started down this road with the recent parity legislation. But we have not committed to providing minimum basic services to all who need care, and the consequences of inaction are tragic. Californians have shown a willingness to spend if they see promise. Therefore, the first step to reforming mental health policy is for all Californians to understand fully the costs and consequences of failed programs and the responsibility we share to care for people with mental illness. We can then commit to building a mental health service system that emphasizes preventive care and intervention programs for all people needing services. We can ensure that no one ends up in the criminal justice system, on the streets or in the emergency room solely because treatment services were unavailable. Too many Californians have lost their hope. Years of inadequate treatment, homelessness and jail time have stripped them of their self-esteem and their confidence that their productive lives can be restored. Too many business owners have steeled their hearts against the mentally ill individuals who scare away their customers. Too many neighborhoods have rejected treatment centers and supportive housing. Too many families have lost their sense of hope that a mentally ill child, parent, friend or neighbor will recover. Importantly, the Commission found reason to be hopeful. We found an unwavering resolve on the part of many who have worked to provide the highest quality care possible, to push against the bureaucracy and do what they know is necessary and right. We found innovative, energized individuals who have built world-renowned models of care. They envision a California mental health system that ensures those in need can live the most fulfilling lives possible as they recover from their illnesses. We can solve the problems facing California's mental health system. We have taken the initial steps and we are making progress. But there is more work to do. We must recognize that sound mental health policy is about compassion for human suffering and the quality of life in our communities, our neighborhoods and in our homes. In recent months the attention on mental health reform has focused on California's involuntary commitment laws - the Lanterman-Petris-Short Act. Involuntary treatment plays an important role in providing the highest quality of mental health care. But voluntary treatment should be the initial response. California needs a continuum of care in which involuntary treatment is the last and final resort - only appropriate when no other form of treatment is effective - and implemented in a way that guarantees and respects the rights of individuals. When we declared that people with mental illness have a right to treatment in their communities we made a promise. It's time we kept our word. We need to provide adequate housing, training, employment and counseling - services that were provided in institutions and need to be provided in our communities. People with mental illness need to be invited back from the edges of our society, out from under bridges and the margins of our conscience. Sincerely, r~R.:i~/ Chairman Being There Making a Commitment to Mental Health November 2000 Table of Contents Executive Summary _______________________________________________________________________________________________________________________ i Introduction ___________________________________________________________________________________________________________________________________ _ Background _____________________________________________________________________________________________________________________________________ 5 Building Public Support for the Mental Health Service System __________________________________________ .29 Strengthening Statewide Leadership __________________________________________________________________________________________ 37 Developing Comprehensive Services ________________________________________________________________________________________ .45 Providing Adequate Mental Health Resources_ ________________________________________________________________________ 57 Decriminalizing Mental Illness_ ___________________________________________________________________________________________________ 67 Coordinating Mental Health and Criminal Justice Services ________________________________________________ ]7 Creating Accountability: Monitoring the Mental Health System _________________________________________ 85 Conclusion _______________________________________________________________________________________________________________________________________ 91 Appendices ______________________________________________________________________________________________________________________________________ 93 Appendix A: Little Hoover Commission Public Hearing Witnesses __________________________________ 95 Appendix B: Advisory Committee Members ______________________________________________________________________ 97 Appendix C: Medical Necessity Chart_ __________________________________________ ..................................... 101 Appendix D: Distribution of Mental Health Funding ........................................................ 103 Appendix E: Glossary of Terms. .......................................................................................... 107 Appendix F: Mental Health Information Sources and Organizations ................................. 10 9 Notes 113 Table of Sidebars The Lanterman-Petris-Short Act (LPS) ....... ________ . _________________________ .. _______________ .. ______________ . __________ . __________ i Who Needs Care _______________________________________________________________________________________________________________________________ ii Living with Mental Illness _________________________________________________________________________________________________________________ iii Immediate Steps ________________________________________________ . ______________________________________________________________________________ .v Immediate Steps ________________________________________________________________________________________________________________________________ vi Immediate Steps __________________________________________________________________ . _____________________________________________________________ vii 1m med iate Steps ________________________________________________________________________________________________________________________________ vi i i Immediate Steps ______________________________________________ . _________________________________________________________________________________ x Immediate Steps ________________________________________________________________________________________________________________________________ xii Jails Have Become Treatment Centers ______________________________________________________________________________________________ xiii Immediate Steps ________________________________________________________________________________________________________________________________ xiv Service Coordination Can Improve Treatment Opportunities _________________________________ . _______________________ xv Immediate Steps ____________________________________ . ___________________________________________________________________________________________ xv Immediate Steps ________________________________________________________________________________________________________________________________ xvi Immediate Steps ______________________________________ . _________________________________________________________________________________________ xvii Immediate Steps ________________________________________________________________________________________________________________________________ xviii Common Mentalilinesses_ ________________________________________________________________________________________________________________ 6 Understanding Mentaliliness ___________________________________________________________________________________________________________ 7 Who is Served by the Public Mental Health Service System? _________________________________________________________ 8 Estimating Unmet Need __________________________ . _________________________________________________________________________________________ 8 Mental Illness and Suicide 10 Defi ni ng Prevention __________________________________________________________________________________________________________________________ 12 Establishing Community Mental Health Services __ ._. __________________________ . ___________________________________ .14 & 15 Who is EI igi ble for Med i-Cal C ________________________________________________________________________________________________________ .14 Joint Committee on Mental Health Reform ______________________________________________________________________________________ 16 The Lanterman-Petris-Short Act (LPS). _______________________________________________________________________________ ._ ______________ 1 7 Where Are They Now? _____________________________________________________________________________________________________________________ 18 Systems of Care _______________________________________ .. _________________________________________________________________________________________ 19 California Mental Health Planning Council. ______________________________ . _____________________________________________________ .20 Cal iforn ia' s State Hospital s. ______________________________________ . ________________________________________________________________________ 21 Mental Health Funding _______________________________________________________________ . _____________________ . ______________________________ .24 Clarifying Expectations ______________________________________________________________________________________________________________________ 32 Immediate Steps ________________________________________________________________________________________________________________________________ 34 Immediate Steps ________________________________________________________________________________________________________________________________ 35 Defining Cultural Competency _________________________________________________________________________________________________________ 39 Immediate Steps ________________________________________________________________________________________________________________________________ 42 Immediate Steps ________________________________________________________________________________________________________________________________ 43 Livi ng with Mental III ness ________________________________________________________________________________________________________________ .46 Providing Comprehensive Services Requires Culturally Competent Care. ______ ..... __________________________ .47 Living in Board and Care Homes_ ___________________________________________________ .. ___ . ____________________ ._. ____________________ .48 Providing Adequate HousinK _______ . ___ ._. ________ .. _.. . _. ______ . __ ....... __________________ ... __________ .. _. _____________________ . ___ .49 Comm un ity Organ izations: Bu i Id ing Housi ng Sol utions ___________ .. _.. .. __________ .... _.. . _____________________________ 50 Defining Employment _________________________ . _________ ._ .... ___________ .... ___________________________________ . ___________________________ 50 Integrating Services -The Village ISA, Long Beach, California_ __ ._ .... _. ________ . ____ . _______________________________ 52 Immediate Steps ______ . ___________________________ ... _________ ..... __ . _______ .... _. _________________________________ .... _______________________ .56 Program Realignment_ _ ._ ... _____ . ____ . ________________ .. _______________________________ .. _. _____________ .. _________________________________ .57 Negotiating Mental Health Treatment_ .. _.. . _______ .. _.. . ______ ._. __ .. ________________________________ .. _. _____________ ._ .. _______ .60 Social Security Insurance: Incentives for Participation _____________________________________________________________________ 61 Partial Data: Distribution of Mental Health Funding Across California Counties. ... __________ .. _. ........ _.63 Pennsylvania'S Best Practices Funding Model ____________________________ ..... ___________ ..... __________ . __ . __________________ .64 Immediate Steps. ________________________________ . __________ . __________ ..... _________________________ ..... __________________________________ . __ .65 Immediate Steps _______________ ._._ .. __________________________________ . ____________________________ . ___________________________________________ 66 Jails Have Become Treatment Centers._ ... _____ .. ___ ._ .. ______ ... __ .. _____________________________________________________ . _____ ... 68 Lack of Community Treatment Criminalizes Mental Iliness. ___________ ...... __________ .... _. ___________ ..... __________ .69 MIOCR Grantees ______________________________ .. ___________ .. _. _____ ........ ___________ . ______________ ... ____________ .. ________________________ 71 Investing in Prevention, Diversion and Incarceration ______________________________________________________________________ 73 Doing the Research: Who Ends Up In Jail? _______________________________ ... ______________ ... _________________________________ ]5 Immediate Steps __________________________ . ___________ .. __________ .. _________ .. _. __________________________________________________ .. _._. __ . ____ 76 The Need for Improved Communication ____________________________________ . ____________________________________________________ 78 Custody-based vs. Community-based Treatment. . _________________ .. _. ______________ . _____________ . ____________ .. ___________ .79 Improving Communication Between Service Providers. _____________________________________ . ____________ .. _____________ .80 Linking Mental Health and Criminal Justice Data _______________________________ ... ________ .. __ .. ______________ . _____________ 81 Immediate Steps ______________________ . ____________ .. _. ____ ... _.. _____ . __ .. __ .. __________ ... ____________ ._. ____________ .. _. ____________ . _______ .83 Developing Outcome Measurement Systems _____ .. _. _________ . ________________ . ________________________________ . _______ . _____ 88 Measuring Outcomes _____ .... _____ ._._. ____________________________________________________ . __________ . _________________ ._ ..... _____________ 89 Immediate Steps ______________ ._ .. __________ .. _________ .... _____________________________________ ._ ..... _______________ . _________________________ 90 Table of Charts & Graphs Distribution of DMH Personnel 2000-01 ________________________________________________________________________________________ yii Mental Health and Substance Abuse Treatment Expenditures by Source 1996-97 ________________________ 9 State Hospital Inpatient Population 1990-2001. ______________________________________________________________________________ )2 Distribution of DMH Personnel 2000-01 _________________________________________________________________________________________ 38 Historical Distribution of DMH Personnel _______________________________________________________________________________________ 38 Total State and County Mental Health Expenditures ________________________________________________________________________ 58 EXECUTIVE SUMMARY Executive Summary A generation ago, California decided that people with mental illness should live in their communities rather than locked in institutions. They had a right to a more everyday life, and it was determined they would benefit from community-based treatment. It is painfully clear that we have failed to follow through with all that was required by this noble decision. Mental health clients have in fact been integrated into our communities; we see them on the street corners and sleeping in parks. They are integrated into our jails and prisons; many are behind bars on what officers call "mercy bookings" - jailed for their protection, not the public's. They are disproportionately represented among the poor, the victims of crime, the unemployed and the homeless. A majority of people erroneously sees them as "dangerous, dirty, unpredictable and worthless" - better shunned than embraced.l Many of us are uncomfortable with what we see and are not sure how to respond. We too often avert our eyes from the face of mental illness. And our public policies reflect this discomfort: Mental health programs are the chronic losers in budget debates. Community officials verbally scuffle with service providers. Neighbors complain about programs sited near their homes. And funds are increasingly siphoned away from the hundreds of thousands who want help leading productive lives to address the small minority of those who are ill and also dangerous. ,f;/ r ); i tJ 'itl; LITTLE HOOVER COMMISSION An estimated 1.5 million Californians are in need of help, but do not receive it.2 Many of those who need help do not reflect the stereotypes. They struggle to hold jobs, maintain friends and care for children - often burdened as much by stigma as disease. Fortunately the plight of those with mental illness - and their families and the neighborhoods where they live - are receiving renewed attention. And in these times of plenty, leaders are able to commit more resources to provide help. The neglect of the past provides the opportunity of a generation to implement fundamental reforms to the community mental health system -- reforms that may outlast the current empathy and budget surplus. The overriding goal of reform is clear: No one who needs mental health care should be denied access to high quality, tailored services. To transform this system, California needs to develop leadership capacity at two levels. First, community leaders need to define for the State a public commitment to serve those with mental illness and advocate for that commitment until it is fulfilled. What sets mental health apart from other social and medical causes is that we do not share a collective expectation or sense of responsibility - and as a result there is little outrage when mental health programs fail. Second, we need to fortify institutional leadership - at the Department of Mental The Commission's central recomnl~rtdation for Health and in communities - to create a r~formjng mental health policy is that no one who system where barriers to improvement are needs care should be denied access to serviCes. identified and lowered, where the best California curre!lt!ycrationsaccess tp~are, first strategies are replicated and improved, and based on the severity ofanillness and then by providing services lIonly to the extent resources where the pu blic and state and local are available. " . . leaders are confident to invest additional resources. To remOve-th~'fuhdingbarrierf;the public and private sectors need tocommit resources to serve Mental health clients and service providers aUof those eligible based on the severity oftheir . are justifiably frustrated. For years i11l1ess. Byurgingtne State to. go further - to set a goal of p.rovidjn~f care to all ~honeed it - the wholesale reforms have been discussed and Commissloni$: o a f cknowledging' t~e human and then shelved. In California there are model fiscal benefits preventative and' early ., providers offering comprehensive and intervention services. integrated services. Experts from around the world come to visit these operations. l:iow to specific:aUy Hf!llt care. is,~J'I important and But California has not replicated their difficultissue tha(needs to be'e-kploredby policy~ makers, community and businessreadersrm~mtal successes; the knowledge they have health professionals and, of course, clients. produced has not been infused into state policies. ii EXECUTIVE SUMMARY Rather, in most communities, care is rationed to those with severe mental illness. Even then, the system seldom recognizes that some clients need a home, others need a job and all need respect - in addition to medication. We do not tell cancer patients to come back if and when their disease has metastasized. But we turn mental health clients away and tell them to return when their symptoms are so severe and persistent that they cannot meet their own needs, and may no longer recognize that they even need care. The commander of the Los Angeles County jail testified that he operates the largest mental institution in the nation - an indicator that the system is broken and is exacting moral, as well as monetary costs.3 Clearly some criminals, who also have mental illnesses, warrant incarceration. But law enforcement officials are now advocating that jail and prison should not be used to house those who have not received adequate care from the mental health system. While we need to dedicate more resources to mental health services, there is reason to believe that this investment will produce positive returns. Researchers are just beginning to tally the costs of unaddressed mental illness - lost productivity, income and tax revenues, as well as increased criminal justice and emergency medical expenditures. Evidence also is mounting that early intervention and more comprehensive services can preserve and restore functionality - providing human, as well as monetary benefits. The intangible consequences must be considered: the turmoil and grief of families, friends and clients who struggle to find assistance and answers. In 1997, 3,430 Californians committed suicide, the leading cause of preventable death.4 Importantly, thousands of individuals are well-served. But credit goes to the dedication of compassionate staff and a growing number of policy makers who have come to understand this public obligation. Overall, however, the State has not developed or supported management and service systems that encourage continuous improvements in the breadth and quality of services. iii LITTLE HOOVER COMMISSION The challenge is to capture the growing concern, knowledge, resources and goodwill to make fundamental reform to policies and programs that have been neglected for so long that they cannot be fIxed by marginal changes. Rather, we need to support fundamental change that ultimately will transform our image of people with mental illness from community liabilities into an accurate reflection of those individuals as our neighbors, family members and loved ones. The Little Hoover Commission has identifIed four core areas of reform that together can move California's response to mental illness from one driven by fear, stigma and lost hope to one offering treatment, success and recovery to those living with mental illness. D Expectations and Leadership. Public policy is driven by public expectations. To raise the public's expectations for mental health services, programs must be able to communicate reliably and clearly their performance and their potential. The Department of Mental Health also needs to step up its efforts to be a statewide leader of the community-based mental health system. D Comprehensive Services and Resources. In many cases, mental health treatment is limited to medication, when what is really needed is help with housing, substance abuse and other problems. While California hosts world-renowned service providers, they are islands of success in a sea of rationed care. Mental health and related programs have been plagued by a lack of resources. Reforms should promote early intervention and more comprehensive services, as a way of preserving functionality and holding down costs for acute care. Over the long term, the State needs to capture funds now spent housing clients in jails to provide better services through the mental health system. D Criminal Justice. Law enforcement offlcials say they have become the safety net for the failing mental health system. California is just beginning - and needs to do much more - to make sure that people do not land in jail because of limited mental health treatment options. And when mental health clients are jailed and released, far more can be done to reintegrate them into communities and prevent their reincarceration. D Accountability. Concern alone for the welfare of people with mental health needs is inadequate to motivate change. Clients, taxpayers, policy-makers and the public must understand how policy and funding decisions move the State closer to realizing their new expectations. Without clear and constant accountability, mental health will continue to reflect an inadequate and forsaken component of California's social service programs. IV EXECUTIVE SUMMARY The Commission believes that successful mental health reform will require systematic change in how mental health policies are conceived, funded and administered. It will require California's community, business and political leaders to understand the costs and consequences of success and failure, and it will require them to drive the reform process. Fundamental reform will move California toward a system of care that has as its goal ensuring access to care and tailoring mental health services for those with debilitating mental illness. But the thousands of Californians in need of services today should not have to wait for fundamental reforms to be achieved. Along with recommendations for transforming the mental health system, the Commission is urging State and community leaders to take immediate steps to expand and improve care. The goal of ensuring that people who need care have access to high quality, tailored mental health services is achievable. It will require strategically expanding access and the capacity of the system over time - enough time to do it right, but not so long as to lose our way again. Toward this end, the Commission offers the following findings and recommendations: Building Public Support for the Mental Health Service System Finding 1: No one who needs care should be denied access to high quality, tailored mental health services. Open access cannot be achieved until the public and policy makers have a shared commitment to care for people with mental illness. Mental health clients have many champions. But they have been unable to make their voices heard in the broader public and policy arena. Without a shared sense of responsibility, the public and their political leaders cannot create expectations, set goals and measure progress. The Surgeon General asserts that stigma is a primary reason why mental health problems are not adequately funded.5 The antidote for stigma is accurate information. The faces of those with mental illness are diverse and cross all social boundaries. Mental health clients who receive adequate treatment are no more violent than other people.6 And failing v LITTLE HOOVER COMMISSION to provide adequate mental health care leads to The faces of those with mental illness are diverse and cross all social higher social, personal and economic costs. boundaries. Mental health clients who receive adequate treatment are no more Californians must understand the social costs and violent than other people. And failing to personal consequences of mental illness. They provide adequate mental health care need to know that people with mental illness can leads to increased social, personal and lead fulfilling, productive lives and they need to economic costs. recognize that mental illness affects everyone. Defining expectations for mental health care will be a challenge. Mental health policy is complicated and reflects diverse and competing interests. The science of mental illness is also complex and continues to evolve. The policy-making process is most challenged by topics that fit this description - intricate policies based on competing interests and incomplete knowledge. Nevertheless, the multiple interests must be brought together to develop a shared understanding of the problems and the possibilities. Creating a California Mental Health Advocacy Commission could assist policy makers in making a commitment, providing direction and pushing for fundamental reform. The Commission should include a broad range of stakeholders, particularly interests not historically involved in mental health discussions, such as business, labor, taxpayer and education groups. The Advocacy Commission could immediately begin to raise public awareness and over time provide detailed proposals to policy- makers. Recommendation 1: The Governor and the Legislature should ensure that no one who needs care is denied access to high quality, tailored mental health services. The first step is to establish a California Mental Health Advocacy Commission to serve as a catalyst for change, set expectations and establish responsibility for mental health services. Specifically, the Commission should: D Be of limited term and funded from public and private sources. To ensure against unnecessary bureaucracy, the Commission should be of limited term. To improve accountability, it should be jointly funded from public and private sources. And to demonstrate clear expectations for outcomes, the Commission should issue periodic reports and a final summary of its Immediate Steps activities and accomplishments . . II The Governor should apPOint a personal D Develop strategies to overcome stigma. The Mental Health Advocate charged with public and policy-makers need an improved building the networks and partnerships understanding of mental health, mental illness and necessary to form the Mental Health AdvocacVCommission. the role of public policy in providing quality mental health care. Vi EXECUTIVE SUMMARY Q Detail need. The public and policy-makers need to understand how Californians are affected by mental health policies, the adequacy of existing programs and the magnitude of additional need. Q Assess costs of failure. The public and policy ,eglslatioo;shOljldl:l'p .... makers need to understand the trade-off an ,~cdQ~ in Janu~ryto'iftf~~. between investing in adequate mental health alize'ffi~'QmmlSsi(>n. .. services and failing to provide appropriate care. Q Provide for on-going policy advice. The Commission should propose strategies for providing the Legislature and Governor on-going direction and advice on mental health policy, and in particular, strategies for understanding the complex and evolving science of mental health and mental illness. Strengthening Statewide Leadership Finding 2: The state Department of Mental Health is not organized or funded to ensure that all Californians have access to mental health services when they need care. The Department of Mental Health is charged with ensuring that targeted mental health clients have access to adequate, appropriate care through a culturally competent system within their communities. The State faces significant barriers to improved care that require the department to exercise this leadership: Care is limited by chronic underfunding and critical shortages of mental health professionals. Stigma and fear limit support for community-based services. Local mental health agencies often do not adopt best practices. Family and client organizations battle over attempts to reform involuntary commitment laws, threatening years of good relations. There is contentious disagreement over the success or failure of managed care. Clients face an increasing shortage of affordable housing. Distribution of DMH Personnel Over 30,000 people in California's jails and prisons need 2000-01 mental health services - many are incarcerated because Departmental they failed to receive adequate community care.7 Admin While each of these issues is challenging, the department's ( attention is divided between leading a statewide community-based system of care and managing a growing Community Services penal code population in state hospitals. As the chart 2% shows, over 95 percent of the department's staff is dedicated to operating institutions; less than 2 percent is available for leadership activities. vii LITTLE HOOVER COMMISSION California will not be able to provide adequate, appropriate mental health care to its citizens without reorganizing state resources to provide leadership and guidance to community mental health systems. Recommendation 2: The Department of Mental Health needs to become the State's mental health champion. The department needs the resources and the political support to ensure that California's mental health system continuously improves. Specifically, the department should: o Advocate and provide policy guidance. The department should be an advocate for mental health clients. It should provide direction and advice to the Legislature and Governor on a policy framework that results in continuous improvement in the availability and quality of mental health care. o Advocate for local mental health programs. The department must ensure that local providers have the support they need from local, state and federal agencies to provide needed care. The department: should pay particular attention to the need for housing, employment: and substance abuse treatment. o Identify barriers and promote change. The ","_,"."" .. """.".""". __ ."l~mec/iate Steps . _.. " _~_"'_""_." ... department should identify statewide and local • The Governor should reassign 10 staff barriers to improved care and recommend state persons from other departments to the and local strategies to overcome those barriers .. Department of Mental Health to . The department should explore strategies to immediately provide additional support motivate improvement through funding, promote for community mental health programs. best practices and improve state and local • The Department of Finance and the accountability. Legislative Analyst's Office should begin the detailed analyses necessary to o Develop mental health workforce. The redesign the Department of Mental department must ensure that California has an Health. adequate workforce capable of providing • The department should convene a task culturally competent, professional mental health force of county mental health officials services throughout the state. The department and national mental health experts to should partner with state and federal agencies identify barriers to improvement and involved in education and workforce development strategiesto promote change. to meet this need. • The department should convene a summit ofpublicancl private experts in o Assess options for managing state hospital human resources and workforce system. The department should determine development to begin assessing human whether providing long-term care services resource needs and crafting short-term detracts from its leadership responsibilities. It and long.-termplans to address the should assess alternatives for the long-term shortage of qualified mental health professionals. .. operation and management of state hospitals. viii EXECUTIVE SUMMARY Developing Comprehensive Services Finding 3: Ensuring access to high quality mental health care means that each community must provide a comprehensive array of mental health and support services. Yet the rule bound mental health system offers fragmented and poorly coordinated care. Like all people, mental health clients face multiple challenges every day. Some are more prepared - and some less - to provide for their housing, health care, employment and independent living needs. Some are unable to provide for themselves because of their mental illness. Although the mental health system is organized around a rehabilitation model, the majority of people served do not receive comprehensive services. California has over 500,000 mental health clients in need of substance abuse treatment, but treatment services do not begin to meet the need.8 Over 75,000 clients need some form of housing assistance.9 But the mental health system and community programs have a limited supply of temporary and permanent housing. Employment presents an even greater challenge. The majority of people with serious mental illness are capable of working with support, but 80 to 90 percent are unemployed. 10 Improving access to services often requires additional funding, but it can also be done by breaking through bureaucratic barriers. The highly regarded program offered by the Village Integrated Service Agency in Long Beach reveals the results of removing institutional barriers. Other agencies, such as Baker Places and the Progress Foundation in San Francisco, have been able to provide integrated services because administrators have the support of local authorities to work through licensing regulations. Jonathan Vernick, director of Baker Places, explains: 11 The mental health system unintentionally contrives against seroice integration. I tried to shop around for a license that would allow the organization to provide mental health and substance abuse treatment services under one roof There is no license that will allow me to offer both seroices in a single residential program. As the mental health leader, the State must make a concerted effort to motivate local agencies to provide comprehensive services - by lowering barriers to integrated services, promoting cost-effective strategies and encouraging innovation. California's Mental Health Planning Council, representing an array of State departments and client and family advocacy organizations, could assist the department in its efforts. ix LITTLE HOOVER COMMISSION Recommendation 3: The State must assertively promote cost-effective, efficient approaches to providing care. The Department of Mental Health must ensure that local mental health programs have the tools and assistance necessary to improve the cost effectiveness of their programs. Specifically, the department should: Q Utilize the resources of the Planning Council. _....... ..... _~!!1~~if.!.~_~~ S~!P!_ _. . __ The department should seek assistance from the <. .< _ _. .....< • The Planning Councilsnould con.vene Planning Council for each of the continuous public hearings aroUlidthe.state to improvement efforts outlined below. identify and document potential best practice models. Q Identify barriers. The department should actively identify the barriers that discourage local • The department should prepare a mental health systems from providing budget change proposal to create and staff a unit charged with Identifying and comprehensive, integrated services that can be promoting cost.,effecl:ive practices that tailored to individual needs. improve outcomes. Q Identify best practices. The refocused • The department should convene a department should create and staff a unit charged working group of mental health with identifying and promoting cost-effective professionals and evaluators charged practices that improve individual and system with developing a protocol for evaluating the effectiveness of service outcomes. models. Q Explore incentives. The department should explore funding, reporting or other mechanisms that can create incentives for state and local mental health officials and service providers to continuously identify and remove barriers to more efficient and effective care. Q Evaluate innovate programs. The department should evaluate promising and innovative practices that have the potential to improve services. Q Report progress. The department and the Planning Council should annually report to the Legislature, local agencies and the public on their activities, progress and on-going challenges to providing comprehensive services. Providing Adequate Mental Health Resources Finding 4: Mental health funding is inadequate to ensure all Californians who need mental health services have access to care. Furthermore, existing resources fail to create uniform incentives for improvement and can prevent local authorities from providing cost-effective, efficient care. Community mental health services are funded through an array of local, state and federal funds. Realignment provides dedicated revenue. Medi Cal, Medicare and Social Security programs provide reimbursements and x EXECUTIVE SUMMARY direct payments for people who qualify. Categorical funds, grants and pilot projects allow some communities to provide additional services. The result of having multiple funding streams is that local mental health authorities must patch together services, and the breadth and quality of programs vary from county to county. Overall, mental health agencies are forced to ration care to only those with the greatest needs and often cannot provide the support services needed to keep individuals stable. One advisory committee member noted that he could not get help until he attempted suicide. Another argued that the only way she can improve the quality of her care is to move to a county that offers better services. California should reexamine how it funds mental health programs. When funding and efficiency levels vary across the State, access and quality also vary. Some counties are able to provide a range of services to many, while others provide more limited services and place greater restrictions on access. Access to high quality mental health services should not be determined by a person's zip code. Other states use funding to promote program effectiveness and efficiency. To promote improvements, Pennsylvania provides additional funds to local agencies willing to adopt programs that have been proven to work. The Pennsylvania funding model is based on a clear assessment of needs and the demonstrated effectiveness of a service approach. The Pennsylvania Partnership for Safe Children has used this model to support youth violence prevention programs.12 It provides incentives to communities to adopt cost-effective programs. California could incorporate a practice similar to the Pennsylvania model as part of an overall funding strategy. The majority of mental health funding, perhaps 90 percent, should be stable, provide incentives that promote efficiency and effectiveness and give local agencies discretion to tailor programs to meet individual needs. In addition, the State should provide incentive funding, perhaps 5 percent of all funding, that the Department of Mental Health could allocate to motivate local authorities to adopt practices proven to enhance services. A third tier of funding should promote innovation, perhaps 5 percent, as well. This funding should encourage counties to invest in approaches that hold the promise of increasing the efficiency and effectiveness of mental health programs. With three tiers of mental health funding, each with explicit incentives, the State can provide stable, discretionary funding while motivating counties to adopt best practices and continuously explore innovative approaches to improving outcomes. xi ---------~-----~------------------------- LITTLE HOOVER COMMISSION Recommendation 4: California should provide adequate funding to ensure those who need care have access to services. The first step is for the Governor and the Legislature to reform the present funding streams. Specifically the legislation should: D Provide stable base funding that motivates quality outcomes. The lion's share of mental health funding should include incentives for local mental health agencies to continuously improve services. Funding should reward local programs that improve system outcomes and generate savings associated with reduced mental health costs, as well as reductions Immediate Steps in the costs of other public services, such as public • The Department of Financearta tne safety and health care. Legislative Analyst's Office/should D Provide incentive funding for the adoption of analyze the cost of fullyftlnding realignment. best practices. In addition to base funding, the State should develop supplemental incentive • In January, the legislature s~ould funding that encourages local agencies to adopt introduce abiU to fully fulid realignment and remove language that proven best practices. limits access Nto the extent resources are D Provide innovation funding to encourage new available. " experimentation and risk taking. Mental health • The Governor should direct the funding should also include resources in addition Departments of Mental Health and to base and incentive funding that promote Managed Care to assess the impact of innovation and risk taking to encourage local parity legislation and constafltlYiclentify strategies for expanding access to care agencies to explore new approaches. through public and private sector D Document the effectiveness and promote mental mental health programs .. health parity. Providing all who need services • The Department of Finance ~ncl the unrestricted access to mental health care means Legislative Analyst's Office should expanding access through the private sector as develop a transition plan to move away well as expanding the safety net offered by the from 19 major~ funding streams toward a more rational approach to funding public sector. The effect of mental health parity mental health services. legislation must be understood, and parity should be expanded to improve access to quality care. Decriminalizing Mental Illness Finding 5: One consequence of an inadequate mental health system is the criminalization of behavior associated with mental illness. The criminal justice system is too often the only resource - the only safety net - available to mental health clients and their families in times of crisis. California's mental health system is designed to ensure that people have access to emergency mental health care. State and local psychiatric facilities provide round-the-clock services for individuals in need of emergency mental health services. But non-emergency senrices are more limited. People who need assistance, but who are not a danger to xii EXECUTIVE SUMMARY themselves or others, are often ineligible for immediate inpatient care, and outpatient assistance may not be available. If every community had a 24-hour assistance center, a safe haven offering care, individuals needing assistance could contact a center for immediate support, while avoiding the high cost of hospitalization or incarceration. In the majority of California communities, however, clients, family members and concerned neighbors have limited options when seeking assistance. In most cases, law enforcement is the only resource available, every day, all day. The majority of law enforcement contacts with people with mental health needs do not result in an arrest.13 Most client-police interactions involve officers facilitating access to mental health services, mediating disputes, calming situations or otherwise responding in ways other than to arrest and jail. Police officers, however, are not routinely trained to interact with the specialized needs and concerns of clients in crisis.14 And when community mental health resources are not available, arrest can be the only option. Aft~r ~~~~~ii'~h Of the 30,000 seriously mentally ill people in .. spraying California's jails and prisons, the majority are handcuffing.him~<ib~pol ce COl:!nty mental h:~l.ll~hfacaity·,!9 se thought to be nonviolent, low-level offenders Was room for R~t,TherewC:l~n,o who landed in the criminal justice system in called the psychii\Jl{i~ nos' part because they did not receive appropriate ·heighborlng county; 110 sp ....... community treatment. IS Unstable housing and facility two counttesdver, n6?space. limited substance abuse treatment are other option they charged Ron,with particularly associated with the likelihood and took him to jajl~},,~?, ... clients will become involved in the criminal justice system.16 The State needs to better understand which people are in jailor prison because they were unable to access mental health care and which should be incarcerated and receive treatment while they serve time. California has begun to identify ways to divert people needing care out of the criminal justice system and into treatment. The Legislature has invested over $160 million in the Mentally III Offender Crime Reduction Grant and the Integrated Services to Homeless Adults programs. Both are designed to reduce the number of mental health clients sent to jail.I7 But these programs are limited and may not provide the most cost effective services to those who can most benefit. The bulk of California's xiii LITTLE HOOVER COMMISSION diversion and intervention efforts focus on clients after they have been arrested and jailed. Greater savings may result from providing alternatives to arrest, such as improved police training, more 24-hour assistance centers and the expansion of supportive housing programs. Recommendation 5: The State needs to decriminalize mental illness by ensuring that no one ends up in the criminal justice system solely because of inadequate mental health care. The Governor and the Legislature should improve and expand mental health crisis interventions. Specifically, the Department of Mental Health, the Attorney General and the Board of Corrections should: o Use data to improve services. The State should Immediate Steps. analyze criminal justice and mental health data to identify priorities, develop promising programs and • The Department of Mental Health inform policy decisions that will reduce the should query the Department oOustfce database to determine how and where number of mental health clients who end up in the clients come into contactwitn the. criminal justice system. criminal jus~ice system. o Identify needs. The State should document the • The LegislativeAnalyst 's Office should need in each county for services that would review crimjnalju~tice diversion and prevent people from ending up in the criminal intervention programs and determine if justice system, such as 24-hour crisis programs, the State is making the best use of existing investments. supportive and affordable housing, substance abuse treatment and other services. • Legislation should be drafted for introduction in January to expand o Evaluate intervention programs. The State facility funding available through the should determine whether the Mentally III Offender Board of Corrections and permit Crime Reduction Grant and Integrated Services to counties to seek funds from the Board to Homeless Adults programs represent the greatest build 24-hour assistance centers or jails. opportunities to reduce client involvement in the criminal justice system. Coordinating Mental Health and Criminal Justice Services Finding 6: Local and State agencies have failed to integrate and coordinate mental health and criminal justice services - and as a result people with mental health needs leaving jails and prisons do not receive adequate services and are too often rearrested. Even if substantial efforts are made to ensure that no one is incarcerated solely because of mental illness, some persons suffering from mental illness will end up in jailor prison for crimes of survival. The criminal justice system also must continue to respond to people with mental illness who have committed serious crimes. In both cases, it must be remembered that nearly everyone in the criminal justice system will be released and re-enter their communities. xiv EXECUTIVE SUMMARY Yet clients leaving the criminal justice system face multiple barriers to community re-integration. They may require housing, employment, substance abuse treatment and independent living services to prevent their return to custody. Many communities fail to offer these services. Where these services are available, it may not be clear how to access them. The biggest barrier to successfully re-integrating mental health clients back into their communities is a lack of cooperation among multiple community ,,' ':':¥~4'1;ji6u " ',;,;'j" and state agencies. The evidence is cOmpelling:CaljfQ;ri;'~i;\rtmJrlb)fC~~~!~~;;i;';h" that participation in treatment services is increased and recidivism is reduced when community criminal justice and mental health services are consistent and coordinated. 18 Yet the State offers limited direction or incentive to support collaboration. Resolving this problem is relatively inexpensive, but essential to improving the lives of these mental health clients. The Texas Council on Offenders with Mental Impairments provides an example of state and community leaders from multiple service areas collaborating to identify strategies to improve services to mentally ill offenders and reduce costs. The National GAINS Center in Delmar, NY, represents a national investment in research, technical assistance and information dissemination to improve community responses to mentally ill offenders. California should explore the potential of these models and develop strategies to realize similar goals: improving program quality, efficiency and research, enhancing education and technical assistance and increasing the ability of the State to draw upon federal resources to provide services to offenders with special needs. Recommendation 6: The State should establish a California Council on Offenders with Special Needs to investigate and promote cost-effective approaches to meeting the long term needs of mentally ill offenders. The council, comprised of state and local officials, should: o Identify treatment strategies. The council should propose policies for improving the cost effectiveness of services for offenders with •, ,' ,. ",E, xecutive, Q"r+der,"'. ;; t x;' , > h ;;' ~':,G,ov,e rnot/: .."•' " special needs within jails and prisons, .·:·uld, e~tablishthe Califq~~ia Council' including service coordination and data sharing on Offenaf)rs withSpeciaff¥~s. among community mental health and criminal justice programs. xv LITTLE HOOVER COMMISSION o Promote coordination. The council should document the need to coordinate mental health • The Legisl!:lture should call fqf an services and improve the ability of clients to Independent evaluation of contr'ac!S transition successfully between corrections-based between the.California DepJ;trtment of . Corrections and lOCal mental health and community-based treatment programs. agencies to prOvide c~re to parql~.~s .. o Provide technical assistance. The council • The Legislature should direcfih~. .. should develop a technical assistance and resource California Department of Corrections to an center to document best practices and provide expand to counties contracts proven information and training to improve the efficiency to successfully prOvide quality mental health care to parolees. . and effectiveness of state and local programs serving mentally ill offenders. • The Legislative Analyst's Office should analyze the .State's response to il1cen.tive D Develop incentives. The council should identify prOgrams offered by the federal Social incentives that will motivate State and local Security Administration and promote agencies to coordinate mental health and criminal the use of incentive payments to fund justice services. pre-authorization efforts that speed up benefits to clients leavi rig jail or prison. Creating Accountability: Monitoring the Mental Health System Finding 7: California will never be able to ensure that all Californians have access to mental health care without clear and continuous accountability for outcomes. When realignment shifted responsibility for care to counties, client advocates were concerned that local agencies would limit their investment in services and the quality of care would suffer. In response, the Department of Mental Health was required to develop a reporting system to assess the performance of counties.19 But it has struggled with the requirements and the reporting system is not fully operational. The department envisions a data-based reporting system that tracks outcomes for all mental health clients receiving services for 60 days or more each year - some 25,000 children and 185,000 adults.2o Data for each individual will track the services used, costs and outcomes. Despite sound planning and pilot testing, the department is challenged by the enormity of the task. There is no unequivocal agreement or standard for measuring the effects of mental health services. There is no clear measure for evaluating the impact of treatment.21 Supporters of the department argue it is difficult to develop a system when the science of performance measurement is still evolving. Critics contend that a lack of progress is a result of the department's interest in ensuring that the data favorably represent all county mental health agencies. The reality is likely somewhere in the middle. Similar efforts xvi EXECUTIVE SUMMARY in other states have shown that data systems often fail to capture the value of local mental health programs. Preliminary data are often suspect, and it can take years of fine tuning to build a reliable measurement and reporting system.22 Despite these challenges, California needs to make progress. The department needs to take first steps regardless of how unstable those steps may be. The department could bolster its efforts by involving nationally recognized experts in outcome reporting and encouraging public awareness and critique of its process and progress. Further, the department should develop data sharing protocols with other state and local agencies to encourage collaborations that can improve the quality of services and client outcomes. Data sharing should explore potentials for organizational improvement by encouraging data based research on the mental health service delivery system. Outcome, assessment and financial data should be widely available and permit mental health stakeholders and the general public to understand the adequacy and efficiency of local mental health programs. Recommendation 7: Improvement, public understanding and support for mental health programs depend on an accurate assessment of California's progress toward its goals. As the State's mental health leader, the Department of Mental Health must continuously inform the public, program administrators and policy-makers on the performance of the system, whether quality and access are improving and how they could be enhanced. Specifically, the department should: CJ Inform decision-makers. The department Immediate/Steps should provide information that can help the general public, policy-makers and program ;i;!;At~a~~a~~f~~~a~~~i~~~~6·.~~·. administrators understand the availability, on the rypesof Cal ifomianswho. are! quality and cost-effectiveness of mental being Ser\f~A,il,!,!d the"Onmetn'" health services. ~ .. ,,;;,';,,;;~ ..' ;,,; , CJ Provide benchmarks. The department should provide information that compares performance with expectations. It should " .,' "' i : "" reveal variations across programs, counties d,"~' The Legislafureshould di.rect and over time. .. . ... '. t of MEmtal Hea!thto he statewiIdi'e,; p,;ei:f:f?d",r:m,.,;a nce CJ Reveal barriers. The department should reporti og system. . Nf;?::;;?:;. ; provide data to permit administrators and ,.,:;;,,;:~~:~:~:~~6~;~~t,~~'~:~~:~:~~::~~i·· researchers to identify barriers to program improvement and alert policy-makers when . the public on its'Rr,~gress inqeveloping:;;;;';' and where policy changes are necessary. the reportirig systern~;; . .. . XVll LITTLE HOOVER COMMISSION D Encourage broad access. All data and ..... Immediate Steps information on mental health programs should be readily accessible to the public, the press, • The department should begin putting data on~1ine for easy public access. researchers and others whose analyses could lead to better pu blic understanding, program • The department should publicize the management and policy making. conditions under which it will interVene to ensure I'nental health services .are D Provide standards. Performance data should be available in every community. . structured to indicate to state and local administrators and policy-makers when mental health services are so inadequate that intervention is warranted. xviii INTRODUCTION Introduction M eeting the needs of people with mental illness has been a persistent challenge for individual communities and together as a State. In this report, the Commission explores some of the issues that make mental health policy unique, as well as those that burden other social services. This report was motivated by concern and compassion for those among us whose illness is most visible. The Commission is not composed of experts in mental health, and the Commission soon recognized that it was not alone. Misunderstanding - or even just a lack of understanding - about mental illness and those who suffer with it shapes the public's often inadequate response. Without clear expectations and obligations, policy-makers spiritedly debate involuntary treatment and separate insurance and payment systems for mental and physical health care. They are uncertain how to flx fragmented mental health policies and programs that fail to comprehensively address client needs. Everyone in California is entitled to physical health care; even those without insurance can walk into an emergency room for treatment of a relatively minor ailment. In contrast, mental health care is not always available. The law says that local mental health programs can turn away those with less severe needs. And when funds are depleted, even the most severely disabled can be turned away. The obligations of government and the expectations of the public for mental health care must be clarifled before California's mental health system will dramatically improve. Several Commission reviews have identifled the role of mental health services in reaching publicly held goals. The Commission has recommended expanding mental health services for abused and neglected children.23 It has recommended improved mental health assessments and treatment for prison inmates and those released on parole. 24 During its review of juvenile justice programs in 1994, the Commission examined the adequacy of mental health services for troubled youth.25 In this review, the Commission attempted to comprehensively examine the State's policies for serving those with mental illness. The Commission strived to understand the full range of service needs and the full range of available services. Whenever possible, the Commission explored these issues from the perspective of mental health clients and 1 LITTLE HOOVER COMMISSION what they needed to maintain or recover functionality. It probed the costs and benefits of providing adequate services, and the costs and consequences of providing inadequate care. As in the previous studies, the Commission observed that the public and private costs of mental illness reach far beyond the resources budgeted for mental health programs. The recommendations in this report are offered to the Governor, the Legislature and the people of California. Together the recommendations call for systematic reforms to the services provided to people with mental illnesses. Most significantly, the Commission believes that fundamental reforms must begin with - and be sustained by - an expanded public understanding of mental health and the impact of mental illness. Mental illness touches the lives of all Californians, and as a result each Californian has a stake in ensuring that services are available, efficient and effective. The report contains seven findings and recommendations that would fortify the mental health system in four areas: Expectations and Leadership 1:1 Because of the nature of mental illness and the large number of people and institutions that must be involved to address it, extraordinary leadership is required. The leadership responsibility must be shared with an array of community leaders who historically have not been involved with this issue. They must help all Californians to understand this illness, to set clear expectations for the public response and persistently advocate for improvements in service and investment of additional resources. In turn, the State must refocus its leadership capacity to help California's communities improve services. Comprehensive Services and Resources 1:1 While the understanding of mental illness continues to evolve, there is general agreement on effective strategies for helping those in need. But for the most part, the State rations care to the most severely mentally ill, forsaking opportunities to intervene early. In the absence of comprehensive, efficient mental health services, mental health clients, their families, California's communities and taxpayers pay a higher price in lost potential and productivity, greater social problems and personal grief. Criminal Justice 1:1 California's local and state criminal justice systems have become a secondary mental health system, and state psychiatric hospitals have 2 INTRODUCTION become a branch of the criminal justice system. The merging of mental health and criminal justice reflects the priority given to public safety. It also reflects the mental health system's inability to adequately care for those in need and prevent the nuisance crimes of survival - vagrancy, public drunkenness, trespassing - that are actions of people with no allies and no options. Accountability Q There is tremendous variation in the availability and quality of mental health services across California's communities. Without clear public expectations for services, some communities have invested more than others in mental health. This variation in the quality and availability of care can be addressed by improved public accountability for outcomes. The State is developing a monitoring and reporting system. It should allow the public, administrators, clients and other stakeholders to assess the adequacy of each local mental health program and identify opportunities for change. The Commission began its work on mental health policy in September 1999 with a public hearing on the mental health service system and the challenges it faces. A second hearing was convened in October where the Commission explored the links between the criminal justice system and mental health. At a final hearing in January 2000, witnesses provided testimony on model programs, strategies for improving services and the ongoing challenges facing people with mental health needs.26 Those hearings were complemented by site visits to Santa Barbara, Los Angeles, Indian Wells, San Bernardino, San Francisco, Sacramento, Vacaville and Napa. The Commission also benefited from the time and energy of over 100 advisory committee members representing state departments, advocacy organizations, youth and adult mental health clients, family members, mental health researchers, public and private mental health providers, hospitals and health systems, law enforcement agencies and others. The Commission also received advice and technical assistance from the University of California, Center for Mental Health Services Research, which helped the Commission to explore specific aspects of this report. As always, the Commission greatly appreciates this assistance, but the conclusions are those of the Commission alone. The pages that follow examine California's public mental health system and services to adult with mental health needs. Considering the differences in how children and adults experience mental illness and the distinct funding and service systems in place, the Commission will follow this report with a review of children's mental health policy. 3 LITTLE HOOVER COMMISSION 4 BACKGROUND Background C alifornia's mental health policy has evolved through episodic changes representing large, but seldom comprehensive reforms. Policy discussions usually focus on the crisis of the day: unstable and limited funding, state versus local responsibilities for care, and the protocols for involuntary treatment. In California's communities, clients and providers struggle with limited access to care, and shortages of essential related services. The ability of policy-makers to address these tensions is hamstrung by their complexity. The scientific understanding of mental illness and treatment options is evolving and is contentiously debated by stakeholders. Stigma, misunderstanding and inaccurate public perceptions of mental illness and those who experience it complicate efforts to solve thorny challenges. Finally, the sheer number of funding streams and agencies responsible for providing care, oversight or assistance confounds efforts to assess and improve the system. No Bright Line between Health and Illness Policy-makers face many challenges when crafting mental health policy and the greatest may be the evolving understanding of mental illness. The U.S. Surgeon General reports that there is no "bright line separating health from illness, distress from disease. "27 How mental illness is defined varies for people from different age-groups, cultures and gender. Social values determine at what point distress becomes illness and those values change over time and across cultural boundaries. There is continuous debate within the scientific and advocacy communities over how to define mental illness, the conditions under which taxpayers should fund services and the goals of treatment. These debates create a moving target for policy-makers and practitioners, particUlarly when they try to capture evolving and conceptual understandings into the rigid language of statutes and regulations. It is generally agreed that illness and health are linked to social, psychological and biological factors.28 But there is disagreement on the role that each factor plays. Social factors include the learned behavior of individuals as they respond to the events around them.29 Psychological factors include stressful events and personality.3o Biological influences include genetic disposition to illness. Sorting out these factors is complicated because mental illness presents itself in different ways in different people. Some experience mental illness following traumatic 5 LITTLE HOOVER COMMISSION events. Others might develop the same illness without such an event. This variation makes it difficult to know whether biological, psychological or social factors are the dominating influence. Extensive research in recent years on brain development has advanced the understanding and treatment associated with biological factors. Based on this research, some have asserted the primacy of biological foundations of mental illness and treatment. Critics respond that biological factors dominate discussions only because social and psychological factors have not been adequately studied. One respected psychiatrist described the tension this way: The significance of biological, psychological and social factors as causes, consequences and correlates of mental illness ranges from complete significance to insignificance - depending on the expert, the client and the illness. In short, the scientific community does not know with certainty what causes mental illness and treatment is not universally effective for all people. Treatment results in degrees of recovery across different people, illnesses and circumstances. The variation in how different people perceive mental illness and respond to treatment is further complicated by how the illnesses run their course. Some people overcome their illnesses. For others treatment can only help them to recover their functionality. This range of experiences, including the duration and receptiveness to treatment, has encouraged practitioners to categorize mental illnesses into degrees of severity and persistence. 6 BACKGROUND Prevalence and Adequacy of Services Assessing the adequacy of mental health services begins with an understanding of who needs services. Because it is difficult to determine when symptoms constitute an illness or when treatment is advisable, it is difficult to measure precisely the gap between the need for treatment and the availability of treatment. County authorities assert that they serve about half the population needing public mental health care.31 Experts generally agree that one in five persons have a diagnosable mental disorder every given year.32 But not all of those people need treatment. The duration and severity of symptoms vary so much that it is hard to apply treatment standards for every person and every circumstance. Many people never access treatment. Those with a diagnosable mental illness but whose symptoms do not significantly interfere with their daily lives are often referred to as the "walking worried" and generally do not need professional care. Two national studies are widely recognized as providing the most reliable data on the prevalence of mental illness. Those estimates are still regarded as imperfect representations of the need for care and services. 33 They suggest the following rates of mental illness: • Adults. An estimated 22 to 23 percent of the adult population experience a mental illness each year. Under a third of those people, about 9 percent of all adults, have an illness that impairs their ability to function.34 Some 5 percent have a severe illness and 2.6 percent have a severe and persistent illness. About 0.5 percent have an illness that is sufficiently disabling to qualify for disability benefits. 35 .AII Mental Illness oSMIOnly oSPMIOnly 7 LITTLE HOOVER COMMISSION • Children and Adolescents. Children and adults experience mental illnesses differently.36 An estimated 20 percent of children have mental illness with some form of functional impairment. Approximately 5 percent to 9 percent of children ages 9 to 17 have more severe impairments known as "serious emotional disturbances. "37 Having a childhood mental illness does not necessarily mean the disorder will continue into adulthood.38 • Older Adults. Older adults are affected differently than younger adults, and it is not clear why. Cognitive impairments associated with aging may affect the prevalence of mental illness. One study suggests that 19.8 percent of the older adult population has a mental illness in a given year, with almost 4 percent having a severe illness and 1 percent a severe and persistent illness. 39 California provides mental health services to more than 467,000 people.40 The Mental Health Planning Council has estimated the gap between services presently available and the number of clients in need. Estimates refer to adults with serious mental illnesses and children with serious emotional disturbances. Those estimates are presented in the box below. 8 BACKGROUND The Costs of Menta/Illness The costs of mental illness are difficult to quantify - and the sum is much greater than the total expenditures on mental health services alone. The direct costs of mental illness represent what the public and private sectors spend to treat and respond to mental health needs. Indirect costs capture lost value, as when clients or family members take time away from work. A greater challenge is determining the intangible costs - the price that families, neighborhoods and communities pay when someone is ill. Direct Costs. The direct costs of mental illness include funding for services people receive as a result of a mental illness. Public sector funding includes state and county mental health services, as well as spending on correctional, vocational rehabilitation, substance abuse treatment, housing, employment, education and other programs serving clients. The private sector also bears direct costs of mental illness. Private sector health insurance may pay for treatment, residential programs, and assisted living or respite services. Many families without insurance may pay service providers directly through "fee for service" arrangements that must also be included in direct cost estimates. One report estimates that the public and private direct costs of mental health care in California are $9.5 billion annually. This estimate applies a 1996 national estimate of per capita expenditures to the California population. This figure includes the cost of substance abuse treatment services and the $2 billion spent by State and local agencies for community mental health Mental Health and Substance Abuse programs. 41 Treatment Expenditures by Source 1996-97 Indirect Costs. Indirect costs are more difficult to measure. They include lost productivity associated with time away from work, inability to work or premature death. They can also include the cost of lost property value, tax dollars and business profits, higher insurance premiums or other costs associated with a popUlation of mentally ill and often homeless people whose presence reduces the tranquility of a business district or neighborhood. The U.S. Surgeon General references a national study that calculated the indirect Source: SGR Health Alliance. 2000. The State of the costs of mental illness at $79 billion based on State of Behavioral Health in California: Alcohol, Drug, 1990 figures. 42 This amount includes lost and Mental Health Services and Systems. On File. 9 LITTLE HOOVER COMMISSION productivity due to illness, premature death and incarceration only. California's share of those indirect costs, based on the state having 12.5 percent of the U.S. population, is roughly $9.875 billion annually, or $823 million each month.43 Undoubtedly, costs have increased in the last decade. Intangible Costs. More difficult to quantify, yet equally significant are the social, emotional and psychological costs when a family member is homeless, unaccounted for, commits suicide or spends time in the criminal justice system because of an illness. The intangible costs of mental illness are tremendous. Some of these costs - such as criminal justice expenditures - are increased because of inadequate treatment and other services that can limit the severity of an illness and prevent the loss of functionality. California has not: attempted to document the full range of costs associated with mental illness or the savings in corrections or other programs that could be captured if more resources were invested in treatment. Most discussions of the cost of mental illness emphasize public expenditures for mental health care alone, which are outlined later in this background. Related Challenges Two challenges in particular fundamentally shape public perceptions and policy responses to mental health clients: substance use and homelessness. Housing is a common problem for clients unable to work and with limited personal income. Many clients deal with substance abuse problems that are linked to their mental illness. Substance Use. Approximately half of the clients with severe mental illness have a history of drug use.44 And at any given time, about half of all clients receiving treatment are using illicit substances, which is often referred to as "co-occurring disorders" or "dual diagnosis."45 Substance use complicates the ability of mental health professionals to diagnose and treat mental illness because drugs can mask or mimic the symptoms of mental illness. Treatment is complicated when people use illicit drugs that interact with powerful psychotropic medicines prescribed to treat a mental illness. And historically, treatment protocols for substance use and mental illness followed opposing philosophies. Substance abuse treatment emphasized complete avoidance of controlled substances, while mental health care embraces the use of drugs in treatment. 10 BACKGROUND Different stakeholders have differing views about drug use by mental health clients. To some, drug use is illegal activity unassociated with an illness. Others see drug use as a way to self-medicate for psychotic episodes, depression, anxiety or other features of their illness. They suggest that unlike prescribed drugs, street drugs have fewer negative side effects. Others believe drug use may alter a person's chemical balance or change the structure of the brain and result in a mental illness. Some also argue that biological, social or psychological aspects of mental illness may trigger street drug use by mental health clients. Homelessness. An estimated 57 percent of all homeless adults suffer from a mental illness.46 The prevalence of homelessness is associated with economics and the mental illness itself. Limited income provides few housing options. As housing prices increase, more mental health clients become homeless. Many mentally ill individuals have a difficult time conforming to, or understanding rules imposed in shelter programs or by landlords. Others have a history of substance abuse that makes them ineligible for housing support. The homeless mentally ill are generally the most difficult homeless people to work with, often refusing to sleep in public shelters. They are thought to be homeless more frequently and for longer periods than other homeless individuals. Substance abuse and the vagrancy associated with homelessness are viewed as criminal activities, coloring perceptions of mental health clients. Both factors challenge the ability of service providers to offer effective treatment. Substance abuse complicates treatment and reduces the likelihood that clients will follow a treatment regimen. Homelessness compounds the effects of mental illness by limiting the ability of clients to build social support networks or follow a treatment program. Client substance abuse and homelessness are considered consequences of deinstitutionalization and inadequate mental health care. California over years adopted policies that moved people out of mental hospitals where they received comprehensive, integrated services for a range of needs, into community treatment programs that in many cases are limited to therapy and medication. Few community programs could guarantee housing for people leaving state hospitals. Substance abuse services were unavailable or not integrated with mental health care. Those same conditions exist today. As a result, mental health clients enter the criminal justice system - often for drug use or crimes of survival associated with homelessness and poverty. Without comprehensive services and increased funding, providers are forced to ration care and emphasize treatment over prevention. 11 LITTLE HOOVER COMMISSION Prevention, Treatment Effectiveness and Recovery Mental illness confounds common notions of illness, where the progression of a disease can be forecast and treatment prescribed. The difference complicates efforts to develop and fund treatment programs early in the onset of mental illness. Still, providers believe it is important to think about mental illness as any other illness, with opportunities for prevention, intervention and treatment with recovery as the goal. Prevention. Adult mental health shares a three-fold definition of prevention with the public health model. 47 Developing effective prevention programs requires some sense of who is at risk of becoming ill. Researchers have identified two types of risks. Fixed risks, such as gender and family history, cannot be changed. But other risk factors, such as lack of social supports, exposure to trauma and stress, provide opportunities for intervention and prevention.48 Research on twins suggests that even with inheritable mental illnesses, such as schizophrenia, environmental factors may reduce risks associated with genetic factors. 49 Prevention can also emphasize strengthening "protective factors," such as housing and social supports, which can improve a person's response to risk factors. 50 Prevention involves assessing risks and changing those that are amenable to intervention, while increasing protective factors to offset potential risks. Treatment Effectiveness. Treatment involves managing or stabilizing symptoms to support the most fulfilling life possible. Treatment includes medication, counseling, skills training and social and psychological supports to increase functional capacity. Many mental health interventions also address risk factors that influence the severity, persistence and likelihood of recurrence, such as housing, employment, independent living skills, substance abuse treatment and assistance with money management. Recovery. The mental health literature does not view a cure as the goal of treatment. Instead, it promotes recovery. But not all stakeholders agree on what constitutes recovery or the goals of treatment. According to standard treatment terminology, treatment goals include reducing the length of an episode, limiting its severity, halting reoccurrence or lengthening the time between episodes. Some advocates however, are concerned that mental illness is presumed to be a permanent disability that can at best be managed.51 Those advocates support the notion of recovery and have built a social movement within the mental health community to promote their view. 52 There are two dominant perspectives on recovery: rehabilitation and empowerment. 12 BACKGROUND Rehabilitative recovery emphasizes restoring functionality. Taking cues from physical health, rehabilitative recovery emphasizes enabling a person to live with an illness. Treatment offers support, often permanent, to help the person function despite limitations. In contrast, an empowerment recovery asserts that full recovery is possible. Mental illness can be overcome and individuals can regain control of their lives. Rehabilitation and empowerment visions are distinct in their treatment goals. Rehabilitative recovery envisions lifelong dependency as acceptable, such as employment support, subsidized housing and assistance with living skills. Empowerment recovery envisions clients living independent of external supports. Gainful employment is a key goal of empowerment recovery. 53 Although it does not include the notion of a "cure" for mental illness, empowerment recovery emphasizes independence and self-purpose. 54 The Public Mental Health System California's mental health system has evolved over the last four decades. This evolution has changed the role of the State and local governments in providing care. Mental health services have moved from being predominately hospital-based and provided by the State to community based and provided through local governments. More recently, mental health stakeholders recognize that mental health care requires an array of services that have not traditionally been available through a community-based service model. For instance, institutional care provides housing, social activity, transportation assistance, vocational rehabilitation and physical health care. Community mental health programs historically have provided more limited services. Multiple state agencies provide health, mental health and related services. The primary agency for ensuring the provision of mental health services is the Department of Mental Health. It operates state hospitals, oversees county-based mental health services and provides leadership on issues of policy and practice. The Department of Health Services is California's lead agency for Medi-Cal, which funds the treatment of some clients. The Department of Alcohol and Drug Programs, Department of Aging, Department of Rehabilitation and multiple others offer services or coordinate programs available to mental health clients. The primary public providers of mental health services are California's 59 local mental health agencies, the majority run by county governments. 55 13 LITTLE HOOVER COMMISSION Establishing Community Mental Health Services In 1957 California established the Short-Doyle program to encourage counties to develop community mental health services. Originally a voluntary program with no state funding, many counties chose not to participate. To spur counties into building programs, the State offered dollar for dollar match funding. Short-Doyle later became a mandatory program. The State provided 90 percent matching funds for inpatient care and 85 percent for outpatient services. In 1965 the U.S. Medicaid program was created to reimburse states providing medical services to low-income individuals. California responded by establishing the California Medical Assistance Program (Medi-Cal). Under Medi-Cal, the federal government reimburses California 51 cents for each dollar the State spends. Some 5 million Californians participate in Medi-Cal programs.56 Originally, Medi-Cal only covered care in nursing facilities and hospitals and the services of psychiatrists and psychologists and was known as Fee-for-Service Medi-Cal (FFS/MC). In 1971 the Legislature folded the Short-Doyle program into the Medi-Cal program to capture federal matching dollars with the funds already dedicated under Short-Doyle. Short-Doyle Medi··Cal (SD/MC) complimented FFS/MC by paying for services provided through hospitals, therapy provided in outpatient settings, and day treatment programs. The SD/MC program added a Targeted Case Management component in 1989 and the Rehabilitation Option in 1993.57 These two components broadened the range of services and providers covered. Medi-Cal funding now covers case management services for targeted clients and treatment for mental disorders and associated functional limitations that are barriers to living in the community. 58 14 BACKGROUND Program Realignment. The lean budget years of the 1980s prompted California to revamp public mental health services. In 1991, the State and counties negotiated "Program Realignment" (known as "realignment"). Prior to realignment, county programs were funded through the annual budget act. Each county program competed for limited funds, counties could not set priorities and funding was unpredictable. The State operated and financed state hospitals and provided other services. Realignment replaced more than $700 million in annual General Fund allocations with dedicated revenue from sales taxes and vehicle license fees. It also made counties responsible for providing treatment and gave them control over local programs. The legislation did not guarantee that people would have access to mental heath care. While Medi-Cal recipients are entitled to services, realignment specified that the counties must only serve other residents to the extent funding is available. A report by University of California researchers argues that realignment improved efficiency, stabilized expenditures and increased the number of people served. Prior to realignment, the number of people served was declining by about 1.5 percent. The first year after realignment, the number served rebounded by 6.5 percent and increased 1.5 percent in the two subsequent years. Prior to realignment, per person costs were increasing by 5.3 percent each year. With realignment, costs dropped by 3.3 percent in the first three years. Under realignment, counties "buy" state hospital services from the state, an arrangement that encourages counties to develop less-expensive community-based services. 59 Mental Health Managed Care. In 1993 California's Department of Health Services initiated a plan to provide public health services under a system of managed care. The Department of Mental Health followed suit with a "carve out" of mental health dollars, separating mental health and physical health funding. Under mental health managed care, mental health services to Medi-Cal participants are available through a single mental health plan in each county.60 California first implemented managed care with the Short-Doyle Medi-Cal program. Later, the State consolidated funding for Short Doyle Medi-Cal and Fee-for-Service/Medi-Cal. The State's initial managed care plan envisioned funding local mental health plans with a fixed monthly allocation for each Medi-Cal participant regardless of service usage.61 Known as capitation, this element of managed care has not been implemented and is controversial. Among the concerns is that capitation will not provide the counties sufficient resources to provide services that clients are entitled to under federal law. 15 LITTLE HOOVER COMMISSION 16 BACKGROUND 17 LITTLE HOOVER COMMISSION 18 BACKGROUND The Department of Mental Health The organization of the Department of Mental Health reflects the evolution of its responsibilities. The department is charged by law to set overall policy for the delivery of services, oversee local mental health plans, monitor compliance with state and federal laws and administer various state-funded programs. It also runs four state hospitals and a psychiatric facility under contract with the Department of Corrections.62 The 1999-2000 budget allocated $1.6 billion to the department. It is organized into four divisions: Systems of Care, Long-Term Care, Program Compliance, and Administrative Services. 1. Systems of Care The Systems of Care division ensures that people have access to treatment and support services in their communities. The 103 staff in the Systems of Care unit provide technical assistance and facilitation services to local mental health programs, assist counties implementing managed care programs, conduct research, oversee special projects and offer assistance to counties dealing with Medi-Cal.63 The division has 11 programs that are outlined in the table below. The Research and Performance Unit within the Systems of Care division has a significant role. It is developing performance reporting requirements and monitoring procedures. Realignment requires county mental health systems to report their performance to the State. Reporting was mandated to ensure counties did not neglect their mental health system once they were given control over how resources would be spent.64 Outcome reporting was designed to complement the department's program compliance division, which handles audits, licensing, and oversight of mental health Medi-Cal billings. 19 LITTLE HOOVER COMMISSION The department's reporting system will include data on all people who receive mental health services for 60 days or more each year.65 The data are intended to permit the department to assess change in people's lives to determine if services are adequate, appropriate and cost-effective.66 The system has encountered several challenges, some technical, such as coordinating reporting across 59 local agencies, and others based on the difficulty of devising adequate measures of treatment impact. The department is the lead agency developing performance measures. The Legislature authorized the California Mental Health Planning Council to review and approve those measures.67 Local mental health boards and commissions also have the authority to review and comment on local efforts to document performance and collect outcome data.68 Both the council and local boards are intended to be independent mental health oversight entities. The council is housed within the Department of Mental Health and the director of the department appoints its members. The Mental Health Planning Council also intends to issue recommendations for improving the reporting and accountability system through its efforts to develop a mental health master plan for the state. 20 BACKGROUND 2. Long-Term Care Services The Long-Term Care Services Division administers four state hospitals, the Acute Psychiatric Program at the California Medical Facility at Vacaville and the Forensic Conditional Release Program (CONREP). Over 8,241 (96 percent) of the department's 8,547 employees work in the Long-Term Care Services Division.69 People treated in state hospitals fall into two general categories: [J LPS clients. Civilly committed individuals determined to be dangerous to themselves or others, or severely disabled. In 1999 the Department of Mental Health served 929 LPS clients in state hospitals. That figure is expected to drop to 850 for the year 2000. [J Forensic or penal code clients (also referred to as judicially committed). The criminal justice system directs people into state hospitals for a variety of reasons. Some are sent to a hospital for treatment while they serve a criminal sentence. Others have been found not guilty by reason of insanity or incompetent to stand trial. They are hospitalized until they are able to stand trial or until they can be released back into their communities. The total forensic population numbered 3,217 in 1999 and is expected to grow to 3,805 for the year 2001.70 Penal code clients make up a growing percentage of state hospital patients, approximately 82 percent. Just 18 percent of state hospital patients are LPS clients.71 21 LITTLE HOOVER COMMISSION State Hospital Inpatient Population 1990 -2001 4,000 3,000 2,000 1,000 o 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Sourc", Department of Finance. 1993/94 _ 2000101. Last Wednesday of Fiscal Year ~:~~:or's Budget. Sacramento, CA: Departmenl of (Figures for 2000 & 2001 are estimates) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Percentage LPS 0,55 0,54 0.52 0,47 0,41 0.35 0.31 0.27 0,24 0,21 0,19 0,18 Percentage PC 0,45 0,46 0,48 0,53 0,59 0,65 0,69 0.73 0.76 0.79 0,81 0.82 Total 4,530 4,510 4,582 4,013 3,768 3,739 3,940 3,961 3,941 4,095 4,585 4,655 The Department of Mental Health also operates the Forensic Conditional Release program (CONREP). CONREP provides enriched oversight and treatment services to a select group of mentally ill offenders on parole. The department contracts with mental health providers for direct services to people enrolled in CONREP. 3. Program Compliance The program compliance unit handles licensing and certifications, Medi Cal oversight and audits. The unit has 51 staff positions. n 4. Administrative Services The department maintains an administrative unit that supports county financial systems, is a liaison with Medi-Cal staff and administers the financial and personnel needs of the department. The administrative services unit has 134 personnel.73 Community Mental Health Systems For the most part, locally elected county boards of supervisors are responsible for oversight of mental health services. 74 State law requires counties to establish a mental health board or commission to advise the local governing board and oversee mental health policies and programs. 75 Local mental health authorities - mostly counties - are charged with providing or arranging for public mental health care for county residents, including: pre-crisis and crisis services, comprehensive evaluation and assessment, individual service planning, medication management, case management, 24-hour treatment services, rehabilitation and support 22 BACKGROUND services, vocational rehabilitation, residential services, services for homeless persons, group services, and wrap around services.76 Realignment established criteria for providing services. Mental health care would first be made available to people with severe mental illnesses. Specifically, realignment funding gave priority to the following groups: • Seriously emotionally disturbed children and adolescents; • Adults and older adults who have a serious mental disorder; • Adults or older adults who require or are at risk of requiring acute inpatient care, residential treatment, or outpatient crisis services because of psychosis or the likelihood of suicide or violence; and, • Persons needing treatment due to a natural disaster or emergency. 77 The State also established a service delivery philosophy to guide local programs - Systems of Care (SOC). Under SOC, services are client directed, available 24 hours a day, integrated and culturally appropriate. Counties are expected to track performance under Systems of Care. 78 The target population established under realignment limits the diagnoses that are covered under local plans. (Appendix C outlines the specific criteria.) People may be denied services on the following grounds: • The diagnosis does not meet eligibility requirements. • Functional impairment does not meet the thresholds for services. • The condition is unlikely to improve with services. • A physical health care provider can treat needs.79 Some local programs provide services to people who do not qualify under Medi-Cal or realignment. Sacramento County, for instance, serves an expanded population by working with its service providers. In some cases the county covers the additional costs, in others it does not. Once eligibility is established, clients are directed to service providers. Many counties employ community clinics to provide services. Prior to 1993, Medi-Cal reimbursement was generally limited to care directed by a physician and provided in clinics. Since 1993, Medi-Cal has reimbursed providers for services delivered throughout communities. Clients also may receive services based on their needs and ;ligibility for benefits under specialized programs funded through the Veterans Administration, Medicare, pilot programs or special grants. 23 LITTLE HOOVER COMMISSION Mental Health Funding Mental health funding is available from federal, state, local and private sources. Services are funded through reimbursements such as Medi-Cal and Medicare. Some clients receive stipends such as Social Security Insurance/State Supplemental Program payments for living expenses. Additional funding is provided through categorical and discretionary funding. Not all counties participate in all funding programs. The distribution of funding reflects historical policies. Some counties receive significant resources while others receive much less. Historical inequities are exacerbated when well-funded counties capture categorical and grant dollars that are not available to counties lacking matching funds or staff to complete complex applications.8o Although realignment created a stable and growing source of funds for local programs, advocates argue that realignment funding has not kept pace with need, nor has it kept pace with funding for other social services. During the 1980s mental health funding was cut. During the 1990s mental health funding growth lagged behind support for similar programs. Integrated Services to General Fund support for pilot projects serving clients at risk of becoming homeless. Homeless Adults .~rni.~'¥IE:;52?ir "":((!.AQ.$rf_MI&[• •S 6i1ui,j~~fol:oiiflll~,Ulmna,~i'l~~:;;'\¥:~.'; .A~~~t ~?:~~"tilJf_;;:S:",,/g~.if~.~f6~~~f_~i~de~~~fH~~i:h to Caregiver Resource Ctrs. General Fund allocation serving people who are caregivers to brain impaired adults. "':lE:i,;• •• ~.~;·'iJ~ .::;i:ij.Qlllt:f.und.artliii~It.~·.~ijliCli~irl\iln,withAl~l~~\~i!!:! Traumatic Brain In·ur S ecial fund allocation for services to adults with ac uired traumatic brain in·u Includes grants obtained from private and non-profit sources. w': " W%:=BW221~!}~;'4lEt~c~!i~Y~ _f,~rt';~f~{~~~N',~JiSl5!",.:~.~~.~1i~ Patient Insurance Counties bill private insurers for services when clients have coverage. stafl.futBni':i ~1imf9r~;;.::i ··:0~~Jfmr~i~~~tI.'(lI!i;lRflfAi4i.i.aU~nQJ County Overmatch County funds dedicated to mental health programs above the required match. p,Q¥faingseNT@s. ~.l:wS6j1Jf"!!fx, PQij~t~'iff!Bnect~~tiheQiffof A catch-all category that includes miscellaneous sources, including reimbursements Other Revenues from schools or other local agencies, endowments, donations or other sources. 24 BACKGROUND Mental Health and the Criminal Justice System Much of California's mental health policy is driven by concerns for public safety. Despite evidence that people with mental health needs are no more violent or dangerous than others, the public perceives mental illness as linked with violence and criminal activity.81 As stated earlier, the prevalence of homelessness and substance abuse contributes to this perception. Research suggests that 10 to 20 percent of people who enter state and local criminal justice systems are mentally ill or suffer some form of functional impairment. About 15 percent of the prison population requires mental health treatment on any given day.82 The California Department of Corrections (CDC) incarcerates 160,000 inmates. Using a rate of 15 percent, there are 24,000 mentally ill prisoners in California. CDC reports that it serves 18,500 inmates with serious mental illnesses, or approximately 11.4 percent.83 The discrepancy can be attributed to mentally ill inmates who fail to receive care because they have gone unnoticed or actively mask the symptoms of their illness. The Board of Corrections reports that local jails book an average of 96,834 individuals per month, or about 1,162,000 persons annually. Again, based on the 15 percent figure, some 145,251 annual bookings involve mental health clients, many of them repeat offenders. In other words, California's jails and prisons have evolved to become a secondary - and for many individuals an unintended and unnecessary - mental health system. In its review, the Commission looked at efforts to divert non-serious offenders with mental illness out of the criminal justice system, and to help those in jails and prisons transition safely back into their communities. Policy Challenges The large number of clients in jails and prisons and the high costs of incarceration and corrections-based treatment present a number of policy challenges for the State, including: 1. Criminalization of Mental Illness. A significant number of people with mental illness - although no one knows how many - end up in jails and prisons because of inadequate mental health services. Client advocates condemn the "criminalization of mental illness" in which untreated mental illness leads to crimes of survival - trespassing, vagrancy, petty theft - and imprisonment. Correctional officials struggling with overcrowded jails recognize that many mental health clients end up in jail for lack of other community facilities. While 25 LITTLE HOOVER COMMISSION access to community mental health services are limited by eligibility criteria and funding, law enforcement officials cannot tum away clients who violate the law - even if only because they are mentally ill. 2. Difficulty Providing Treatment in Jails and Prisons. Law enforcement officials widely recognize that officers often lack the training and awareness to effectively deal with mental health clients. Paranoid, delusional people often react violently in confrontational settings. The harsh confines of jails and prisons challenge the ability of mental health providers to build therapeutic relationships with clients and improve their functionality and recovery. 3. Costs of Incarceration and Treatment. Providing mental health services in jails and prisons is expensive and difficult. The CDC reports difficulty hiring mental health staff willing to work in prisons. On average the annual cost of incarceration in prison :is $21,243 per inmate.84 Mental health services cost an additional $880 and $9,600 for general outpatient and enhanced outpatient care, respectively.85 In total, CDC spends $400 million annually to incarcerate and treat mentally ill prisoners. 86 Local jails have an easier time recruiting qualified personnel but also face difficulties. Los Angeles County reports spending nearly $5 million on psychotropic medications each year.87 The Pacific Research Institute estimates that state and local agencies spend between $1.2 billion and $1.8 billion annually on law enforcement, court, jail, prison, parole and processing costs associated with serving seriously mentally ill people.88 4. Providing Follow-Up Services. Mental health clients coming out of jail or prison have inadequate access to community mental health services and they often cycle right back into custody. State and community mental health and criminal justice officials do not routinely share information on the people they jointly serve. They do not routinely coordinate care or capture the savings associated with keeping clients from entering or returning to the criminal justice system. California's Responses Select state and local agencies have responded to the high cost and increasing number of mental health clients in the criminal justice system in a variety of ways. Some efforts intend to prevent criminality by improving access to high quality services, or to divert clients into treatment programs. Other efforts emphasize coordination between local and state law enforcement and mental health agencies. 26 BACKGROUND Diversion and Intervention Services. Successful diversion and intervention programs reduce the incidence and length of incarceration or re-incarceration by providing enhanced mental health services. Some counties have adopted formal diversion programs, such as mental health courts. Others employ less formal approaches, such as coordinating services with non-profit organizations such as Volunteers of America (VOA). VOA staff respond to calls from law enforcement, business owners and others and arrange services for mental health clients as an alternative to arrest for activities such as vagrancy, trespassing or public drunkenness.89 California's formal diversion and intervention efforts include the following programs: o Mental Health Courts. Mental health courts provide a single point of contact where a defendant with a qualifying mental illness may receive court-ordered treatment and support services in connection with a diversion from prosecution, a sentencing alternative, or a term of probation. Modeled after drug courts, specialized mental health courts allow the judicial system to better tailor programming and sentencing to the needs of offenders. o Crisis Response Teams. Crisis response teams often pair law enforcement and mental health staff to respond to people in crisis. Traditionally, law enforcement officials who confront a mental health client can transport the individual to a treatment center, release them to a responsible adult such as a spouse or parent, or make an arrest. In contrast, crisis response teams divert clients from costly jailor psychiatric hospitals by providing immediate services to stabilize a situation. The State has funded these and other efforts through the Mentally III Offender Crime Reduction (MIOCR) grants. The Board of Corrections has awarded MIOCR grants to 15 counties to develop diversion and intervention programs. Some counties have used the funding to establish mental health courts or crisis response teams. Others have pursued specialized programs that improve the identification of mentally ill offenders and emphasize reducing re-arrest or time spent in jail. The MIOCR program is discussed in greater detail in Finding 5. The State also has developed and funded the Integrated Services for Homeless Adults program under AB 34 (Steinberg). AB 34 (Chapter 617, Statutes of 1999) provided funding for counties to provide enhanced services to clients who are homeless or likely to be incarcerated. Three counties have received AB 34 funding. Each has developed a distinct approach to reducing incarceration rates, including increased housing support, better coordination between law enforcement and mental health staff and improved outreach to clients who are homeless. 27 LITTLE HOOVER COMMISSION Improving Coordination of Community Reintegration Services. Federal and state laws require jail and prison staff to provide mental health clients with necessary treatment. This treatment is intended to stabilize the person during his or her incarceration. Upon release, many clients encounter difficulty obtaining continuous services as they transition back into their communities. People who were ineligible for county treatment before their incarceration generally remain ineligible. Even when eligibility is established, law enforcement and mental health staff do not routinely share information or coordinate treatment services. The need for improved service coordination is discussed in detail in Finding 6. California has a long way to go to improve its response to mental health clients, particularly those who become involved with the criminal justice system. Ongoing efforts to improve mental health care signal increasing recognition that improving mental health services, particularly early intervention or prevention services, can reduce the costs associated with mental health treatment and incarceration. 28 BUILDING PUBLIC SUPPORT fOR THE MENTAL HEALTH SERVICE SYSTEM Building Public Support for the Mental Health Service System Finding 1: No one who needs care should be denied access to high quality, tailored mental health services. Open access cannot be achieved until the public and policy makers have a shared commitment to care for people with mental illness. For many policy areas, the public obligation is clear. All agree that protecting children from abuse is important and all young people deserve a public education. But communities are less clear about their responsibility for people - who as a result of mental illness - cannot meet their own needs. Importantly, many more people than is commonly realized are affected by mental illness. And public understanding is limited and often inaccurate. Before real improvements can be made in California's mental health system - before the state can even establish a vision and set a course for reform - the public and policy-makers need to clarify public expectations for mental health care. They need to establish the responsibility of communities for providing services. And they must call for public leadership to improve mental health services. Menta/Illness is a Community Issue Mental health services have traditionally been considered a concern of clients, their families and service providers - but not society at large. Despite evidence that mental illness-related costs approach $20 billion a year in California, concern for the effectiveness of mental health care has not captured the attention of main street. 90 One in five Californians experiences some form of mental illness. One in 20 Californians experiences a debilitating disease.91 Every California community, every neighborhood and every family stands to benefit from improved mental health care. Clients, families, employers and taxpayers pay the price of mental illness. Although often unrecognized, the true constituents of mental health reform are neighborhood and community leaders, employers and unions, taxpayer advocates and the general public as well as the people who experience mental illness and their families. The community response to residents with mental health needs vary across the state. California does not have a uniform commitment to providing high quality mental health care. The State has not made it 29 LITTLE HOOVER COMMISSION clear what it hopes to accomplish through mental health policies, who is responsible for ensuring care and what the costs and consequences of inaction may be. As a result, it is hard to build consensus for additional mental health resources or how that money should be invested. Without expectations and a vision to drive mental health agendas, policy makers do not know when the system is broken until a crisis occurs. And they have limited access to meaningful information on how the system should be ftxed or who should ftx it. To create expectations and a vision for mental health policy, the public and policy-makers need to understand the personal and social costs and consequences of mental illness. They need to be aware of opportunities for clients to recover and lead fulftlling, productive lives. And they need to recognize that the consequences of mental illness affect everyone. The public and policy-makers must understand the goals of a successful mental health policy and take responsibility for Policy-makers have made the the challenge. They must understand that mental health is a connection between business issue, a workforce issue and a community and investment in transportation family issue. systems and improved quality of life and productivity for all The Governor's 2000-01 budget pointed out that congestion Californians. They have not on California roadways costs an estimated $7.8 million a day. made a similar connection for The budget included $7.5 billion for transportation projects.92 mental health. Mental illnesses are leading causes of disability and lost productivity. 93 National estimates suggest that mental health and related substance abuse costs an estimated $79 billion each year.94 California's share equals $9.875 billion, or $27 million each day. Public mental health funding in California is about $2.5 billion annually.95 Policy-makers have made the connection between investment in transportation systems and improved quality of life and productivity. They have calculated the costs of inaction and have responded with measured investment. Policy-makers have not made a similar connection for mental health. The costs of inaction are not self-evident. Stigma - Barrier to Improving Mental Health Services Mental health advocates argue that society's reluctance to take responsibility for mental health care is the result of stigma. Recognized as a mark of shame or discredit, stigma is based on limited awareness of mental illness and its origins. The Surgeon General argues that stigma represents one of the greatest challenges to mental health policy:96 30 BUILDING PUBLIC SUPPORT FOR THE MENTAL HEALTH SERVICE SYSTEM Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, Stigma deprives people renting to, or employing people with mental disorders, of their dignity and especially severe disorders such as schizophrenia. It interferes with their full reduces patients' access to resources and opportunities participation in society. (e.g. housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its more overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society. The public's support for mental health programs is shaped by their understanding of mental illness and the effectiveness of treatment. 97 Limited public awareness and concern over the quality of programs restricts support for funding, policy reform and overall attention to the needs of clients and their families.98 Stigma has historically been addressed through education. As public understanding of particular illnesses has improved, inaccurate stereotypes have dissipated and public compassion and support for treatment has improved.99 Yet the public views people with mental illness with fear. A greater percentage of people associated mental illness with violence in the 1990s than did so in the 1950s.100 Despite research showing that mental health clients are responsible for only a small fraction of violence, they are labeled as violence prone and feared.101 One study found that people typified a mentally ill man as "dangerous, dirty, unpredictable and worthless." 102 The more people understand its ongms and symptoms, the One study found that more they equate mental illness with physical illness. people typified a mentally Reframing and improving public understanding of mental ill man as "dangerous, health can increase the public's support for programs and dirty, unpredictable and raise expectations for their effectiveness. 103 worthless." Reframing public understanding is difficult. But it can be done. The public should understand that mental illness does not reflect moral weakness, poor parenting or an inherent inclination for violence. 104 The public needs to understand that mental illness is treatable; people can and do recover, and they contribute to their communities. People who experience mental illness are valued members of California's communities. 31 LITTLE HOOVER COMMISSION Reframing Mental Health Care Reform discussions in the year 2000 parallel conversations from the 1970s. Advocates have made little progress. Steve Fields, executive director of the Progress Foundation, testified that he has discussed the same mental health reforms with legislative leaders in California for four decades. Client advocates and service providers have spent many years seeking stable and adequate funding for mental health services. They have championed increased access to substance abuse treatment, supportive housing, rehabilitative care and employment services. They have had little success. Each decade presents a renewed interest in mental health reform, but little change. The San Diego Union Tribune cited mental health as the "perennial loser" of budget negotiations. lOS Mental health funding has lagged behind support for other public services, including funding for transportation, education and public safety. Tax relief has been given a higher priority than ensuring that mental health programs are effective and make the best use of public resources. These policy areas receive public and political support because they are well understood. The impact of failed policies is calculated and the need for investment and the potential returns are understood. The Senate Select Committee on Developmental Disabilities and Mental Health and the Assembly Select Committee on Mental Health held a joint hearing in February 1999. The Little Hoover Commission held three public hearings on mental health later that year, and the Joint Committee on Mental Health Reform held four more. Client and family 32 BUILDING PUBLIC SUPPORT FOR THE MENTAL HEALTH SERVICE SYSTEM advocates turned out in force. County, service providers and law enforcement representatives testified. Participation by the business and labor community was limited or absent. Yet a single form of mental illness, depression, results in more workplace disability claims than any other ailment. 106 The views of taxpayer advocates also were underrepresented, even though mental health care represents a significant investment of public dollars. Reframing mental health policy requires making it explicit that providing adequate mental health care benefits all members of society. Mental health is a business, labor and taxpayer issue. It is also a policy area affecting clients, family members and service providers. Mental health policy impacts everyone. Promoting Investment in Mental Health Policies While lawmakers can increase expenditures and make incremental changes to specific programs, wholesale change will require the commitment of community leaders. For these improvements to be sustained when the spotlight moves to another crisis, the public commitment to cost-effective and compassionate care must be firmly in place. To build a solid foundation for fundamental reform, four issues need to be addressed: [J Stigma. Improved information on the effectiveness of adequate mental health care and the policy choices available to the state are essential to improving services. California should educate, inform and improve public awareness of the challenges of mental illness and the benefits of mental health treatment. [J Inadequate advocacy. By themselves, mental health advocates have pushed for reform unsuccessfully. New advocates - including business and labor, faith and other community leaders - must join existing stakeholders and define policy goals. Their challenge is to develop a framework for understanding mental health policy that can guide policy decisions. [J Costs are high and diffused. The public and private sectors spend billions of dollars each year to provide mental health care, respond to unaddressed mental illness through the criminal justice system or otherwise cover the direct and indirect costs of mental illness. Policy makers and the public need to understand these costs and the trade off of providing adequate versus inadequate care. [J Science is evolving. Mental health policy is complex. Political decisions require a negotiation of competing interests, often with 33 LITTLE HOOVER COMMISSION contradictory understandings of the science of mental health, the problems to be solved and the solutions available. Policy-makers struggle the most with decisions laced with uncertainty, confusion, complexity and contradictory direction.107 Mental health policy presents these very challenges. Policy-makers draw upon multiple tools when they need to understand complex policy issues. Advisory bodies can provide compelling and reliable information on complex issues, particularly those where scientific understanding is evolving. Congress chartered the National Academy of Sciences specifically to advise the federal government on complex and contentious scientific and technical matters related to public policy.108 Similarly, advisory bodies can be used to build common understanding and agreement among an array of interest groups. A California Mental Health Advocacy Commission could assess and establish expectations for mental health care and outline strategies for realizing those expectations. It could be non-partisan, funded with public and private resources to create broad interest and accountability. Broad-based funding could promote oversight, collaboration across the public and private sectors and interest in the committee's labors. Membership could include traditional mental health advocates, including client, family member and service provider representatives, and non traditional stakeholders representing labor, business and taxpayer organizations. California's foundation community has a role in building public leadership and should be part of this partnership to create a civic agenda for mental health policy. Some of the barriers to reform can be lowered quickly - others will take time. What the State needs is to create a catalyst for change that can guide policy-makers immediately and over the next five years. Recommendation 1: The Governor and the Legislature should ensure that no one who needs care is denied access to high quality, tailored mental health services. The first step is to establish a California Mental Health Advocacy Commission to serve as a catalyst for change, set expectations and establish responsibility for mental health services. Specifically, the Commission should: o Be of limited term and funded from public and private sources. To ensure against unnecessary bureaucracy, the Commission should be of limited term. To improve accountability, it should be jointly funded from public and private sources. And to demonstrate clear expectations for outcomes, the Commission should issue periodic 34 BUILDING PUBLIC SUPPORT FOR THE MENTAL HEALTH SERVICE SYSTEM reports and a final summary of its activities and accomplishments. o Develop strategies to overcome stigma. The public and policy-makers need an improved understanding of mental health, mental illness and the role of public policy in providing quality mental health care. D Detail need. The public and policy-makers need to understand how Californians are affected by mental health policies, the adequacy of existing programs and the magnitude of additional need. D Assess costs of failure. The public and policy-makers need to understand the trade-off between investing in adequate mental health services and failing to provide appropriate care. D Provide for ongoing policy advice. The commission should propose strategies for providing the Legislature and Governor ongoing direction and advice on mental health policy, and in particular, strategies for understanding the complex and evolving science of mental health and mental illness. 35 LITTLE HOOVER COMMISSION 36 STRENGTHENING STATEWIDE LEADERSHIP Strengthening Statewide Leadership Finding 2: The state Department of Mental Health is not organized or funded to ensure that all Californians have access to mental health services when they need care. The Department of Mental Health (DMH) is entrusted with leadership of California's mental health system. It is charged with ensuring the availability of effective, efficient, culturally competent, community-based mental health services. Yet the department is not organized or funded to lead a statewide system of community-based care. It needs new direction from California's policy-makers to focus its staff, resources and efforts on returning California's mental health system to a national model. California's mental health system faces many tough issues that require focused leadership, consistent attention and aggressive effort. The Department of Mental Health has demonstrated those capacities. Yet the State faces many more hurdles than the department can manage given its present organization: oversight of Medi-Cal mental health managed care, identifying an expanded funding base, negotiating calls to reform California's involuntary commitment laws, solving human resource crises and implementing a statewide performance reporting system. The department's resources and its mission are divided between providing direct services through the State's hospital system and providing leadership for California's community mental health programs. Its role as a direct service provider threatens to overwhelm its ability to inspire and guide community-based programs. Over 95 percent of DMH staff provide direct services to people in the state hospital system, a popUlation that includes a growing percentage of penal code clients. Less than 2 percent of the department's staff is available for leadership activities. The challenge for the Department of Mental Health is to implement a vision for community mental health care.109 Its leadership function should not be compromised by the need to provide direct services to a growing and politically sensitive penal code population. The department should be reorganized to reinforce its efforts on setting standards for services, improving the cost-effectiveness of local mental health programs and driving the debate on how to build a continuously improving mental health service system. 37 LITTLE HOOVER COMMISSION Department of Mental Health Resources While dozens of State entities serve mental health clients in some way, the Department of Mental Health is the only state entity charged with leading California's community-based mental health system. The department is expected to ensure that county programs are effective, efficient and take advantage of every opportunity to improve services. Yet the department's personnel are overwhelmingly dedicated to serving the growing number of penal code clients in state institutions. The department has 8,547 staff positions: 8,241 (96.4 percent) provide long-term care in institutions; 51 (0.6 percent) ensure compliance with state and federal statutes, 103 (1.2 percent) assist counties with mental health services; and, 152 (1.8 percent) administer the department. The department has almost an equal number of staff available to monitor and assist California's community mental health programs as are available to administer department offices in Sacramento.110 Distribution of DMH Personnel The 103 personnel available to 2000-01 assist local mental health agencies divide their time between 11 Departmental separate community service Administration programs. Just 10 positions are dedicated full-time to providing technical assistance and training ~ for community programs.lll Few Community resources are available to Services Long Term 2% Care Services document best practices, identify 96% barriers to improved services and support county programs. Between 1991-92 and 2000-01, the number of Historical Distribution of DMH Personnel department personnel has 9000 -----------------------_.- increased by 23 percent - 8000 +----~-------- 1,591 new positions. 7000 Nearly all (1,586, 99.7 6000 t===Jb_. ....~ --- percent) have been 5000 +----~--------- dedicated to long-term 4000 +------------ care operations. The size 3000 +----------------- of the Community 2000 +-------------- Services program, which 1000 +------------- includes both Systems of O~~~~===+====~~·~=~=-~~~~~====*===~ Care and Program 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999- 2000-01 Compliance divisions has 2000 actually been reduced.lI2 38 STRENGTHENING STATEWIDE LEADERSHIP California Faces Numerous Leadership Challenges In addition to supporting local programs, the department's leadership role requires it to address statewide issues affecting the availability and quality of mental health services. The challenges are numerous and significant: 1. Providing Adequate Funding and Promoting Efficient Spending. Mental health services in California are believed to be seriously underfunded. The California Association of Mental Health Directors asserts that mental health funding provides sufficient resources to meet approximately half of all mental health needs. Services are rationed as a result. No one is sure how many people access mental health services through private insurance plans or how that number may expand under newly enacted state and federal insurance parity laws. Mental health funding is detailed in Finding 4. 2. Addressing Human Resource Needs. According to the California Mental Health Planning Council, the vacancy rates for mental health professional positions exceeds 30 percent. Los Angeles County has a 30 percent vacancy rate for psychiatrists. The Bay Area has a 30 percent vacancy rate for licensed clinical social workers and spends 4 months filling each position. In the Central Valley, it can take 10 months to fill similar positions. In the northern region, it can take almost a year and a half to fill vacancies for psychiatrists and psychologists. 113 It is even more difficult to find multilingual, multi-cultural mental health professionals. Providing culturally competent care in the primary languages of clients is a significant challenge. Local agencies cannot resolve this problem individually. A statewide response involving California's higher education and workforce development agencies will be required. 3. Focusing on Prevention and Reducing Stigma. Stigma is a leading barrier to improved use of mental health programs and public support for 39 LITTLE HOOVER COMMISSION mental health services. Public education can improve the public's awareness of unmet needs and reduce the effects of stigma. But a successful campaign will require enormous collaboration with nonprofit organizations, community leaders and the media and entertainment industries. 4. Developing, Documenting and Disseminating Best Practices. Local mental health programs face an array of competing priorities. They have few resources that allow them to explore practices elsewhere. Yet the lessons learned in one part of the state can inform the work of others. The Department of Mental Health has a statewide vantage point. Its responsibilities include developing, documenting and disseminating best practices in the provision of mental health services. The department recognizes this responsibility and is building partnerships with local and national leaders. But the staff and resources dedicated to this effort are limited. 5. Meeting the Need for Comprehensive Community Services. Mental health clients have a variety of daily living challenges. Providing mental health care requires attention to housing, counseling, substance abuse treatment, vocational rehabilitation and independent living needs. Too often local mental health agencies cannot muster the resources or the political capital to integrate services provided by multiple state and local agencies. The department must assist agencies in this effort. It must ensure that local mental health agencies receive the support and services they require from State agencies and it must promote the capacity of local agencies to integrate and coordinate their services. 6. Growing Penal Code Client Population. California has a growing population of penal code clients in the state hospital system. The demands of this population often differ from those of civilly committed people with no history of crime. State and local agencies have developed multiple approaches to preserving public safety while providing appropriate mental health care. The Department of Mental Health has a leadership obligation to ensure the coordination and integration of state and local efforts to preserve public safety and address the mental health needs of penal code clients reintegrating into their communities. Mental health and the criminal justice system are discussed in detail in Findings 5 and 6. 7. Addressing Demands for LPS Reform. Assemblymember Helen Thomson has made a forceful and passionate plea to improve the ability of seriously mentally ill individuals to receive mental health services. Her efforts unearthed a long-standing concern over the need to reform California's involuntary commitment laws and expand opportunities for 40 STRENGTHENING STATEWIDE LEADERSHIP outpatient involuntary treatment. The Department of Mental Health, along with other mental health stakeholders, convened a series of community dialogues to explore the need for mental health reform. The Legislature established the Joint Committee on Mental Health reform and included the charge of investigating the need to reform LPS. But the committee was unable to reach consensus on how to approach this issue. Policy-makers can benefit from a clear and detailed assessment of the need to reform the LPS Act. 8. Implementing Managed Care. The State's federal waiver of Medicaid requirements allows it to pursue innovative ways to reduce costs, increase access and improve services. Recent analyses disagree on the value mental health managed care has brought to the State. An independent evaluation commissioned by the department lauded the State's efforts. 114 In contrast, an independent review commissioned by a client advocacy organization, Protection and Advocacy Inc., raised many concerns. It argues that under managed care people have been denied access to a full range of mental health services and they have not been adequately informed of their treatment options. The report found that California's oversight system lacks enforceable standards, meaningful reporting, the means to ensure compliance and equitable funding. lIS 9. Supporting Mental Health Parity. AB 88 (Thomson) established mental health insurance parity under California law. The 1999 law requires health insurers to cover nine severe mental illnesses, and pay for services for seriously emotionally disturbed children. It is unclear how many people will receive mental health services through private insurance programs. Increased coverage could impact the already severe human resource shortage in the mental health field. Private insurance companies may provide mental health coverage through carve outs that some contend do not create parity. 116 While the newly formed Department of Managed Care will enforce mental health coverage, the Department of Mental Health could help the new department understand how parity will affect access and quality of care. 10. Improving Oversight and Accountability Mechanisms. Realignment mandated the development of a performance outcome monitoring system. Since 1994 the department has been implementing a statewide information system that can monitor access and participation across all local mental health systems.!l7 The department reports less than 10 counties are linked to the system. Its leadership responsibility requires the department to complete the work. Accountability and monitoring are discussed in greater detail in Finding 7. 41 LITTLE HOOVER COMMISSION Refocusing the DMH on Statewide Leadership Each of the leadership challenges mentioned above requires focused attention, long-term planning and aggressive action for breakthrough change to occur. The department can realize solutions to each of these challenges given adequate support, resources and direction from the Legislature and the Governor. Historically the department was California's primary provider of institutional care. Under realignment California made the decision to shift the attention of the department away from providing institutional services and to lead a community based service system. Through various policy decisions, the role of the department has evolved back into providing institutional care, primarily for penal code clients. Responsibility for nearly 3,800 penal clients should not detract from the department's responsibility for the nearly 500,000 people in the community based system - and the nearly equal number of Californians who need help from the public system, but are not receiving it. lIB The department's leadership role includes providing policy direction to the Legislature and Governor, directing data gathering and research, and advocating on behalf of clients and local mental health systems. It includes identifying barriers to success and strategies for overcoming them. Recommendation 2: The Department of Mental Health needs to become the State's mental health champion. The department needs the resources and the political support to ensure that California's mental health system continuously improves. Specifically, the department should: Q Advocate and provide policy guidance. The .................................... _..... ... .......................... _...... ........... .. !.'!!.~~!!l~!f!_~!~~_ department should be an advocate for mental • The Governor should reassign 10 staff health clients. It should provide direction and persons from other departments to the advice to the Legislature and Governor on a policy Department of Mental Health to framework that results in continuous improvement immediately provide additional support in the availability and quality of mental health for community mental health programs. care. • The Department of Finance and the Legislative Analyst's Office should begin Q Advocate for local mental health programs. The the detailed analyses necessary to department must ensure that local providers have redesign the Department of Mental the support they need from local, state and federal Health. agencies to provide needed care. The department should pay particular attention to the need for housing, employment and substance abuse treatment. 42 STRENGTHENING STATEWIDE LEADERSHIP o Identify barriers and promote change. The department should identify statewide and local barriers to im proved care and . Tnedepaftment should cOl1vene atask' recommend state and local strategies to force ·o(county mental·h~alth· ~ffici~.l~,. overcome those barriers. The department .a nd national mental health e~perts to should explore strategies to motivate .'.,iidentify b9rriersto improvement and improvement through funding, promote best strategies to' promotecnange. .. . practices and improve state and local The .qepartmentshou.ld'~ol1.Yenea. in,,· accountability. .,summit of public. and private experts HuJijan resources 8m:iyvornrprce. ... .. o Develop mental health workforce. The >geveloptnentto begin assessing human department must ensure that California has .. resource needsandcr:aftingsnort.term an adequate workforce capable of providing and long-term ptansto addressthe culturally competent, professional mental 'sf)prtage of qHalified mental health professionals. . health services throughout the state. The department should partner with state and federal agencies involved in education and workforce development to meet this need. o Assess options for managing state hospital system. The department should determine whether providing long-term care services detracts from its leadership responsibilities. It should assess alternatives for the long-term operation and management of state hospitals. 43 LITTLE HOOVER COMMISSION 44 DEVELOPING COMPREHENSIVE SERVICES Developing Comprehensive Services Finding 3: Ensuring access to high quality mental health care means that each community must provide a comprehensive array of mental health and support services. Yet the rule bound mental health system offers fragmented and poorly coordinated care. Many mental health clients face daunting challenges that prevent their successful recovery. Homelessness, unemployment, substance abuse, and debilitating physical and mental illnesses can thwart the recovery of even tenacious individuals. In contrast, many others face a serious mental illness, but have a home, a job, supportive family members and good physical health. They require much less intervention to stabilize their illness or promote recovery. The public mental health system must respond equally well to everyone in need. Ideally, a spectrum of services would be available - just as the physical system provides residential care to Alzheimer's patients and rehabilitative services to accident victims. Mental health care means more than medication and emergency services. Adequate care may require housing, counseling, substance abuse treatment, vocational rehabilitation and independent living skills training. Every client does not need each of these services, but every client does need tailored services that will provide her or him with the stability necessary to promote recovery. Homelessness and substance abuse can undermine treatment and recovery efforts. Yet we ration care and often leave it to the people who are struggling the most to piece together these ingredients of their recovery. In contrast, "tailored" services provide what is needed, when it is needed, in ways that respect culture, language and other individual attributes. In most instances, doctors, counselors and social workers know what it takes to enable people to manage their illnesses and lead productive lives. Yet policies and programs are not structured to provide the necessary supports and services. Model programs around the country demonstrate that best practices can cost-effectively enable people with mental illness to lead productive lives. And many people successfully transition from a life of despair and homelessness to hope and stability. 45 LITTLE HOOVER COMMISSION The Best Form of Therapy is ... Dr. Mark Ragins, director of medical services for the Village Integrated Service Agency in Los Angeles, has stated that the best form of therapy is a job. Steve Fields, director of the Progress Foundation in San Francisco" has stated that the best form of therapy is adequate housing. Both testified that providing employment and housing are key elements of comprehensive services for many clients. In other words, the best form of care is to assemble the supports and services each person needs .. For some, treatment will involve medication alone. These individuals will meet their other needs through other means. Others have needs either related to their illness or the product of their disability that they cannot living with Menta/Illness I want to echo the importance of having a compassionate and humanistic-oriented community~ based mental health support system. I am from Massachusetts originally. I lost my sight as the result of a suicide attempt when I was 16 years old. I ended up in a locked psychiatric hospital for roughly two months, and I got to know firsthand the terror and the feeling of powerlessness and helplessness of being thrown into a mental health system that treats people as a diagnosis and not asa human being. After I was released from the hospital, I was forced to seek treatment from psychiatrists who were trained in the old school way of thinking. It was just very degrading and humiliating. When I came to California roughly 17 or 18 years ago, I refused to have anything to do with the mental health system. I continued to suffer from extreme depression, suicidal thinking. I was a -I had a very difficult time continuing with my life. However, at some point, I ended up trying to seek treatment again after some encouragement from people who had had some positive experiences with the mental health system here. I began to receive treatment for my depression, began to receive medication, and received counseling services. I graduated from California State University, Sacramento with a bachelor's degree in political science. After that I attended the McGeorge School of law and graduated with my juris doctorate degree in 1996 and was admitted to practice law in December of 1996. I continue to receive psychiatric services. I continue to take the medication that helps me to stay emotionally out of the active depression. Had I not done that - had I let the fear of being locked up for speaking truthfully about how I really felt, I never would have received the treatment. I would have probably ended up killing myself or I may have ended up just staying in the house, not having the courage to go out and do anything. I would not be a productive member of society. So I think it is very important to have the rehabilitation services that were talked about so much today. '" - John, formerly homeless Thursday, January 27, 2000 Testimony before the Little Hoover Commission 46 DEVELOPING COMPREHENSIVE SERVICES meet on their own. For them, stability and recovery may depend on publicly provided housing, psychosocial therapy, day treatment services, physical health care, money management, employment and transportation assistance, crisis support and self-help services. As with physical health care, mental health care can require more than medication. Dr. Ragins asserted that when California scaled back state hospitals and moved mental health clients into community programs, the State failed to provide the range of services that were provided in hospitals. Hospital care included then - as it does now - housing, physical health care, social interaction and employment services. In contrast, too often community care is equated with medication and counseling. He called for a new approach to providing community care: There needs to be a widespread understanding of, and commitment to, the creation of a community integration system to replace the present one. The present system is about as good as an institutional/ medical model can be. If we want substantial improvement we have to replace our system. 119 Pr(Jvirlirig Compr:eh~nS!fe $er'rices"Reqgir~~ Cultl.lraIIY'Competent{;4fre, " ." , j As California~spqpufatfon ha~ g~ow~jn si~e af,ld dj"ersitv, them~l1t~rheafth system has strain'ffij ·t~ke~pup with the. need. for care ... ,C::~lt~raland 1~l1gu~g~ to barri~rs me,ntal he~ilth car~arepar~icularly Significant;; TneU.s;Offlce of Civil Ri~htsis investigatingdalrns aga.inst Fresno County,th~t,Spa!1ish-sl?eaking peopl¢ do not h~\fe,access to servic~s b~causethe county do~snoterrfpl()yadeq",ate Spanish:speaking staff. Anincreasej/'l ~~e population oftaotian,tjOl0l'1gancf Cam a b s o cj.i an residents in thetount)/"pfesents si ll1 i! t a o r. <;onc~rns~, T~~barriefs'tp cCire are simple and"as intr!'lctaple,ashot f)eirig aBle comm unicate>beca~se 110; coui'ttystaffwho speak these langw\ge,s are availab~e when.a crisis occurs. , ba;~~ers !o u~te tn; LosAngel~s CUltural'dlfferences alsoprese,n;; adeq 'care;" County Departme[lt 9f Mental HE!alth~er\fes people from hundr~~$ gicultul'at groups, many withdist.inct communication styles/attjtud~s towardmentaJ UJness"' andmental heaJtM:are. The c()l,mtI~s have difffculWfindingstaffwitli theT language and ()ther. skill s to o~er cu IturaUycorQpetent cqre;;,Ihe cJ!(I1ensjonot~ is challenge expands as counties move to offer crisis . ices throughhutrarge cOl'l1monities,such as LosAngel~s, and make jf a lab'le onaernand 24bours a, .. day/every qaY7,' ...... j .. '. Building succ~ssf~rmental h~alth programs requi;es·'t~ar;;'e~taf l1ealth/, authoritiestooffer serVices in ways th~t respect and reflect the l!'ll)g~,~gesand coltural,identities of.each cliEmt··· .... .. .. . .'. . '. 47 LITTLE HOOVER COMMISSION The mental health field is embracing programs that offer a continuum of community care to promote stability and reduce hospitalization, symptom severity and relapse. Continuum models, such as the Integrated Service Agency, offer a single point of responsibility for a range of treatment and services. Among those services: 1. Housing. Stable housing improves mental health outcomes by reducing stress, decreasing victimization and allowing people to participate in other treatment opportunities, including employment. Housing is often the linchpin of mental health services. Yet many of California's communities struggle to provide adequate, affordable housing. In Sacramento County, for instance, outpatient mental health services are organized into four residential zones. Clients are directed to service providers based on where they live. Those who are homeless receive services through a separate agency that specializes in working with homeless clients, but offers a more limited array of services. Homeless clients face long waiting lists for public housing programs. One Sacramento County facility has a list of Living in Board and Care Homes 600 waiting for one of 65 spaces. 120 less than 5 percent of Sacramento County's mental Nationally, an estimated 57 percent of health client population lives in board and care people who are homeless experience facilities, but the quality of board and care life mental illness. 121 The California dominates the attention of client advocates. The Statewide Supportive Housing Initiative Commission toured a variety of board and care facilities to understand how B&Cs operate. The Act reports that 75,000 mental health Commission asked to see the best and brightest as clients are homeless in California. 122 well as the most challenging facilities for advocates and licensing staff. Client housing needs range from The Commission visited wonderful facilities in which independent housing to assisted-living clients had private rooms in cheery residences. The facilities. At one end of the spectrum are homes paralleled high quality assisted living facilities. low-cost apartments and homes and The Commission also visited large, dreary Victorian unsupervised room and board homes where clients slept two and three to a room. arrangements. In a room and board Bare and worn wood floors, scuffed hole-pocked home, people rent beds from homeowners walls and worn out furniture filled common areas. and receive meals. They often share the Residents congregated around the hazy television or room with others. in front of the house, smoking around coffee can ashtrays. Board and care homes also rent beds to The "challenging" board and care homes met minimum licensing standards. But few people would individuals. But they are licensed by the choose to live there. Minimum standards do not State because operators provide mean desirable conditions. It is hard to imagine how assistance with money management, sharing a room with one or two other people while medications support and other services. spending each day with little or no constructive The federal Social Security program activities can contribute to successful recovery. augments Social Security Insurance 48 DEVELOPING COMPREHENSIVE SERVICES payments to clients living in board and care facilities to cover the cost of additional services. Under licensing rules, board and care operators typically receive full social security payments to cover the cost of the board and care, less a monthly allowance of about $40 that is given to the client for personal expenses. At the other end of the spectrum is supportive housing. This model offers long-term housing with support services, uPply';&fapp;~p~!j~e .housing isa including physical and mental health leading ,ar~ .. clienfrecovery,::)"et finding .. afforg~blehousrng jsa:perenniali,$~ue. TM'supplyof care, substance abuse treatment, family low-cost housing.-particur~dy boarc;Jandcare'"i,' support, counseling, employment h()llles, roomal'ldboard hofues,supP(}u1ve and';";"'" assistance and other programs. . itional housing ~is dri ....~ ~·~y a complex amly6f ;' m~r~et, regulatory;'finandal~:O~:other forces. . Supportive housing helps clients T~;da;~~h()Ysing chaflenges,comm~ri'iti~~need to establish themselves in communities understandwhere.mentalhealth Clients a.reli .... ing,Jne and decreases demands on high cost appropriatenessoftheir hOusing arningements and,·. . emergency and acute care services.123 ~tr9tegies for improving acce~s to high quality Supportive housing is particularly .hql,lsing. . .... important for people with substance abuse problems who are poorly served "Th~S~te, county authorities and mental health /advocates'lneach comm4p.ity should consider the by less structured housing options. 124 following steps to analyze and improve dOCUIl}~!ltf the qualify,9ffli~nt housing, Few communities have an adequate supply of low cost independent and 1. Create an inventory. County mental health staff supported housing. Limited public should understand the housingQ~ions availaBle' funding and acceptance for large to mental health clients'in their'~qrnxnunities. facilities restrict opportunities to expand standarJ!~ assessqu~ii~i~;The '2: Develop .. and housing options. Meanwhile, licensing . "";;immediat~ and long;;term succ~ss of iocalimentaJ .. authorities are concerned that rigorous ;';"Heafthprograms wilkrequire county autb~~jtj~~to'.;: enforcement of regulatory and oversight have'rel,J~lil~informati()n on thEfgy,dlty and,·• .. ".. x .. "·",'·'··'·_ requirements will drive providers out of appropr'iatelless of die~t.housing~'; . . the licensed housing market into the 3. Build strategies to influen<:e the unregulated room and board business. Local authoritiesn~edto call u As a result, regulators told the federal autnoritiesto assistthern by..... sing Commission they strive to maintain '. fiscaf,. reg(j latory and other poH~!.~s that reStrict the , adequate standards while ensuring that slJpplyofhigh quality;·affordabl~housingfor;;'''''6';'' clients. . .. . ... homes do not close, which often pits them against client advocates who believe the quality of board and care homes is declining. The best client housing is often provided by community and non-profit organizations that have worked to patch together funding, build relationships with neighbors, and pressure regulators to adjust rules so that they can provide high-quality housing that meets the needs of individuals. 49 LITTLE HOOVER COMMISSION Community Organizations: Building Housing Solutions Two innovative community organizations display the potential for providing quality living situations: Pine Tree Gardens (PTG), Yolo County A non-profit, long4erm residence for mentally disabled adults, PTG provides housing, social and daily Hving skills and supported employment for 13 residents in a quiet residential neighborhood. PTG has been successful using a social rehabilitation approach and works closely with area neighbors, businesses and community organizations. Placer County NAMI Housing Program local National Alliance for the Mentally III (NAMI) members have leased residential housing under service agreements with Placer County Mental Health. County employees provide mental health and supportive services, while NAMI coordinates and organizes rent, food and insurance payments. The housing program is self-supporting, using client SSI/SSP reimbursements. NAMI charges clients less than board and care homes. 2. Vocational Rehabilitation. After years of neglect vocational rehabilitation is being recognized as an important part of mental health treatment. The Americans With Disabilities Act provides federal protection from discriminatory practices to workers with mental disabilities. And the Social Security Administration has revised policies to permit recipients of Supplemental Security Income to work part time without incurring financial penalties. Defining Emp/oyment These policies, in part, recognize that holding a job can improve a person's recovery. In addition to providing income, Supported employment: Offers ongoing, flexible employment allows clients to build relationships within their assistance to enable clients to communities. Vocational rehabilitation leads to supported join the workforce. employment and even competitive employment that is free of subsidies. Both forms of employment are thought to be Competitive employment: better at helping clients maintain long-term employment Unsubsidized, unassisted than sheltered or segregated job programs. employment. 125 Sheltered/Segregated Despite evidence that vocational rehabilitation and employment: Provides employment can improve treatment outcomes, clients do not structured, isolated routinely receive vocational services. Unemployment 126 employment opportunities. among persons with schizophrenia is estimated to be 75 to 80 percent, yet only 10 percent are permanently or totally disabled. 127 CalWORKs funding is available to reduce employment barriers for qualified clients, but differing service philosophies and competing priorities limit the number of people who benefit. 3. Substance Abuse Treatment. Approximately half of the population with severe mental illnesses also have substance use disorders. At any given time, about half of all people receiving mental health treatment are 50 DEVELOPING COMPREHENSIVE SERVICES using illicit substances.128 Some argue that substance use reflects attempts to self-medicate. Illegal drugs are thought to have fewer negative side effects while calming anxieties, masking the "voices" that indicate psychotic episodes, or otherwise helping clients to cope. While the actual reasons for high rates of co-occurring mental illness and substance use are unclear, others suggest that biological, psychological or social aspects of their illness trigger street drug use. 129 Still others see no connection and view substance abuse as illegal activity unassociated with an illness. Regardless of the relationship to mental illness, substance-using clients need treatment that is coordinated with their physical and mental health care and which compliments their living and employment arrangements. For instance, research suggests that outpatient substance abuse treatment may not be effective for homeless mentally ill clients because they lack a stable living situation that is important to recovery efforts.13o 4. Physical Health Care. Many clients suffer co-occurring physical and mental illnesses, one often masking signs of the other. It is estimated that between 24 percent and 60 percent of clients have related physical and mental health needs with about half receiving treatment for acute physical disorders. 131 HIV among the mentally ill is of particular concern. Identifying physical health needs in mental health clients is key to building successful treatment plans. Physical disease can cause mental illness and can worsen symptoms or promote the progression and severity of a mental illness. Many clients may be unable to recognize that they are experiencing a physical disease because of their mental illness and therefore do not seek treatment. 132 5. Independent Living Skills. Many mental health clients do not grow up with the luxury of learning to live independently over the course of many years, with a supportive family and the transition years of college and young adulthood. Young adults may be forced to transition out of foster care, group homes or other facilities, which they depended on during their youth, into independent living situations. Older adults may also face changes in their living situations through the loss of a spouse, guardian or other caretaker. Research demonstrates that mental health clients who receive focused assistance learning the skills necessary to live in communities have a higher success rate for independent living than others who do not receive that training.133 Teaching the skills of independent living includes all the training an individual needs to function in a way that does not endanger their safety and facilitates their day-to-day activities, including: using and balancing a checkbook, cooking, cleaning, navigating pu blic 51 LITTLE HOOVER COMMISSION transportation systems, shopping, applying for employment, working responsibly, using mail and banking systems, etc. 6. Other Services. Each client will present a range of needs that may require providers to offer additional services, such as money management, transportation and assistance with medical needs. Promoting recovery entails providing an individualized package of services necessary for recovery to be successful. Integrating Mental Health Services Service integration refers to bringing together services and funding from multiple sources. It provides a single point of entry and improves the coordination and continuity of care. Proponents of serv:lce integration argue that it results in more cost-effective treatment by reducing duplication and allowing organizations to focus on what they do best. But there is conflicting evidence about how or whether integrated services improve outcomes for clients. Two studies have failed to show convincingly that service integration actually results in cost savings. Although access and service coordination improved with integration, outcomes did not necessarily improve and costs did not necessarily decrease. Some suggest that integration has not been adequately explored, particularly in California. 134 Dr. Ragins with the Village Integrated Services Agency testified that institutional care not only provided comprehensive, but integrated Integrating Services The Village ISA, Long Beach, California The Village Integrated Services Agency is a comprehensive program for 276 people with serious mental illnesses. Its mission is to "empower adults with psychiatric disabilities to live, learn, socialize and work in the community." The Village integrates services and support, opportunity and encouragement. The Village's service philosophy centers on strengthening the abilities of members while lessening their disabilities. Services are based on needs, not the limitations of a service system. Services are tailored to address each client's distinct employment, housing, psychiatric, health, recreation and financial choices. Village staff are "coaches," they stand supportively with members who make decisions and take responsibility for moving into their own apartments, starting new jobs or returning to school. At the Village, services are built around a team concept. Staff teams are made up of a psychiatrist, social worker, psychiatric nurse and three psychosocial staff who can tap the expertise of specialists in employment, recreation, money management and substance abuse services. Employment is a cornerstone of the Village. All members are encouraged to work and are supported on the job by Village staff. The Village helps members create opportunities for competitive jobs in the community as well as offering paid job experience at Village-run businesses. 52 DEVELOPING COMPREHENSIVE SERVICES services. When institutional care was replaced with community-based care, integration was left behind. Clients in need of services outside the mental health system, such as substance abuse or housing, are referred to separate providers. Comprehensive and integrated institutional care was replaced with limited, competing and often uncoordinated care. Research on clients with mental health and substance abuse needs argues that integrated treatment produces better outcomes than coordinated but separate mental health and substance abuse treatment. Traditional substance abuse treatment that is not integrated with mental health care is ineffective.135 Similarly, supported employment that is integrated with mental health treatment is more effective than non integrated services.136 Integration is also important for mental and physical health care. Screening, treatment and support services can be combined to ensure effectiveness and reduce complications, such as those associated with taking multiple prescription medicines. 137 Barriers to Integrated, Comprehensive Services Integrated and comprehensive services allow clients to succeed in employment, reduce reliance on expensive hospital care, and improve participation in treatment.138 Yet integrating services is complicated by differing philosophical approaches of key service providers, limited cross training, poor communication and coordination, and political barriers between agencies that historically competed for funding.139 These challenges undermine efforts to provide the best treatment practices.140 But barriers can be overcome. Administrators of comprehensive, integrated services argue that successful programs require tremendous commitment to identify and lower legal and political hurdles. Unfortunately California offers no incentives and no rewards for those who take on this challenge. State and local regulatory and oversight mechanisms can actually discourage providers from integrating services. Two Bay Area providers explained their difficulty in obtaining licenses to operate integrated residential programs. In the first instance, no single licensing category covers substance abuse and mental health programs. In the second instance, licensing categories did not allow for programs serving parents and their young children. Baker Places in San Francisco provides integrated substance abuse and mental health services through a residential treatment program. It offers services to clients who are coming out of the hospital or jail and require ongoing treatment. 53 LITTLE HOOVER COMMISSION Jonathan Vernick, the director of Baker Places, explains: 141 The mental health system unintentionally contrives against seroice integration. I tried to shop around for a license that would allow the organization to provide mental health and substance abuse treatment services under one roof There is no license that will allow me to offer both seroices in a single residential seroice program. Seroices may be available in a hospital setting. But where do clients go when they leave the hospital? They have to go into two very different systems of care for their mental health needs and their substance abuse needs. They would benefit much more from an i.ntegrated program. Instead Baker Places has dual programs with separate mental health and substance abuse funding. Each source of funding has its own reporting requirements and limitations. Steve Fields, the executive director of the Progress Foundation, expressed similar frustrations. The Ashbury House is a licensed, 24-hour adult community care facility. Some of the clients are single parents with custody of young children. But when Ashbury House was established, the State did not have a category for supported residential programs where parents and children can llive together. 142 For five years I looked for funding that would support a comprehensive seroice model. I needed a funding stream that was able to break down the traditional categorical barriers to providing a comprehensive response to client needs. The federal government came out with McKinney funding that was so general - it covered seroices to homeless mentally ill adults - that it could work. They said I could use the funds to pay for program staff Once I got federal money, it was much easier to talk with state licensing authorities. But without federal funding no one would listen to my idea of providing comprehensive seroices through a 24-hour residential model. At the time, community care licensing categories dl'd not address the notion of housing children with their parents. The regional coordinator from the Department of Social Seroices and I sat down and figured out how we could make this program work without triggering a licensing problem. DSS allowed me to provide social rehabilitation for programs for mothers as long as they were the caretakers of their children. I could not provide child care. If I was required to obtain a child care license as well, this program would not be here today. 54 DEVELOPING COMPREHENSIVE SERVICES Without Ashbury House, residents would be forced to relinquish their children to the overcrowded and expensive foster care system. Conflicting treatment philosophies among providers also complicate integration efforts. Officials of Santa Barbara County's mental health court are frustrated in their efforts to find housing for clients with substance abuse problems. In one case, court officials wanted to send a client to a substance abuse residential facility, but the gentleman was on medication. The facility initially resisted because of its policy prohibiting the use of any drugs, even those prescribed to treat mental illness. The Challenge of Improving Services The success of individual programs throughout the State suggests that mental health providers often know how to best serve people with mental health needs. But that success rarely transfers across communities or across the state. The challenge for California is to increase the number of service providers employing the most effective practices. Given adequate resources and expertise, more mental health clients would receive tailored, integrated services. Mental health providers know that clients need more than medication. Unfortunately, practitioners do not routinely use, and policies do not encourage the use of, the best available treatment opportunities.143 The Village ISA succeeds in part because it was legislatively exempted from funding and administrative barriers that hamper the integration of services.144 Similarly, the Progress Foundation negotiated a solution to a licensing hurdle that would otherwise divide families. But the State has not used those examples to examine practices and craft reforms to remove those barriers for other communities. California must identify, document and promote effective and efficient approaches to comprehensive services. As the leader, the state Department of Mental Health should show the way. The Village ISA has hosted site visits from the Governor's Office, from New Zealand and many other U.S. states. But many California communities have yet to understand how The Village operates. In Recommendation 2 the Commission proposed that the Department of Mental Health be refocused on its leadership role. The department should more assertively investigate, document and promote best practices. The unit should network with local, state, national and world mental health leaders to provide the information local mental health authorities need to improve client outcomes and motivate and challenge them to move ahead. The department should call upon the Mental Health Planning Council to assist it in these efforts. 55 LITTLE HOOVER COMMISSION Recommendation 3: The State must assertively promote cost-effectJive, efficient approaches to providing care. The Department of Mental Health must ensure that local mental health programs have the tools and assistance necessary to improve the cost effectiveness of their programs. Specifically, the department should: o Utilize the resources of the Planning Council. ....... ___. .... _11J]1!!..~~!f!:.~~ ... §.~~P..~_"" .. "._""_ ......_ _ .... _.. _ ... The department should seek assistance from the • The Planning Council should convene Planning Council for each of the continuous public hearings around the state to improvement efforts outlined below. identify and document potential best o Identify barriers. The department should practice models. actively identify the barriers that discourage local • The department should prepare a mental health systems from providing budget change proposal to create and comprehensive, integrated services that can be staff a unit charged with identifying and promoting cost-effective practices that tailored to individual needs. improve outcomes. o Identify best practices. The refocused • The department should convene a department should create and staff a unit charged working group of mental health with identifying and promoting cost-effective professionals and evaluators charged practices that improve individual and system with developing a protocol for outcomes. evaluating the effectiveness of service models. o Explore incentives. The department should explore funding, reporting or other mechanisms that can create incentives for state and local mental health officials and service providers to continuously identify and remove barriers to more efficient and effective care. o Evaluate innovate programs. The department should evaluate promising and innovative practices that have the potential to improve services. o Report progress. The department and the Planning Council should annually report to the Legislature, local agencies and the public on their activities, progress and on-going challenges to providing comprehensive services. 56 PROVIDING ADEQUATE MENTAL HEALTH RESOURCES Providing Adequate Mental Health Resources Finding 4: Mental health funding is inadequate to ensure all Californians who need mental health services have access to care. Furthermore, existing resources fail to create uniform incentives for improvement and can prevent local authorities from providing cost-effective, efficient care. Realignment created incentives for local mental health agencies to pursue efficient, effective service approaches. But the majority of mental health funding is not distributed in ways that promote innovation or cost-effective treatment. Further, the variety of mental health funding sources creates inequities among counties in the availability and quality of care. And multiple funding streams force local authorities to patch together services based on the eligibility and use restrictions of categorical, pilot and reimbursement funding sources. The result is a mental health service system defined by funding streams rather than people's needs. Local programs are unable to offer tailored services when they are most needed and wanted - potentially increasing the demand for costly acute care and the anguish associated with mental illness. Inadequate Mental Health Funding Between 1989 and 1999 State and local mental health funding grew from $1.57 billion to $2.99 billion, a 90 percent increase. 145 But funding has not kept pace with demand. In 1989, the public mental health system provided services to 1.4 percent of the state population - about half of those estimated to need public services. While funding has increased, so has the population. And so despite increases, the system continues to serve about 1.4 percent of the state population, or about half of those estimated to need help. 146 Program Realignment In 1991 realignment fundamentally changed mental In 1991 the State and counties health funding and the relationship between the State flegoti~tedto replace anriual state and counties. Annual General Fund allocations for budget allocations witn dedicated tax mental health services were replaced with dedicated .r evenue from sales and revenue from sales taxes and vehicle license fees. Local vehicle licens~·fe,es. Realignment/ . gave counties control over . mental health agencies were given responsibility and spending dedsionsand provided authority for providing mental health care. The State's consistent funding across budget ...... role was focused on leadership and oversight of the years. statewide network of community mental health programs. 57 LITTLE HOOVER COMMISSION Total State and County Mental Health Expenditures Billions $3.5 ,.-_____ ---.--I $3.0 Actual Dollars $2.5 ........ $2.0 ~;:::::= $1.5 1989-90 Dollars $1.0 $0.5 $0 0 l..-_~ __~ _ 1989-90 1990-91 1991-92 1992-93 1993-94 1994-95 199&.96 1996-97 1997-98 1998-39 1999-00' 2000-01" Source: legislative Analyst's Office. 2000. 'California's Mental Health System: Selected Data.' Presented to Joint Committee on Mental Health Reform. Figure 1. Mental Health Expenditures in California State Hospitals and Community Mental Health All Funds: 1999-2000 figures estimated, 2000-01 figures proposed. Realignment was intended to replace the annual and unpredictable way the State allocated mental health funding to counties with a stable and growing revenue source. While revenues have increased, realignment also required counties to use that same source of funds to cover expanding caseloads in other social service programs before additional money can be spent on mental health programs. Realignment also allows counties to transfer up to 10 percent annually between local mental health, public health and social service accounts to reflect local priorities. The first three years following realignment, counties shifted more money into mental health accounts than out. But since then mental health programs have lost $72 million to other local programs. 147 The money has gone to worthy causes - indigent health care, foster care or other social services. But: in the long run, local mental health programs have not benefited from adequate growth. 148 Realignment also acknowledged that the system is chronically under funded in two ways. First, the legislation made it clear that: services are only required to the extent resources are available. Second, it defined a target population that would be given priority service - severely mentally ill and disabled individuals.149 Target criteria and the need to ration care limit the ability of providers to offer intervention and prevention services to clients before their needs become acute, even though such programs have proven to prevent the recurrence of symptoms and prolong time between psychotic episodes.1so Instead, counties often require clients with limited needs to wait until the severity of their symptoms escalate before they can access services. Some 70 percent of the people served through public mental health programs are covered by Medi-Cal, which means the federal government 58 PROVIDING ADEQUATE MENTAL HEALTH RESOURCES pays 52 percent of the cost of serving them. Unlike realignment, Medi Cal is not capped. The remaining 30 percent of public mental health clients are not on Medi-Cal and California covers the full cost of their care. lSI The central challenge for California is to increase the number of people served. First, the State needs to make sure that all existing clients who are eligible for Medi-Cal are enrolled, thus taking advantage of additional federal reimbursements. Second, the State must also identify Medi-Cal eligible individuals who need mental health services, but are not receiving them. Both initiatives would stretch state money to provide more services to Californians. Comprehensive Services are Not Funded Limited mental health funding typically results in counties rationing care to only those most in need of assistance. But counties must also struggle to patch together resources to provide support services that can make or break client efforts to recover. In general, clients eligible for services under Medi-Cal or realignment have access to basic mental health care. But that eligibility does not necessarily open doors to other services, such as housing assistance, vocational rehabilitation services or drug abuse treatment. Many of those programs serve even larger popUlations and have waiting lists of their own. Individuals may qualify for some of these supports through programs intended specifically to provide them to mental health clients and funded through categorical, pilot or grant programs. But many do not. The result is a community mental health system that cannot provide comprehensive care tailored to individual needs. While agencies often know how to provide high quality, low cost services, including intervention and prevention programs, they are limited by eligibility rules, service criteria or funding constraints. In Sacramento County, for instance, when new clients meet with a service coordinator, housing needs are assessed. Clients receiving social security income can generally afford to live in an apartment or in a board and care facility if they need a structured living environment. Those without social security may find space in county housing programs, such as the AB 34 program. But most without income are referred to homeless shelters. One staff person commented that the best he can do for people without personal income is to encourage them to arrive at homeless shelters before 5 p.m. to improve their chances of finding a bed. Otherwise they sleep on the streets. 59 LITTLE HOOVER COMMISSION Negotiating Mental Health Treatment California's local mental health programs have access to some 19 major local, state, federal and private funding sources. While most funds strictly limit how they can be spent, some allow greater discretion. 1. The first step in providing mental health services is to .a ssess the needs of clients. 1. Assess cI ient 2. Clients are also assessed to see if they are eligible for specialized programs or if they must be covered with limited discretionary funding. 2. Determine program eligibility 3. Determine program capacity 3. Before program staff can prepare a treatment plan, they must also determine the capacity of community programs. Housing programs in particular fill quickly. 4. Treatment plans therefore are based on a negotiation between client needs, program eligibility and available space. Because of these limitations, providers are often unable to tailor services or provide care when it would be most effective and most efficient. One consequence of underfunding the mental health system is the increased costs imposed on other public programs. Those costs have not been well defined, but are mounting. Law enforcement officials in particular have argued that the thousands of mental health clients ending up in county jails would be better served in local mental health programs. Assistant Sheriff Sean McDermitt of Sonoma County testified before the Legislature that the number of mental health clients in the Sonoma County jail doubled between 1996 and 1999.152 Dr. Bar:ry Perrou, Los Angeles County Deputy Sheriff, testified that the Los Angeles County Sheriffs department is the safety net for the mental health system. Los Angeles County Sheriffs Mental Evaluation Teams (MET) received 15,000 calls since 1993, an average of 7 mental health calls each day. 153 Commander Taylor Moorehead, Los Angeles County Sheriffs Department, testified that the Twin Towers Correctional Facility provides acute mental health services to 2,300 clients. The jail facility spends over $16 million on mental health services each year, nearly $5 million on psychotropic medications alone, and costs are growing.1s4 60 PROVIDING ADEQUATE MENTAL HEALTH RESOURCES Social Security Insurance: Incentives· for Participation u.s: The Surgeon Qenerajreports'thatabout'o:5 per~~nt of adu,t;1re sufnd~ptly disiIl;>led by a mental cilln~ss to qualify fo~qisabih~t)eriefits. A primary source of disabili~ paymehts)sthe 'sOcial security ; program.tv1entaf'health clients may be eJlgiblei(ortwo"s'Qurc~soffunding. The"SQGial Security Disabili~ .. Insurance (SSDI) program cover~.r,:lientfwho have paid into a trust'fund'through qualifying employment. The Supplemental SeCuJi~lnsur~nce (SSI) program covers disabledJndjvlduals;iwithlfmi,t~p income;· uij~6j~'to ~~;~·becaUS~9fa perliiste~r~~~~iti'Qn~U~ljfyfor paym~hts fro~ Clients wijQ are. that range ·'$44 to $647, per month ..C aliforni~~l.Igrnents 5S1 payme~tswith.fstat~~:Hpplement~lpayment·.(SSP) that ranges from $0 to $355 per fl1()nti'CPayment amounts vary based ofi inc0!11e, livingsituation and other factor~. Most peoplewho~teeligible for SSI areautomatically enrolled in M~qi:<:al. Thus SSI .... participation opens the door to medical coverage, asweU.as providing federal assistance to cover housing, food; personal needs and other expenses; ... Some Calif~rniaCOfT1munities aggressiVel}tp~rsue enrolling seriously mentally ill clients inthe SSI/5S~, prognlin. The average processing time for a appllc<lt~smjs60 days in California. The f~Qeral Social Security Ad inisttation (SSA) will r~imburse .. I agenclesthatcover a client's Iivjngexpe.l}~es prior to fT1 .. ahapplication being approved,' although officials say some counties are unaware of this poricy. WhH~;the::verage SSA~Pprov~'/;~processed heal~h<servlce within 60 days, mental providers report'tflat clients often must.~ait longer than a year before be.rlefit~J)ecomeavailabre. The delays are caused by the appe<ils proces~)• •. Many.Clients are initi~lly>deniedaccess to SS~SSDI because they lack the proper ,docomentatioil.l;iomelessness compounqlHhe difficulty of maintaining documentation, staying in touch withemployers'o[ publ IC medic;alcllnic~ that can provide backup records,dffollowingwup with ~Qe application process. . . When an 551 recipient enters jail, prison or a state.\1ospifaJo~.apenal code status, SSJ/SSP payments are su~pended •.W henbenefjts aresuspende.qJqrmore than a yeartheyareterrninated:C;:lientsmust reapply .. once they are released. .... .. .. The SSAd~es not automati~ailYf{hOw when an el1rolleelose$ eligibility. To redu,ce the number of lnappropriate. payments, the SSA pays an in~eritive to state'and local authorities that report when clients are incarcerated or are in state hosPi.tals~ Incentive payments are $200 or $400 per case. There is no cap on the number of incentive PClyments a facility can receive. "" ;. ;. / • ~;' , u The~SA reports th~t'C~ljforn i<linstitutions.h~ve f~eived ov~:r$6'fulllion i.n. incentive payments since 1997. Although California's Statehospitalsalreaoy share daiawith the S~AfCaliforniahas not signed of agreements qualifying the statef()J.inceiltive payments. The Department Corrections has received $725,800 in payments~The balance went to 40 of California's,?~. counties. The State of Texas reports that partici~ation in the incentive payment progralllenables itto speed the proces~ 'df re--enroUing clients r A programs upon release from jail or prison~ .D ata sharing allows 1exas'institutions to establish !lity prior to,clients being rj3h'!ased, making it easier forlhose clients to become re:established in their communities. .......' ... ? to~aximize p~yment~ andl~~alinstituti~ns andirlCre~Se Calif6rnianeeds the incentive received by state the number ofclients re-enrolled in SSDI/SSI; TI)~ State mustalso explore strategies for reducing the processing time to speed benefits to neVI( applicants and re-enrollees. Sources: Sandra D.Moore. Regional Public Affairs Specialist, U.S. SociillSeq,lrity Admioistratioo.2000, Personal Communication •.O n file. ... . ...... .. . . . .. 61 _._-----_._-- LITTLE HOOVER COMMISSION Mental Health Funding Lacks Incentives Under realignment, each county receives a set amount of funding regardless of how much it spends or how it spends it. Under realignment, some counties have developed innovative and efficient ways to use funds and improve care. In particular, local mental health agencies have found ways to move clients out of expensive, acute inpatient care into stable, community-based programs that draw down additional state and federal dollars. The majority of mental health funding programs, however - particularly Medi-Cal and many categorical programs - do not encourage counties to invest in cost-effective program changes. By combining responsibility for services and a dedicated funding stream, realignment allowed counties to benefit from improved efficiency. Analysis of pre-realignment and post-realignment services found that inpatient expenditures dropped, the number of people served increased and the overall cost of providing care decreased. Counties also were able to expand their use of revenue from federal and other sources, and county administrative costs decreased. One researcher commented that prior to realignment local administrators spent their time in Sacramento negotiating for funding. Since realignment they spend their time responding to local needs. ISS However, the incentives in place under realignment do not extend to other forms of mental health funding. For instance, under the AB 34 program, some clients receive help with housing. But most do not qualify and funding levels limit services to those who do. AB 34 provided $10 million to three counties and provided services to 1,027 clients.Is6 While the program drew attention to the plight of the mentally ill, highlighted the potential to bolster services, and improved care for about 1,000 people, it perpetuated a state practice of establishing new funding streams, most which narrowly define how resources can be used. Access to Services Varies by Zip Code AB 34 - again, despite its important benefits - also is an example of how limited categorical funding has contributed to a funding system that creates inequities among counties. Since realignment, the State has created multiple categorical programs that are only available to some of the 59 local mental health authorities. As a result, the quality and availability of mental health services varies depending on one's address. The disparity actually began with realignment, which locked in historical inequities that have become exaggerated by nearly a dozen specialized 62 PROVIDING ADEQUATE MENTAL HEALTH RESOURCES programs. Counties with more resources tend to capture still more money by crafting proposals and investing in innovative programs that attract grants. Appendix D displays mental health funding for each county by funding source. While all mental health plans receive realignment and Medi-Cal funding, specialized pilot, grant and categorical funds are available on a limited basis. The following table displays just some of the inequities among counties. While specialized funding sources are small in comparison to managed care and realignment funding, they provide the opportunity to meet particular needs and stretch other mental health resources. The disparity in funding levels creates wealthy programs in some communities and impoverished or non-existent services in others. Using Funding to Improve Services The structure of mental health funding can motivate programmatic change. Pilot and discretionary funding can encourage local agencies to identify and evaluate promising new approaches to improving outcomes. Funding of proven approaches or "best practices" can motivate agencies to adopt strategies proven to deliver efficient, effective services . ., :PartipJDatii"iDistribution o/Mental Health, AB 34and.MIOCRfundins .!."Across California~ounties, 1997·98 (unless otherwise noted) Realignment., S~ort-DOy~ .. Community Svcs Adult Dual AS 34 MIOCR PATH Medi<al .O ther Treatment . 59(; Diall~~is. Crants"Crants Alameda 44,658;88,6 ')'26,1;~,475 AI~lne ";'L177/5O' 0 Ar9ador'Y 672,799 168, gt. ..... ' ,. . ,' ' Birtte5/31,551 ...... 3,810!99~l,·L4 . Calaveras";" 787;0'1f ,;,;'244;108 ... i ...' ,633 tra Costa,'! 24,418,626 3. Del Norfu" . 857,793 2 .... ,., ......., .• . Ef Dor"l,#4,i" 2,800,892 .• .,• . i .. ,.• }';.; . .. 10,00'0' . Fresno 23 ,47 5,~:32 (;'6,865;9 i' 1 45,278 . Glenn .. /·86;,~17 ... 353,974 . .. . • 3,1~6 Humboldt" 4,445,559 ;:~j~i'··'·:i··"·· 10,000 . linpgfi~1 ...... 3,918,926'. '10',000' InY&8~;)A3r .;{115,298 '2,217 ~~rn16;5(j5, 115 9,249,297 31~013 ,};y+t'; Y'Kj':lgs"3t068(?~8 J ~~~~;f:!e lake ,. . :J,726,043'· lassen . 6i';'Y'"'''' 849,678 losAilgeles 266t206~290 . 5,000000 . 577;271. .. 1 63 LITTLE HOOVER COMMISSION California's Pi/ot Programs. Since realignment the Legislature has created numerous mental health pilot projects. But in general, the State has not used the experience gained in pilot projects to reshape policy statewide. For example, the Adult System of Care program has demonstrated effectiveness, but has not become state policy. Pilot and discretionary funding can provide mental health agencies with wide latitude in how to spend resources. With limited or no strings, discretionary funding allows agencies to take risks as they pursue promising, innovative approaches to improving care. Pilots can inform policy-makers on the effectiveness of new service approaches. They should be designed to experiment with and evaluate new programs, such as the Integrated Services for Homeless Adults program funded through AB 34 and the Mentally III Offender Crime Reduction (MIOCR) grant program. But more commonly, they represent incremental expansion of funding that benefits a few counties and gradually erodes the strategy of local control established under realignment. Best Practice Funding. Funding can also be structured to encourage local agencies to adopt proven practices. The State of Pennsylvania has adopted a funding approach that provides resources to support programs that have been demonstrated to address local needs. State funding provides the incentive for local agencies to explore programs that have worked elsewhere and determine whether they would apply locally. Pennsylvania's Best Pradices Funding Model Pennsylvania has developed an innovative funding program designed to accomplish four key challenges: • Change institutional responses to addressing community needs. • Mobilize community leaders to become involved in addressing needs. • Adopt data..cJriven research·based programs as community policy. • Provide local agencies with appropriate tools to improve community programs. Under the Partnership for Safe Children, Pennsylvania provides grants to communities that adopt programs known to address specific community needs. The State's criteria for funding include: • The community has conducted an assessmentto identify specific problems to be addressed. • Community leaders demonstrate evidence of broad community involvement in developing proposals. • Community leaders have identified a service approach that has been empirically tested and shown to effectively address the specific needs identified in their assessment. • The community has consulted with experts who can assist them to ensure they implement the program as it has been designed and evaluated. • The community has committed itself to completing the program and any requirement~ it may have for success, such as staff training, service coordination, etc. Source: Pennsylvania Partnership for Children. 64 PROVIDING ADEQUATE MENTAL HEALTH RESOURCES Reforming California's Mental Health Funding System Improving California's mental health system requires policy-makers to understand the incentives and limitations inherent in its funding structure. The bulk of mental health funding does not allow local agencies to tailor programs to needs or pursue cost- effective service approaches. Limited funding forces local decision-makers to ration care and piece together a patchwork of services. Service providers are then required to negotiate eligibility criteria based on fund sources. Providing services means finding the overlap between client needs, program space and funding availability. Needs that fall outside that overlap often go unaddressed. When problems become acute across the state, a new categorical program is created to cover the particular need. Realignment created a basis for mental health programs to benefit from a stable, growing revenue source. It provides flexibility and incentives to scale services to needs and invest in prevention and intervention programs. California needs to reinvest in that funding approach. Mental health funding should be restructured to motivate counties to pursue efficient, effective service approaches that improve client outcomes. Mental health funding could be tiered, with the majority having built-in incentives for efficiency and effectiveness. The State could also develop supplemental funding designed to motivate counties to adopt proven approaches to solving particular needs. A third tier of funding could be used to encourage innovation and risk taking as local agencies explore ways to improve access, quality and efficiency. Recommendation 4: California should provide adequate funding to ensure those who need care have access to services. The first step is for the Governor and the Legislature to reform the present funding streams. Specifically the legislation should: D Provide stable base funding that motivates quality outcomes. The lion's share of mental • The Department of Finance and the health funding should include incentives for Legislative Analyst's Office should analyze the cost of fully funding local mental health agencies to continuously realignment. .. improve services. Funding should reward local programs that improve system outcomes and • In January, the Legislature should introduce a hill to fully fund generate savings associated with reduced . realignment and remove language that mental health costs, as well as reductions in limits access "to the extent 'resources are the costs of other public services, such as available. II public safety and health care. 65 LITTLE HOOVER COMMISSION Immediate Steps o ProvidE~ incentive funding for the adoption of best practices. In addition to base funding, the • The Governor should direct the State should develop supplemental incentive Departments of Mental Health and funding that encourages local agencies to adopt Managed Care to assess the impact of proven best practices. parity legislation and constantly identify strategies for expanding access to care o Provide innovation funding to encourage new through public and private sector experimentation and risk taking. Mental health mental health programs. funding should also include resources in addition • The Department of Finance and the to base and incentive funding that promote Legislative Analyst's Office should innovation and risk taking to encourage local develop a transition plan to move away agencies to explore new approaches. from 19 major funding streams toward a more rational approach to funding o Document the effectiveness and promote mental mental health services. health par'ity. Providing all who need services unrestricted access to mental health care means expanding access through the private sector as well as expanding the safety net offered by the public sector. The effect of mental health parity legislation must be understood, and parity should be expanded to improve access to quality care. 66 DECRIMINALIZING MENTAL ILLNESS Decriminalizing Mental Illness Finding 5: One consequence of an inadequate mental health system is the criminalization of behavior associated with mental illness. The criminal justice system is too often the only resource - the only safety net - available to mental health clients and their families in times of crisis. Santa Barbara County Sheriff Jim Thomas said law enforcement officials have few options when dealing with mental health clients who need help. Limited mental health resources force them to arrest individuals who otherwise might be directed into mental health services. Other law enforcement leaders expressed similar concerns. Law enforcement has become the mental health safety net. The police respond when no one else will, although they may lack the resources and training to provide the most appropriate care. Law enforcement officials and others agree that serious and violent offenders with mental illness should continue to be arrested, convicted and incarcerated. Mental health treatment is available in California jails and prisons for this population of offenders. Their concerns are with mental clients who commit nuisance crimes associated with their illness: trespassing, vagrancy, disturbing the peace or other infractions that allow a police officer to exercise discretion over whether to arrest and jail or to help the person receive care. Few California communities offer 24-hour stabilization or crisis centers. Thus officers are often forced to abandon clients they encounter or make an arrest knowing the individual will qualify for mental health services in jail. The number of clients in county jails has led to overcrowding and increased demands on law enforcement budgets. Several county Sheriffs are taking the lead to reduce the number of mentally ill people who end up in jail solely because of inadequate mental health services. The State has also begun to invest in programs that divert non-serious offenders from the criminal justice system and prevent criminal activity by improving access to mental health care. Community treatment programs have greater flexibility than jail mental health settings and clients can qualify for Medi-Cal, federal reimbursements or other programs unavailable while they are in jail. Research suggests it is also cheaper to serve people in the community than to arrest them and serve them in jail. 67 LITTLE HOOVER COMMISSION The Criminal Justice Systeln is Serving More Cli4p.nts The number of mental health clients in the criminal justice system is increasing. Two factors are credited for this trend: First, as institutional care was reduced, more clients with serious mental illness returned to communities - often homeless, medicating with street drugs and unable to access mental health services. Second, the overall number of people in jails and prisons has increased as public safety policies have sought to incarcerate a wider range of offenders, including petty offenders. 157 Researchers in Vermont, for instance, found that mental health clients were more likely to be arrested than the general population, 7.2 percent for clients versus 1.7 percent in general. Clients with substance abuse histories were even more likely to be arrested, 14..4 percent158 Advocates assert that mental illness has been "criminalized" - as clients who cannot access services commit "crimes of survival" or are arrested for displaying in public the symptoms of unaddressed mental illness. Camping in public, urinating on private property and "feIony mouth" - aggressive confrontations with police - are crimes committed by people with no place to live, suffering from paranoia and other symptoms. The Mental Health Consumer Network is concerned that California's adoption of a managed care approach to providing mental health services will aggravate this trend by limiting services and further shifting costs from community mental health to the Jails Have Become Treatment Centers criminal justice system. 159 Others suggest that the higher threshold f,,)r involuntary After several days of taking over-the-counter commitment enacted in the 1960s antihistamines, Ron was manic. His father resulted in more arrests of people who describes him as "bouncing off the walls and slamming doors." otherwise would be directed into inpatient treatment programs. 160 At one point his father called 911 because Ron was making noise, it was late and he was concerned A number of factors may contribute to the about the neighbors and his son's safety. When the circumstances when mental health clients police responded, Ron walked out the front door, commit criminal acts. The response of the raised his arms straight in the air and said to the police, "I will (expletive) kill you." criminal justice system to those activities depends upon the awareness that After spraying Ron with pepper spray and individual decision-makers have of mental handcuffing him, the officers called the county illness and its symptoms. There is mental health facility to see if there was room for widespread lack of knowledge regarding Ron. There was no space. They called the mental illness on the part of law psychiatric hospital in the neighboring county, no space. They called a facility two counties over, no enforcement officials, prosecuting and space. With no other option they charged Ron with defense attorneys, judges, probation and assault and took him to jail. parole officers, jail and corrections staff. 161 68 DECRIMINALIZING MENTAL ILLNESS Inadequate Community Services Many factors contribute to the decision of a law enforcement officer to arrest a mental health client: the nature of the complaint, the circumstances surrounding their behavior, the possibility of an involuntary hold under Penal Code section 5150, and the officer's awareness of mental illnesses and their symptoms. Serious crimes result in an arrest. Even minor criminal activity may lead to a client being taken to jail. 162 Law enforcement personnel may be reluctant to bring an offender to a psychiatric facility where custody and security are limited, or where they must wait for hours before the person is admitted. Officers also have the options of releasing clients into the custody of a responsible adult, making a referral or doing nothing. While eligibility rules limit who is served by mental health programs, the criminal justice system refuses no one. Officers who want to remove clients from public settings often weigh the appropriateness of the mental health system and its long waiting times and shortage of bed space, against jails that guarantee at least minimal custody and control. Further, the criminal justice system does not question the officer's judgement in arrest, while the mental health community may challenge his interpretation of symptoms as mental illness. 163 When community mental health services are not available, arrest may be the only viable option for an officer attempting to ensure public safety and defuse a situation. But preventive mental health services can eliminate the need for initial contact with law enforcement. Researchers have found that adequate mental health treatment can prevent crime. 164 Lack of (;'ommunity J~atment Criminalizes Mental Illness Ithas besome"'~ppar~~t to me that ou'f::j~iI~and pris9:ps hax~'J;c6m~the prqviderQi)ast resort for the mentally i II. Prior to committing f;tcflme, or put~!ngthemselves or'othersat risk, the mentally ill and their families, and their health'p~oviders, are virtuaflyignored until they are in a seriolls crisis. ~;, ,>/' . ' '" , _u O~[ system is ~~rking back\o\'aid~ for ~hos~. .: whdare severely mentally ill. "Before they can, gettreatment, th~y neegJo gf!t better~",Before they~tthe treatment thatt~ey n~~to g~t better, they have ..to get worse they and often must go to jail first to receiveany lJlenta1ijealthservices. Wewait until the mentally ill end up in jail, the most inappropriat~()f settingS':md only then where it costs tnemost dO we provide comprehensive, medIcaliynecessary treatment. . " , The:ltjm~teiroI1YiS spendl~~aU men~IIY after that mohey to stabili,ze the ill injail, we let them olltinto the publicl'nental healthsystem,whicn is underfunded and understaffed. iAssemblymemper Helen Thomson Pu~'ic He~ring/F~Rruary 16, 1999 Senate Select Committee on Developmental Disabilities<,tnd Melital Health and Assembly Select Committee on Mental Health 69 -------------------------- LITTLE HOOVER COMMISSION H. Richard Lamb, professor of psychiatry and director of the Division of Mental Health Policy and Law at the University of Southern California, argues that inadequate services lead to a "revolving-door" syndrome that inappropriately relies on expensive jails and hospitals. "The lack of adequate community psychiatric resources, including acute and long stay hospital beds, subjects mentally ill persons to inappropriate arrest and incarceratio!l."165 Alternative Sentencing & Diversion Programs Some communities have taken it upon themselves to find a better way. Several counties have adopted policies that link law enforcement with mental health staff. The Los Angeles County Mental Evaluation Team (MET) pairs an officer and a mental health professional to respond to police calls involving clients. Forming the MET team has enabled the county to direct more clients into treatment rather than incarceration. 166 Not all clients are diverted however. When a client is arrested and jailed, mental health assessments are conducted to determine if the individual requires specialized treatment or custody arrangements, such as segregated housing. These assessments also help prosecutors decide whether to bring charges. But once a criminal charge is filed, judges have limited ability to divert clients out of the criminal justice system. State policy does not provide mental health clients with diversion opportunities similar to those afforded developmentally disabled individuals. The penal code allows the court to divert developmentally disabled individuals into services offered through regional centers. 167 California has invested in two mental health diversion programs - AB 34 and the Mentally III Offender Crime Reduction (MIOCR) grant program: AB 34 - Integrated Services to Homeless Adults. In fiscal year 1999- 2000, AB 34 provided $10 million to determine if comprehensive services can keep severely mentally ill adults from being homeless or going to jail. Programs in three counties - Los Angeles, Stanislaus and Sacramento - were able to reduce the number of days that clients spent in jail, homeless and hospitalized. Five months following implementation, the program has shown success. The Department found that the effect of the intensive, integrated outreach and community-based support was to enable the target popUlation to reduce symptoms that impaired their ability to live independently, work, maintain community supports, care for their children, remain healthy, and avoid crime. 168 70 DECRIMINALIZING MENTAL ILLNESS AB 34 targets clients who are likely to end up in high-cost treatment settings, such as hospitals and jails. Through aggressive outreach and comprehensive care, AB 34 has demonstrated that mental health services can keep clients from entering or returning to the criminal justice system. Mentally JII Offender Crime Reduction Grants. The 'MIOCR Grantees MIOCR program was developed to assist county efforts to reduce crime and offenses committed by Jnitial Grantees people with serious mental illnesses. 169 The Legislature provided over $100 million to the Board Humbhldt County $2,268 986 1 of Corrections (BOC) to support local programs that Kern County $3,098,768 . $5,034,317 will reduce crime, jail overcrowding and criminal Or~nge. Sacramento .. $4,719,320 justice costs by improving prevention, intervention San Bernardino . $2,477,.?57·. and incarceration services to clients who become Santa Barbara $3,548,398 involved with the criminal justice system.170 The 'Santacruz $1,765,012 BOC has awarded a total of $50.6 million to 15 counties. Allocation plans for the remaining $50 1999-2000 Grantees million are underway. Los Angeles $5,000;000 Placer $2,139,862 MIOCR funds have been used to establish mental Riverside $3,()16,673 health courts, improve services for mentally ill San Diego. $5,000,000 offenders reintegrating into the community after San Francisco $5,000,000 San Mateo $2,137,584 release from jail, improve jail assessment and Sonoma. $3.,704,473 treatment services, provide diversion opportunities StanislaJs $1,713,490 for repeat offenders or a combination of jail, court ;'~~rce: Cal ifor~'ia Bgard of Corrections; .. . and community activities. MIOCR programs involve police responses. Clients receive services after an initial qualifying offense or a subsequent police contact. There is general agreement that clients who have committed minor crimes - trespassing and disorderly conduct - could be diverted into community services.171 And a majority of crimes committed by mental health clients fit into this category.l72 Research on well-established diversion programs found that psychiatric emergency teams have been able to divert almost all clients they encountered into mental health services, including those with a history of substance abuse and violence. 173 And appropriate training for law enforcement officers has improved their ability to work with clients in ways that avoid violent confrontations and encourage productive relationships. 174 71 LITTLE HOOVER COMMISSION The Value of Diversion Programs Diversion programs can generally be divided into four categories: 175 1. Pre-Booking. Provide community-based services as alternatives to arrest. 2. Post-Booking. Encourage client involvement in community mental health programs with court agreement. 3. Post-Arraignment. Negotiate treatment plans with multiple actors, including the client and representatives of community mental health, jail, court, probation/parole and pre-trial service providers. 4. Mixed. Include combinations of pre-booking" post-booking and post arraignment diversion options. Key components of successful diversion programs include: Case management; training to work with mental health clients; aggressive identification of appropriate cases - within the first 24 to 48 hours of detention - and competent data systems to track clients through criminal justice and mental health systems. 176 Diversion programs have broad support and are considered the most promising avenue for reducing client involvement with law enforcement. Yet there has been insufficient research on diversion programs to determine when and how they work best. 177 Some argue that diversion is unnecessary when clients are receiving adequate services or when mental health professionals are able to respond to client needs. Sacramento County uses a pre-diversion approach. Organizations such as Volunteers of America respond to clients in situations when police might otherwise be called. Business owners and citizens can call VOA instead of police to refer clients into community programs or move them away from public settings to defuse situations,. A VOA response to a non-criminal situation is significantly cheaper than a law enforcement response. Similarly, Birmingham, Alabama uses community service officers, who are civilian police employees, to respond to these situations. 178 Public safety organizations are critical of programs that offer an alternative to a law enforcement response to a client in crisis. They contend that only law enforcement is equipped to respond to a public safety incident. Yet law enforcement contacts with mental health clients do not routinely lead to arrest. Of 15,000 responses by the Los Angeles County Mental Evaluation Team, just 437 resulted in an arrest. 179 72 DECRIMINALIZING MENTAL ILLNESS Investing in Prevention, Diversion and Incarceration The challenge for California is to serve mental health clients in a way that ensures public safety, provides appropriate treatment services and is efficient and effective. The graphic below displays the criminal justice process and the opportunities for prevention and intervention. Call for Assi~tance: . Mental health .... Prevention Police orCommunity . conta<;t,lovitntlient. Mental Health A~ A~';t)34;"~~e Integrat~dSeryjcestoH·~mel~s!) 341 MuftS Ptogr~m proV;ides servicesto cI ientS who arf!j:lOmeless, af ,risk/of hornele$sness,. Qrat rlsk.of incar.ceratk.m •. Jhe · program provides intensive outreach and tailored servic~~to i;i'P;ia-B~oking . JrJ1prov~theabili~ of clients tQlive independently, 'wo'l-t<., ';'OJverslon ;;~jmaintaJhcommuni~supportS;car~ fortneir children, ...... · remain healthy and avofcfcrime;'" ~ . ". .." <" ; ... j.. . .' . partici patil)g "~ n the t)4f;)ntallyJII. Offe!ld~r Critne Red" rygrant program havedeveloPed my!!ip/e Post-Booking approaches to reducing crime, jailcrowdiflS and criminal Diversion j us~ice cg!)!$ assoc.i,ated with mentally i II offenders. pre.: "pre-Booking: The MIOCRprogram'does not fund .bggking'dlversion}>fograms.Funds are limited to post;; oboking and post-arrai~9ment·a'pproache~. .' ' ..... . Po~~Book~,~g: The. $antaB'~rbara C6unty MIOeR program · brings together a'judge, district attorney, probation·staff/jj. psy~hologi$tf hOY$ingand employment sPecialistsahd other .. ' cgurtaild mental health staff 10 PIepareindivjdi.J~Ii?:ed responses to mentally ill offenders. Release from jail is cO'ltingepton a~~eloping a treatll1entplcm witfithEl. /'agreement ofthe court;·, .. ." ." ~ t," , .', Post*Arraignmenh The San 8ernardindCoun~MIOCR program serves c:fif.'lntsafter they have served time for ilt;l ... or in itia.1 qualifying gffel1se. Arallge services ar~. avaJrable · roclients when they commit a subsequent qualifying ..• , offense.,Report~dly, the Sacr<lmento~ountyprogra:m' ~urr~SdientHo have,a nistdry of at least tWo arrests, before qualifying tor MIOCR services. ..".'. Mix~: Th~lTlaj~iity Qf,Jhe Ml0CR programs provide range otservice~ to targefed clients. .. , , ,.. .'-., 73 -----------------_ .. _--_._--- LITTLE HOOVER COMMISSION The availability of 24-hour crisis services and prevention programs such as those provided under AB 34 could reduce law enforcement costs and crime. A mental health response to clients in crisis can result in significant cost savings. A mental health professional can work to maintain the client in their own living situation, resolve the immediate need and work toward recovery at the outset of a problem.. In contrast, post-police diversions require an initial police response, often an initial period of incarceration, the involvement of the court and the valuable time of other law enforcement personnel. National researchers working with the Federal Substance Abuse and Mental Health Services Administration are investigating the trade-off between pre-plea and post-plea interventions. Early evidence suggests that pre-plea interventions have greater cost-savings potential because they involve less time in jail and avoid expensive court costs. Post-plea interventions have greater potential for success because the court has greater ability to negotiate client participation in treatment. 180 Building a Continuum of Mental Health Responses California needs to better understand why so many mental health clients end up in the criminal justice system. Clearly, some clients commit crimes and should be incarcerated. Equally important, limited criminal justice resources should not be siphoned away to help mental health clients who would have been better served by other community services. The State needs to ensure that no client ends up in jail solely because they did not receive appropriate care. A detailed analysis of arrest and jail trends could help policy-makers fashion an appropriate and cost effective range of responses for each California community. Policy-makers need to better understand the conditions that result in clients entering the criminal justice system and the options available to keep them from drawing criminal justice resources away from serious offenders. The Legislature and the Governor need to understand the range of strategies available to the state to improve the availability of mental health services and target programs to clients likely to end up in jail. Diversion and prevention programs such as the MIOCR grant and AB 34/ AB 2034 programs are an appropriate start, but more information is needed to determine if these programs offer the most cost-effective responses to the criminalization of mental illness. 74 DECRIMINALIZING MENTAL ILLNESS ,.f{~~earchersjnMis~Q,ut{~~d'M~rylandha~~j~~ked~ttrye rate (>fj~llentinvotV~ment'in the ctfminal.justitet· .systerilOi;Even baSic· questi?ns h. . allowed resEl~rc~~r~. to'expioretrealrnenteffElctiveness,'recidivism, access to services ard the.natu . client in~9JvementwiththecriminaIjusti~ElsyStern~{jj,;;; ·;·;;:\~i~", .. fn C:aJifqmia, state. an?, local+government~.mait;ltain de!ai led~ataba.sEls;.o.~jhe "!penfa,! •h eal!lj·. needs ,.of Research proposals involving mental cUentsal1gAheJrhistory of jnvolv~m:eht withJDe< health and criminal justice data should: crimjnal]'ustice system;, . ..... . ....... • Protect the confidentiality of clients. 'f< The Departljlent .9fMentarH~alth ang,lociil behavioral • Involve client and family members in health. programs maintain data,.on· 380,OOQ .. aciive determining research goals and mElntal health dients.SiipilarlY, the DElpartment of protocols. Justice and locclltaw enforcement agenCies maintain • Identify the types of crimes clients are detailed;,. . ,etbrds of individuals Involved with the involved in and determine factors crirnlnaljustrcesysteOl- from arr~st angincarceration contributing to their involvement with through releaSe. ... . the criminal justice system. ;<B'in~j~;t~getherthe tWi/~~~r~te • Emphasize policy development. datasyster,ns could allow state ';iI'nd local Qffidalsto'e mp ir ic:ally ,determ in e • Lead to improvements in community •. theprofile of dientS.Olosflikely to become inyolved· mental health programs and correctional wJth the Friminid'j ustice system~nd Tn what capacity. mental health programs. R~wiewhlg th(¥ treatme"nt histories of clic:JofS"'fn the jail • Determine whether mentally ill andprison.systeni~'coula further jnf6rmpolicieson offenders have adequate access to .. ' treatme~r approaches integra!i ng'servicesrandlinking community mental health services . l •.••. Jai!lprison mental. health and comml.1l1ity m~ntal health. . , '" The State has dedicated over $160 millionclollars to redUc~ reCidivism, jail overcrowding and'~rilTljnal justice cost~through the MIOCR andlntegrate.9 Services to H,omeless Adults (AS 34/AS2034) programs. local agencies haye provided rich a~ecdotaldata to support the need for these Interventions .. Fot;Q.Sed· analysis of existing data could improve the ability· of the legislature and the Administratiqn to target serviceswhere they are most effective. ,. W'; < /; ~ , Research ,on 'fnental health and triminal justice data couldlTlor~.clearly answer the follOWing questions: of"crjmeam~ng mental~ealth dient~incorrimunity h~aith·· What istlle prevalence aqive mentar systems? How doese/lent involvement with the ~r,ilTlinaljustice system compare with the ge,neral population's overallfnvolvement with the criminal justice system? .. . . . What typ~s of crimes are' clients. Ii kely to commit? .. Are clients arrested for crimes of survival as rn~ny advocates assert? Do patterns of arrest and release suggest that law enforcement officials make Itmercy bpokingsli because community mental h~alth se,vICesare unavailable? Are AB 34/AB 2,03<4 and MIOCR programs availabl~ to the clie!1tsmost in need of and able to benefjtfrom interyentlbns? , ~ ;; ,;.> .>,. ' ".',- "' '/'" a'nd Which counties face the highestrate ofdienfinv61vement with the criminal justice sY$tem for What types of behavior? Do those ~ountjes receive AB 34/AB2034 and MIOCR funds? po clients witha history ofinvolvemerlt with the criminal justice system have access to COrruTlunity me'1till health resources equal tc) that of other clients?·· . . SpurceS:Pandiani, John A. eta!. 1999. 'Using Inca~tationRates to MeasureMEmtal H~fth Program Peri'ormance Journal of Behavior.irH~alth ,5ervi<;eS & Research. 25{3};;)00-311. Perso~al O;nnmunication. J\!'Y 8, 2000; On file. . .~ •. , 75 LITTLE HOOVER COMMISSION Recommendation 5: The State needs to decriminalize mental illness by ensuring that no one ends up in the criminal justice system solely because of inadequate mental health care. The Governor and the Legislature should improve and expand mental health crisis interventions. Specifically, the Department of Mental Health, the Attorney General and the Board of Corrections should: D Use data to improve services. The State should Immediate Steps analyze criminal justice and mental health data to identify priorities, develop promising programs and • The Department of Mental Health inform policy decisions that will reduce the should query the Department of Justice database to determine how and where number of mental health clients who end up in the clients come into contact with the criminal justice system. criminal justice system. D Identify needs. The State should document the • The Legislative Analyst's Office should need in each county for services that would review criminal justice diversion and prevent people from ending up in the criminal intervention programs and determine if justice system, such as 24-hour crisis programs, the State is making the best use of existing investments. supportive and affordable housing, substance abuse treatment and other services. • Legislation should be drafted for introduction in January to expand D Evaluate intervention programs. The State facility funding available through the should determine whether the Mentally III Offender Board of Corrections and permit Crime Reduction Grant and Integrated Services to counties to seek funds from the Board to Homeless Adults programs represent the greatest build 24-hour assistance centers or jails. opportunities to reduce client involvement in the criminal justice system. 76 COORDINA TlNG MENTAL HEALTH AND CRIMINAL JUSTICE SERVICES Coordinating Mental Health and Criminal Justice Services Finding 6: Local and State agencies have failed to integrate and coordinate mental health and criminal justice services - and as a result people with mental health needs leaving jails and prisons do not receive adequate services and are too often rearrested. California's prisons and jails hold an estimated 30,000 mental health clients. The majority are incarcerated for non-violent crimes of survival. California spends between $1.2 billion and $1.8 billion each year to process, treat and hold these individuals.181 When they are released, they are left alone to negotiate California's network of community mental health systems. Mental health programs and community parole and probation programs do not work together to reintegrate clients into their communities. Community mental health and criminal justice agencies seldom work together. They compete for funding, have disparate mandates and lack a culture and history of shared values. Despite estimates that 40 percent of public mental health clients will be arrested at some point in their lives, these two public agencies do not routinely collaborate.182 State prisons and prison parole services also compete with county programs for resources. Limited funding forces county mental health programs to ration care to the general population. They are reluctant, if not truly unable, to provide services to mental health clients on parole and under the supervision of the State. As stated in Finding 5, California must do a better job of preventing mental health clients from entering the criminal justice system solely because of inadequate mental health care. Other mental health clients will end up in jailor prison because of criminal behavior unassociated with their illness. Still others develop mental illnesses while incarcerated. Almost all of these clients will leave jailor prison and return to their communities. To improve the chances that they will successfully reintegrate back into their communities, State and community criminal justice programs and State and community mental health programs must collaborate to provide quality services. Entering and Exiting the Criminal Justice System While in the custody of state and local criminal justice agencies, clients receive a variety of mental health services. Law enforcement agencies assess inmate treatment needs through an intake process. Mental 77 LITTLE HOOVER COMMISSION health services are generally provided on an outpatient basis, with the inmate living in the general population. In some cases, services are provided on an "inpatient" basis, with the client in a special custody unit providing more structured oversight and care. Discharge planning has long been a concern among advocates, who argue that clients leaving conrectional institutions need assistance transitioning back into their communities. Homelessness and a lack of adequate treatment and support services often led to the incarceration in the first place. Releasing a client back into a community without adequate support often results in their returning to custody. When a client is preparing to leave jail, it is common for an outreach worker to visit and explain what community resources are available upon release. Outreach workers offer meal and hotel vouchers and can help reestablish public assistance or access to community programs. In Sacramento County, clients are released from jail and directed to the outreach trailer - which is two miles away, across a train yard and through open fields. Sacramento County has one of the more coordinated community mental health systems in California, yet many clients fail to show up for services and cycle back into custody. County law enforcement and mental health providers have been unable to improve the link between the two programs. Failed Communications Community mental health programs and local criminal justice systems often operate at cross-purposes and often without mutual truSt.183 For instance, non··emergency community mental health programs do not generally operate after business hours. Yet county jails routinely release mentally ill offenders between the hours of 9 p.m. and 2 a.m. with limited or no release planning. The Need for Improved Communication CDC operates five parole regions. In one of those regions, 1,650 parolees were required to attend outpatient mental health services, but just505 (31 percent) showed up following release from prison. Parole staff report that when clients are released from parole, the best staff can do is "cross their fingers" that clients make follow~up appointments with community mental health programs. Parole staff generally have no connection with community mental health programs and therefore are unable to track whether clients receive care through community programs. Sacramento County asked the CDC for a list of prisoners to be paroled into the county between June 2000 and December 2000. All but two inmates had contact with county mental health prior to entering prison. Despite the value of sharing data, the CDC does not routinely share this information with local mental health programs. 78 COORDINA TlNG MENTAL HEALTH AND CRIMINAL JUSTICE SERVICES Clients and providers point out that treatment plans in jail often differ from community treatment plans. Many clients require weeks to become accustomed to specific psychotropic medications and inconsistent treatment plans can reduce the overall effectiveness of treatment efforts. A similar gap exists between state prison and parole mental health programs and community mental health services. Mental health clients on parole from State prison are often prevented from accessing community mental health services. County mental health departments, strapped for funds, contend that the State should serve parolees. Parole outpatient staff argue that they are unable to assist mentally ill parolees with services such as housing, independent living skills, vocational rehabilitation and other services often provided by community programs. Client advocates argue that poor coordination and CustodY-basedV~ •... barriers between community mental health and state ,,£ommunify:~ased .• ;".,>;;" parole agencies conspire to return clients to prison. They charge that parole officers are trained to ensure clients Tre~tment "follow the rules." They are not trained to help them Prison become established back into the community. Custo~y$11i243 Treatment $7;:346 At the same time, community mental health agencies are Total ... '. $28,589 ~~ ~·/T/, reluctant or unable to provide them with needed .. ... ....... Jail services. 184 One high-profile example of this problem "CustpQY $f~!?oo Treatment .,,$7;100 involved a sex offender taking a medication that was not available through county mental health services. When :T " ot . al . $ ..2..6 ' 800' his supply of medication ran out, his parole officer J'Parole returned him to prison because without medication he Supervisio~ $2,182 Treatment" $3,600'i'·9;' was likely to re-offend. Total$S,782 .; The Benefits of Collaboration ..... . C~~fupnity . ". Total, including housing: $1,'5()0-$)?,OOO:< It costs the State about $120,000 each year to house a ,;,yhe averagecUst0dyc(}sts in mental health client in a state hospital. Community care the equations above do not ranges from $1,500 to $35,000 per year.18S .... refled add itional~)(Q~l1se "assodateq witft~everely The average annual cost of custody in prison is meotallyHI inmates whb $21,243.186 Prison-based psychiatric services for require spedal supervision:' seriously mentally ill inmates cost the State an additional 'Elguresalso do not il1c1ude law $7,346.187 Parole services cost the State $2,182 per . enforcement and·courfcosts. person, with parole-based mental health care adding up to about half what it costs to provide those services in prison. 188 79 LITTLE HOOVER COMMISSION Figures for California's jails are similar. Custody costs average $19,700 per year.189 The Los Angeles County jail provides acute mental health care to 2,300 inmates at an average annual cost of $7,100 each.190 These figures suggest it is more cost-effective to treat clients in the community than in custody. Most people who enter the criminal justice system eventually return to their communities. About 40 percent of California's prison population is released each year. Overall, 90 percent of plisoners are eventually released, with the majority getting out in less than two years. 191 County jails generally hold inmates for less than a year. Those that are not sent to other correctional institutions are released. Most are released in a matter of months. Research on the general prison population Improving Communication between shows that less than 5 percent of inmates Service Providers participate in reentry programs designed to improve their reintegration into society. In some communities, service providers working Once released, the average parolee receives with mentally ill offenders are coming together to just two 15-minute sessions of face-to-face discuss shared goals and challenges. Staff from contacts with a parole agent each month. county mental health, jail psychiatric services, About 20 percent of parolees fail to parole, parole outpatient clinics and law enforcement are discussing ways to improve their maintain contact with their parole agent. ability to maintain public safety and improve Parole violators constitute 71 percent of all services to shared clients. admissions to state prisons, presenting an important opportunity to intelvene.192 These individuals recognize that community rehabilitation is not necessarily a shared goal across their organizations. Yet successful client Despite the large revocation rate for parole reintegration into community life requires supervision, the State has not adequately improvements in how treatment is delivered, the considered the ability of support services - types of support services available and how the including housing and supportive disparate public entities view their roles and employment - to prevent parolees from responsibilities. returning to custody. Appropriate mental Unfortunately, staff receive little institutional health care creates stability, improves support for their efforts. There is a reluctance to client functioning and can prevent discuss organizational failings and limited criminal behavior. Finding 5 described the opportunities for promoting change among their opportunities to analyze existing data to agencies. better understand trends and identify opportunit ies. Promising Approaches Pilot programs have begun to demonstrate the potential for coordinated efforts to reduce client involvement in the criminal justice system. The AB 34/ AB 2034 Integrated Services to Homeless Adults, the Forensic Conditional Release Program (CONREP) and diversion programs demonstrate that coordination can improve client services and reduce 80 COORDINATING MENTAL HEALTH AND CRIMINAL JUSTICE SERVICES recidivism and criminal justice costs. Clients spent 74 percent less time in jail under AB 34 programs, re-offense rates are reduced under CONREP and diversion programs can reduce the number of clients who return to custody. 193 Several states, including California, the federal government and local communities have developed strategies to link and coordinate services for mental health clients leaving correctional institutions. The National GAINS Center in New York, the Texas Council on Offenders with Mental Impairments, a data link project in Maryland, and California's AB 34/ AB 2034 and MIOCR grant programs reflect efforts to improve services and outcomes for mentally ill offenders and reduce recidivism. The National GAINS Center. The National GAINS Center for People with Co-occurring Disorders in the Criminal Justice System disseminates information on effective mental health and substance abuse services for people with co-occurring disorders who come in contact with the justice system. The Center is a partnership of the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Center for Mental Health Services, National Institute of Corrections, Office of Justice Programs, and the Office of Juvenile Justice and Delinquency Prevention. It brings together researchers, policy-makers, practitioners, consumers, and family members to gather the best available information on the coordination of mental health and substance abuse services in criminal justice settings. It provides technical assistance to improve programs that serve individuals in courts, jails, prisons, probation and parole. Linki1Jg Mental Health andCrimlnai Justicel)ata Maricot~ Gnu nty in Arjz,()n~"h~s a dat~ Unk'b~tweellcou nty~ental .. h,ealth .;ndcri mi nal justice., Data . sharing allows law enforcement t().determine the appropriateness of referringdients into comrri'unity s~rvices,The.program diverts diEmts who comm it crimes of sUI)'.ival. Withouta data match, law time enforcemenfoffidals face a more difficult deterrnil'ling ~f{ich. offenders 'areel igible for treatment and·· . ... . dW~~.- .>Dat~matching b~tweerirrieritalhealth arcf law enforcement jscont~civersiaL. Client advocates ~ar thaf' law enforcement agencies will us~.hi$tory of mental illness in making arrest ~ecisions. They argue that medical history information iscdrifidential and has no b~adngon a client's legal status. Yet the trend nationally is to use mental health .data to improve decision~making by police officers. Mental health advocates champion the use of crimjnalJustid~andl'Tlehtal health data t6 demonstrate the .. jnadequad~~of local mental heqlth systems.pata sharing andanalysis can improve the ability of local mental health systems to tailor services toneeas and keer:>s:lients,~tJt of jails and prisons. Source: NationafCAlNS Center, 1999. "t)sing Manageme~t Informati~n Systems to locate People ~ith Serious Mental Illnesses and Co-Oc;<;urring Substance Use Disorders in the. Criminal Justice System for Diversion.· On File. (gains@prainc.com) , ,,"" n ;;,.. ,. ,. ~ • ~~ • • • • , 81 LITTLE HOOVER COMMISSION The Texas Council on Offenders with Mental Impai,.ments. The council provides a formal structure for criminal justice, health and human service, and other agencies to communicate and coordinate on policy, legislative, and programmatic issues affecting offenders with special needs. The council's target population includes offenders with serious mental illnesses, mental retardation, terminal or serious medical conditions, physical disabilities and those who are elderly. The council has been instrumental in improving service coordination and reducing state costs. It has developed a special needs parole program that provides early parole review for offenders who could be diverted from incarceration into more cost-effective treatment alternatives. In some cases, parole diversions allow the state to receive federal reimbursements for treatment services through Medi-Cal, Medicare or Social Security. The council reports that for every dollar spent on these alternatives it draws down an equal dollar from federal or other sources. The council also has developed policies that have streamlined mental health assessments across loca.l and state criminal justice programs, improved communication among agencies and improved coordination among programs. The council's efforts have reduced arrest and re arrest rates for special needs offenders by 33 percent and they have lowered the cost of parole aftercare. 194 Maryland's Community Criminal Justice Treatment Program. Maryland has improved the coordination of services and communication between mental health and criminal justice programs by creating a multi-agency collaborative that provides treatment and support services to mentally ill offenders. The state has programs in 18 of Maryland's 24 local jurisdictions. Local programs are lead by a task force of state and local leaders. Services include cnS1S intervention, screening, counseling, discharge and community service planning. The program provides transitional case management, long-term housing support and substance abuse treatment. The goal of the program is to reduce criminal justice costs and disruptions, reduce the need for hospitalizations and improve the ability of clients to transition out of the criminal justice system.195 Opportunities for California The Texas Council on Offenders with Mental Impairments provides an example of state and community leaders collaborating to improve services and reduce costs. The National GAINS Center represents a national investment in research, technical assistance and infonnation dissemination to improve community responses to mentally ill offenders. 82 COORDINA TlNG MENTAL HEALTH AND CRIMINAL JUSTICE SERVICES California leads the nation in prison and jail populations and has the largest number of mental health clients in the country. The State should explore the potential of these models and develop strategies to realize similar goals: improving program quality and efficiency and improving research, education and technical assistance. Most importantly, California needs a strategy to break down the barriers between the criminal justice system and the mental health system in every California community. Recommendation 6: The State should establish a California Council on Offenders with Special Needs to investigate and promote cost-effective approaches to meeting the long term needs of mentally ill offenders. The council, comprised of state and local officials, should: o Identify treatment strategies. The council 'Immediate Steps should propose policies for improving the cost effectiveness of services for offenders with • <lilly. Executive Order f. theCiover~ri;"<~, .s hould establish the California Council special needs within jails and prisons, on Offenders with Special Needs. including service coordination and data sharing among community mental health and • The Legislature should call for an .. , 'independent evaluation ofc ontractS criminal justice programs. ~:lWeen the California Departmenfof o Promote coordination. The council should Cqrrectionsand local mental health document the need to coordinate mental agencies to provide care to parolees. health services and improve the ability of • The Legislature should direct the CDC clients to transition successfully between to expa'Of;i tp all counties contracts corrections-based and comm unity-based proven to ~uccessfu"y provide quality ii treatment programs. mental health care to parol~es.· ii. o Provide technical assistance. The council • The LegislativeAnalyst's OffiCe should' i analyze the State's response to incentive should develop a technical assistance and programs offered by the federal Sodal resource center to document best practices Security Administration and promote and provide information and training to the use of Incentive payments to fUnd improve the efficiency and effectiveness of pre-authorization effClrts that speed liP state and local programs serving mentally ill benefits to clients leaving ja~1 pr prisCln. offenders. o Develop incentives. The council should identify incentives that will motivate State and local agencies to coordinate mental health and criminal justice services. 83 LITTLE HOOVER COMMISSION 84 CREATING ACCOUNTABILITY: MONITORING THE MENTAL HEALTH SYSTEM Creating Accountability: Monitoring the Mental Health System Finding 7: California will never be able to ensure that all Californians have access to mental health care without clear and continuous accountability for outcomes. Reforming California's mental health policy begins with establishing clear public expectations and responsibility for providing quality mental health care. Transforming the system to meet those expectations requires a strong accountability component that will allow clients, policy-makers, taxpayers and citizens to understand when and where progress is made and change is necessary. The Department of Mental Health is developing an outcome and performance reporting system as required under realignment. The reporting system is intended to provide the information needed to assess the quality of mental health services in each county. The department must complete its reporting system as required by law. But the department's goal should not be to build a reporting system, but rather to create true accountability. Particularly for mental health, community leaders, state policy-makers and the public at large need to understand the importance of the services and the value they bring to individuals and communities. In this context, accountability motivates continuous improvement and guides public investments. Accountability is essential to make the previous recommendations meaningful. o Expectations. Public policy is driven by public expectations. To raise the public's expectations for mental health services, these programs must be able to reliably and clearly communicate their goals, their performance and their potential. o Statewide Leadership. The department is emerging as the statewide leader needed to help communities improve services and help the state develop more effective policies for funding and managing social service programs. These roles are bolstered by the availability of sound data that can be used to evaluate existing services and their alternatives. o Comprehensive Services. Mental health, like most other social service programs, is burdened by a reliance on multiple state and local agencies to provide all of the assistance that clients need to succeed. 85 LITTLE HOOVER COMMISSION An effective system of accountability that identifies the weak links and the under-performing partners is essential to developing a system that provides clients with comprehensive, tailored and potentially integrated services. o Resources. Mental health and related programs have been plagued by a lack of resources. But policy-makers and the public will not dedicate additional resources without confidence the money will be well spent and improve client and system outcomes. o Criminal Justice. Low expectations, limited services and inadequate resources have resulted in higher criminal justice expenditures and in many cases the inappropriate incarceration of clients. An effective accountability system would document the costs and consequences of this failure and guide solutions that would better serve clients and allow criminal justice resources to be used in ways that better protect the public. Concern alone for the welfare of mental health clients is inadequate to motivate change. Clients, taxpayers and the public must understand how policy and funding decisions move the State closer to realizing expectations. Without clear and constant accountability, mental health will continue to reflect an inadequate and forsaken component of California's social service programs. Mf.mtaJ Health Oversight When the Legislature enacted realignment, it included a requirement that local mental health programs collect and report outcome measures to the State.196 Client advocates were concerned that without reporting, counties would not adequately fund or administer programs. Reporting requirements were intended to ensure the State was aware of the condition of local mental health programs and able to intervene if necessary. The State's oversight authority also is established in federal law governing Medi-Cal. The California Code of Regulations, California's waiver from the Health Care Financing Authority and the requirements built into specific programs require the department to ensure that local mental health programs operate in ways that are public, include grievance procedures and meet access and quality standards. The department's oversight activities have evolved since realignment to include a number of specific efforts. For instance, the department employs a human rights specialist to assist clients concerned with the quality of mental health treatment. Moving into managed care, the 86 CREATING ACCOUNTABILITY: MONITORING THE MENTAL HEALTH SYSTEM department created an "Ombudsman Office" to solve problems and investigate complaints. Additional oversight efforts include on-site reviews, contract management and monitoring, licensing and certification reviews, financial oversight, and a quality improvement process that features a collection of stakeholder committees. The department's oversight philosophy emphasizes self-monitoring, rapid attention to problems and clear public accountability. The department's white paper on accountability states: 197 It is of paramount importance that the oversight system and the information it produces is accessible not only to the mental health community but to the general public whose tax moneys support the public mental health system In addition to focused oversight activities, such as compliance reviews, the department is developing a program to monitor and evaluate local mental health services through a performance outcome information system. Much of the department's present oversight efforts are resource intensive and therefore limited in their ability to motivate change in a timely fashion. For example, department staff visits SAMHSA-funded projects once every three years. Those visits are complemented with "desk reviews" of reports submitted by local agencies. But desk reviews and a visit every 36 months offer limited opportunities to respond to emerging needs or reform ineffective programs. In contrast, the department's statewide data system offers the promise of providing accurate and timely information to the public, mental health officials and policy-makers on the status of mental health programs. California's Performance Outcome Data System The Department of Mental Health envisions a data system that includes information on all mental health clients who receive services for more than 60 days each year. Approximately 25,000 children and 185,000 adults fit this criterion. Each client will receive a unique identifier allowing the department to track demographic, service utilization, cost and outcome data. 198 The data are intended for statewide oversight of local programs and to provide program administrators feedback on the quality of services. The department's effort is driven in part by the larger trend in social services to adopt data-based analytic tools. The Department of Social Services, the Board of Corrections and other state departments are working to 87 LITTLE HOOVER COMMISSION develop similar data-driven evaluation tools. Departments within the Health and Human Services Agency are discussing how to link data collection and analyses across programs. California is not alone in moving toward outcome measures for mental health. 199 Managed care has pushed public and private health systems to develop measures of clinical practice, outcomes and cost effectiveness.2oo Yet despite significant effort, no unequivocal agreement or standard exists for measuring the effects of mental health services. There is no clear measure for evaluating the impact of treatment.201 Challenges to Measuring Mental Health Outcomes Despite nine years of effort, the department does not have a working outcome reporting system. Limited progress has caused some to question the department's commitment to the process. Critics contend that limited progress reflects the department's interest in mollifying the fears of local mental health agencies that their programs will be viewed poorly when subjected to outcome measures. In contrast, supporters argue the enormity of the task undertaken by the department and two pilot surveys to pre-test outcome measures are evidence of true commitment to building an accountability system. Deve/oping Outcome Measurement Systems Anne Morris, Ph.D., of the Center for Mental Health Service Research, University of California, has summarized five general principles from recent literature guiding outcome measurement systems. Principle #1: Success depends upon a shared sense of urgency about the need for change. Although there may be an urgency about accountability and the need to implement outcome assessments at the state level, this may not be fully shared by administrators and staff on the H "front Iines of mental health care. Principle #2: There must be a clear vision at the top defining the need for change and the goals of the new system. This vision must be widely communicated throughout the organization. There must be a consensus about the Hworthiness" of those goals. Principle #3: There must be "buy-in" from front-line managers and direct care staff. Without the "buy_in" of managers and staff, implementation efforts are doomed to failure. Principle #4: Information should flow in both directions. Managers and staff in mental health organizations should receive feedback about consumer outcomes and program performance on an ongoing basis. This information should be user-friendly and guide decisions about programs and the allocation of scarce resources. Principle #5: Implementation of new technology/change efforts should be tied directly to the organization's mission and goals, and should be anchored in the culture and climate of the organization. Implementation must be clearly linked to the goals -of quality improvement in services to consumers. 88 CREA TlNG ACCOUNTABILITY: MONITORING THE MENTAL HEALTH SYSTEM It is likely that both claims have merit. The department must build a reporting system that local mental health agencies will respect and that will ¥~eral'states havedeveloped';trategies' provide meaningful information. One challenge is "'for track1 n8<;:1 ientand $"Ystemoutcomes.· developing the ability to accurately measure the 'lp~jed~ral government ist:;t.lfrerltlY'.j{t3T· impact of treatment. A second challenge will be suppqrtinga project tocoordinate . " ,';h , '''e{fortsto dey~ldpfommonlndi,c;:at()rs. mustering the political will to set standards that may \,The Mental Health Statistics, . not completely reflect the value of diverse treatment ·'t'mproveh,ent Program (MHSIP) Pql!GY systems. p i~,~orklflg w1tb, offi¢.l.~I,s lrii!16 • .' s tates to/collect iniormationthat <;an" Other states have collected mental health help'ad!"rl,in'istrators, J?,plicy~m~r<.efS~l;ld. performance data. One lesson learned is that ·,.EJfS Understand who'S prbvfdirg the best serylc;es at ~he'best prjce~who departments must understand that they will struggle ,,,ineegs serv.i<;es,·\lVpat thE!pest'tr tments with data that does not reflect the value of their work. "are for differentkindsofprobl 'an.~t2'/· Research suggests the first few years of data are often ·eve.a.;)Vno nas tFie,friendljest'staif!,,,... ... ........ . suspect and should not be tied to funding or '_/"'_'.}i?'.';'U ,,Source: Mental H~alth ,StatiStics, ImproYell1enf' administrative decisions. The measurement and progfa.n~.JwWw.ll1hslr:iprg) .....,;<. reporting process, however, matures with experience. Providers and departments must accept that measurement tools will evolve over time and generally do not provide quality information at the outset.202 Collecting Performance Data is Not Enough Identifying and collecting performance data is a first step in building an accountability system. But accountability requires the information to be accessible, understandable and meaningful for funding and policy decisions. Policy-makers need guidance on when, where and how additional funding can best improve outcomes. Administrators need feedback on the success of their programs, and information to guide refinements. And the public needs the information to recognize their investment in mental health services is well spent. Community mental health programs are rarely asked to document how they have changed the lives of the people they serve. A well-designed accountability system can provide consumers and the public with compelling information on how mental health programs change lives. 89 ----"------~-------- LITTLE HOOVER COMMISSION Recommendation 7: Improvement, public understanding and support for mental health programs depend on an accurate assessment of California's progress toward its goals. As the State's mental health leader, the Department of Mental Health must continuously inform the public, program administrators and policy-makers on the performance of the system, whether quality and access are improving and how they could be enhanced. Specifically, the department should: o Inform decision-makers. The department Immediate Steps should provide information that can help the • The department should publicly report general public, policy-makers and program aggregated information for each county administrators understand the availability, quality on the types of Californians who are and cost-effectiveness of mental health services. being served and the unmet need. o Provide benchmarks. The department should • The department should commit to provide information that compares performance develop and publicize benchmarks that with expectations. It should reveal variations outline annual goals for expanding access to mental health care. across programs, counties and over time. • The Legislature should direct the o Reveal barriers. The department should Department of Mental Health to provide data to permit administrators and complete the statewide performance researchers to identify barriers to program reporting system. improvement and alert policy-makers when and • The department should provide where policy changes are necessary. quarterly reports to the Legislature and o the public on its progress in developing Encourage broad access. All data and the reporting system. information on mental health programs should be readily accessible to the public, the press, • The department should begin putting data on-line for easy public access. researchers and others whose analyses could lead to better pu blic understanding, program • The department should publicize the management and policy making. conditions under which it will intervene to ensure mental health services are o Provide standards. Performance data should be available in every community. structured to indicate to state and local administrators and policy-makers when mental health services are so inadequate that intervention is warranted. 90 CONCLUSION Conclusion Throughout California, mental health clients have difficulty accessing care. The available services often fail to address core needs such as housing, making it difficult for clients to recover or stabilize. There are no standards or goals for mental health services. And there is no pressure for county mental health agencies or the Department of Mental Health to improve programs. As a result, the quality of mental health care is variable - but generally poor - and does not improve. Members of the advisory committee and hearing witnesses argued for minimum standards to guide county mental health programs. They called for an ongoing commitment on the part of policy-makers and the public to invest in and improve mental health care. But it is difficult to know what gaps in care need to be filled and how best to fill them. Experts do not agree on the number of people in need of mental health services. No one knows the full extent of the costs associated with ignoring mental health needs. And the public and policy-makers have no shared understanding or obligation to serve mental health clients. Historically, mental health policy has lurched along from one controversy to the next. Each policy shift reflects an emerging concept, but not a commitment to address mental health needs. Thirty years ago the public demanded an end to state-run institutions where clients were warehoused under intolerable conditions. Despite promises of financial support, mental health funding did not follow clients into their communities. Ten years ago, the State enacted realignment and shifted responsibility for providing direct services to the counties. But limited funding has not allowed the counties to provide adequate services. As a result, California rations care. Taken together, the Commission's seven findings and recommendations articulate the need to establish broad public expectations for mental health policy and an obligation for providing mental health services. The Department of Mental Health and state funding need to be aligned to the goals of helping communities provide comprehensive mental health care. Finally, the State must end its reliance on the criminal justice system to serve as a surrogate for community-based mental health services. 91 LITTLE HOOVER COMMISSION 92 ApPENDICES Appendices ../ Public Hearing Witnesses ../ Adult Mental Health Advisory Committee ../ Medical Necessity for Specialty Mental Health Services that are the Responsibility of Mental Health Plans ../ Distribution of Mental Health, AB 34 and MIOCR Funding ../ Glossary of Terms ../ Mental Health Information Sources and Organizations 93 LITTLE HOOVER COMMISSION 94 ApPENDICES Appendix A Little Hoover Commission Public Hearing Witnesses Witnesses Appearing at Little Hoover Commission Mental Health Hearing on September 23, 1999 Karen Hart, Vice President, United Larry Poaster, Director, Stanislaus County Advocates for Children of California Mental Health Department Sally Zinman, Executive Director, Catherine C. Camp, Director, California California Network of Mental Health Mental Health Directors Association Clients Saul Goldfarb, Chief Executive Officer, Randall Hagar, Legislative Advocate, Gateways Hospital and Mental Health National Alliance for the Mentally Ill Center, Los Angeles California Roy Alexander, Executive Administrator for Robert Schladale, Assistant Secretary, Operations, Victor Treatment Centers, Health and Human Services Agency Chico Stephen W. Mayberg, Director, California Al Rowlett, Assistant Director, Turning Department of Mental Health Point Community Programs, Sacramento Robert Presley, Secretary, Youth and Adult Correctional Agency Witnesses Appearing at Little Hoover Commission Mental Health Hearing on October 28, 1999 Collie F. Brown, Assistant Director, Donald Specter, Director, Prison Law Office, National GAINS Center, Delmar, New York San Quentin Harold E. Shabo, Supervising Judge, John J. Vacca, Head Deputy, Mental Health Mental Health Division, Branch, Los Angeles County Public Los Angeles Superior Court Defender's Office Jim Thomas, Sheriff, Santa Barbara C. A. "Cal" Terhune, Director, California County Department of Corrections Taylor Moorehead, Commander, Twin Jon DeMorales, Executive Director, Towers Correctional Facility, Los Angeles Atascadero State Hospital Verne Speirs, Chief Probation Officer, Gregorio "Greg" S. Zermeno, Director, Sacramento County California Youth Authority 95 LITTLE HOOVER COMMISSION Witnesses Appearing at Little Hoover Commission Mental Health Hearing on January 27,2000 Sandra Naylor Goodwin, l~xecutive Steve Fields, Executive Director, Progress Director, California Institute for Mental Foundation Health Tim Brown, Executive Director, Loaves and Gary Pettigrew, Deputy Director" Fishes, Inc. Department of Mental Health Dave Hosseini, Executive Director, Mark Ragins, Medical Director, The Consumers Self-Help Center and Office of Village Integrated Services Agency Patients' Rights 96 ApPENDICES Appendix B little Hoover Commission Adult Mental Health Advisory Committee The following people served on the Adult Mental Health Advisory Committee. Under the Little Hoover Commission's process, advisory committee members provide expertise and information but do not vote or comment on the final product. The list below reflects the titles and positions of committee members at the time of the advisory committee meetings in 1999 and 2000. Howard S. Adelman, Co-director John Brunges Center for Mental Health in Schools California Mental Health Planning Council Department of Psychology, UCLA John Buck, Executive Director Sylvia Aguirre-Aguilar, Executive Director Turning Point Community Programs El Hogar Mental Health & Community Service Center, Inc. Catherine Camp, Executive Director California Mental Health Directors Cassandra Auerbach Association Citizens' Commission on Human Rights Diana E. Clayton, President Conni Barker California Association of Local Mental Director of Government Relations Health Boards & Commissions California Psychiatric Association Frank Cuny, President Gale Bataille, Director California Citizens for Health Freedom Mental Health Services Solano County Health and Social Services Betty Dahlquist, Executive Director Department California Association of Social Rehabilitation Agencies Ken Berrick, CEO/President Seneca Center Mike Danneker, Executive Director West Side Regional Center Steve Birdlebough, Legislative Advocate Friends Committee on Legislation of F. Jerome Doyle, President/ CEO California Eastfield Ming Quong Children and Family Services Melissa Bittner Citizens' Commission on Human Rights Nuin Dunlap Sacramento American Friends Service Committee Oakland Ann M. Blackwood, Senior Consultant Assembly Health Committee Geraldine Esposito, Executive Director California Society for Clinical Social Work Isabel Bravo California Alliance for the Mentally III Marianne Estes, Staff Services Manager II Placer County Program Accountability California Department of Alcohol & Drug Tim Brown, Executive Director Programs Loaves & Fishes 97 LITTLE HOOVER COMMISSION Lara Flynn, Legislative Advocate David Hosseini, Executive Director Family Service Council of California Consumers Self-Help Center Kate Fogle, Executive Director Susanne Hughes, Acting Chief California Child, Youth and Family Department of Health Services Coalition Medi-Cal Managed Care Division Lana Fraser, Assistant Deputy Director Valeri Kennedy, Legislative Advocate California Department of Rehabilitation Protection & Advocacy, Inc. Joyce Fukui, Deputy Director Kenneth M. Larsen, Legislative Advocate California Department of Aging Friends Committee on Legislation of California Michael Garabedian Attorney at Law Steve Leoni Mental Health Planning Council Barbara A. Gard, Executive Director California Psychiatric Association Kimberly Lewis California Association of Mental Health Lenny Goldberg, Legislative Advocate Patients Rights Advocates Family Service Council of California MarIetta Logan-Curry Gary Grice, Program Coordinator California Association of Local Mental Sacramento County Mental Health Division Health Boards and Commissions Randall Hagar Bob Macaluso, Director National Alliance for the Mentally III Government Relations California & California Treatment Advocacy Crestwood Behavioral Health Coalition Maria Mar, Director Michael Haley, Executive Director Rehabilitation Support Team California Psychological Association Community Support Network Karen Hart Janice K. Marques, President United Advocates for Children of California Association for the Treatment of Sexual Abusers Pam Hawkins, Family Coordinator Sacramento County Division of Mental Felicia McCarty Health Support Coalition International Rebecca Hawkins, Youth Advocate Brett McFadden Sacramento County Division of Mental Director of Government Affairs Health California Association of School Psychologists Maxine Hayden Interested Individual Elin Modjeska, President California Division-American Association Kathleen Henry, Executive Director for Marriage and Family Therapy Sacramento County Mental Health Treatment Center Lou Mone Downtown Mental Health Clinic and Stacie Hiramoto California Coalition for Ethical Mental Government Relations Director Health Care National Association of Social Workers California Chapter 98 ApPENDICES Joseph F. Murphy, Senior Assemblyman Daphne Shaw, Chair California Senior Legislature California Mental Health Planning Council Sandra Naylor Goodwin, Executive Director Charles W. Skoien, Consultant California Institute for Mental Health Community Residential Care Association of California Marcus Nieto* California Research Bureau Charles Sosebee, Coordinator California Clients for LPS Reform Joyce Ott-Havenner California Network of Mental Health Clients Steven Szalay, Executive Director California State Association of Counties Margaret Pella California State Association of Counties Zoey Todd Poulton Sacramento County Division of Mental Gary M. Pettigrew, Deputy Director Health Systems of Care Division Department of Mental Health Richard Van Horn, President & CEO Mental Health Association in Los Angeles Darlene Prettyman County Director, Government Affairs Anne Sippi Clinic Riverside Ranch Diane Wake1in, Deputy Chief Operations Mental Health Planning Council Officer / Clinical Director Sunny Hills Children's Garden Vickie Reis-Allen, First Vice President Family & Children's Services California Association of Local Mental Health Boards and Commissions Edward P. Walker, Director Marin County Dvision of Mental Health Mary Riemersma, Executive Director Services California Association of Marriage & Family Therapists Sharron Watts Dementia Program Specialist Abram Rosenblatt, Director of Research State Funded Services Branch Child Services Research Group Department of Aging University of California, San Francisco Irene Williams, Director Patricia Ryan, Vice President Agewell Behavioral Health California Healthcare Association Gayle Wilson, Director Center for Youth Policy and Advocacy John J. Ryan, Director Riverside County Mental Health Pete Zajac California Youth Authority Robert Schladale, Assistant Secretary Health and Welfare Agency Sally Zinman, Executive Director California Network of Mental Health Clients Rusty Selix, Executive Director California Council of Community Mental Health Agencies/California Coalition for Mental Health *The Commission would like to acknowledge Marcus Nieto of the California Research Bureau for his assistance to the Commission on issues related to the criminal justice system. 99 LITTLE HOOVER COMMISSION 100 ApPENDICES Appendix C Medical Necessity for Specialty Mental Health Services that are the Responsibility of Mental Health Plans iOSM A. DiagnoseS: Must have6ne of the(~rlowirig IV diagnoses, which will be the fo~usofthe interv.eralion being pr!-lVided: Included Diagnoses: ..... Excluded Diagnoses: • Pervasive Developmental Disorders, except Autistic; Disorder which is excluded . • Mental Retardation • Learning Disorders • Attention Deficit and Disruptive Behavior Disorders • Motor Skills Disorder • Feeding & Eating Disorders of Infancy or Early • Communication Disorders Childhood • Autistic Disorder • Elimihation Disorders • Tic Disorders • Other [)isorders of Infancy,Childhood, or Adolescence • Delirium, Dementia, and Amnestic • Schizophrenia & OtherPsychotic Disorders and Other Cognitive Disorders • Mood Disorders • Mental Disorders Due to a General • Anxiety Disorders Medical Condition • Somatoform Disorders • Substance-Related Disorders • Factitious Disorders • Sexual Dysfunctions • Dissociative Disorders • Paraph iI ias • Sleep Disorders • Antisocial Personality Disorder • Genderldentity Disorders • Other Conditions That May Be a • Eating Disorders Focus of Clinical Attention, except • Adjustment Disorders Medication Induced Movement • Impulse-Control Disorders Not Elsewhere Classified Disorders which are included • Personality Disorders, excluding Antisocial Personality Disorder A beneficiary may receive services for • Medication-Induced Movement Disorders an included diagnosis when an excluded diagnosis is also present B. Impairment Criteria Must have one of the following as a result of the mental disorder(s)identified in the diagnostic (HA") criteria; Must have one, 1, 2, or 3: . 1 .. A significant impairmentin an important area of life functioning, or 2. A probability of significant deterIoration in an important area of life functioning, or 3. Children also qualify if there is a probability the child will not progress developmentally as individually appropriate. Children covered under EPSDr qualify if they have a mental disorder which can be corrected or ameliorated (current DHS/EPSDT regulations also apply) C. Intervention Related Criteria Must have all, 1, 2, and 3 below: 1. The focus of proposed intervention is to address the condition identified in impairment criteria liB" above,and 2. It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning, and/or for children it is probable the child will progress developmentally as individually appropriate (or if covered by EpsDTcan be corrected or ameliorated), and 3. The condition would not be responsive to physical healthcare based treatment. 101 LITTLE HOOVER COMMISSION 102 ApPENDICES ::;i;}: PATH . · . "Grants , "r... . "74,70'1 ..i ·') ::i):!: 2;526 ·':3,8tD,060 :···,.12,376 ... 244,108 .y 147,n.9····· 11,618<J?55 39,982 665.46;;. 'i.' 2,848 ::. 1,33.4,674 ;·)~:m·.· ...... ~;865,911 ,/~ :Gleiih' 809,617 974' , .., ;;': 3,486 ;;• • ;;0,000' .H.un1boldt:.';::,: 4,MS'lS59 71. ,;;' ;:;;/" 10,000 468,000 h11perial ..... . 3f~18,926 ,581. iF , .;.,)0,000 . 100;000 !!lYo '. ....•... 895,433 ,,:." 115,269;.::;::,'. ···· .. ·2,217 :::,;. 77;000 ····Kern· .. ,:<.w; 16;505. 1.15')';" 9,249,29j"·:·.,.: 3T;013 1,400,0'0'0' 8,461,271 :Ki" ..... 3,068,558 1,PQJ.()44 10,000' " &3,333 ···.·245;575· Lake 1 ':;#,,;514,157 . . 7,162 '54,0'0'0' 154,5Q~ ta&.en ~73.644 · : .• ';' 3003'" 116,667 ;'145,980 LoSArigel~': 69:il~2.334 :."577)71. 2,132,893 27,i~2,476 Madera:::;: ;.:;1)'2,906,276:;:';: 984,371 10,0'00' 248,461 617,608 X <;;[:: ~arln"···· "'i1t;!io' ;/;'9:,553,8f)5);,i 2,065;4tl'f'Y" 10,000 ;,40',000 j=±~:;;i:" 2,:~t~~1~~~~: 1,359 89,833 '.~6;4~4 10,006 183,750 '402,105 Met~ed 6,229;733 :;::2,884,383 250,000 ],1,565 50'.070 Modoc '/'474,644 ,.": 179.504 100',00'0: . 92,848 Mono. 369.341 . 10.815 20,196 1'3;&2 : Monterey 8,386,6Z1., 3,611.,Hi7 927,479.;· .. "Napa;' 4,6118,47°4 1,809A87 9,743 ~< ,.'·'~t7~llt.,,;~t, 97 175,000t'i'i231;903"';; . Nevada 1, 5,81 :7',"966997,:970'10'7 O"ange 51,!ro8.426 .j'; 80,856 -4,788,6Q5 ., lo ''''/\g, ~acef' ':,:;~:~06,BMi>;' §tlo ',z84,OOO •...•: :.,:~~,!l59/i l 'Piumas;.;!T·· 638,10$ ..; ' 2,498 · ,Riverside ,::' 27,798,5.97' .41,26r" 2,523,560 'Sacramento.;:' 32,903;018 64,150:: ",400;000. Siin Benito'" ... : ,?94,565 ,,::..": .;;\:~: <: . " . " .. . , , ~ se",altlln,o,38,191,226': 52,198 '115,000";1, iSanDlego ".;::i 65,457.037 111,21n 800,000" , San francisco;';: 50,301,046 · ... 75,832 583,333 ·: San Joaqldn 16,308;064 ····; .•· 30,299 29,Mt5 ~ LUis.pbispo :4,535,328 10,000 450(PQ~ San Mateo J .:.23,054,59,{w 9,831;968 2¥;~68 ····621,306·· JJ~56t498 i ;; iSanta Barbata 8,734,172 1:;.;a09~451· 'j:'3/" 15,526 3,~lQ,535' ')i:. Santa Clara 42,419,973 .. ' 2~!477t362 ....... 2~jOO.OOO 62,364 . 1,121,m . 2;357,962 . Siinta Cruz 5,276,616 .' 6,338,330' d. 11,~J4 722,694: .• :. .1,439,784 ,'Shasta4,782,86~ 2, 182,88,;,?: v y 10,OP,Q ,(~;;O,OOO ",,1},904 Sierra 246;353 ;;?f" - ,"" \022,422 Siskiyou 1,217,286 ..• ..;.0" 14J,571:Wl,4l3'.': 'SOlano ~,62i,909 '4';419,371.. ;; 15676' 505,212'.1 7 ::SonOma 10,011,487 5,813,263::':::.,:. 20,505 16:405' ... - 2 · Stanislaus 10, 1 ..7 ,181,012 .. .: .. 20,50~J: 22,5?6 . , f,3,~5,782 . ;'2;;,;:~:::'~>:, .Sutter":'Yuba .. :.,4,120',690 l,884,69? .. 10,000 ...• 50',000' 845,360' )Tehanla " 867,905: 6,073 ':.':. 594,000 118,474 ;'TrinitY , . 276,f)19 50,000 • 48,3&9 :Tulare . ;' .. 10,59S',228 4,744,229 22,100 .. , ,248,537:l':i e;:Tuolumne • .... 1;158,853<./·'471,215 4,574 . 199,{)33 296,576 '(Ventura' ·::;)~!592,484;;· 9,837, 162 .' . ike 20;505 4,000,000 25,271' 1,33f;44p .• 'Yolo .. 'f!,541,975 ,':, yf 1,795,239'/ 10,000:::2;;O',O'O'O'.9J~f{l29i . :'T" "/158,S51' 334,~16,701 1.000,000 1,646/4~ .•.~ o,o14,872 108,7~~/'.~~i: 103 ----.------.~--"" - .--"-------~-.--------------------~------ LITTLE HOOVER COMMISSION Continued Distribution of Mental Health, AB 34 and MIOCR Funding Across California Counties, 1997-98 (unless otherwise noted) County EarlyM.H. Mental Health S£PAsse5s 97~98 Base 96-97RoIlover CSOC County Initiative Managed Care Trmnt.Cas.Mgmt. SAMHSAUnaiiocated SAMHSA MOE Alameda 347,352 4,819,310 383,940 378,270 3,086,507 Alpine 7,606 12,883 Amador 55,972 64,299 12,883 12/563 Butte 174,876 '/395,989 79/063 140,761 271,345 Calaveras 32,666 152,644 24,029 85,203 2,748 7,189 Colusa 62,052 12,883 50,124 19,208 8,040 Contra Costa 544,642 1,678,653 477,362 1,421,004 1,080,774 Del Norte 112,177 12,883 86,257 12,481 £1 Dorado 73,381 350,496 20,919 56,427 81,344 16,510 fresno 303,641 5,179,765 386,963 620,786 19,994 955,639 Clem 155,999 12,883 88,206 10,144 Humboldt 126,712 398,052 46,674 211,338 8,703 183,692 43,803 Imperial 263,989 647,341 62,851 222,868 18,731 Inyo 66,213 12,883 158,289 4,000 23,857 Kern 99,061 4,556,279 215,804 629,737 744,867 Kings 39,285 352,061 39,550 70,953 15,870 34,551 lake 115,929 567,583 17,078 136,090 40,358 Lassen 193,715 12,883 61,546 Los Angeles 3,285,412 46,132,205 2,778/722 10,330/198 460,612 1,012/034 16,467,826 Madera 154,425 607,125 31,144 114,169 8,429 Marin 66,261 1,126,810 151,052 146,092 10,000 529,485 Mariposa 37,990 72,450 12,883 87,928 3,318 Mendocino 51,286 519,726 38,987 18,372 28,640 Merl:ed 47,924 1,076,690 83,545 275,040 152,478 351,535 266,911 Modoc 10,238 59,568 12,883 Mono 26,765 12,883 7,149 Monterey 313,498 803,567 138,195 303,844 740,475 532,678 Napa 111,584 507,617 81,685 102,386 126,315 Nevada 213,770 27,537 33,934 30,893 Orange 580,472 10,040,021 699,001 1,043,752 3,436,264 Placer 125,847 311,081 92,966 146,111 444,188 231,960 Plumas 100,394 15,054 191,291 7,671 7,672 Riverside 510,899 6,879,433 496,344 1,691,795 1,513,199 Sacramento 440,578 8,648,805 339,791 915,196 46,230 1,761,153 San lIenito 16,791 104,383 31,710 18,152 29,539 San Bernardino 884,142 9,470,432 721,668 1,850,813 7,840 1,842,753 San Diego 2,045,793 9,982,226 813,276 1,406,965 90,706 3,173,290 San Francisco 287,625 2,804,717 387,233 1,267,103 89,507 2,748,050 San Joaquin 485,278 3,487,252 260,686 529,768 125,765 1,063,736 San Luis Obispo 161,719 277,414 96,368 63/094 254,061 335,430 San Mateo 17,370 1,813,554 568,934 507,581 1,477,507 Santa Barbara 80,333 116,703 154,961 129,876 644,045 Santa Clara 778,544 3,816,164 959,599 350,860 1,551,653 SantaCruz 75,379 1,455,237 284,054 71,261 328,689 Shasta 68,193 627,384 60,015 111,485 266,778 Sierra 16,082 13,841 48,318 Siskiyou 20,190 228,807 18,594 71,946 20,364 7,402 Solano 68,062 119,582 68,492 749,016 Sonoma 172,920 638,684 212,920 157,353 28,347 560,252 Stanislaus 349,920 1,873,737 201.i,244 335,189 195,039 1,001,530 647,182 Sutler-Yuba 61,672 1,453,654 66,312 192,314 11,123 22,803 Tehama 18,953 277,026 17,858 137,148 25,947 Trinity 106,357 12,883 81,884 27,102 5,924 Tulare 267,358 2,451,149 121,178 442,510 334,122 Tuolumne 21,166 202,471 14,017 24,623 20,042 Ventura 302,870 1,187,826 236,184 128,006 40,549 1,027,131 Yolo 19,507 553,895 96,797 17&,135 377,365 Total 14,117,705 140,8:U,61 S 11,334,000 28,ml1,406 1,465,200 3,987,515 48,545,544 104 ApPENDICES Continued '<''< P(s't~ibuJj~o7~entar~~lth,AB:r4~nd~~16CR·~!Ana· 6cr~§~Calif~fpicfCoug,ti,~~,'1'1'997~9~",(~nles~othervdse'ogf~ J'" '. Othef'v "~~ &' ';£;t.nts Insuram;~'" 121 372 100,239 5,977,. · .. 1,072,782 "jS2;514 2,975,303 ""'18,696,656 ," 5,775 ··1p09,765 959;526 5,372,9~J'fT 5122931, 3;414;255 1,149,988 60;093,888" , 5,311 164,50~ 52,061 .2,631,745 95,482 2,33!). 304;09~ .. "S,756,fflt,y, .. " U'S6,579 .102,737 797,918 , ,~04,,66,2: ;;~ 40,.,11).1' ,<, ' ~'>A;i;1Ln '1,901;tsi1',,, • Glenn' ',,,;,/';' . 20,045 . ",;",,}.13,571 "Humboldt .717',389 272,718, "451,361. 799,225 . ":";'1~951,457 .. . 72 '.rial./ . .. 264,130 )'J7;432 77,805.····· 175,635 .fn.y.o .. 2,534 3,644 ' .. 77,930 130',';:J-: ., ..' Kern l t 422 t 348,101 "~6,630 44,789,024 : Kings 46,;'!56'" 80,953 ..., 102,026 199,186 ,• . ,,",~;I;21,519 37,742 33,583 '''''3,404,234. LaSSen 44,590 47,706 1,74'Al~,/ Los Angel.,. .. >3;~lJ,770 3,242,997 27,863,345 9,196,681, 492,638,011 '. Madera .... "44,308 114,169 40,579 147,976 5,789,040 . . , ..> " Marin'" 147, 4.4 4" 637,467 . "1,816;298 1,839,645 .. ',~8,660,368 ,Mariposa .3,297 5t;41.\6 .27,16V 50,666 . 1,060,859" .• ' Mendocino ' 12.1,305 91,565 246,730 5;~,202. . Merced·" 52,580 . 90,000 96,481 ...3 44,767 12,263,102 ModQC 34,295 19,389 983,369 . Mono ,,,7"/"·' 211875 469,024 .• Monterey 72i31;17 80,151 46;379 202,763 . 392,161 "1/l,768,311. NaPa ... 46;708 822,992 99,978 338,884 ' 255,208 '9;578,378; .. Nevada .·· •• 36,310 , n""';~ 20,647 . 128,495 u/, ' 3;572,216' Orange 10,565,561 689,270 nn :;~;" ,/' ' 1,592,036 5~4~~t;815 10,585,561 109,460)J45 Placer 19,492;·1;'; ):~~;652 504,696 207,201 .... . 8,76~,88t.. { . Plumas .. 68,035" .4,754 . ';330,119., {• . , Riverside .. 83',832 91'(413 575,682 1,070,622 'l7;371,008 3,995,957 79,405,813 sacramento 50,164 707,008 ... .1.46;683 1,679,500 71,900,217 .s an Benito 77,072 25,934 .J;$'t6Ji15 .. . san Bernardino ~/1J3,616 608,124 "997,467' .2,911,208. .... f,103,26€L • 75,~7,"'3" . san Diego' :492;919 ... 28,732 . 2,461,836 ·.J,437,316 . 232,447" 107,998,801. san Fram;lsCo )2,676,896 '2,865,852 1,122,175 701,756 'iO,Q7Q,904 4,808,675 nO,298,779 san Joaquin 411,068" 37,203 688,466 "Z;962,889 87,133 34,861;773 Siln Luis Obispo 902,500 729,A50', 417,325 883,855 88,617 · 12,377,173 san 1,2()3>IIlIl Mateo 2,Z56,549 253,495 .5,316,801 ".2,429,787 51,534,100' santa Barbara 200,545 f;014,831 3,087,305 166,768 3,057,996 .:;>'28,372 28,773,421' Santadara 21,976,234 3,893,$56 '176,096 952,162 4,808,289 1,748,407 113,150,396 ,santaCruz 2,582,9F 297,1ZQ" 381,004 90l,636, 661,141 331,062 'Z1;409,308 . Shasta ".839',381 186,698 246,192 10,047,784 . Sierra, 3,628 15,677 344,099' . Siskiyou 74,141 , 97,2n 52;333 3;534,706 Solano 119,982;." 593,169 '74;7=*9· 2,177,534 327,123 .' ;~,565;552 SOnoma 222,299 1,583,439' . 170,793 8,025,594 1,018,837 · 30,134,210. . $tanislaus 1,274,530 'll,142 2,720,410 3;170,581 956,618 34,988,~,;. Sutter-Yuba 29,091 288,310 105,987 110,555 9,252;569 .. Tehama 45,974 38,253 .. 74,386,'· 307,691 "'4;356,01& 1rillity 9,997 35,973 1,157,773 Tulare 133,025 126,458 95,675 ~7,849 46,832 20,686,356 Tuolumne 8a,806 184,452 ,53,092 84,559 Z)JZ3,47!t,··, Ventura 4,475,034 2,311,724 139,037' 858,566 361,229 41;4ofi,331 ... Yolo 41,390 109,506 274/255 262,813 9;556,933 12,225,738 138)J38,854 105 LITTLE HOOVER COMMISSION Continued Distribution of Mental Health, AB 34 and MIOCR Funding Across California Counties, 1997. . 98 (unless otherwise noted) In addition to providing the funding outlined above, the State also provides the following funds. MIOCR A834 (1998 & 1999) (1991)..2000) Humboldt $2,268,986 San Diego $5,000,000 los Angeles $4,800,000 Kern $3,098,768 San Francisco $5,000,000 Sacramento $2,800,000 los Angeles $5,000,000 San Mateo $2,137,584 Stanislaus $1,900,000 Orange $5,034,317 Santa Barbara $3,548,398 Placer $2,139,862 SantaCruz $1,765,012 Riverside $3,016,673 Sonoma $3,704,473 Sacramento $4,719,320 Stanislaus $1,713,490 San Bernard in o $2,477,557 Caregiver Resource Centers: .CSUC Research Foundation: $309,775 Serving: Butte, Glenn, lassen, Modoc, Plumas, Shasta, Siskiyou, Tehama and Trinity • Del Oro Caregiver Resource Center: $428,004 Serving: Alpine, Amador, Calaveras, Colusa, EI Dorado, Nevada, Placer, Sacramento, San Joaquin, Sierra, Sutter, Yolo and Yuba eFamily Caregiver Alliance: $786,230 Serving: Alameda, Contra Costa, Marin, San Francisco, San Mateo and Santa Clara eHealth Projects Center: $310,775 Serving: Monterey, San Benito and Santa Cruz -Inland Caregiver Resource Center: $437,014 Serving: Inyo, Mono, Riverside and San Bernardino -North Coast Opportunities: $459,475 Serving: Del Norte, Humboldt, lake, Mendocino, Napa, Solano and Sonoma .Rehabilitation Institute of Santa Barbara: $384A35 Serving: San luis Obispo, Santa Barbara, Ventura .Southern Regional Resource Center: $416,829 Serving: Imperial and San Diego .St. jude Medical Center: $328,699 Serving: Orange .USC, Andrus Older Adult Center: $498,790 Serving: los Angeles -Valley Caregiver Resource Center: $315}375 Serving: Fresno, Kern, Kings, Madera, Mariposa, Merced, Stanislaus, Tulare and Tuolumne eFamily Caregiver Alliance: $571,594 Statewide Resources Consultant AIDS Contracts Mental Health/Health Departments Private Nonprofit Agencies Los Angeles $376,000 Aid Service foundation of Orange County $85,714 San Diego $85,000 Center for Social Services (San Diego) $65,114 San Francisco $264,000 Hemophilia Council of California (Sacramento) $300,000 San Joaquin $34,286 Inland AIDS Project (San Bernardino) $34,286 San Mateo $60,000 Minority AIDS Project (los Angeles) $34,000 Santa Barbara $25,000 Pacific Center for Human Growth (Alameda) $27,312 Santa Clara County $75,000 TRAUMATIC 8RAIN INJURY CONTRACTS Central Coast Center for Independent living (Santa Cruz) $193,388 The Betty Clooney Foundation (los Angeles) $223,741 Mercy Healthcare (Sacramento) $125,000 St. Jude Medical Center (Orange) $124,821 Source: Department of Mental Health. 106 ApPENDICES Appendix E Glossary of Terms 5150. California Health and Welfare Code, Section 5150 outlines the circumstances in which a person can be detained against their will for mental health treatment. Those circumstances are when a person is a danger to self or others, or gravely disabled, meaning unable to provide for their own clothing, food or shelter. Biological factors. Factors that contribute to mental illness that are biological in origin, such as genetics, chemical imbalances or the structure of the brain. Civilly committed clients. Refers to clients who have been committed to an institution under the Lanterman-Petris-Short Act. Co-occurring disorders. Refers to two or more disorders occurring simultaneously. Generally refers to mental health and substance use disorders but can refer to mental health, physical health, developmental or other disorders. Dual diagnosis. Refers to mental health clients who have been diagnosed with a mental illness and a substance use disorder. Fixed risks. Factor that can contribute to mental illness that cannot be altered, such as genetic factors, gender or age. Insurance Parity. Federal and state laws that establish the extent to which insurance providers can impose limits on access to mental health care that are more restrictive than limits imposed on access to physical health care. Legislation to align access to mental and physical health care under insurance programs is referred to as parity legislation. Integrated services. Generally refers to providing an array of services through a single agency or entity. Often requires discretionary or blended funding to cover the cost of multiple services. Lanterman-Petris-Short Act (LPS). California Welfare and Institutions Code, Section 5100 - 5550 is known as the Lanterman-Petris-Short Act. It establishes provisions for providing community-based care to mental health clients. The LPS Act includes provisions for providing involuntary treatment. Outpatient involuntary treatment. The LPS Act limits the conditions under which mental health clients can be involuntarily treated. In practice, involuntary treatment is only provided on an inpatient basis where service providers can compel clients to participate in treatment, by force if necessary. Several states, including New York, have adopted legislation that allows the use of outpatient treatment that is involuntary. In general, outpatient involuntary treatment refers to mandating participation in outpatient treatment with the threat of forced inpatient treatment. Protective factors. Factors that can reduce the likelihood that a person will experience a mental illness or will reduce the severity or reoccurrence of symptoms. Stable and safe housing and social support networks are examples of potential protective factors. 107 LITTLE HOOVER COMMISSION Psychological factors. Psychological attributes that can contribute to the likelihood that a person will experience a mental illness, such as how person responds to stress. Rehabilitation option/Rehabilitation model. Federal law, under the Medicaid Rehabilitation option, allows mental health providers to bill Medi-Cal for an array of services that contribute to a client's rehabilitation. The Rehabilitation model contrasts with the Clinic Model that is more restrictive in the services that are covered. Self-help. Refers to a movement within the mental health field in which clients develop and provide mental health services to other clients to promote recovery. Social factors. Refers to learned behaviors and other social attributes that contribute to the likelihood that a person will develop a mental illness. Supportive housing. Supportive housing is an approach to providing services and housing in a single location. It recognizes that some people who are homeless are poorly equipped to navigate the social service system. The concept of supportive housing is based on the premise that providing an array of services very near people's homes can improve outcomes. (Source: Corporation for Supportive Housing. Nd. Why Supportive Housing. New York, NY: Corporation for Supporting Housing. 'NWW.csh.org) Systems of Care. An approach to providing services that links multiple agencies, provides care in the community as opposed to institutional care and offers a continuum of services. Systems of Care often involves measuring the costs and outcomes of services. (Source: Abram Rosenblatt, Center for Mental Health Service Research, University of California. 2000. On file.) Wrap-around services. An approach to providing services that are individualized and unconditional. Wrap-around services are usually possible only with flexible funding that allows service providers to develop individual treatment plans that address an array of needs. (Source: Abram Rosenblatt, Center for Mental Health Service Research, University of California. 2000. On file.) 108 ApPENDICES Appendix F Mental Health Information Sources and Organizations The following organizations can provide useful information, data and resources on mental health services and policies. This is a partial list. Educational Institutions and Research Centers Center for Mental Health Service Research Center for Mental Health in Schools University of California Department of Psychology, UCLA 2020 Milvia Street, # 405 Box 951563 Berkeley, CA 94720 Los Angeles, CA 90095-1563 http:// socrates. berkeley.edu:80 I-cmhsr lin http:// smhp.psych. ucla.edul dex.html National GAINS Center. 345 Delaware Avenue, Delmar, NY 12054 http://www.prainc.com/gains/index.html State and Federal Offices Assembly Select Committee on Mental Health California Department of Alcohol & Drug State Capitol, Room 4140 Programs P.O. Box 942849 1700 K Street, 4th Floor Sacramento, CA 94249-0001 Sacramento, CA 95814 http://www.assembly.ca.gov lacs/newcomfra http://www.adp.cahwnet.gov / meset.asp?committee=83 California Department of Corrections California Board of Corrections 1515 S Street 600 Bercut Drive Sacramento, CA 95814 Sacramento, CA 95814 http://www.cdc.state.ca.us/ http://www.bdcorr.ca.gov I California Department of Health Services California Commission on Aging 714 P Street 1020 9th Street, Room 260 Sacramento, CA 95814 Sacramento, CA 95814 http://www.dhs.cahwnet.gov I http://www.aging.state.ca.us/internet! ccoa.h tm California Department of Managed Health Care California Department of Aging 980 Ninth Street, Suite 500 1600 K Street Sacramento, CA 95814 Sacramento, CA 95814 http://www.dmhc.ca.gov I http://www.aging.state.ca.us/ California Department of Mental Health 1600 9th Street, Room 130 Sacramento, CA 95814 http://www.dmh.ca.gov I 109 LITTLE HOOVER COMMISSION California Department of Rehabilitation Senate Select Committee on Developmental 2225 19th Street Disabilities and Mental Health Sacramento, CA 95818 State Capitol, Room :3070 http://www.rehab.cahwnet.gov / Sacramento, CA 95814 http://www.sen.ca.gov /ftp/sen/committee California Department of Veterans Affairs /sellect/DEVELOP/ home1/PROFILE.HTM 1227 "0" Street Sacramento, CA 95814 Substance Abuse and Mental Health http://www.ns.net/cadva/ Services Administration Room 12-105 Parklawn Building California Mental Health Planning Council 5600 Fishers Lane 1600 9th Street, Room 350 Rockville, MD 20857 Sacramento, CA 95814 http://www.samhsa~ http://www.dmh.ca.gov /mhpc/default.htll! Texas Council on Offenders with Mental Maryland Community Criminal ,Justice Impairments Program. 8610 Shoal Creek Blvd. Department of Health and Mental Hygiene Austin, TX 78757 201 West Preston Street http://www.tdcj.state.tx.us/tcomi/tcomi Baltimore, MD 21201 home.htm Pennsylvania Partnership for Children Clay R. Yeager, Executive Director P.O. Box 1167 Harrisburg, PA 17108-1167 http://www.cp.state.pa.us Non-Profit Agencies and Associations California Alliance of Child & Family California Association of Social Services Rehabilitation Agencies 2201 K St. Post Office Box 388 Sacramento, CA 95816 Martinez, CA 94553 http://www.cacfs.org http://www.casra.o~ California Association of Local Mental California Child, Youth and Family Health Boards & Commissions Coalition 20224 Goleta Court 1220 H Street, Suite 103 Redding, CA 96002 Sacramento, CA 95814 http://www.ccyfc.or:g California Association of Marriage & Family Therapists California Citizens for Health Freedom 7901 Raytheon Road 8048 Mamie Avenue San Diego, CA 92111-1606 Oroville, CA 95966 http://www.camft.org http://www.citizenshealth.orgl California Association of School California Coalition for Ethical Mental Psychologists Health Care 1400 K Street, Suite 311 1568 6th Avenue Sacramento, CA 95814 San Diego, CA 92101 http://www.casponline.org http://www.ccernhc.org/horne.htrnl 110 ApPENDICES California Council of Community Mental Community Residential Care Association of Health Agencies/California Coalition for California Mental Health Post Office Box 163270 1127 11th Street, Suite 830 Sacramento, CA 95816 Sacramento, CA 95814 http://hometown.aol.com/SNCNEWS/inde http://www.cccmha.org x.html California Division-American Association Los Angeles Coalition to End Hunger and for Marriage and Family Therapy Homelessness 57 Longfellow Road 548 South Spring Street, Suite 339 Mill Valley, CA 94941 Los Angeles, CA 90013 http://www.aamft.org/ http://www.lacehh.org/ California Healthcare Association LPS Task Force 1215 K Street 203 Argonne B-1 04 Sacramento, CA 95814 Long Beach, CA 90803 http://www.calhealth.org Mental Health Association in Los Angeles California Institute for Mental Health County 2030 J Street 1336 Wilshire Boulevard, 2nd Floor Sacramento, CA 95814 Los Angeles, CA 90017-1705 http://www.cimh.org/ http://www.mhala.org/ California Mental Health Directors Mental Health Client Action Network Association 1024-A Soquel Avenue 2030 J Street Santa Cruz, CA 95062 Sacramento, CA 95814 http://www.sasquatch.com/-mhcan/index http://www.cmhda.org/ .shtml California Network of Mental Health Clients National Alliance for the Mentally Ill, 1722 J Street, Suite 324 California Sacramento, CA 95814 1111 Howe Avenue, Suite 475 http://www.cnmhc.org/ Sacramento, CA 95825 email: namica@pacbell.net California Psychiatric Association http://www.nami.org/aboutlnamica/ 1400 K Street, Suite 302 Sacramento, CA 95814 National Association of Social Workers, http://www.calpsych.org/ California Chapter 1016 23rd Street California Psychological Association Sacramento, CA 95816 1022 G Street http://www.naswca.org/ Sacramento, CA 95814 http://www.calpsychlink.org/ Protection & Advocacy, Inc. 100 Howe Avenue, Suite 185N California Society for Clinical Social Work Sacramento, CA 95825 720 Howe Avenue, Suite 112 http://www.pai-ca.org/ Sacramento, CA 95825 http://www.cswf.org/states/ calif! cascsw.h Volunteers of America tml 530 Bercut Drive Sacramento, CA 95814 Citizen's Commission on Human Rights http://www.voa.org Post Office Box 1730 Thousand Oaks, CA 91358 http://www.cchr.org 111 LITTLE HOOVER COMMISSION 112 NOTES Notes 113 LITTLE HOOVER COMMISSION 114 NOTES Notes 1. Nunnally, J. 1981. Popular Conceptions of Mental Health. New York, NY: Holt, Rinehart and Winston. As referenced in Link, Bruce G., Jo C. Phelan, Michaeline Bresnahan, Ann Stueve and Bernice Pescosolido. 1999. "Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance." American Journal of Public Health. 89(9): 1328-1333. 2. California Mental Health Planning Council. 2000. Letter to the Assembly Budget Committee on "unmet needs." April 7, 2000. On file 3. Taylor K. Moorehead, Commander, Los Angeles County Sheriffs Department. Twin Towers Correctional Facility. Testimony before the Little Hoover Commission. October 28, 1999. Sacramento, State Capitol Building. 4. Mcintosh, John L. nd. "USA State Suicide Data 1997: Rate, Number, and Ranking of Suicide, Each U.S.A. State." Washington, D.C.: American Association of Suicidology. (www.iusb.edu/-jmcintos/USA97StatesTab.htm) 5. U.S. Department of Health and Human Services. 1999. Mental Health Report: A Report of the Surgeon General. Rockville, MD: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Page 6. 6. U.S. Department of Health and Human Services. 1999. (See endnote #5) Page 57. 7. The California Department of Corrections provides mental health services to 18,500 inmates with serious mental illness. C. A. "Cal" Terhune. Director, California Department of Corrections. Testimony before the Little Hoover Commission. October 28, 1999. Sacramento, State Capitol Building. California's jails hold an estimated 11,500 mentally ill individuals. California Board of Corrections. 2000. Improving California's Response to Mentally III Offenders: An Analysis of County-Identified Needs - Staff Report. Sacramento, CA: California Board of Corrections. 8. The National Co morbidity Study found that 41.2 percent of those with affective disorders had any alcohol or drug disorder and that 50.9 percent of persons with any mental disorder had any alcohol or drug disorder. The Department of Finance reports that California has 24,882,708 adults (ages 18 or older). National estimates suggest that 21 percent of adults experience some form of diagnosable mental illness, or 5,225,368 California adults. Similarly, 5.4 percent of all adults experience a serious mental illness, or 1,343,666 adults in California. Based on the National Comorbidity study, 50.9 percent of the 5,225,368 million adults who experience some form of mental illness also have some form of alcohol or drug disorder, or 2.659 million adults in California. Using the more conservative co-morbidity estimate of 41.2 percent, applied only to adults with serious mental illness, the figure is about 553,590 adults. Sources: Candace Cross-Drew. Department of Mental Health. Personal Communication October 10, 2000. On file. Kessler, Ronald C., Christopher B. Nelson, Katherine A. McGonagle, Mark J. Endlund, Richard G. Frank, Philip J. Leaf. 1996. "The Epidemiology of Co-Occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization." American Journal of Orthopsychiatry. 66(1): 17-31. Department of Finance. 1998. "Race/Ethnic Population with Age and Sex Detail, 1970-2040." Sacramento, CA: Department of Finance. http://www.dof.ca. gov / newdr / california. txt. Department of Alcohol and Drug Programs. 2000. "Drug and Alcohol Treatment Access Report." Sacramento, CA: Department of Alcohol and Drug Programs. On file. 9. California Statewide Supportive Housing Initiative. Welfare and Institutions Code, Section 53250. 115 LITTLE HOOVER COMMISSION 10. David Pingatore, Ph.D., Center for Mental Health Service Research. University of California. 2000. "Summary of Best Practice Guidelines." Personal Communication. On file. 11. Jonathan Vernick. Director, Baker Places San Francisco. Personal Communication. July 18, 2000. 12. Pennsylvania Partnership for Safe Children. 2000 .. Personal Communication. 13. Wolff, Nancy, R. J. Diamond and T. W. Helminiak. 1997. "A New Look at an Old Issue: People with Mental Illness and the Law Enforcement System." Journal of Mental Health Administration. 24:152-165. As referenced in Clark, Robin E., Susan K. Ricketts and Gregory J. McHugo. 1999. "Legal System Involvement and Costs for Persons in Treatment for Severe Mental Illness and Substance Abuse Disorders." Psychiatric Services. 50(5):641-647. Page 642. 14. Substance Abuse and Mental Health Services Administration. 2000. "Jail Diversion Programs Enhance Care." SAMHSA News. 8(2): 1-4. City of Memphis. Nd. '"Memphis Police Crisis Intervention Team." On file. 15. Clark, Robin E., Susan K. Ricketts and Gregory J. McHugo. 1999. (See Endnote #13) Page 641. 16. Clark, Robin E., Susan K. Ricketts and Gregory J. McHugo. 1999. (See endnote #13) 17. The Legislature has authorized $104 million for the Mentally III Offender Crime Reduction Program and $60 million for the Integrated Services to Homeless Adults (AB :34/ AB 2034) program. 18. Substance Abuse and Mental Health Services Administration. nd. "Jail Diversion: Knowledge Development and Application Program." Washington, D.C.: Substance Abuse and Mental Health Services Administration. 19. Welfare and Institutions Code. Section 5600.2(J). 20. California Mental Health Planning Council. September 29, 2000. "Draft - Mental Health Master Plan." Page 77. On file. 21. Wayne Clark and Bill McConnell. 2000. Center for Mental Health Service Research. University of California. "Implementation of Outcome Measures." Personal Communication. On File. 22. Wayne Clark and Bill McConnell. 2000. (See Endnote #21). 23. Little Hoover Commission. 1999. Now in Our Hands: Caring for California's Abused and Neglected Children. Sacramento, CA: Little Hoover Commission. 24. Little Hoover Commission. 1998. Beyond Bars: Correctional Reforms to Lower Prison Costs and Reduce Crime. Sacramento, CA: Little Hoover Commission. 25. Little Hoover Commission. 1994. The Juvenile Crime Challenge: Making Prevention a Priority. Sacramento, CA: Little Hoover Commission. 26. Please contact the Commission if you would like copies of the testimony provided to the Commission during these hearings. 27. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 39. 28. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 52. 29. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 57. 30. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 55. 116 NOTES 31. Catherine Camp. Executive Director. California Mental Health Directors Association. Testimony before the Little Hoover Commission. September 7, 1999. Sacramento, State Capitol Building. 32. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 46. 33. Regier, D. A., Narrow, W.E., Rupp, A., and Rae, D. S. (in press). "The Epidemiology of Mental Disorders Treatment Needs: Community Estimates of 'Medical Necessity.' As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 49. 34. National Advisory Mental Health Council. 1993. "Health Care Reform for Americans with Severe Mental Illnesses: Report of the National Advisory Mental Health Council." American Journal of Psychiatry. 15: 1447-1465. As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 46. 35. National Advisory Mental Health Council. 1993. (See Endnote #34) 36. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 48. 37. Friedman, Robert M., Judith W. Katz-Levey, Ronald W. Manderschied and Diane L. Sondheimer. 1996. "Prevalence of Serious Emotional Disturbance in Children and Adolescents." In R. W. Manderschied and M. A. Sonnenschein. (Eds.) 1996. Mental Health, United States. Rockville, MD: Center for Mental Health Services. Pages 71-88. 38. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 48. 39. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 48. 40. Legislative Analyst's Office. April 14, 2000. "California's Mental Health System: Selected Data." Presented to Joint Committee on Mental Health Reform. Sacramento, CA: Legislative Analyst's Office. Figure 4c. "Clients Receiving Publicly Funded Community Mental Health Services. Medi-Cal and Non-Medi-Cal Status and Expenditures. All Funds. Selected Years." 41. Gelber, Suzanne and David Rinaldo. 2000. "The State of the State of Behavioral Health in California: Alcohol, Drug, and Mental Health Services and Systems." Berkeley, CA: SGR Health Alliance. Page 151. 42. Rice, D. P. and L. S. Miller. 1996. "The Economic Burden of Schizophrenia: Conceptual and Methodological Issues, and Cost Estimates." In M. Moscarelli, A. Rupp and N. Sartorious. (Eds.) Handbook of Mental Health Economics and Health Policy. Volume 1: Schizophrenia. New York: John Wiley and Sons. Pages 321-324. As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 411. 43. U.S. Population, January 1, 2000: 274,024,000. As reported by the U.S. Census Bureau. "Monthly Estimates of the United States Population: April 1, 1980 to July 1,1999, with Short-Term Projections to July 1,2000." (www.census.gov /population/estimates/nation/intfile1-1.txt) California population, January 2000: 34,336,000. As reported by the Department of Finance. "City/County Population Estimates and Annual Percentage Change." (www.dof.ca.gov/HTM/DEMOGRAP/e-1table.html). 44. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 288. 45. RachBeisel, Jill, Jack Scott and Lisa Dixon. 1999. "Co-occurring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research." Psychiatric Services. 50(11): 1427-1434. Page 1427. 46. National Survey of Homeless Assistance Providers and Clients. 1999. Homelessness: Programs and the People they Serve. Washington, D.C.: Interagency Council on the Homeless. 117 LITTLE HOOVER COMMISSION 47. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 63. 48. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 63. 49. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 63. 50. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 63. 51. Harding, C., J. S. Strauss, and J. Zubin. 1992. "Chronicity in Schizophrenia: Revisited." British Journal of Psychiatry. 161:27-37. As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 97. 52. Frese, F. J. 1998. "Advocacy, Recovery, and the Challenges of Consumerism for Schizophrenia." Psychiatric Clinics of North America. 21:233-249. As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 97. 53. Fisher, Daniel. nd. "A New Vision of Recovery: People Can Fully Recover from Mental Illness, It is Not a Life-Long Process." Lawrence, MA: National Empowerment Center. On file. 54. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 98. 55. California has 59 local mental health authorities. Fifty-six counties operate authorities, two counties, Yuba and Sutter, have a joint mental health authority and two cities, Berkeley and a Tri-City authority in eastern Los Angeles County, operate public mental health services directly. Source: Catherine Camp. September 7, 1999. (See Endnote #31). 56. Medi-Cal Policy Institute. 2000. "Frequently Asked Questions." Oakland, CA: Medi-Cal Policy Institute. www.medi-cal.org/resources/faqs/index.html. On file. 57. Under Medicaid states can receive reimbursement under a "clinic option" or a "rehabilitation option." The clinic option provides federal funds primarily for mental health treatment offered through a clinical setting. In contrast, the rehabilitation option allows reimbursement for services offered in a variety of settings intended to treat a mental disorder as well as services intended to address functional limitations associated with a mental disorder. See California Department of Mental Health. 1994. Medi-Cal Managed Mental Health Care. Sacramento, CA: Department of Mental Health. Attachment M, Page 2. 58. California Department of Mental Health. 1999. "Frequently Asked Questions About Systems of Care, Medicare and Medi-Cal." Sacramento, CA: Department of Mental Health. 59. Scheffler, Richard and Neal Wallace. 1999. "The Impact of the 1991 Program Realignment on California's Public Mental Health System." CPRC Briefing. Berkeley, CA: California Policy Research Center. November 18, 1999. 60. California Department of Mental Health. 1994. (See Endnote #57) 61. California Department of Mental Health. 1999. "Report to the Legislature: Status Update on the Implementation of Mental Health Managed Care." Sacramento, CA: Department of Mental Health. 62. California Department of Mental Health. 2000. "Description of the Department." Sacramento, CA: Department of Mental Health Homepage. (www.dmc .. cahwnet.gov/programs.html). 63. Department of Finance. 2000. "Department of Mental Health." Governor's Budget: 2000- 01. Sacramento, CA: Department of Finance. Page HHS 109. The Governor's Budget 2000-01 reports 153.7 personnel positions for the "Community Services" division. The Department of Mental Health refers to this unit as the "Systems of Care" division in its organizational chart. The 153.7 figure includes 51 positions dedicated to the department's 118 NOTES "Program Compliance" unit. Source: Department of Mental Health. Personal Communication. September 20, 2000. 64. California Mental Health Planning Council. 1997. Adult Performance Outcome Study: Wave 1 to Wave 3. Sacramento, CA: Mental Health Planning Council. 65. California Mental Health Planning Council. January 2001. (See Endnote #20) Page 77. 66. California Mental Health Planning Council. January 2001. (See Endnote #20). 67. Welfare and Institutions Code, Section 5772(c). 68. Welfare and Institutions Code, Section 5604.2. (See Endnote # 19) 69. Department of Finance. 2000. (See Endnote #63). 70. Department of Finance. 1993/94 - 2000-01. "Department of Mental Health. State Hospital Inhospital Population Count." Governor's Budget: 1993-94 through Governor's Budget: 2000-01. Sacramento, CA: Department of Finance. 71. Department of Finance. 1993/94 - 2000-01. (See Endnote #70). Penal Code figures include clients reported in the budgets as "PC" and "Other" clients. "Other" clients as reported in the budget include PC2684/PC2974, Youth Authority, Developmentally Disabled-Forensic, Other PC and SVP clients. 72. Department of Mental Health. 73. Department of Mental Health. 74. Counties are the responsible authority for the delivery of public mental health services. Catherine Camp. September 7, 1999. (See Endnote #31). 75. California Association of Local Mental Health Boards and Commissions. 2000. Letter to the Little Hoover Commission. On File. 76. Department of Mental Health. 1999. California Department of Mental Health. Sacramento, CA: Department of Mental Health. On File. 77. Welfare and Institutions Code, Section 5600.3 as cited in California Mental Health Planning Council. 1995. Effects of Realignment on the Delivery of Mental Health Services. Sacramento, CA: Mental Health Planning Council. Page 81. 78. Department of Mental Health. 1999. (See Endnote #58). 79. Protection and Advocacy, Inc. 1999. "Medi-Cal Mental Health Managed Care: Questions and Answers." Sacramento, CA: PAl, Inc. 80. Mental Health Planning Council. Letter to Senator Chesbro and Assemblymember Thomson. April 25, 2000. On file. 81. Nunnally, J. 1981. (See endnote #1) 82. Nieto, Marcus. 1999. Mentally III Offenders in California's Criminal Justice System. Sacramento, CA: California Research Bureau. Norman, Cotton and Associates. 1989. Stirling Report. California Department of Corrections, Western Consortium for Public Health and Scarlett Carp and Associates. Mental Health Services Delivery System. 1993. As referenced by Donald Specter, Director, Prison Law Office, San Quentin, California. Testimony before the Little Hoover Commission, October 28, 1999. Sacramento, State Capitol Building. 83. C. A. "Cal" Terhune. October 28, 1999. (See endnote #7) 84. California Department of Corrections. 2000. "CDC Facts." www.cdc.state.ca.us/factsht.htm. 119 LITTLE HOOVER COMMISSION 85. Donald Specter. October 28, 1999. (See Endnote #82). 86. As referenced in Assembly Bill 34, Steinberg, Chapter 6178, Statutes of 1999. 87. Commander Taylor Moorehead. October 28, 1999. (See endnote #3) 88. Izumi, Lance, Mark Schiller, and Steven Hayward. 1996. "Corrections, Criminal Justice and the Mentally Ill: Some Observations About Costs in California." San Francisco: Pacific Research Institute for Public Policy. 89. Leo McFarland. Executive Director, Volunteers of America, Sacramento, CA. Personal Communication. September 12,2000. 90. The U.S. Surgeon General reports the indirect costs of mental illness at $79 billion for the United States. California's share based on population is $9.875 billion. SGR Healthcare Alliance reports the direct costs of mental illness in California at $9.5 billion. U.S. Department of Health and Human Services. Page 411. Gelber, Suzanne and David Rinaldo. 2000. "The State of the State of Behavioral Health in California: Alcohol, Drug, and Mental Health Services and Systems." Berkeley, CA: SGR Healthcare Alliance. Page 151. On file. 91. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 46. 92. Department of Finance. 2000. (See Endnote #63) Page 15. 93. Ostiin, T. Bedirhan. 1999. "The Global Burden of Mental Disorders." American Journal of Public Health. 89(9):1315-1318. 94. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 411. 95. Appendix D lists the latest available expenditure data for county mental health programs. In fiscal year 1997-98 California counties spent $1.939 billion on public mental health services. These figures reflect State, local, federal and private expenditure on services delivered through the public mental health system. Expenditure data for later fiscal years are not available but have undoubtedly increased. That same year the State spent an additional $451 million on the State hospital system. The 1999-2000 fiscal year budget for the state hospital system exceeds $500 million .. The $2.5 billion estimate also does not include the costs of treatment provided through the criminal justice system or other criminal justice and public safety costs .. 96. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 6. 97. Link, Bruce G., Jo C. Phelan, Michaeline Bresnahan, Ann Stueve and Bernice Pescosolido. 1999. (See Endnote # 1) 98. Hanson, K. W. 1998. "Public Opinion and the Mental Health Parity Debate: Lessons from the Survey Literature." Psychiatric Services. 49:1059-1066. 99. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 9. 100. Phelan, J., B. Link, A. Stueve and B. Pescosolido. 1997. "Public Conceptions of Mental Illness in 1950 in 1996: Has Sophistication Increased? Has Stigma Declined?" Paper presented at the meeting of the American Sociological Association, Toronto, Ontario. As referenced in U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 7. 101. Swanson, J. W. 1994. "Mental Disorder, Substance Abuse, and Community Violence: An Epidemiological Approach." In ,John Monahan and Henry J. Steadman. (eds.) 1996. Violence and Mental Disorder: Developments in Risk Assessment. Chicago, IL: University of Chicago Press. (Pages 101-136.) Chicago, IL: University of Chicago Press. Pescosolido, Bernice A, John Monahan, Bruce G. Link, Ann Stueve and Saeko Kikuzawa. 1999. "The Public's View of the Competence, Dangerousness, and Need for Legal Coercion of Persons with Mental Health Problems." American Journal of Public Health. 89(9): 1339-1345. 120 NOTES 102. Nunnally, J. 1981. (See endnote #1) 103. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 9. 104. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 9. 105. Clark Brooks. May 9, 2000. "County's Mental Health Services May Get Boost." Union Tribune. San Diego, CA: Union Tribune. 106. Society for Human Resource Management and the National Foundation for Brain Research. 1999. "Depression in the Workplace Survey." As reported by Guynn, Jessica. 1999. "Job Sites Hurt by Depression." San Ramon Valley Times. Danville, CA: San Ramon Valley Times. 107. Dayton, Bruce. 2000. Maxwell School of Citizenship and Public Affairs. Syracuse University. Personal Communication. July 5,2000. 108. National Academy of Sciences. 2000. "About the NAS." Washington, D.C.: National Academy of Sciences. On file. 109. In 1993 the California Mental Health Planning Council stated that the "major role of the DMH is to passionately articulate the vision for the mental health system and to facilitate achievement of the mission and goals." California Mental Health Planning Council. 1993. "Report on the Mental Health Governance Study." Sacramento, CA: Mental Health Planning Council. Page 15. 110. Department of Finance. 2000. (See Endnote #63) Page HHS 109. 111. Department of Mental Health. 2000. Personal communication. September 8, 2000. 112.In 1991-92 the department employed a total of 6,956 personnel: 159 in Community Services, 6,655 in State Hospital Services and 151 in Departmental Administration. Source: Department of Finance. 1993. Governor's Budget. 1993-94. Sacramento, CA: Department of Finance. Page HW 47. In 2000-01 the department employs 8,547 personnel: 154 in Community Services, 8,241 in Long Term Care and 152 in Departmental Administration. Source: Department of Finance. 2000. (See Endnote #63) Page HHS 109. 113. California Mental Health Planning Council. 2000. "Statewide Survey on Vacancy Rates in MH Positions." Sacramento, CA: California Mental Health Planning Council. 114.I.D.E.A. Consulting. 1999. "California's Medi-Cal Mental Health Service Delivery System: Assuring Access, Quality, and Cost Effectiveness." On file with the California Department of Mental Health. Sacramento, CA. 115. Protection and Advocacy, Inc. 2000, Letter to the Little Hoover Commission. On file. Protection and Advocacy, Inc. 2000. Managing Mental Health Care: A Report on California's Medi-Cal Mental Health System, 1997-1999. Los Angeles, CA: Protection and Advocacy, Inc. 116. Editorial. July 3, 2000. "Separate and Equal? Some Insurers Treat Mental Health Care as 'Carve-Out. '" Sacramento Bee. 117. Department of Finance. 1993. Governor's Budget: 1993-94. Sacramento, CA: Department of Finance. Page HW 48. 118. California Mental Health Planning Council. 2000. (See Endnote #2) 119. Dr. Mark Ragins, Medical Director. The Village Integrated Services Agency, Long Beach. Testimony before the Little Hoover Commission. January 27, 2000. Sacramento, State Capitol Building. Page 3. 120. Editorial. October 21, 1999. "Homeless in Sacramento: Build Solutions Such as Quinn Cottages, Not More Jails." Sacramento Bee. 121 LITTLE HOOVER COMMISSION 121. National Survey of Homeless Assistance Providers and Clients. 1999. (See Endnote #46) 122. California Statewide Supportive Housing Initiative Act. (See Endnote #9) 123. California Statewide Supportive Housing Initiative Act. (See Endnote #9) 124. Hurlburt, Michael S., Richard L. Hough, and Patricia A. Wood. 1996. "Effects of Substance Abuse on Housing Stability of Homeless Mentally III Persons in Supportive Housing." Psychiatric Services. 47:731-736. United States General Accounting Office. 2000. "Homelessness: Barriers to Using Mainstream Programs." Washington D.C.: General Accounting Office. GAO/RCED-00-184. 125.Bond, Gary R, Robert E. Drake, Kim T. Mueser and Deborah R Becker. 1997. "An Update on Supported Employment for People with Severe Mental Illness." Psychiatric Services. 48(3):335-347. Judith A. Cook and Lisa Razzano. 2000. "Vocational Rehabilitation for Persons with Schizophrenia: Recent Research and Implications for Practice." Schizophrenia Bulletin. 26(1):87-103. 126. Cook, Judith A. and Lisa Razzano. 2000. (See Endnote #125) 127. David Pingatore. (See Endnote #10) 128. RachBeisel, Jill, Jack Scott and Lisa Dixon. 1999. (See Endnote #45) Page 1427. 129. U.S. Department of Health and Human Services. 1999. (See Endnote #5) Page 288. 130. United States General Accounting Office. 2000. (See Endnote # 124) Page 10. 131. Kaplan, A, B. Sadock and J. Grebb. 1998. Synopsis of Psychiatry. 7th Edition. NP: Williams and Wilkins. Page 299. Koran, L. 1985. "Physical Illness in a Sampling of California Psychiatric Patients." Paper presented at the Academy of Psychosomatic Medicine 32nd Annual Meeting. November. As referenced in California Mental Health Planning Council. 2000. (See Endote #20) Page 45. 132. Koran, Lorrin. M.D. 1991. Medical Evaluation Field Manual. Prepared for the California Department of Mental Health and Local Mental Health Programs Pursuant to Chapter 376, Statutes of 1988. AB 1877. On file. 133. Kopelowicz, Alex, Charles J. Wallace and Roberto Zarate. 1998. "Teaching Psychiatric Inpatients to Re-Enter the Community: A Brief Method of Improving the Continuity of Care." Psychiatric Services. 49(10):1313-1316. 134.Anne Morris, Ph.D. Center for Mental Health Service Research, University of California. Personal Communication. 135. Drake, Robert E. and Kim T. Mueser. 2000. "Psychosocial Approaches to Dual Diagnosis." Schizophrenia Bulletin. 26(1): 105-118. 136.Bond, G. R, Robert E. Drake, Kim T. Mueser and D. R Becker. 1997. (See Endnote #125) 137. Koran, Lorrin M.D. 1991. (See Endnote #132) 138. Chandler, Daniel, Joan Meisel, Michelle McGowen, Jim Mintz and Kristin Madison. 1996. "Client Outcomes in Two Model Capitated Integrated Services Agencies." Psychiatric Services. 47:175-180. 139. McFarland, Bentson H. and Gary Blair. 1995. "Delivering Comprehensive Services to Homeless Mentally III Offenders." psychiatric Services. 46: 179-181. Morrissey, Joseph, Michael Calloway, Matthew Johnsen and Michael Ullman. 1997. "Service System Performance and Integration: A Baseline Profile of the ACCESS Demonstration Sites. Access to Community Care and Effective Services and Supports." Psychiatric Services. 48:374-380. Young, Nancy and Christine Grella. 1998. "Mental Health and Substance Abuse Treatment Services for Dually Diagnosed CHents: Results of a Statewide Survey of County Administrators." Journal of Behavioral Health Services & Research. 25(1):83-92. 122 NOTES 140. Lehman, Anthony F. and Donald M. Steinwachs. 1998. "Patterns of Usual Care for Schizophrenia: Initial Results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey." Schizophrenia Bulletin. 24(1):11-32. 141.Jonathan Vernick. July 18,2000. (See Endnote #11) 142. Steve Fields, Executive Director, Progress Foundation. February 16,2000. Personal Communication. 143. Lehman, Anthony F. 2000. "Commentary: What Happens to Psychosocial Treatments on the Way to the Clinic." Schizophrenia Bulletin. 26(1):137-139. 144.AB 3777, Statutes of 1988. On File. Mark Ragins. 2000. (See Endnote #119) "History of the Village." 145. Legislative Analyst's Office. 2000. (See Endnote #40) 146. Legislative Analyst's Office. 2000. (See Endnote #40) 147. Legislative Analyst's Office. 2000. (See Endnote #40) 148. California Mental Health Planning Council. 2000. (See Endnote #80) 149. Welfare and Institutions Code, Section 5600.2. (See Endnote #19) 150. David Pingatore. (See Endnote #10) 151. Legislative Analyst's Office. 2000. (See Endnote #40) "Figure 4c. Clients Receiving Publicly Funded Community Mental Health Services. Medi-Cal and Non-Medi-Cal Status and Expenditures. All Funds. Selected Years." 152.Sean McDermitt. Assistant Sheriff, Sonoma County. Testimony before the Senate Select Committee on Developmental Disabilities and Mental Health and the Assembly Select Committee on Mental Health. February 16, 1999. Sacramento, CA: State Capitol Building. Pages 63 - 67 153. Dr. Barry Perrou. Deputy Sheriff, Los Angeles County Sheriffs Department. Testimony before the Senate Select Committee on Developmental Disabilities and Mental Health and Assembly Select Committee on Mental Health. February 16, 1999. Sacramento, CA: State Capitol BUilding. Page 73. 154. Commander Taylor Moorehead. October 28, 1999. (See endnote #3) 155. Neal Wallace. Center for Mental Health Service Research. Personal Communication. 156. Department of Mental Health. 2000. "Effectiveness of Integrated Services for Homeless Adults with Serious Mental Illness: A Report to the Legislature as Required by Assembly Bill (AB) 34 Steinberg, Chapter 617, Statutes of 1999." Sacramento, CA: Department of Mental Health. 157. Lamb, Richard H. and Linda E. Weinberger. 1998. "Persons with Severe Mental Illness in Jails and Prison: A Review." Psychiatric Services. 49(4):483-501. Conly, Catherine. 1999. "Coordinating Community Services for Mentally III Offenders: Maryland's Community Criminal Justice Treatment Program." National Institute of Justice Program Focus. Washington, DC: National Institute for Justice (www.ojp.usdoj.gov/nij). 158. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 159.Van Tosh, L. (Ed.) 1996. Consumer Managed Care Network Platform for Action. Washington, DC: Consumer Managed Care Network. As referenced in Pandiani, John A., Steven M. Banks and Lucille M. Schacht. 1999. "Using Incarceration Rates to Measure Mental Health Program Performance." The Journal of Behavioral Health Services and Research. 25(3):300-3111. Page 300. 123 LITTLE HOOVER COMMISSION 160. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 161.John Vacca. Head Deputy, Mental Health Branch, Los Angeles County Public Defender's Office. Testimony before the Little Hoover Commission, October 28, 1999. Sacramento, State Capitol Building. Page 3. 162. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 163. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 164. Dvoskin, Joel A. and Henry Steadman. 1994. "Using Intensive Case Management to Reduce Violence by Mentally III Persons in the Community." Hospital and Community Psychiatry. 45:679-684. 165. Lamb, H. R. and Roderick Shaner. 1993. "Where There are Almost No State Hospital Beds Left." Hospital and Community Psychiatry. 44(10):974-976. 166. Dr. Barry Perrau. 1999. (See Endnote #153) Pages 68-80. 167.John Vacca. 1999. (See Endnote #161) Page 5. Penal Code Section 1001.20 et. seq. 168. Department of Mental Health. 2000. (See Endnote # 156) Page 2. 169.SB 1485 (Rosenthal), Chapter 501, Statutes of 1998. 170. California Board of Corrections. 2000. (See Endnote #7) 171. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 172. Husted, J. R., R.. A. Charter and Barry Perrau. 1995. "California Law Enforcement Agencies and Mentally III Offenders." Bulletin of the American Academy of P~!y'chiatry and the Law. 23(3):315-329. 173. Lamb, Richard H. and Linda E. Weinberger. 1998. (See Endnote #157) 174. Substance Abuse and Mental Health Services Administration. (See Endnote #14 ) 175. Backer, Thomas E., Elizabeth A. Howard, Donald ~r. Richardson and Carla Jacobs. 1997. Resource Manual for Local Systems Change: Improving Mental Health Services in California's Local Criminal Justice System. Los Angeles, CA: Human Interaction Research Institute. Page 13. 176. Backer, Thomas, Elizabeth Howard, Donald J. Richardson and Carla Jacobs. 1997. (See Endnote # 175) Page 13. 177. Steadman, Henry. Joseph Cocozza and Bonita Veysey. 1999. "Comparing Outcomes for Diverted and Nondiverted Jail Detainees with Mental Illness." Law and Human Behavior. 23(6):615-627. 178. Steadman, Henry, Martha Williams Deane, Randy Borum and Joseph Morrisey. 2000. "Comparing Outcomes of Major Models of Police Response to Mental Health Emergencies." Psychiatric Services. 51(5):645-649. 179. Dr. Barry Perrou. (See Endnote # 1.53) 180. Matthew Farley. Health Economist. Research Triangle Institute. Personal communication. July 20, 2000. 181. Izumi, Lance, Mark Schiller, and Steven Hayward. 1996. (See Endnote #88). 182. Torrey, E. Fuller, J. Stieber, J. Ezekiel, S. M. Wolf, J. Sharfstein, J. H. Noble, and L. M. Flynn. 1992. Criminalizing the Seriously Mentally Ill: the Abuse of Jails as r~ental Hospitals. Washington, DC: Public Citizen's Health Research Group and National Alliance for the Mentally Ill. As referenced in Backer, Thomas, Elizabeth Howard, Donald J. N.ichardson and Carla J aco bs. 1997. (See Endnote # 175) Page 7. 124 NOTES 183. Roskes, Erik and Richard Feldman. 1999. "A Collaborative Community-Based Treatment Program for Offenders with Mental Illness." Psychiatric Services. 50(12):1614-1619. 184. Roskes, Erik and Richard Feldman. 1999. (See Endnote #182). Jemelka, Ron, Eric Trupin and John A. Chiles. 1989. "The Mentally III In Prison: A Review." Hospital and Community Psychiatry. 40:481-491. Draine, J., P. Solomon and A. Meyerson. 1994. "Predictors of Reincarceration Among Patients Who Received Psychiatric Services in Jail." Hospital and Community Psychiatry. 45:163-167. 185.$1,500 figure reflects Sacramento County cost for outpatient services through contract service provider. $35,000 reflects high-end cost at an Integrated Services Agency (ISA), based on conversation with Turning Point ISA, Sacramento County. 186. California Department of Corrections. 2000. (See Endnote #84). 187. California Department of Corrections. 1999. Letter from C.A. "Cal" Terhune, Director. Department of Corrections to Assemblymember Thomson. March 15, 1999. Data reflect costs from fiscal year 1997-98. 188. California Department of Corrections. 2000. (See Endnote #83). 189. Little Hoover Commission. 1998. (See Endnote #24) Page 50. 190. Commander Taylor Moorehead. October 28, 1999. (See endnote #3) The Los Angeles County Jail provides acute mental health services to 2,300 inmates with a budget of $16.3 million. 191. Petersilia, Joan. 2000. "Challenges of Prisoner Reentry and Parole in California." CPRC Brief. University of California, Berkeley: California Policy Research Center. 192.Petersilia, Joan. 2000. (See Endnote #191) 193. Department of Mental Health. 1999. (See Endnote # 156). Wiederanders, Mark and Noelle Sprinkman. 1999. "Questions and Answers About the Effectiveness of CONREP." Sacramento, CA: Department of Mental Health. 194. Texas Council on Offenders with Mental Impairments. 1998. "Rate of Reduction in Arrests for Special Needs Offender Program." Austin, TX: Texas Council on Offenders with Mental Impairments. 195. Conly, Catherine. Nd. (See Endnote #157) 196. Legislative Analyst's Office. 1992. "The 1991-92 State and Local Program Realignment: Overview and Current Issues." Reprint. In California Institute for Mental Health. Nd. Realignment Fiscal Manual. Sacramento, CA: California Institute for Mental Health. 197. Department of Mental Health. June 18, 1998. White Paper: "State of California. Department of Mental Health. System of Care. Mental Health Medi-Cal Managed Care Oversight." Sacramento, CA: DMH. Page 4. 198.Mental Health Planning Council. 2001. (See Endnote #20). 199.Wayne Clark and Bill McConnell. 2000. (See Endnote #21). 200.Sederer, L.I., Dickey, B. 1996. Outcomes Assessments in Clinical Practice. Philadelphia, PA: Williams and Wilkins. As referenced by Wayne Clark and Bill McConnell. 2000. (See Endnote #21). 201.Wayne Clark and Bill McConnell. 2000. (See Endnote #21). 202. Michael Dow. Professor and Director, Research Division. Department of Community Mental Health. Florida Mental Health Institute. July 6, 2000. Personal Communication. 125 LITTLE HOOVER COMMISSION 126 LITTLE HOOVER COMMISSION MEMBERS CHAIRMAN RICHARD R. TERZIAN (R-Los Angeles) Originally appointed to the Little Hoover Commission by Governor George Deukmejian in May 1986. Reappointed by Governor Pete Wilson in March 1994 and in March 1998. Partner in the low firm of Bannon, Green, Fronk & Terzian. Chairman of the Commission since March 1994. Served os Vice Chairman from 1992 to 1994. VICE CHAIRMAN MICHAEL E. ALPERT (D-Coronado) Originally appointed to the Little Hoover Commission by Assembly Speaker Willie L. Brown, Jr. in May 1994. Reappointed by the Senate Rules Committee in August 1997. Retired partner in the low firm of Gibson, Dunn & Crutcher. Former Chief Deputy Commissioner of the California Department of Corporations. ASSEMBLYMEMBER BILL CAMPBELL (R-Villa Pork) Appointed to the Little Hoover Commission by Assembly Speaker Antonio Villaraigosa in January 1999. Elected to the 71 st State Assembly District in 1996. Vice Choir of the Assembly Appropriations Committee. CARL COVITZ (R-Los Angeles) Appointed to the Little Hoover Commission by Governor Pete Wilson in October 1993. Reappointed in March 1996. Owner and President of Landmark Capitol, Inc. Served os Secretory of the Business, Transportation and Housing Agency from 1991 to 1993 and Undersecretary for the U.S. Department of Housing and Urban Development from 1987 to 1989. DANIEL W. HANCOCK (D-Milpitos) Appointed to the Little Hoover Commission by Assembly Speaker Cruz Bustamante in July 1997. President of Shapell Industries of Northern California since 1985. ASSEMBLYMEMBER SALLY HAVICE (D-Cerritos) Appointed to the Little Hoover Commission by Assembly Speaker Antonio Villaraigosa in April 1998. Elected to the 56th State Assembly District in 1996. Choir of the Assembly International Trade & Development Committee. SENATOR CHARLES S. POOCHIGIAN (R-Fresno) Appointed to the Little Hoover Commission by Assembly Speaker Curt Pringle in March 1996. Reappointed by Speaker Antonio Villaraigosa in November 1997, and reappointed by the Senate Rules Committee in February 1999. Elected to the 14th State Senate District in 1998. Vice Choir of the Senate Revenue and Taxation Committee. H. ERIC SCHOCKMAN (D-Sherman Oaks) Appointed to the Little Hoover Commission by Assembly Speaker Antonio Villaraigosa in January 2000. Associate Dean and Associate Professor of Political Science at the University of Southern California. Former administrator and consultant to the California State Assembly and to the City Council of Los Angeles. SENATOR JOHN VASCONCELLOS (D-Santa Claro) Appointed to the Little Hoover Commission by the Senate Rules Committee in February 1997. Elected to the 13th State Senate District in 1996 after serving in the Assembly for 30 years. Choir of the Senate Public Safety Committee, the Senate Education Committee, the Subcommittee on Aging and Long-Term Care, and the Select Committee on Economic Development. SEAN WALSH (R-Oakland) Appointed to the Little Hoover Commission by Governor Pete Wilson in December 1998. Former Deputy Chief of Stoff. Communications & Press for Governor Wilson. STANLEY R. ZAX (I-Beverly Hills) Appointed to the Little Hoover Commission by the Senate Rules Committee in March 1994. Reappointed in January 1998. Chairman and President of Zenith Insurance Company. STANLEY M. ZIMMERMAN (D-Beverly Hills) Appointed to the Little Hoover Commission by Governor Gray Davis in January 2000. President of Home P,LJdget I ocms in los Angeles. nnd involved with Mortgage Mart, Inc., a property management firm. "Den10cracy itself is a process of change, and satisfaction and complacency are ene:tnies of good government." ( JI)\ ('I/wr I (/I7JUf)c/ (I. "{Jdl" /)n)\\lI, c1cfclre,sillg tile' in,llIgUJd/IIH'diIJg nllhC' i ittle flumer (CJl7ll7li~'i()lI. All/if :!.J, 7 ()():!. \,l< r,1I1]()11l0, cdlitolll!d The cover art was created by Shir1e/ Cooley. on art with the Creative Arts COllSortiunl in Scm Diego. Colifornic. It is entitlecJheing There," Vvllich inspireci Hie ttle of this report.