Promises Still to Keep: a Second Look at the Mental Health Services Act

Promises still to KeeP: A second looK At the mentAl heAlth services Act Report #233, September 2016 A Little Hoover Commission Letter Report to the Governor and Legislature of California To Promote Economy and Efficiency Little Hoover Commission The Little Hoover Commission, formally known as the Milton Marks “Little Pedro Nava Hoover” Commission on California State Government Organization and Chairman Economy, is an independent state oversight agency. Jack Flanigan Vice Chairman By statute, the Commission is a bipartisan board composed of five public members appointed by the governor, four public members appointed by Scott Barnett the Legislature, two senators and two assemblymembers. David Beier In creating the Commission in 1962, the Legislature declared its purpose: Anthony Cannella Senator ...to secure assistance for the Governor and itself in promoting economy, efficiency and improved services in the transaction of the public business in Chad Mayes Assemblymember the various departments, agencies and instrumentalities of the executive branch of the state government, and in making the operation of all state Don Perata departments, agencies and instrumentalities, and all expenditures of public funds, more directly responsive to the wishes of the people as expressed by Sebastian Ridley-Thomas Assemblymember their elected representatives... Richard Roth The Commission fulfills this charge by listening to the public, consulting with Senator the experts and conferring with the wise. In the course of its investigations, Jonathan Shapiro the Commission typically empanels advisory committees, conducts public hearings and visits government operations in action. Janna Sidley Its conclusions are submitted to the Governor and the Legislature for their Helen Torres consideration. Recommendations often take the form of legislation, which Sean Varner the Commission supports through the legislative process. Commission Staff Cover photo by Little Hoover Commission staff at Hacienda of Hope – Project Return Peer Support Network, Long Beach, California. Carole D’Elia Executive Director Contacting the Commission Jim Wasserman Deputy Executive Director All correspondence should be addressed to the Commission Office: Tamar Lazarus Little Hoover Commission Project Manager 925 L Street, Suite 805 Sacramento, CA 95814 (916) 445-2125 littlehoover@lhc.ca.gov This report is available from the Commission’s website at www.lhc.ca.gov. Letter from the Chair Letter from the Chair September 8, 2016 The Honorable Edmund G. Brown, Jr. Governor of California The Honorable Kevin de León The Honorable Jean Fuller President pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Anthony Rendon The Honorable Chad Mayes Speaker of the Assembly Assembly Minority Leader and members of the Assembly Dear Governor and Members of the Legislature: More than a decade ago, California voters passed a landmark tax initiative that promised to expand access to mental health services and transform how people get help by providing services, when and where needed, at any stage of an illness. For some Californians, the Mental Health Services Act (MHSA) has fulfilled this promise. Proposition 63-funded programs have helped individuals with mental illness recover and thrive. For some, the funding created programs that offer housing, healthcare, medication and help to become self-sufficient. For others at risk of developing mental illness, the funding provides safe, supportive local centers to stay and work through episodes of crisis. These are but two examples of the types of programs in which counties invest money from the Act. Throughout this report we offer a glimpse into nine programs the Commission visited this year and give voice to some who have benefited from these programs. But these inspiring stories of success are shadowed by a continuing failure of the state to demonstrate what is collectively being accomplished. The state still can’t provide conclusive data to show how it is keeping promises made to voters in 2004, or to wealthy taxpayers who fund Proposition 63 programs with a 1 percent surtax, and most importantly, to the individual Californians and their families who rely on these services for much-needed help. Others have shown this can be done. The County Behavioral Health Directors Association partnered with a non-profit public policy institute to release two reports showing successful outcome measures for county full-service partnership program participants. In its January 2015 report, Promises Still to Keep: A Decade of the Mental Health Services Act, the Commission called on the state to better validate how money generated by the Act is used. The report cited a dispersed governance system with no definitive center of leadership. It also found a lack of meaningful data to account for expenditures or demonstrate outcomes to paint a picture of who is being served. In May 2016, the Commission revisited the topic, inviting relevant agencies, as well as stakeholders, to discuss progress in addressing shortcomings raised in the Commission’s 2015 review. Despite some encouraging developments, many of the same concerns remain. The Commission heard repeatedly from stakeholders desperate for more oversight of the Act and concerned about the lack of Little Hoover Commission | 1 Promises Still to Keep: A Second Look at the Mental Health Services Act consequences for bad behavior. Many said the processes to oversee the distribution and use of MHSA funds at the local and state levels are still woefully inadequate and leave those with questions or concerns confused about where to get answers. Others said that without more detailed demographic data, policymakers won’t know whether more can or should be done to reach underserved communities. The Commission admits to remaining somewhat baffled by the extreme complexity of interlaced agencies and data reporting systems that collectively still can’t handily tell taxpayers how their money is being spent, who is being helped and what impact it is making. Though Proposition 63 created a new entity to oversee programs funded by the Act, the Little Hoover Commission has questioned why an oversight commission exists if it cannot deliver meaningful oversight. Additionally, though the Department of Health Care Services is empowered and funded to enforce the Act, this responsibility appears to be lost among others. Without strong leadership at the top, it is uncertain who is responsible to look out across the system to see what is working and make sure those lessons are being shared statewide. The state itself spends more than $100 million from the MHSA and there is little oversight of that spending, beyond the regular budget process. It is clearer than ever in the wake of the Commission’s second review that the state must identify a well-defined leader to administer, oversee and enforce the MHSA or it will remain difficult to articulate a cohesive vision for the Act and ensure accountability to alleviate many of the visible statewide impacts of mental illness. This leader also should take charge to ensure counties are appropriately engaging stakeholders and that success stories are shared statewide. Consequences of a long-standing inability to demonstrate the value of statewide Proposition 63-funded programs are already apparent. Lawmakers have begun chipping away at this lucrative funding source. Recently enacted legislation championed by the Steinberg Institute steers $130 million in annual proceeds to finance a $2 billion bond for supportive housing for homeless individuals with mental illness. This is one way to inject state priorities and accountability into how MHSA funds are used. Some, however, expressed concerns to the Commission that this may open a floodgate for setting additional priorities beyond those specified in the voter-approved ballot measure. As lawmakers debate other possible diversions, the state’s plans to finally provide data are tied up in a massive, multi-year technology project. Counties and others, at least in a partial way, are moving more quickly toward fiscal accountability and transparency of MHSA funds. The Commission believes the state must more rapidly develop its own data system to monitor and measure outcomes being delivered by MHSA funding. Proposition 63 backers in 2004 assured voters a high level of statewide oversight for this new revenue stream. Twelve years without definitive data to meet these assurances is hardly what voters expected, and if known, may well have provided a different outcome at the ballot box. Despite some of these misgivings, the Commission remains hopeful that the many proposals it heard to improve fiscal transparency and accountability for outcomes will lead to necessary improvements. The Commission was most inspired by the stories shared during the site visits by those whose lives have been improved. With better accountability, the Commission also remains hopeful that many more Californians, rather than just some, will receive the help that they need. The Commission respectfully submits recommendations to strengthen the oversight of the Mental Health Services Act and stands ready to assist in this important initiative to improve the health of Californians. Sincerely, Pedro Nava Chair, Little Hoover Commission 2 | www.lhc.ca.gov Contents Contents 5 Introduction 7 A Continuing Challenge: “Muddled” Leadership Still Over- sees MHSA Spending 12 The Question Remains: Where is the Money Going? 15 Still Unknown: Is the Act Achieving its Goals? 19 Californians Still Need Meaningful Ways to Participate in Spending Decisions 21 Counties Need More Ways to Share Success 23 Appendices 29 Notes Sidebars 8 Key Components of the Mental Health Services Act 8 Key Components of the Mental Health Services Act 15 Quality Data Could Thwart Raids on MHSA Funding 16 Measuring MHSA Outcomes: It Can Be Done 17 Improving Data Collection, Performance Measures and Outcomes for California’s Youth Offenders Little Hoover Commission | 3 Promises Still to Keep: A Second Look at the Mental Health Services Act 4 | www.lhc.ca.gov Introduction Introduction More than a year after the Little Hoover Commission’s first look at the Mental Health Services Act, it The Commission also found overlapping and sometimes decided to conduct a follow-up review and found that unaccountable bureaucracies and an oversight body many concerns remain unheeded. The Commission lacking “teeth” for enforcement. Stakeholders, and launched its initial study of the Act in June 2014 to ultimately the Commission, were concerned that the better understand what happens after voters say yes to state lacks an organization that can effectively oversee a spending plan at the ballot box. Introduced to voters the Mental Health Services Act. The mental health in 2004 as Proposition 63, the Act imposed a 1 percent program within Department of Health Care Services is surtax on the wealthiest Californians to directly fund overshadowed by the state’s massive Medi-Cal program specific types of mental health programs and services and, without authority, the Mental Health Services across the state and invigorate a faltering statewide Oversight and Accountability Commission (oversight mental health system. Since 2004, the Act has generated commission) cannot help counties correct deficiencies in approximately $17 billion for mental health programs their plans or enforce changes to comply with the law. and services throughout the state – currently at a Recommendations from the Commission’s January 2015 rate of $2 billion annually. These funds now comprise report are in Appendix B. approximately 24 percent of the state’s entire public mental health budget.1 Oversight Hearing and Site Visits Proposition 63 allowed the Legislature to modify the Act The Commission initiated this follow-up review in without seeking voter approval for each reform. In the May 2016 to gauge progress in addressing the serious years since, the Legislature has exercised its authority concerns raised in its 2015 report. The Commission to make significant amendments five times. Early heard from state agencies responsible for overseeing reforms expedited distribution of money to on-the- the act, representatives from county mental health ground service providers, eliminated the state’s upfront directors and local boards, as well as the Act’s authors review of spending plans and reoriented accountability and numerous stakeholders, including clients, family for expenditures to the counties. Other reforms have members and advocates. Hearing participants are listed expanded the variety of allowable programs or diverted in Appendix A. funds for specific, one-time expenditures. In May and June 2016, Commissioners also visited In its last review, the Commission heard many accounts nine programs funded in part or entirely by the Mental of success, including programs and services for the state’s Health Services Act in three counties: San Bernardino, mentally ill that likely would have been unaffordable Sacramento and Los Angeles. During these visits, the without Proposition 63 funding. Often these anecdotal Commission saw how programs funded by the Act help successes, however, lacked verifiable data. In its January Californians before they need intensive care, and others 2015 report, Promises Still to Keep: A Decade of the recover and reclaim their lives. These visits introduced Mental Health Services Act, the Commission voiced the Commission to programs that give individuals short concern that as money comes through the MHSA pipeline respites while getting needed help and others that help each year, the state lacks an accountability mechanism to people transition from unstable living situations to assure taxpayers, voters, and most importantly, mental permanent, supportive housing. Most significantly, the health care consumers and advocates, that the money is Commission heard directly from Californians whose lives being spent in ways voters intended. and health are improving as a result of these programs. Little Hoover Commission | 5 Promises Still to Keep: A Second Look at the Mental Health Services Act Descriptions of programs visited, as well as the voices of some participants, are included throughout this report. The Integrated Mobile Health Team, Los Angeles County Based on its 2015 report, the information provided at its May 2016 hearing and visits to programs funded by The Integrated Mobile Health Team helps the Mental Health Services Act, the Commission has clients transition from homelessness into identified several challenges that persist. Important permanent supportive housing, improving their questions remain unanswered: Who oversees MHSA mental health and substance use disorders. Mental spending, where does the money go and is the Act health, physical health and substance abuse services achieving its goals? Furthermore, though the Act built- are provided by multi-disciplinary staff working in a stakeholder process for spending plans, Californians as one team, under one point of supervision and do not yet have a clear path for participating in, or operating under one set of administrative and question, spending decisions. And though the Act operational policies and procedures, using an promised opportunities to transform the way mental integrated medical record/chart. Through a “street health services are delivered in California by funding medicine” approach, the program staff bring care new and innovative programs, the state does not offer to its clients wherever they are – whether living counties meaningful ways to share lessons learned. The in an encampment, a car or on the street. In July Commission offers recommendations on pages to come 2016, the team received the National Association to help the state keep its 2004 promise to Californians. of County’s Achievement Award. (CSS-funded, formerly INN) One client explained he joined the program and came off the streets because “I didn’t like the feeling of being worthless.” Photos by Little Hoover Commission staff and the Integrated Mobile Health Team, Mental Health America of Los Angeles in Long Beach, California. 6 | www.lhc.ca.gov A Continuing Challenge: “Muddled” Leadership Oversees MHSA Funding A Continuing Challenge: “Muddled” Leadership Oversees MHSA Funding When voters approved Proposition 63 in 2004, they State mental health leaders say the DHCS’ role in also approved a statewide governance system to overseeing the Act is focused on monitoring and administer and oversee new mental health programs auditing for compliance and providing fiscal and program funded by the Act. The Department of Mental Health oversight. In practice, the department’s oversight of the was to take the lead state role in implementing most Act appears minimal. of the new programs created in the measure, as well as allocate funds for those programs through contracts The annual performance contracts the department with counties (The Department of Health Care Services establishes with each county mental health program picked up oversight responsibilities for the Act after the are its main tool for program oversight. Department Governor and the Legislature dismantled the Department leaders conduct onsite reviews of these contracts every of Mental Health in 2012). A new Mental Health Services three years, at a rate of about 15-18 counties per year Oversight and Accountability Commission also would – to ensure compliance with state and federal laws and review county plans for mental health services and the terms of the contract between the department approve expenditures for certain programs. The measure and county mental health programs.6 The executive layered these additional responsibilities within the director of the oversight commission told Commissioners existing mental health system and throughout the state’s in May, “the DHCS has profound capacity through its Welfare and Institutions Code. As such, the Act left intact performance contracts to shape these programs.”7 the responsibilities of other existing agencies, including However, these performance contracts encompass a the Mental Health Planning Council to review, to oversee broad range of mental health programs and services, and review the state’s mental health system.2 (Examples of statutory roles and responsibilities for these agencies El Hogar Guest House Homeless Clinic, are included in Appendix C.) Sacramento County In the years since, the Legislature has amended this “The Home” is an entry point for mental health system several times, but three state agencies continue and homeless services in Sacramento County. to share responsibility for administering and overseeing The facility provides a clinic for homeless individuals aspects of the Act. At times, these three entities are and temporary housing for adults 18 and older. required to work together to fulfill their roles – providing Services include comprehensive mental health technical assistance, designing a comprehensive joint assessments and evaluations, medications, links to plan for a coordinated evaluation of client outcomes housing and applications for benefits and services. and developing regulations and other instructions to The program used MHSA funds to expand services administer or implement the Act.3 State law also assigns for client care, such as offering subsidies for housing specific oversight functions to each: and dental work. (CSS-funded) The Department of Health Care Services (DHCS). The One client, thankful for the help she received department alone has the authority to enter into through El Hogar explained, “California has so many performance contracts with counties, enforce compliance programs compared to [my experiences in] other and issue administrative sanctions if necessary.4 In fiscal states. I wish they could have even 10 percent of year 2016-17, the department received funding from the what California has. Being able to have housing, Mental Health Services Act for 19 full-time equivalent dental work and services has been awesome for me.” staff for these and other functions related to the Act.5 Little Hoover Commission | 7 Promises Still to Keep: A Second Look at the Mental Health Services Act of which those funded by the Mental Health Services The department alone holds power to address local Act are but one part – and a relatively new one. After shortcomings in implementation of the Act by imposing the absorbing responsibilities from the Department administrative sanctions such as withholding part or all of of Mental Health in 2012, DHCS in fiscal year 2013- state mental health funds from the county and requiring 14 added questions specific to the Act in its reviews. the county to enter into negotiations to comply with state Currently, the department’s review protocol includes laws and regulations. The department also can refer only 17 questions related to the Mental Health Services issues to the courts. The Commission heard testimony Act – these take up just eight out of the protocol’s 121 from some stakeholders that it is appropriate for the pages.8 The department’s deputy director admitted to department to serve as the enforcer of the Act. However, the Commission that these reviews of the Act are “not when Commissioners asked department officials how very robust.”9 they might ensure that bad actors are not continuously getting funding, the deputy director said “there isn’t a To provide fiscal oversight, the department also performs requirement on the department that we can point to “a desk review” of each county’s annual revenue and that says this is our role and responsibility.” Additionally, expenditure report to ensure accuracy and consistency from in a subsequent conversation with Commission staff, year to year. Counties are required to submit these annual the deputy director said that if a county is found out reports, identifying MHSA revenues, expenditures and of compliance with the Act, rather than initiating unexpended funds and providing information to evaluate administrative sanctions she prefers to phone the programs funded.10 However, as of August 2016, 37 counties county’s mental health director and prompt them for had submitted reports for fiscal year 2013-14 and just 26 corrective action.13 counties had submitted reports for fiscal year 2014-15.11 (A list of each county’s reporting status is included in Appendix The Mental Health Services Oversight and D.) For those reports received, the department reviews Accountability Commission. The Mental Health Services the balance of unspent funds, reportable interest, revenue Act established the oversight commission to oversee received and program expenditure levels, and compares the programs funded by the Act, as well as the state’s balance of unspent funds reported in the prior year’s report systems of care for adults, older adults and children. As to ensure they match. The department also reviews the such, leaders from the oversight commission view its amount of revenue counties report receiving with what the oversight responsibility broadly, to encompass the whole State Controller’s Office says it distributed.12 However, it does public mental health system, not just the Mental Health not analyze the data reported in these reports to determine Services Act. “Because [the oversight commission] was whether counties spent the funds as they proposed. created by Proposition 63, people think its role is just Key Components of the Mental Health Services Act Community Services and Supports (CSS). 80 percent of county funding from the Mental Health Services Act treats severely mentally ill Californians through CSS. Within this component counties fund a variety of programs and services to help people recover and thrive, including full-service partnerships and outreach and engagement activities aimed at reaching unserved populations. Full-service partnerships provide “whatever it takes” services to support those with the most severe mental health challenges. Prevention and Early Intervention (PEI). Counties may use up to 20 percent of their MHSA funds for PEI programs, which are designed to identify early mental illness before it becomes severe and disabling. PEI programs are intended to improve timely access to services for underserved populations and reduce negative outcomes from untreated mental illness. Innovation. Counties may use up to 5 percent of the funding they receive for CSS and PEI to pay for new and innovative programs that develop, test and implement promising practices that have not yet demonstrated their effectiveness. 8 | www.lhc.ca.gov A Continuing Challenge: “Muddled” Leadership Oversees MHSA Funding to oversee the Act. But it’s broader,” one senior official State law articulates a role for the planning council in at the oversight commission explained.14 In addition, developing plans to address the state’s mental health state law also assigns the oversight commission specific workforce needs and shortages.19 In fiscal year 2016-17, functions and responsibilities related to the Act, such as the planning council received funding from the Mental receiving all county plans for review, and for approving Health Services Act for five full-time equivalent staff.20 Innovation programs. In fiscal year 2016-17, the Mental Health Planning Council officials say it lacks the oversight commission received funding from the Mental data it says it needs to assess the strengths of the mental Health Services Act for 30 full-time equivalent staff to health system overall. carry out its responsibilities.15 In its 2015 report, concerned that the DHCS did not consistently exercise its enforcement authority over the Act in a timely fashion, the Commission recommended expanding the oversight commission’s authority to Hacienda of Hope, Los Angeles County review and approve county MHSA Prevention and Early Intervention (PEI) plans, as it does with Innovation Hacienda of Hope is a short-term respite plans. The Commission also recommended the oversight home run by “peers” – adults who are living commission be granted authority to respond to critical with mental illness themselves. The respite issues identified in county spending plans and clarify the program, operated by Project Return, The Peer process by which problems get solved. The intent of Support Network, offers support and tools to that recommendation was not punitive, but to expedite foster wellness and manage crisis and recovery a review process that was, at times, taking DHCS up to for up to eight guests in the program’s two-story two years. Some advocates and stakeholders still believe home. Guests create individualized wellness and that the state should reinstate authority of the oversight recovery plans and connect with local resources commission to review and approve county spending for employment, housing and mental and plans, as well as statewide projects funded by the Act.16 physical health care. Adults 18 and older who are experiencing distress or a life crisis, but who are not In response to the Little Hoover Commission’s in immediate danger or in need of on-site medical recommendation, the oversight commission executive treatment are eligible to stay. Typically, guests stay director told Commissioners that he was working to between one and three days. They may stay up to “strengthen the local process, strengthen the boards 14 days if additional help is needed. (CSS-funded, of supervisors, and [the oversight commission’s] ability formerly INN) to do oversight based on the outcomes.” He said that giving the oversight commission “teeth” could potentially A former client, now peer-advisor said of the distract his commissioners and staff from other functions program, “This is a hopeful place to go when you and would require them to “to really think differently don’t have hope, when you are broken.” about how we do our job.”17 The lack of progress of the oversight commission over the last year even to develop a response to the Commission’s previous recommendation indicates that something else must be done to improve accountability and facilitate achievement toward the Act’s goals. The Mental Health Planning Council. Among other functions, the planning council reviews program performance of the overall mental health system, including programs funded by the Mental Health Services Act. Also, it annually reviews program performance outcome data to identify successful programs and make recommendations for replication in other areas.18 Little Hoover Commission | 9 Promises Still to Keep: A Second Look at the Mental Health Services Act Without Direction, Some Oversight Functions State law does not require any state agency to review, analyze Haven’t Happened and summarize information contained in all of the county MHSA program plans and ensure the counties are spending The state has laws requiring counties to provide a the MHSA funds as they said they would. Perhaps it should. substantial amount of information about the Mental Health Services Act that could be used for evaluation. Multiple Agencies, But Who is Accountable? Counties, for example, submit three-year MHSA program and expenditure plans and annual updates to the “Individually, each of the entities – the oversight oversight commission and the DHCS.21 These plans commission and department of health care services – is include descriptions of MHSA programs, that if compared very clear about their own responsibilities as set in law,” with expenditure reports, could be used to ensure Josephine Black, Chairperson, and Jane Adcock, Executive counties spent their MHSA dollars as they proposed. Yet, Officer, of the California Mental Health Planning Council no state agency performs this type of review. wrote in testimony to the Commission. “However, when taking a global look, the roles are muddled resulting in DHCS, when it implements recent legislative reforms, divided (and weakened) leadership for key aspects of the will post online county plans as well as revenue and public mental health system and no clear designation of expenditure reports.22 This reform should improve fiscal authority. Who is to hold the system accountable? Who transparency, but falls short of ensuring accountability. is to hold the oversight entities accountable?”24 The oversight commission does not broadly review Advocates, stakeholders and others told the Commission information contained in counties’ program and they remain confused and dissatisfied with the diffusion expenditure plans to identify compliance issues or and overlap of responsibilities at the state. They are still compile a statewide picture of implementation of the Act. concerned that no one is accountable for overseeing the Currently, oversight commission staff only read counties’ Act and systematically and comprehensively evaluating its plans within the context of reviewing Innovation outcomes. Questions remain about which agencies are programs. However, according to its deputy director, the ultimately responsible for ensuring the promises made to oversight commission plans to build technology to make voters are kept: it easier to analyze the county-submitted reports and compare and contrast information across plans.23 • Is it the responsibility of the oversight commission to focus its oversight and evaluation efforts specifically on programs funded by the Palmer Apartments, Sacramento County Mental Health Services Act, or on the broader public mental health system? And if the Run by Transforming Lives, Cultivating Success oversight commission’s role is broad, how does (TLCS), the Palmer Apartments offer short- that differ with the planning council? term housing for up to 48 adults experiencing homelessness and psychiatric disability. The • Is it the responsibility of the department to program provides a safe, hospitable alternative investigate whether county spending plans align to shelters and access to permanent housing with actual expenditures or is this a function of within 30 days once income is secured. Longer- the oversight commission? term temporary housing also is available for those • Which agency is responsible for ensuring awaiting openings in MHSA-financed housing the state’s progress toward achieving the developments. Clients and staff work collaboratively transformational vision of mental health services to break the cycle of homelessness during average stays of six to eight months. (CSS-funded) proposed to and approved by voters in 2004? • Which agency is ultimately responsible for Reflecting on his experience, one client said “This is determining how to evaluate the programs the first step for me being who I am. These people funded by the Act – is it the oversight give us hope and from here, I’m learning how to live commission, the department, counties or the again.” Health and Human Services Agency? 10 | www.lhc.ca.gov A Continuing Challenge: “Muddled” Leadership Oversees MHSA Funding • Which agency is best situated to enforce compliance with the Act and to hear and address Recommendation 1: The Legislature should further concerns raised by consumers, family members, clarify the roles and responsibilities of the state stakeholders and advocates if and when issues agencies responsible for administering, overseeing arise at the local level? and enforcing the Mental Health Services Act. • When problems are identified by the oversight Specifically it should: commission or the planning council, how do ƒ Clarify expectations for the scope of either of these entities ensure corrective action is responsibilities of the department, oversight taken by the department which has authority to act? commission and planning council and define the separate roles of each in ensuring the When looking for accountability to the Mental Health Mental Health Services Act funds are used as Services Act, it’s difficult to see clearly because a tangled voters intended. web of organizations with conflicting and overlapping oversight responsibilities is tasked with the job. Some ƒ Call on the entity charged with enforcement, argue that this diffusion makes sense: the Act is but currently the Department of Health Care one funding stream for a diverse and complex mental Services, to identify the mechanism by which health system. But who is truly accountable? When it will enforce the Act. The entity should asked by Commissioners, former State Senator Darrell identify metrics it will apply to evaluate county Steinberg and co-author of the Mental Health Services performance with potential consequences. Act, said ultimately, it’s elected leaders – the Governor Repeated poor performance should result and the Legislature.25 At some juncture, policymakers in mandatory redistribution of money to may question this division of responsibilities and consider compliant counties. whether California needs all three organizations. In the meantime, despite past clarifications, more must be done to further articulate the roles and responsibilities of the various state agencies that administer, oversee and enforce the Act. Voters enacted the measure with the expectation of oversight, putting a strong onus on the state to ensure that these dollars – specifically – are spent as voters intended and produce the outcomes promised. The state should notify any non-compliant county behavioral health department and board of supervisors with a written notice including a deadline and specific remedy to achieve compliance and these written notices should be prominently published on a state website. To ensure compliance, the state should withhold money from non-compliant counties – as current law allows – and redistribute this money to other counties that are complying with the Act. The Legislature should enhance current law to make this withholding mandatory after one or more formal written notices regarding non- compliance are sent to the county. Little Hoover Commission | 11 Promises Still to Keep: A Second Look at the Mental Health Services Act The Question Remains: Where is the Money Going? To better answer basic questions about the statewide Gallagher, program director for the California Youth allocation and use of Mental Health Services Act Empowerment Network, told the Commission. “So funds, the Commission in 2015 recommended the Mental where is all the money going?”29 Health Services Oversight and Accountability Commission post meaningful financial information on its website. At a New Tools Promise Easier Access to Local Financial minimum, the Commission suggested, this should include Information a fiscal snapshot of overall and current year revenues and allocations by program component areas. It also should Some suggested a state entity should be made include information on how the state spends MHSA state responsible for dispersing the information in a user- administration funds. friendly format online. Also needed: a reporting process that quickly makes the information public.30 Since the Commission’s last review, the oversight commission launched an updated website which A new fiscal transparency tool could show local MHSA includes some financial elements recommended by expenditures online. According to its executive director, the the Commission. Among them: a breakdown of the oversight commission built the tool using data that counties cumulative MHSA revenue reported since the Act passed must submit to the state in annual revenue and expenditure in 2004.26 The website also includes a placeholder page reports. The tool, he said, can show the distribution of for county-submitted reports and financial evaluation MHSA funds to each county by component, identify how reports. When posted, the public will find important much has been spent and how much remains unspent, information about the Act in one centralized location.27 and show cumulative balances for each component of These, and planned improvements described below, the MHSA. Plans to showcase the tool on the oversight are steps in the right direction. But, more can be done commission’s website have stalled while addressing county to help voters, taxpayers and mental health advocates, consumers and their families understand how money One Stop Transitional Age Youth Center, from the Act is used locally and statewide. San Bernardino County Though some counties make financial information The one stop center – one of four in the about their MHSA expenditures readily available, the county – provides a range of drop-in services Commission heard from stakeholders and other members for youth ages 16-25 with, or at risk of, mental and of the public that in some communities it is still difficult emotional issues. The goal of treatment: to offer to track how MHSA funds are spent. (Counties receive employment assistance, educational opportunities, about 95 percent of the dollars generated by the Act each shelter housing, counseling and group activities to year in amounts based on a formula established by the help clients become independent, stay out of the Department of Health Care Services. In fiscal year 2016- hospital or higher levels of care, reduce involvement 17, counties received approximately $1.9 billion.28) in the criminal justice system and reduce homelessness. Because of disproportionate over- “Mental health advocates, providers, and stakeholders representation in the justice system and foster care alike, all want to know where the money is going. Most system, the program specifically targets Latino and counties are not transparent with MHSA growth revenue African-American youth. The county’s Probation and and additional resources are not trickling down to the Children and Family Services, and other community providers who offer mental health services,” Matthew groups, act as program partners. (CSS-funded) 12 | www.lhc.ca.gov The Question Remains: Where is the Money Going? concerns about the validity and reliability of the fiscal data readily-available data about revenues and expenditures on which it is built.31 Despite setbacks, plans are in place to by component, by county, the legislation also would launch the tool by October 2016.32 implement Commission recommendations. The No Place Like Home initiative, a legislation package Accomplishments of State Administrative Funds are signed by Governor Brown in July 2016, established a Still Difficult to Track new program for addressing homelessness and also included accountability measures. The legislation Though the bulk of Mental Health Services Act funds go requires counties to certify the accuracy of their revenue directly to counties to spend on programs and services, and expenditure reports – and reiterates that the 5 percent goes each year to state administration of the Department of Health Care Services may withhold Mental Act. As the tax base grows, so, too, does the state’s Health Services Funds for counties that fail to submit share. In fiscal year 2016-17, the Act is expected timely reports. Additionally, the legislation requires to generate approximately $102 million for state the department and the oversight commission to post administration, about $15 million more than during the county revenue and expenditure reports online.33 When Commission’s last review.36 implemented, this will help fulfill one of the Commission’s previous recommendations. State law guides how this portion of funds is spent. The Mental Health Services Act, as presented to voters in The Department of Health Care Services intends to begin 2004, directed the California Mental Health Planning posting these reports online no later than mid-September Council and the Mental Health Services Oversight 2016, beginning with reports from fiscal year 2014-15.34 and Accountability Commission to use the state It is clear to the Commission that making reports publicly administration funds “to implement all duties pursuant to available will create additional pressure on noncompliant the [MHSA] programs.” The Act further specified that the counties to submit their reports, as would, at a minimum, state administration funds be used for two purposes: posting each county’s submission status. • “assist consumers and family members to ensure the appropriate state and county agencies give “State level reporting does not allow for full consideration to concerns about quality, review of where the funding is going besides structure of service delivery or access to services” the full services partnerships, and also does and not provide meaningful comparison of the • “ensure adequate research and evaluation relative costs and results of each FSP program. regarding the effectiveness of services being We don’t know who or what produces the best provided and achievement of the outcome results and how the answers might vary based measures set forth [in the Act].”37 on age, sex or ethnicity.” Rusty Selix, Executive Director of Policy and Current law gives these funds to five state agencies – Advocacy, Mental Health America of California35 the Department of Health Care Services, the California Mental Health Planning Council, the Mental Health Additionally, proposed legislation, if signed by the Services Oversight and Accountability Commission, the Governor, would make it easier for Californians to Office of Statewide Health Planning and Development understand how counties, alone and collectively, use and the Department of Public Health – as well as any MHSA funds. With this information, local decision- other state agency that implements MHSA programs. makers, advocates and stakeholders may be able to In fiscal year 2016-17, these five agencies received identify best practices in other counties and better inform approximately $22 million to support 72.5 positions and their own spending decisions. Specifically, the measure, provide oversight of the Act. (Of this, the DHCS, planning AB 2279 (Cooley), would require the DHCS, by July 1, council and oversight commission together received 2018, to analyze data submitted by counties in their about $15 million and 54 positions). Additionally, eight revenue and expenditure reports and annually produce other agencies received funding for 23.5 positions and a summary of revenues, expenditures and funds held in a myriad of programs ranging from supporting student reserve. By requiring the department to make mental health, conducting outreach to service members, Little Hoover Commission | 13 Promises Still to Keep: A Second Look at the Mental Health Services Act funding regional centers that develop innovative PEI The former Department of Mental Health coordinated projects and administering various grants.38 interagency partnerships among the various entities that received MHSA state administration funds. It The Commission, concerned that there is insufficient also established memorandums of understanding oversight of this large and growing pot of money, with receiving entities that clarified expectations and recommended in 2015 the oversight commission bolster responsibilities for use of the MHSA funds.41 This type its oversight of the state administration funds and provide of oversight is needed again. To strengthen oversight of policymakers with analysis, beyond the straightforward the ever-growing amount of state administrative funds fiscal accounting provided by the Department of Health and make it easier to analyze and evaluate their uses, the Care Services. The annual MHSA Expenditure Report, oversight commission should regularly analyze how state produced by the DHCS, provides a high-level overview administrative funds are spent and what they achieve. of overall MHSA revenues and expenditures, as well Findings could help legislators and policy leaders better as a brief description of how and where the state determine the successes of state programs funded with administration funds are disbursed. It does not offer an MHSA dollars, and make more informed decisions about analysis, however, of how the various state entities use spending increases or cuts as the fiscal climate demands. the funds to achieve MHSA goals. Recommendation 2: The Governor should approve Currently, decisions about the allocation of state legislation, AB 2279 (Cooley), to make it easier administration funds are made through the regular for Californians to see how and where their budget process. The Department of Finance issues Proposition 63 tax dollars are being spent. policies and procedures for departments to propose budget changes – including proposals for departments Recommendation 3: The Department of Health to access MHSA funds. Rules prevent the oversight Care Services should immediately begin posting commission from consulting on MHSA-related budget online the MHSA Revenue and Expenditure reports change proposals. However, the oversight commission it has available, instead of waiting for all counties does consult with the Department of Finance, the to submit all reports. Legislative Analyst’s Office and legislative committees on specific budget proposals.39 For example, the oversight commission currently is working with the Department Recommendation 4: The state must ensure MHSA of Finance and the Legislature to make it easier to state administrative funds are spent properly. understand how much is available in unspent state ƒ The Mental Health Services Oversight and administrative funds. Accountability Commission’s financial oversight committee should reinstate The state needs to ensure that its 5 percent share of presentations from departments receiving MHSA funds are spent appropriately. Someone must be a portion of the state administrative funds, responsible for asking: is it spent on purposes defined by the Act and what is it achieving? analyze expenditures and compile an annual report for consideration of the full oversight During the Commission’s last review, the Mental Health commission. Services Oversight and Accountability Commission’s ƒ The oversight commission should share its financial oversight committee had begun inviting entities findings with the Department of Finance, that receive part of the MHSA state administrative funds Legislators and the public. to report how the money is used. These presentations were helpful for decision-makers and stakeholders to better understand how these funds were being used and what they were accomplishing. However, the last time the committee heard a presentation from one of the state departments receiving funds was in November 2014.40 14 | www.lhc.ca.gov Still Unknown: Is the Act Achieving its Goals? Still Unknown: Is the Act Achieving its Goals? Despite compelling claims that the Mental Health oversight commission and the Department of Health Services Act has transformed mental health services Care Services to develop a plan and timeline for a data in communities across California, the Commission noted collection system capable of blending information for in its 2015 report that the state cannot yet demonstrate MHSA programs and other state behavioral and mental meaningful, statewide outcomes across the range of health programs. programs and services supported by Proposition 63 dollars. In large part, this is due to the lack of robust data Since the Commission’s 2015 review, the state has that can show policymakers and mental health leaders continued with long-term plans to modernize legacy what interventions are working in specific populations. data systems for its mental health and alcohol and drug abuse programs. The proposal: a seven-year, multi- “Data is not just esoteric. It provides necessary phase, multi-million dollar project to upgrade the state’s information to share with policymakers who may not existing mental health data systems and streamline data believe that there is any real solution to the state’s collection. The oversight commission in 2015 funded homelessness crisis, or to help people stop cycling out the Department of Health Care Services to prepare a of emergency rooms when they need immediate mental preliminary plan for this upgrade. As of July 2016, the health assistance,” former state Senator Darrell Steinberg, department is awaiting approval from the Department of co-author of the Act, told the Commission.42 Technology to submit the preliminary plan to the federal Josephine Black, Chairperson, and Jane Adcock, Executive Quality Data Could Thwart Raids on Officer of the Mental Health Planning Council echoed a MHSA Funding similar sentiment about the importance of mental health data: “We have many individual stories of success and At its May 2016 hearing, the Commission heard they are extremely important and put a human face on testimony from advocates and members of the the progress. However, data is the fundamental and public that recent legislative proposals to steer universally-accepted evidence of progress.”43 MHSA funds to new uses, while well-intended, may weaken the ability of counties to care for the MHSA Data Effort Lost in Broader Mental Health mentally ill. Some said these proposals simply Data System Fix target the Mental Health Services Act as a “go to” funding source for ever-expanding programs and To tell a successful Proposition 63 story, the Commission will lead to “theft” from the Act in future budget in 2015 urged state mental health leaders to improve years.56 During the 2015-16 legislative session, online access to existing MHSA information, plans members proposed several bills to redirect Mental and reports and showcase more model programs and Health Service Act funds, including approximately best practices. The executive director of the oversight $130 million annually in bond interest payments commission said he plans additional upgrades to the and more than $7 million dollars in one-time organization’s website over the next three to five years to expenditures. These funds were proposed to map programs by type, geography and outcomes.44 This construct permanent, supportive housing for is a promising vision. chronically homeless people with mental illness, expand on-campus mental health services at The Commission also recommended the state develop a colleges and provide funds for administration and comprehensive, statewide mental health data collection technical assistance for specific programs.57 system. As a first step, the Commission called on the Little Hoover Commission | 15 Promises Still to Keep: A Second Look at the Mental Health Services Act Centers for Medicare and Medicaid Services.45 Next steps Meanwhile, Counties Initiate Their Own MHSA Data include another plan to implement the project, then issue a Collection Projects bid for vendors to design, develop and build the new system by June 2021.46 Cost estimates are not yet available. But Some counties individually have used MHSA money the initial planning phase will cost nearly $3 million, with the to develop local data systems to track outcomes. Los federal government picking up most of the tab.47 Angeles County built an application to measure MHSA outcomes and now produces a quarterly newsletter While recognizing that a process to transition and highlighting outcomes for participants in MHSA-funded modernize legacy data systems is complex, the programs. Debbie Innes-Gomberg, district chief of the Commission has strong reservations about the current Los Angeles County MHSA Implementation and Outcomes data modernization proposal. It is unreasonable to Division, also told the Commission the value of the data wait nearly two decades for the state to collect and is “not just about saying that MHSA has made an impact. report data about the Proposition 63 funding stream. It’s about making decisions using that data, learning from Government agencies across the nation – at the federal, that data and improving the quality of our services.”49 state and local levels, are demonstrating that new These reporting practices should be a model for other approaches to data collection and sharing can cost less counties that still lack capacity to report outcomes of and be implemented faster than efforts to maintain MHSA-funded programs. outmoded technology. For example, the California Department of Social Services in 2015 partnered with In the absence of a statewide mental health data system Code for America and the federal government’s tech capable of reporting MHSA program outcomes, the innovation team, 18F, to change its approach to procuring County Behavioral Health Directors Association initiated technology for a new Child Welfare System. Instead of its own data collection project in 2014, association issuing a massive contract for the project as a executive director Kirsten Barlow told Commissioners whole – traditionally a costly approach with low success in May. The Measurement, Outcomes and Quality rates – the department will build the new system in a Assessment (MOQA) project enables counties to report series of projects focused on developing and delivering collective results of some MHSA programs using data user-centered services and open source practices.48 The counties already collect. Specifically, it aims to create Commission highlighted similar efforts in its 2015 report, uniformity in outcome reporting across different types of A Customer-Centric Upgrade for California Government. MHSA-funded programs.50 Measuring MHSA Outcomes: It Can Be Done Los Angeles County now has a decade worth of data for some MHSA-funded programs, which it uses to guide decisions about where to refine or expand services countywide. Using money from the Act, Los Angeles County in 2006 built a data system to capture outcomes of clients enrolled in full-service partnership (FSP) programs – one type of program funded under MHSA Community Services and Supports (CSS). In the years since the county has twice expanded the system to capture outcomes from field capable clinical services (FCSS), another CSS-funded program, as well as Prevention and Early Intervention (PEI) programs. Through its Outcome Measure Application, the county records and monitors clients’ progress and response to services and reviews the impacts that programs have on clients’ welfare. For example, data from the system shows that while in FSP programs, clients experience fewer hospitalizations, less homelessness, reduced incarceration and fewer emergency events. Children improve their grades, more adults live independently and some gain employment for the first time. Clients in FCCS programs spend more time engaging in meaningful activities, such as working, volunteering or participating in community activities. PEI clients show dramatic reductions in symptoms; they are less depressed, less anxious, parents report fewer behavior problems and fewer symptoms related to trauma. Reports produced from the data also are shared with providers to encourage them to think about how they use and analyze outcome data in their own programs, county staff said.51 16 | www.lhc.ca.gov Still Unknown: Is the Act Achieving its Goals? The project allows counties to report on outcomes some adults were able to find jobs after one year in a through an online portal, supported and maintained by program.53 The process also has improved data collection the California Institute for Behavioral Health Solutions. and reporting processes and increased use of data to Currently, the database is set up only to collect outcome inform best practices and administrative decisions.54 data from full-service partnership programs – one of the largest types of programs funded with MHSA Community Additionally, reports about the California Mental Health Services and Supports dollars. Common data elements Services Authority’s (CalMHSA) statewide Prevention and for these programs include average percent of clients re- Early Intervention programs demonstrate reduced stigma hospitalized within 30 days, reduction in homelessness, and discrimination around mental illness. Investments also psychiatric hospitalizations and incarcerations for adults have educated many Californians about how to intervene and reduction in trauma symptoms for children. The with people at risk for suicide. CalMHSA, created by association is developing additional outcome measures counties in 2010, uses MHSA funds to implement for Prevention and Early Intervention programs.52 The statewide Prevention and Early Intervention services.55 MOQA database was built with funding from the Department of Health Care Services. These reports and others demonstrate outcomes for portions of programs funded by the Mental Health With compiled data, the California Behavioral Health Services Act. They begin to paint a statewide picture of Directors Association, in partnership with the Steinberg what the Act has achieved and are critical for providing Institute, has released two easy-to-understand reports policymakers with evidence of how the programs are since 2015 showing that participants of county full- working. These types of reports demonstrate the type service partnership programs help people recover and of statewide analysis and reporting that should be the get better when they have the right kind of support. (The norm for all programs funded by the Act. In the long Steinberg Institute is a statewide organization launched term, it is not sustainable nor prudent to rely on other in 2015 to advance sound public policy and inspire organizations to do the work that should be done by the leadership on mental health issues.) Among 25,418 state in its oversight capacity. children and adults served between 2013 and 2014, The State Still Needs to Improve MHSA Data Collection homelessness and emergency shelter use declined, as did arrests, psychiatric hospitalization and mental health State leaders must immediately build on the counties’ MOQA emergencies. Most children did better in school and project to produce statewide MHSA outcome reports. Improving Data Collection, Performance Measures and Outcomes for California’s Youth Offenders California’s juvenile justice data system has lingered without a significant state investment in data modernization for more than two decades. Among its challenges: outdated technology that cannot be upgraded, inability to track important case and outcome information and a lack of performance outcome measures, poor transparency and availability of statewide information, and, fractured data collection and reporting responsibilities among different state agencies and lack of integration with county-level data systems.59 To address long-standing concerns about the state’s lack of a juvenile justice data system, the Legislature in 2014 established a working group to help clarify what would be needed for the state to build capacity to collect and use juvenile justice data to support evidence-based practices and promote positive outcomes for the children and youth who move through the system. Staff from the Board of State and Community Corrections supported the working group by coordinating meetings, taking notes and drafting reports. After more than a year of meetings, research and deliberation, the working group released a report offering recommendations to improve and modernize the data system, while addressing concerns related to the cost of replacement technology as well as the need to create a system that leverages the infrastructure of existing county data systems.60 Little Hoover Commission | 17 Promises Still to Keep: A Second Look at the Mental Health Services Act State mental health leaders, with relevant stakeholders, to the state. Membership includes key staff from the should collectively identify indicators that will show oversight commission, Mental Health Planning Council progress toward reducing the negative outcomes and counties. However, it is not clear from conversations from untreated mental illness. Defined by the Act, with participants whether this group meets regularly, those include suicide, incarcerations, school failure or has an ultimate purpose for meeting, and whether the dropping out rate, unemployment, prolonged suffering, meetings or meeting materials are available to the public. homelessness, and removal of children from their homes. Evaluation efforts by the counties show that reporting The state should leverage the momentum spurred on these types of indicators is already possible for some by local data collection efforts, as well as burgeoning components of the Act. coordination among state agencies to review mental health data requirements in order to build a modern, Web-based data collection system to report outcomes “We wonder whether mental health disparities from MHSA-funded programs. are being reduced. But because of the lack of data, no one can really prove anything beyond Recommendation 5: Before proceeding further anecdotal examples.” with the data modernization project, the Stacie Hiramoto, Director, REMHDCO58 Department of Health Care Services should immediately consult with civic technologists and data experts to refine and streamline its approach State leaders also should collect data to better to modernizing the state’s mental health data understand who is being served. Throughout the collection system. Commission’s last review and again at its May 2016 hearing, advocates, stakeholders and members of the Recommendation 6: The Legislature should public voiced concerns that the state still cannot account establish a Mental Health Services Act (MHSA) for the number of people served by the Act, nor produce data workgroup within the Department of Health basic demographic data. Of particular importance, Care Services to build on existing county MHSA many said, is reporting data on racial, ethnic and other data collection efforts and develop and support a minority communities so the state can better understand statewide MHSA database. The workgroup should: how the Act is reducing disparities in services and guide ƒ Be comprised of representatives from entities future spending decisions. They said statewide outcome who collect and use mental health data at the measures should include demographic information about state and local levels, stakeholders as well as who benefits from the Act, including their ages, gender, technology experts and should be supported racial and ethnic background and language spoken. by department staff. Additionally, state mental health leaders should ƒ Define the statewide outcomes needed acknowledge the anxiety that the collection of outcome to evaluate the MHSA, identify whether data can cause. They should emphasize the use of existing data collection efforts are data to improve services and promote best practices, sufficient for reporting and articulate not to sanction poor performers. To ease the anxiety, the technological needs for such a data representatives of those who will collect and use the data collection system. If existing data is should be included in the process to clarify what the state not sufficient, the workgroup should must collect to oversee the Mental Health Services Act. The recommend how counties and providers state’s work to build a juvenile justice data system offers a might collect the additional data without model to begin a conversation about building an appropriate creating undue work or redundancies for outcome data system for MHSA-funded programs. counties and providers. The Department of Health Care Services has started a ƒ Specify how demographic data will be workgroup to identify common ways counties measure collected, including age, gender, racial and and report MHSA and other behavioral health data to the ethnic background and language spoken. state and to consider what doesn’t need to be provided 18 | www.lhc.ca.gov Californians Still Need Meaningful Ways to Participate in Spending Decisions Californians Still Need Meaningful Ways to Participate in Spending Decisions The Mental Health Services Act established a process Counties have complied with the state requirements,” – and allocated resources – for stakeholders to Rusty Selix, MHSA co-author told Commissioners. participate in county decisions about how to spend “Unfortunately that guidance has missed the mark by MHSA funds. The Act specifically calls for stakeholder measuring how many people attended meetings and how involvement in developing counties’ three-year program many groups the counties reached out to.” He explained and expenditure plans and annual updates. It also that counties are not required to describe how the funds requires counties to “demonstrate a partnership with are proposed to be spent compared to how they are constituents and stakeholders through the process that actually spent. Nor are they required to have meaningful includes meaningful stakeholder involvement on mental discussions that welcome stakeholder views before and health policy, program planning, and implementation, after spending decisions are made.62 Some stakeholders monitoring, quality improvement, evaluation and budget say spending decisions seem to be made before they are allocations.”61 These provisions codify a central and asked to provide input, and that their input is “window ongoing role for stakeholders in determining how and dressing.”63 where counties should invest their MHSA resources. “The approach to community engagement matters,” However, in this review and the last, the Commission Stacie Hiramoto, director of the Racial and Ethnic Mental heard that some counties fall short in including Health Disparities Coalition, told Commissioners. “A stakeholders in meaningful decisions. “Proposition 63 lot of times, counties have a big meeting at a big public included specific requirements that county spending place. For many people in underserved communities plans be developed through a stakeholder process. it’s not our culture to come out in public. And, in some of our communities, the stigma regarding mental health issues is actually more acute.” Ms. Hiramoto and others Boulevard Court Apartments, also explained there can be language or cultural barriers Sacramento County that impede participation, as well as scheduling barriers that make it difficult for workers to attend meetings Operated by Mercy Housing California, the during regular business hours. Boulevard Apartments offer a low-income housing program for homeless people with special To make it easier to participate in MHSA planning needs. Using MHSA funds, the program renovated efforts, stakeholders suggested counties partner with a formerly dilapidated motel in a high-need community groups or trusted leaders to figure out the neighborhood into a campus with 74 studio and best ways to approach certain cultural groups and show one-bedroom units that offer residents supportive respect for their distinct values. With the help of these services such as health care education, financial partners, counties could advertise meetings in different literacy and community involvement. With stable languages and hold discussions in smaller venues where housing in a supportive environment, residents people feel comfortable. Scheduling meetings in the can focus on successfully managing their individual evening or on weekends also could help working families disabilities. (CSS-funded) participate.64 Additionally, they suggested counties – as well as the state – establish advisory committees that “I like being here,” one participant said. “The best involve consumers, family members and representatives thing is that it is affordable for me and there’s a of underserved communities in decisions. Many of doctor onsite. Otherwise, it takes two to two and a these suggestions echo recommendations from various half hours transportation time by the bus [to get to groups, including the Mental Health Planning Council, a doctor].” Little Hoover Commission | 19 Promises Still to Keep: A Second Look at the Mental Health Services Act the California Stakeholder Process Coalition and the concerns to be addressed, the oversight commission’s oversight commission to fortify stakeholder engagement executive director told the Commission. The Commission in implementation of the Act.65 commends this effort and encourages the oversight commission to develop tools and templates to improve Additionally, clients and advocates suggested the state the local issue resolution process, including making it strengthen the process for stakeholders to report issues easier for clients, advocates and others to learn how to and concerns at the local and state levels. Several told engage and how and where to elevate their issue to the Commissioners they are unsure where they should turn state, if necessary. when they identify problems with the local planning process and program implementation. Some said Recommendation 7: The Mental Health Services they fear retaliation for speaking out against spending Oversight and Accountability Commission should decisions or registering a complaint with the local provide guidance to counties on best practices process. Others said that even when local leaders in engaging stakeholders in MHSA planning articulate a plan of correction, there is no oversight by processes, and offer training and technical the state to ensure that what was promised is done. assistance if necessary. Additionally, the oversight commission should develop standards and a In its triennial performance audit of counties, the template for counties to create consistency in Department of Health Care Services reviews whether reporting and responding to concerns about counties have an issue resolution process for the Mental the Mental Health Services Act. The oversight Health Services Act and that they maintain a log of all commission and the Department of Health Care issues received and the dates they were resolved. The Services should clarify the process for elevating department does not, however, review the quality of issues or concerns related to the Mental Health these processes nor does it assess whether they are Services Act from the local level to the state. sufficient for capturing and responding to concerns. In response to concerns about the adequacy of the issue resolution process, the oversight commission has begun a formal project to review the process and identify opportunities to clarify and strengthen ways for stakeholders to raise concerns and for those Navigation Teams, Los Angeles County Eight navigation teams work regionally across the county to help individuals and families access mental health and other supportive services. Navigation Team members help quickly identify available services tailored to a client’s cultural, ethnic, age and gender identity, and follow up with clients to ensure they received the help they need. Team members also build an active support network through partnerships with community organizations and service providers and map availability of local services and supports in the area. (CSS-funded) A team member described the program as concierge mental health services – “navigators help people directly link to the services they need.” 20 | www.lhc.ca.gov Counties Need More Ways to Share Success Counties Need More Ways to Share Success The Mental Health Services Act provides Innovation Additionally, the department, oversight commission funds for counties to experiment with promising and individual counties occasionally contract with the practices that have not yet proven effective. This California Institute for Behavioral Health Solutions financial commitment allows local communities to develop training programs on evidence-based throughout the state to become testing grounds for new practices, hold conferences and policy forums, among and innovative mental health programs and practices. other consultative activities. The nonprofit institute, Brought to scale, successful programs could transform established in 1993, helps health professionals and the way mental health services are delivered in the others improve the lives of people with mental health state. However, key to that transformation is the ability and substance use challenges. When the Mental Health of local mental health leaders, providers and clients and Services Act was initially passed, the Department of their families to regularly share information and lessons Mental Health contracted with the institute to help learned about what’s working, what’s not and why. counties develop and run full-service partnership programs. With input from state and local mental health Counties and providers currently have several venues to leaders, providers, clients and family members, the share best practices and lessons learned. For example, institute developed toolkits to help providers implement Mike Kennedy, Sonoma County’s Behavioral Health full-service partnership programs, ensure ongoing quality Division Director, told the Commission in September 2014 improvement and improve access to care for unserved that counties can learn about successful approaches in and underserved ethnic and cultural groups.67 The other counties through the County Behavioral Health institute has not yet been approached to coordinate Directors Association and its subcommittees, conferences similar training around successful MHSA Innovation and forums.66 The associations’ MHSA committee also programs.68 holds monthly conference calls or meetings to share information about programs funded by the Mental Health Despite existing efforts to collaborate, the Commission Services Act. heard from stakeholders that more is needed and suggested the state could play a key role in fostering information sharing and by providing additional technical The Transitional Age Youth Behavioral Health assistance. At each county visited, the Commission Hostel – The STAY, San Bernardino County heard providers say in various ways, “I’m not sure if other counties have a program like this.” The hostel offers a short-term crisis residential program for up to 14 Transition Age Youth One member of an award-winning MHSA-funded between ages 18 to 25 who are experiencing an Innovation program in Long Beach lamented, “I’ve been acute psychiatric episode or crisis and is the first thinking about putting together a training program crisis residential treatment facility in the county. because no one seems to have anything like this. But I Services are culturally and linguistically appropriate, just haven’t found the time.” with a particular emphasis on diverse youth (African American, Latino, LGBTQ, etc.) as well as former Another provider – a “navigator” who links individuals foster youth or youthful offenders. The hostel is and family members to appropriate mental health primarily peer run by individuals representing the services, and provides referrals and responds to pleas county’s diverse ethnic communities and cultures. for help – said she wishes for a way to “connect the (INN-funded) connectors.” She explained that while she and the other “navigators” are familiar with the various programs in her Little Hoover Commission | 21 Promises Still to Keep: A Second Look at the Mental Health Services Act county, it would be helpful also to know what is available agencies, as well as counties and service providers, to elsewhere. “It would be great to have conferences, more leverage innovation as a strategy for transformational provider-to-provider learning opportunities,” she said. change, the executive director said.70 Again, this is a “If we don’t see anything outside our county, we’re not promising vision, but more must be done to ensure that learning.” counties get the help they need to leverage best practices across the state, fulfilling one of the original intentions of The state could spread promising practices across the Mental Health Services Act. communities and county boundaries by collecting information from successful Innovation programs and To scale up promising MHSA-funded Innovation working with providers to develop training programs and programs, mental health practitioners need more share best practices. opportunities to learn from each other about what’s working well so that successful programs can be The oversight commission has the statutory authority replicated. As part of its oversight responsibilities, the to establish technical advisory committees, employ oversight commission should prioritize fostering the technical assistance staff and other appropriate strategies transformational potential of the Mental Health Services as necessary to perform its duties.69 But, according to its Act’s Innovation programs. executive director, “the oversight commission does not currently have the staff to provide technical assistance Recommendation 8: The Mental Health Services and training on how innovation can be transformative.” Oversight and Accountability Commission should Nor does it “currently have the capacity to fully identify best practices in counties achievements disseminate information on the lessons learned through with MHSA programs, and provide training innovation investments.” and technical assistance to disseminate these practices statewide. It also should develop regular The oversight commission requested, and received in opportunities to convene local mental health the 2016-17 budget funding for additional staff to better leaders and practitioners to spread lessons learned document how counties are innovating, what has worked beyond county borders. and why. The oversight commission plans to develop tools and provide technical assistance around Innovation programs, as well as disseminate best practices. It also intends to reach out to partners in the business community, universities, foundations and federal Crisis Respite Center, Sacramento County Since opening in December 2013, the Crisis Respite Center provides crisis intervention services that reduce law enforcement calls and unnecessary emergency room visits. The program stabilizes adults experiencing mental health crises with 24/7 drop-in services in a warm and supportive setting. The program provides a stable, supportive environment to help “guests” explore their crises with a solution-oriented mindset. (CSS-funded, formerly INN) A client reflected, “Here I had the chance to settle Photo by Little Hoover Commission staff at the Crisis down and think straight because I felt safe. I had Respite Center – Transforming Lives, Cultivating Success in the chance to regroup coming here.” Sacramento, California. 22 | www.lhc.ca.gov Appendices Appendices Appendix A: Public Hearing Witnesses Public Hearing Revisiting the Mental Health Services Act May 26, 2016 Jane Adcock, Executive Officer, California Mental Stacie Hiramoto, Director, Racial and Ethnic Mental Health Planning Council Health Disparities Coalition Kirsten Barlow, Executive Director, County Behavioral Debbie Innes-Gomberg, District Chief, Los Angeles Health Directors Association County MHSA Implementation and Outcomes Division Karen Baylor, Deputy Executive Director of Mental Health and Substance Use Disorder Services, Daphne Shaw, Councilmember, California Mental California Department of Health Care Services Health Planning Council Phillip Deming, Chair, San Diego County Behavioral Rusty Selix, MHSA Co-Author and Executive Director Health Advisory Board of Policy and Advocacy, Mental Health America of California Toby Ewing, Executive Director, Mental Health Services Oversight & Accountability Commission Darrell Steinberg, Former Senate President Pro Tem and Founder, Steinberg Institute Little Hoover Commission | 23 Promises Still to Keep: A Second Look at the Mental Health Services Act Appendix B: Recommendations from the Little Hoover Commission’s January 2015 report, Promises Still to Keep: A Decade of the Mental Health Services Act Recommendation 1: The Legislature should expand the authority of the Mental Health Services Oversight and Accountability Commission. Specifically, it should: ƒ Strengthen the ability of the state to conduct up-front reviews of the more controversial programs funded by the act before funds are expended by requiring the oversight commission to review and approve county Prevention and Early Intervention plans annually, as it currently does for Innovation plans. ƒ Refine the process by which the state responds to critical issues identified in county three-year plans or annual updates to ensure swift action. Empower the oversight commission to impose sanctions, including the ability to withhold part of the county’s MHSA funds, if and when it identifies deficiencies in a county’s spending plan. Decisions of the oversight commission should become mandatory unless they are overturned by the Department of Health Care Services within a reasonable period, such as 60 days. Recommendation 2: To provide greater oversight and evaluation of the state administrative funds, the oversight commission should annually develop recommendations for and consult with the Department of Finance before the funds are allocated. Recommendation 3: To make MHSA finances more transparent and make it easier for voters, taxpayers and mental health advocates, consumers and their families to see how and where the money is spent and who benefits from its services, the Mental Health Services Oversight and Accountability Commission should add to and update material on its website to include: ƒ MHSA revenues, by component and annual allocations, and the cumulative total revenue since voters approved the act. ƒ Data about who benefits from the act, including the number of individuals served, their ages, gender, racial and ethnic background and language spoken. ƒ Data to demonstrate statewide trends on key indicators such as rates of homelessness and suicide that show how well the act’s programs help those living with mental illness to function independently and successfully. ƒ A rotating showcase of model programs in each of the component areas to clearly demonstrate examples of what works. ƒ All county MHSA plans and reports submitted to the state, including: 9 MHSA annual revenue and expenditure reports. 9 Three-year program and expenditure plans and annual updates. 9 Other relevant mental health reports, such county cultural competence plans that describe how a county intends to reduce mental health service disparities identified in racial, ethnic, cultural, linguistic and other unserved and underserved populations. 24 www.lhc.ca.gov Appendices Recommendation 4: To promote meaningful accountability of the MHSA, the state needs access to reliable, timely information that allows it to monitor effective progress toward the act’s goals. The Mental Health Services Oversight and Accountability Commission and Department of Health Care Services should: ƒ Immediately develop a formal plan and timeline to implement a comprehensive, statewide mental health data collection system capable of incorporating data for all MHSA components, as well as other state behavioral and mental health programs. 9 This plan should address how the development of such a data collection system would be funded and should use a portion of the MHSA state administrative funds to support the effort. ƒ Regularly report to the Legislature on the progress made in developing this data system and identify challenges that arise. Little Hoover Commission | 25 Promises Still to Keep: A Second Look at the Mental Health Services Act Appendix C: Examples of Statutory Roles and Responsibilities Assigned to Mental Health Agencies State law – California’s Welfare and Institutions Code – prescribes various roles and responsibilities for state and local agencies to implement the Mental Health Services Act. Examples of some of these roles and responsibilities are included below. Code Description Section 26 www.lhc.ca.gov SCHD CAOSHM CPHM rehtO ytnuoC ADHBC 5655 DHCS shall, upon request and with available staff, provide consultation services to the local mental health directors, local governing bodies and local mental health advisory boards. If the director of DHCS considers any county to be failing, in a substantial manner, to comply with any provision of this code or any regulation, the director shall order the county to appear at a hearing, before the director  or the director’s designee, to show cause why the department should not take action. If the director finds there has been a failure, the DHCS may withhold part or all of state mental health funds for the county, require the county to enter into negotiations for the purpose of ensuring county compliance with those laws and regulations and bring court action as appropriate to compel compliance. 5722 The MHPC shall have the powers and authority necessary to, among other duties, review, assess and make recommendations regarding all components of California’s mental health system, review program performance in delivering mental health services by annually reviewing performance outcome data, identify successful  programs for recommendation and for consideration of replication in other areas, advise the DHCS if a county’s performance is failing, advise the Legislature, DHCS and county boards on mental health issues and the policies and priorities the state should be pursuing in developing its mental health system. 5845 (a) MHSOAC established to oversee: Part 3: the Adult and Older Adult Mental Health System of Care, Part 3.1: Human Resources, Education and Training Programs, Part 3.2: Innovative Programs, Part  3.6: Prevention and Early Intervention Programs, Part 4: Children’s Mental Health Services Act 5845 (d) In carrying out its duties, the MHSOAC may, among other things, obtain data and (6) information from DHCS, OSHPD or other state or local entities that receive MHSA funds for the commission to utilize in its oversight, review, training and technical     assistance, accountability and evaluation capacity regarding projects and programs supported with the MHSA funds 5845 (d) Advise the Governor or Legislature regarding actions the state may take to improve  (9) care and services for people with mental illness. 5845 (d) If the commission identifies a critical issue related to the performance of a county   (10) mental health program, it may refer the issue to the DHCS. 5845 (d) Assist in providing technical assistance to accomplish the purposes of Part 3, Part 4    (11) in collaboration with the DHCS and in consultation with the CBHDA Appendices Code Description Section Little Hoover Commission | 27 SCHD CAOSHM CPHM rehtO ytnuoC ADHBC 5845 (d) The MHSOAC may work in collaboration with DHCS and the Mental Health Planning (12) Council, and in consultation with the CBHDA, in designing a comprehensive joint plan for a coordinated evaluation of client outcomes in the community-based      mental health system, including but not limited to parts listed in 5845(a). The California Health and Human Services Agency shall lead this comprehensive joint plan effort. 5897 (c) The DHCS shall implement the provisions of Part 3, Part 3.2, Part 3.6 and Part 4   through the annual county mental health services performance contract. 5897 (d) The DHCS shall conduct program reviews of performance contracts to determine compliance. Each county performance contract shall be reviewed at least once   every three years, subject to available funding. 5897 (e) When a county mental health program is not in compliance with its performance contract, the department may request a plan of correction with a specific timeline   to achieve improvements. The department shall post on its website any plans of correction requested and the related findings. 5898 The DHCS, in consultation with the MHSOAC, shall develop regulations, as necessary, for the DHCS, the MHSOAC, or designated state and local agencies to     implement this act. 5899 (b) The DHCS, in consultation with the MHSOAC and CBHDA shall revise the instructions for the Annual Mental Health Services Act Revenue and Expenditure    Report by July 1, 2017, and as needed thereafter, to improve the timely and accurate submission of county revenue and expenditure data. Notes: DHCS: California Department of Health Care Services MHSOAC: Mental Health Services Oversight and Accountability Commission MHPC: California Mental Health Planning Council Other: A state agency, other than DHCS, MHSOAC, MHPC CBHDA: County Behavioral Health Directors Association, formerly, County Mental Health Directors Association Promises Still to Keep: A Second Look at the Mental Health Services Act Appendix D: County Submission Status of MHSA Annual Revenue and Expenditure Reports (as of August 26, 2016) Fiscal Year Fiscal Year County County 13-14 14-15 13-14 14-15 Alameda Orange   Alpine Placer Amador Plumas Berkeley City   Riverside  Butte   Sacramento Calaveras   San Benito  Colusa   San Bernardino   Contra Costa   San Diego   Del Norte   San Francisco   El Dorado   San Joaquin Fresno   San Luis Obispo   Glenn   San Mateo Humboldt  Santa Barbara Imperial   Santa Clara Inyo   Santa Cruz  Kern  Shasta  Kings   Sierra Lake Siskiyou Lassen  Solano   Los Angeles Sonoma Madera Stanislaus   Marin Sutter-Yuba Mariposa Tehama   Mendocino  Tri-City   Merced  Trinity  Modoc   Tulare   Mono   Tuolumne   Monterey Ventura   Napa Yolo Nevada  Source: Kendra Penner, Legislative Coordinator, Department of Health Care Total FY 13-14 37 Services. August 30, 2016. Personal communication with Commission staff. Total FY 14-15 26 28 www.lhc.ca.gov Notes Notes communication with Commission staff. 27 MHSOAC. “County Submitted Reports.” Accessed August 5, 2016 12 Karen Baylor, Deputy Director at http://mhsoac.ca.gov/county- 1 Department of Health Care Services of Mental Health and Substance Use submitted-reports. Also, “Ensuring (DHCS). January 2016. Mental Health Disorder Services, DHCS. September Fiscal Accountability” at http://mhsoac. Services Act Expenditure Report: Fiscal 23, 2014 and May 26, 2016. Written ca.gov/ensuring-fiscal-accountability. year 2016-2017. Also, Mental Health testimony to the Commission. Also, “Measuring Outcomes” at http:// Services Oversight and Accountability mhsoac.ca.gov/measuring-outcomes. 13 Welfare & Institutions Code, Section Commission (MHSOAC). “Proposition 63 History.” Accessed August 5, 2016 at 5655. Also, Karen Baylor. See Endnotes 28 DHCS. See Endnote 1. 6 and 12. http://mhsoac.ca.gov/history 29 Matthew Gallagher, Program 2 Secretary of State Kevin Shelley. 14 Brian Sala, Deputy Director, and Director, California Youth Empowerment November 2, 2004. Official Voter Filomena Yeroshek, Chief Counsel, Network. May 5, 2016. Public Information Guide. Page 34. MHSOAC. July 8, 2016. Personal comment to the Commission. communication with Commission staff. 3 Welfare & Institutions Code, Sections 30 Sally Zinman, Executive Director, 5845(d)(11), 5845(d)(12), 5898, 5899(a-b). 15 DHCS. See Endnote 1. California Association of Mental Health Peer Run Organizations. May 25, 2016. 16 Rusty Selix, Executive Director of 4 Welfare & Institutions Code, Section Written testimony to the Commission. Policy and Advocacy, Mental Health 5655. America of California. May 26, 2016. 31 Toby Ewing. See Endnote 7. 5 DHCS. See Endnote 1. Written testimony to the Commission. 32 Brian Sala, Deputy Director, 6 Karen Baylor, Deputy Director of 17 Toby Ewing. See Endnote 7, hearing MHSOAC. July 29, 2016. Personal Mental Health and Substance Use video at 1:50:04 to 1:51:37. communication with Commission staff. Disorder Services, DHCS. July 12, 2016. Personal communication with 18 Welfare & Institutions Code, Section 33 AB 1618. See Endnote 22. Also, Commission staff. 5772(b) and (c). Welfare & Institutions Code, Section 5899. 19 Welfare & Institutions Code, 7 Toby Ewing, Executive Director, MHSOAC. May 26, 2016. Testimony to Sections 5820 and 5821. 34 Kendra Penner. See Endnote 11. the Commission. Accessed September 20 DHCS. See Endnote 1. 35 Rusty Selix, Executive Director of 8, 2016 at http://calchannel.granicus. Policy and Advocacy, Mental Health com/MediaPlayer.php?view_id=7&clip_ 21 Welfare & Institutions Code, America of California. May 2016, id=3752. Sections 5847 and 5848. Testimony to the Commission. 8 Department of Health Care Services. 22 AB 1618 (Committee on Budget). 36 DHCS. See Endnote 1. September 23, 2015. MHSUDS Chapter 43, Statutes of 2016. Also, Information Notice: 15-042. Subject: Welfare & Institutions Code, Section 37 Kevin Shelley. See Endnote 2. Annual review protocol for consolidated 5848(e). Pages 107-108. Specialty mental health services and other funded services for fiscal year 23 Brian Sala. See Endnote 14. 38 Welfare & Institutions Code, Section 2015-16. 5892(d). Also, DHCS. See Endnote 1. 24 Josephine Black, Chairperson, 9 Karen Baylor, Deputy Director of and Jane Adcock, Executive Officer, 39 Toby Ewing. See Endnote 7. Mental Health and Substance Use California Mental Health Planning Disorder Services, DHCS. May 26, 2016. Council. May 26, 2016. Written 40 Financial Oversight Committee, Testimony to the Commission. testimony to the Commission. MHSOAC. Minutes. March 27, 2015. Accessed July 18, 2016 at http:// 10 Welfare & Institutions Code, Section 25 Darrell Steinberg, former Senate Pro archive.mhsoac.ca.gov/Meetings/ 5899. Tem and Founder, Steinberg Institute. docs/Meetings/2015/March/FOC/ May 26, 2016. Testimony to the FOC_032715_Agenda.pdf. 11 Kendra Penner, Legislative Commission. Coordinator, Department of Health Care 41 The WayBack Machine Internet Services. August 30, 2016. Personal 26 MHSOAC. See Endnotoe 1. Archive. Captured January 21, 2012, Little Hoover Commission | 29 Promises Still to Keep: A Second Look at the Mental Health Services Act http://www.dmh.ca.gov/Prop_63/ Chief, and Kara Taguchi, Phys.D., Los Improve Data Collection, Performance MHSA/State_Interagency_Partners.asp. Angeles County MHSA Implementation Measures and Outcomes for California and Outcomes Division. June 16, Youth.” 42 Darrell Steinberg. May 5, 2016. 2016. Personal communication Steinberg Institute and County with Commission Staff. Long Beach, 60 California Juvenile Justice Data Behavioral Health Directors Association California. Also, Debbie Innes-Gomberg, Working Group. See Endnote 59. press event. Sacramento, California. See Endnote 49. 61 Welfare & Institutions Code, Section 43 Josephine Black and Jane Adcock. 52 Kirsten Barlow, Executive Director, 5848(a). See Endnote 24. Mary Ader, Deputy Director of 62 Rusty Selix. See Endnote 16. Legislative Affairs and Adrienne Shilton, 44 Toby Ewing. See Endnote 7. Director of Intergovernmental Affairs, 63 Racial and Ethnic Mental Health 45 Karen Baylor. See Endnote 9. County Behavioral Health Directors Disparities Coalition (REMHDCO). Association. July 6, 2016. Sacramento, July 20, 2016. Survey on Proposition 46 Kendra Penner, Legislative CA. Personal communication with 63/Mental Health Services (MHSA) Coordinator, DHCS. July 27, 2016. Commission staff. community planning process. Personal communication to Commission staff. Also, Renay Bradley, Director of 53 Steinberg Institute and County 64 REMHDCO. See Endnote 63. Research and Evaluation, MHSOAC. Behavioral Health Directors Association. June 10, 2016. “MHSOAC Data May 5, 2016. Changes to Number 65 California Mental Health Planning Strengthening Efforts.” of Clients After Entering Full Service Council. December 2015. “We’re Partnership Program. Listening: A Community Dialogue 47 Kendra Penner, Legislative on Mental Health.” Also, Resource Coordinator, DHCS. July 29, 2016. Personal 54 Adrienne Shilton. See Endnote 50. Development Associates for the communication to Commission staff. MHSOAC. August 8, 2014. “MHSA 55 Wayne Clark, Executive Director, Community Program Planning Processes 48 Dan Hon. November 30, 2015. California Mental Health Services – Promising CPP Practices.” Also, the Code for America Blog Archive. “A New Authority. May 20, 2016. Written California Stakeholder Process Coalition. Approach to Procuring Government testimony to the Commission. April 2012. “Transforming California Technology in California.” Accessed 56 Josephine Black, Chairperson, Mental Health System through July 28, 2016 at https://www. Mental Health Planning Council (MHPC). Consumer Engagement.” codeforamerica.org/blog/2015/11/30/ June 8, 2016. “Letter to Honorable a-new-approach-to-procuring- 66 Mike Kennedy, Director, Sonoma Kevin de Leon, President Pro Tempore, government-technology-in-california/. County Behavioral Health Division. California State Senate RE: No Place Also, V. David Zvenyach and Andre September 23, 2014. Written testimony Like Home Legislation – Oppose unless Francisco, 18F. March 22, 2016. “From to the Commission. amended.” Also, Josephine Black, 1,500 pages to 10: Helping California buy a new Child Welfare System.” Chairperson, MHPC. June 24, 2016. 67 California Institute for Behavioral Accessed July 28, 2016 at https://18f. “Letter to Assembly Member Kevin Health Solutions. FSP Toolkits. gsa.gov/2016/03/22/helping-california- McCarty RE: AB 2017 College Mental Accessed July 21, 2016 at http://www. buy-a-new-child-welfare-system/. Health Services Program – Oppose.” cibhs.org/introduction/fsp-toolkits. 49 Debbie Innes-Gomberg, District 57 AB 847 (Mullin and Ridley-Thomas), 68 Sandra Naylor Goodwin, President Chief, Los Angeles County MHSA AB 1618 (Committee on Budget), AB and CEO, California Institute for Implementation and Outcomes Division. 2017 (McCarty), SB 614 (Leno), SB 852 Behavioral Health Solutions. July 21, May 26, 2016. Testimony to the (Budget Trailer Bill). 2016. Personal communication with Commission. 58 Stacie Hiramoto, Director, Racial Commission staff. 50 Adrienne Shilton, Director of and Ethnic Mental Health Disparities 69 Welfare & Institutions Code, Section Intergovernmental Affairs, County Coalition. May 26, 2016, Testimony to 5845. the Commission. Behavioral Health Directors Association 70 Toby Ewing. See Endnote 7. Also, of California. July 7, 2016. Personal 59 California Juvenile Justice Data California Enacted Budget. MHSOAC. communication to Commission staff. Working Group. January 2016. Accessed July 21, 2016 at http://www. 51 Debbie Innes-Gomberg, District “Rebuilding California’s Juvenile Justice ebudget.ca.gov/2016-17/pdf/Enacted/ Data System: Recommendations to GovernorsBudget/4000/4560.pdf. 30 | www.lhc.ca.gov Little Hoover Commission Members Chairman Pedro Nava (D-Santa Barbara) Appointed to the Commission by Speaker of the Assembly John Pérez in April 2013. Advisor to telecommunications industry on environmental and regulatory issues and to nonprofit organizations. Former state Assemblymember. Former civil litigator, deputy district attorney and member of the state Coastal Commission. Elected chair of the Commission in March 2014. Vice Chairman Jack Flanigan (R-Granite Bay) Appointed to the Commission by Governor Edmund G. Brown Jr. in April 2012. A member of the Flanigan Law Firm. Co-founded California Strategies, a public affairs consulting firm, in 1997. Scott Barnett (R-San Diego) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in February 2016. Founder of Scott Barnett LLC, a public advocacy company, whose clients include local non- profits, public charter schools, organized labor and local businesses. Former member of Del Mar City Council and San Diego Unified School District Board of Trustees. David Beier (D-San Francisco) Appointed to the Commission by Governor Edmund G. Brown Jr. in June 2014. Managing director of Bay City Capital. Former senior officer of Genetech and Amgen. Former counsel to the U.S. House of Representatives Committee on the Judiciary. Serves on the board of directors for the Constitution Project. Senator Anthony Cannella (R-Ceres) Appointed to the Commission by the Senate Rules Committee in January 2014. Elected in November 2010 an re-elected in 2014 to the 12th Senate District. Represents Merced and San Benito counties and a portion of Fresno, Madera, Monterey and Stanislaus counties. Assemblymember Chad Mayes (R-Yucca Valley) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in September 2015. Elected in November 2014 to the 42nd Assembly District. Represents Beaumont, Hemet, La Quinta, Palm Desert, Palm Springs, San Jacinto, Twentynine Palms, Yucaipa, Yucca Valley and surrounding areas. Don Perata (D-Orinda) Appointed to the Commission in February 2014 and reappointed in January 2015 by the Senate Rules Committee. Political consultant. Former president pro tempore of the state Senate, from 2004 to 2008. Former Assemblymember, Alameda County supervisor and high school teacher. Assemblymember Sebastian Ridley-Thomas (D-Los Angeles) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in January 2015. Elected in December 2013 to represent the 54th Assembly District. Represents Century City, Culver City, Westwood, Mar Vista, Palms, Baldwin Hills, Windsor Hills, Ladera Heights, View Park, Crenshaw, Leimert Park, Mid City, and West Los Angeles. Senator Richard Roth (D-Riverside) Appointed to the Commission by the Senate Rules Committee in February 2013. Elected in November 2012 to the 31st Senate District. Represents Corona, Coronita, Eastvale, El Cerrito, Highgrove, Home Gardens, Jurupa Valley, March Air Reserve Base, Mead Valley, Moreno Valley, Norco, Perris and Riverside. Jonathan Shapiro (D-Beverly Hills) Appointed to the Commission in April 2010 and reappointed in January 2014 by the Senate Rules Committee. Writer and producer for FX, HBO and Warner Brothers. Of counsel to Kirkland & Ellis. Former chief of staff to Lt. Governor Cruz Bustamante, counsel for the law firm of O’Melveny & Myers, federal prosecutor for the U.S. Department of Justice Criminal Division in Washington, D.C., and the Central District of California. Janna Sidley (D-Los Angeles) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. General counsel at the Port of Los Angeles since 2013. Former deputy city attorney at the Los Angeles City Attorney’s Office from 2003 to 2013. Helen Torres (NPP-San Bernardino) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. Executive director of Hispanas Organized for Political Equality (HOPE), a women’s leadership and advocacy organization. Sean Varner (R-Riverside) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. Managing partner at Varner & Brandt LLP where he practices as a transactional attorney focusing on mergers and acquisitions, finance, real estate and general counsel work. Full biographies available on the Commission’s website at www.lhc.ca.gov. “Democracy itself is a process of change, and satisfaction and complacency are enemies of good government.” Governor Edmund G. “Pat” Brown, addressing the inaugural meeting of the Little Hoover Commission, April 24, 1962, Sacramento, California