County Mental Health Underfunded, Understaffed

Editor’s note: This is an edited version. To read the complete report, see
www.co.santa-cruz.ca.us/Portals/0/County/GrandJury/GJ2023_final/2023-6_BHD_Report.pdf

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The Grand Jury investigated the Santa Cruz County Behavioral Health Division of the Health Services Agency to ascertain how well they were handling the additional demands on their services caused by the Covid pandemic.

It found the BHD to be seriously understaffed — as much as 30% — including management, clinicians and support staff.

It also found inadequate crisis stabilization capacity, lack of step-down capability for those released from jail, and insufficient outreach to the Latino/a community, but the BHD cannot be expected to improve in these areas without significantly more staff.

Statistics point to a disturbing reality. Santa Cruz has more homeless people per capita than anywhere else in California; some 2,300 residents are without housing. An estimated 37% of the BHD’s clients are homeless. About 67% of homeless residents experience chronic substance abuse, and 43% of BHD’s substance use disorder clients are involved with the criminal justice system.

The Grand Jury urgently recommends increasing BHD’s staffing to meet the overwhelming demand for mental health services in this county.

It further recommends increasing capacity of the crisis stabilization program and transitioning the Mobile Emergency Response Teams for adults and youth to 24/7 availability.

It finally recommends improving service to marginalized populations, especially homeless people, those involved with the criminal justice system and the Latino/a community.

Background

The United States has been in the midst of a mental health crisis since long before the Covid pandemic, which has made it even worse. Mental health struggles and rates of substance use disorder have been dramatically escalating for more than two years in Santa Cruz County.

A longstanding shortage of mental health workers in the country, combined with the now increased demand for mental health services following the pandemic, has impacted all parts of the country, including Santa Cruz County.

What makes the problem even more pressing here is Santa Cruz has the highest number of homeless persons per capita in the state, along with a very high incidence of substance use disorder.

The County’s Behavioral Health Division is the primary provider of mental health care for low-income adults and children who lack private health care coverage.

BHD is one of four divisions of the Health Services Agency. BHD services are designed to address the most significant mental health needs of the County and to ensure services and access for all residents, with an emphasis and priority focus on serving individuals at highest risk for experiencing mental health service gaps and access barriers.

This population includes individuals experiencing homelessness, those who do not speak English as their primary language, racial and ethnic minorities, low-income people and inmates released from county jails. Santa Cruz has continued to see increased community need for behavioral health services, especially for serving Spanish speaking residents and individuals experiencing homelessness.

The County has a complex network of preventive and mental health treatment options for adults and children. Approximately 34% of the services are provided directly by the County and 66% are provided by private contractors.

The BHD oversees many programs, including but not limited to the following:

Two county mental health clinics, one in North and one in South County ● A Crisis Stabilization Program for adults and children ● A 16-bed Psychiatric Health Facility for adults (opened for $15 million in 2013) ● Crisis response teams: Mobile Emergency Response Teams for Adults and Youth in North and South County, known as MERT and MERTY ● A mental health liaison program to local law enforcement ● Homeless support programs such as the Downtown Outreach Team ● A locally staffed 988 Suicide Crisis Line ● A 24-hour line for referrals to local mental health services ● Jail mental health program ● Residential step-down programs – sub acute and residential ● Case management services for severely mentally ill persons.

BHD’s annual budget to accomplish this is over $100 million, includin County money and State funding such as Medi-Cal.

Investigation: Goals Not Met

The Grand Jury began this investigation by examining documents that evaluated whether goals set by BHD for itself were met. It soon discovered nearly all goals were not met, even those representing very small improvement.

Of 14 goals in their Integrative Behavioral Health Quality Improvement Work Plan, FY 2021-2022, only two were met, and these were not directly related to service quality.

Goals not met included access to services, response times to service requests and cultural responsiveness.

In March 2023, BHD released a draft of their Mental Health Services Act (MHSA) FY 2023-2026 Three-Year Plan and FY 2023-2024 Annual Update.

This plan includes results of the Community Program Planning Process, a method of soliciting community input to identify local needs and funding priorities.

The results of this process are startling.

The plan states, “Community members and providers alike shared concerns about staffing shortages throughout the county system of care, including psychiatrists, therapists, counselors, and specialty mental health case managers.”

The report highlights the lack of enough beds in higher-level care facilities that can lead to people with serious mental illness repeatedly cycling through the system. Patients and families report delays in receiving needed services, or inability to find services when they need them.

The report states that homeless people and those involved with the criminal justice system have unique needs and barriers, and experience long wait times to access BHD services.

Looking at the county’s Medi-Cal population, BHD serves a lower percentage of the eligible Latina/o residents than any other ethnic group.

The major service gaps became the focus of the Grand Jury’s investigation.

While the scope of mental health care overseen by the county is commendable, the complexity of the system, with each program having its own eligibility requirements, makes understanding and accessing services difficult for patients, especially marginalized people the County serves.

Gaps in continuing care are particularly difficult for these vulnerable persons. Studies show a delay in diagnosis, a delay in appropriate treatment, and a lack of continuity in care make achieving successful outcomes more difficult and increases the overall cost of mental health care.

Staffing Crisis

The Santa Cruz County Behavioral Health Division has a 30% staff vacancy rate.

At the time, 4 of the 10 director positions were vacant, filled by interim employees performing the tasks of at least two positions.

In response to critically low management staffing, the department hired a consultant to consider structural changes.

There are vacancies at every level, including psychiatrists, psychiatric nurses, licensed mental health practitioners, and other direct service practitioners, especially bilingual staff.

Contractors providing mental health services for the county are reported to be struggling to fill open positions.

Behavioral Health and Personnel staff point to limited pools of applicants for licensed mental health clinicians.

Despite openings in all licensed mental health job classifications, there were no available candidates in the pipeline.

The BHD lacks analyst positions, which would allow them to analyze tracking data more efficiently, to evaluate contracts and to financially plan.

Unfilled Positions	FTE	%Vacant
Access & Crisis:	11	31%
Adult Mental Health:	17.3	27%
Behavioral Health Admin:	2.65	25%
BH Support:	5	18%
Children’s Mental Health:	14.3	24%
Quality Improvement:	1.75	11%
Federally Qualified Health Centers:	14.25	31%
Substance Use Disorders:	8	29%
Overall:	74.25	29%

Critically low staffing levels have had a negative impact on access to and quality of treatment.

From interviews the Grand Jury learned that the Crisis teams — the Mobile Emergency Response Team (MERT) and the Mobile Emergency Response Team for Youth (MERTY) — are frequently understaffed by as much as 50% and are unable to expand to weekend coverage due to lack of staffing despite having funding.

Year over year Quality Improvement reports reference low staffing as the reason for not meeting performance goals.

Staff shortages impact contractors’ ability to meet contracted goals.

Telecare, the contractor that runs the only Crisis Stabilization Unit Program in the county, has frequently had to close admissions due to staff shortages.

These closures cause diversions to local hospital emergency rooms.

Multiple interviewees (all high-level managers) did not know who was responsible for oversight of each contract. This may be due to temporary staffing in these positions or unfamiliarity with the oversight hierarchy.

In response to behavioral health staffing shortage statewide, Gov. Newsom and the State Legislature have recently passed large initiatives focusing on more funding and more streamlined funding for mental health support.

But factors specific to Santa Cruz County heighten the staffing crisis:

Extremely high cost of living, especially housing, ● Increased competition with private and public mental health providers and hospitals, ● Competition with wealthier local counties, ● Lower salaries ● The difficulty of the work, and ● The large homeless population which makes delivering mental health treatment very challenging.

Multiple interviewees pointed to Santa Cruz County’s hiring practices and lower salaries as a barrier to being competitive. Some noted that it takes as long as two months between the interview and the final hire –these practices are outdated and out of alignment with current hiring practices.

They pointed to the need for more automated application processes and more responsiveness in updating hiring classifications to suit a younger workforce that wants more flexibility.

County Personnel Department

The County Personnel Department does not recognize a staffing shortage in Behavioral Health and maintains Behavioral Health salaries are locally competitive by pointing out that Santa Cruz County behavioral health salaries are average in comparison to six other Bay Area counties.

The closest county where workers can comfortably commute is Santa Clara, where in 2020, they paid Sr. Mental Health Specialists $10,000 more per year.

The Personnel Department does not regularly conduct competitive analysis of salaries, only as needed or prior to negotiations with the union.

In trying to verify the hiring practices, the Grand Jury was told the Personnel Department does not collect data by department such as Time to Hire, Acceptance Rates, Turnover Rates, and Retention Rates. They only collect data for the county as a whole, so they have very little means for analysis by department. Data collection about hiring is left to each department. What they did report is that “a typical process could be 30-90 days.”

While some hiring incentives have been introduced for psychiatrists, psychiatric nurse practitioners, and physicians and medical directors, there are no incentives for licensed mental health practitioners such as Licensed Clinical Social Workers and Marriage, Family and Child Counselors.

Santa Clara County has a $5,000 signing bonus, loan repayment, workforce tuition, and public service loan forgiveness for open MFCC and LCSW positions.

Recruitment and retention is a problem.

It is difficult to recruit and retain people in a county with the second highest housing costs in the nation without commensurate salaries. UC Santa Cruz does not offer master’s degree programs in psychology or social work. San Jose State University and Cal State University Monterey Bay are the nearest universities to offer these degrees. Interviewees pointed to the need to develop connections to these university programs such as internships or stipends to strengthen the professional pipeline for licensed and unlicensed mental health clinicians in Santa Cruz County

Crisis Stabilization Crisis

Crisis stabilization services are needed for people who are experiencing an acute mental health crisis. These services assess a patient’s mental health status, providing the initial steps in diagnosis, treatment, and determination of their mental health needs.

While MERT and MERTY can provide some screening in the field, this initial evaluation is meant to be provided by the Crisis Stabilization Program at the Psychiatric Healthcare Facility or PHF. A patient may stay up to 24 hours in the CSP which is considered an outpatient setting. Since an overnight stay is not allowed, patients are considered to be in chairs, not beds. If a patient is deemed to not be gravely disabled or a threat to themself or others, they can be discharged to outpatient care. Otherwise they remain on a mental health hold, known as a 5150 for adults and a 5585 for minors.

This is an involuntary 72-hour mental health hospitalization, which for adults could be at our PHF if beds are available.

The County’s CSP and PHF are operated by Telecare, a company based in Alameda and has been treating mental illness since 1965.

Santa Cruz County is the primary provider of mental health crisis stabilization services for all adults and children, regardless of payor class.

Unfortunately, the demand for acute crisis services often exceeds the capacity of the 12-chair CSP and 16-bed PHF. Capacity depends on the number of chairs/beds and staffing available.

Since the facility often lacks the capacity to take new patients, patients are diverted to the Emergency Department of local hospitals.

In 2022 the average number of CSP patients at the Dominican ED was 29.1 per month, and at the Watsonville ED 8.8 per month.

Patients may have to wait up to 24 hours in the ED to be evaluated. This evaluation can be performed by MERT or MERTY. However, these teams are available only from 8 am to 5 pm Monday through Friday.

Efforts to expand have been hampered by staffing shortages.

Outside those hours, hospitals must rely on their own resources to assess the patient.

If the patient cannot be released for outpatient mental health follow-up, the arrangement for a 5150 or 5585 psychiatric inpatient stay becomes the responsibility of the hospital.

This placement can take days and is generally outside of our county, since our PHF is often full.

According to the nonprofit Treatment Advocacy Center our current 16-bed PHF falls far short of the number of beds needed to serve this county’s population. They estimated 50 beds are needed per 100,000 population, which means that for the county’s population of about 270,000, there should be about 135 beds, vastly more than are actually available.

Even considering the County’s efforts to treat patients in the least restrictive environment, more beds are needed.

The occupied ED bed negatively impacts the hospital’s ED, which is already very busy dealing with patients who do not have a mental health emergency.

Patients brought into the ED by law enforcement require continuous supervision by an officer to protect against violence or possible escape until a mental health assessment. This practice not only ties up an ED bed but also pulls law enforcement away from other critical duties.

The patient’s assessment, diagnosis, and treatment is delayed when they are diverted to an ED.

Psychiatric Healthcare Facility Issues

The current PHF is a free-standing facility and is therefore limited to 16 beds to be eligible for Medi-Cal and Medicare reimbursement for services.

Since there has not been a separate unit for children or youths needing crisis support, up to four of the 12 CSP chairs at the PHF have been held for youths under 18. However, patients under 18 who need inpatient psychiatric treatment must ultimately be placed in a facility outside of our county, since our current PHF is for adults only. The County has acquired a building in Live Oak and plans to open a psychiatric healthcare facility specifically for children and youth, which will include 8 CSP chairs and 16 inpatient beds, by late 2024 or early 2025. (This is a $15.2 million project.)

Unfortunately, starting on July 1, 2023, patients under 18 will no longer be accepted at the current PHF for CSP services. While this will free up four chairs in the CSP, the BHD says the total number of chairs at the adult CSP will remain 12.

To minimize the potential 18-month gap in youth crisis care, the BHD is trying to open a temporary four-chair CSP for children and youths by the fall of 2023.

Due to ongoing issues at the PHF run by Telecare, the County sent out a request for proposals to see if other vendors could run the current adult CSP/PHF programs. While about a dozen groups received information about the RFP, as of the March Mental Health Advisory Board meeting, only one group had responded.

Some in the Health Service Agency feel that many groups did not submit a proposal due to the staffing challenges in this county.

In February this year, the County increased payment to Telecare, because they have had to increase their wages to attract and retain clinical staff.

Since that time, the percentage of time the CSP is diverted to the hospital ED has been falling.

In the final quarter of 2022, the diversion rate for children was 86.7%, and for adults 44%. During February through April 2023, this dropped to 50.3% for children and 11.8% for adults.

Presumably, this means the diversion rate is also falling. However, factors such as seasonal variation may affect demand.

High-Cost Beneficiaries

The FY 2021-2022 Medi-Cal Specialty Behavioral Health External Quality Review revealed that Santa Cruz County has three times the number of mental health High-Cost Beneficiaries than the state average for calendar years 2018 through 2020.

This review defined a HCB as a Medi-Cal patient who has approved treatment claims of $30,000 or more in one year.

There are many possible reasons. High cost of care typically occurs when a beneficiary requires intensive treatment repeatedly. This may result from failure to provide timely appropriate care, especially step-down care.

HCBs occupy treatment slots and may cause a cascading effect on other beneficiaries, who in turn cannot receive sufficient care. This places them at risk of becoming a high utilizer themselves.

External auditors found through analysis of our Medi-Cal Specialty Mental Health plan billing and claims data that our county’s Medi-Cal beneficiaries received more crisis stabilization and intervention services than the statewide average.

The auditors postulated this was in part due to the “robust” crisis stabilization and intervention services the County of Santa Cruz provides compared to other counties.

However, it was also reported that the County pays for the transfer of a patient from our CSP to an out-of-county inpatient psychiatric facility and pays 100% of the cost for that care for a Medi-Cal beneficiary. Since the County does not receive the Federal match for any Medi-Cal out-of-county care, the shortage of in-patient psychiatric beds in this county hurts the County financially.

It is not clear if the high cost of crisis stabilization and intervention services is due to the “robust” services, number of patients sent out of the county for treatment, or other factors.

Watsonville Behavioral Health Center

In spite of the severe staffing issues and in addition to the planned Live Oak facility, there is some really good news. Encompass Community Services has just been awarded more than $9 million in state funds to support continued development of a new South County mental health facility, the Sí Se Puede Behavioral Health Center, a $14 million project to be built at 161 Miles Lane, Watsonville.

Encompass is the county’s largest community-based behavioral health and human services provider, offering counseling, substance use recovery, and housing for mental health patients.

Groundbreaking will commence in 2023 on the new facility with 7 new residential substance-use disorder treatment beds specifically for the 18-25 years old, and 30 residential treatment beds in total. There will also be 106 annual outpatient treatment slots available and the center will have capacity to serve an estimated 1,300 community members annually.

Encompass has partnered with nonprofit developer MidPen Housing to include a 72-unit affordable housing development on the forthcoming health campus.

Learn more about the project at www.sisepuedecenter.org/.

Step-Down Care

Behavioral Health’s FY 2021-2022 Quality Management Plan outlines significant capability to support patients leaving mental health care either as an outpatient or from an inpatient psychiatric facility.

Their Assertive Community Treatment Team provides intensive, wrap-around case management services for patients returning to the community from locked psychiatric care. The goal is to support their psychiatric stabilization, successful transition back into the community, increase independent living skills and decrease the need for locked care.

BHD works with Encompass, which runs the El Dorado Center, a community-based, short-term treatment program for individuals who may be stepping down from locked care. An intensive structured residential program, EDC is an unlocked, home-like environment facilitating the healing process in preparation to transition back to community living. Staff provide individual and group counseling, crisis intervention, structured activities, community outings, and assistance with independent living skills and connecting to the community.

Encompass’s funding from the County was recently increased by $1.7 million to a total of $9.4 million. (This is separate from the funding for the new Watsonville facility described above, and is in addition to Behavioral Health funding.)

Encompass also runs programs for anyone diagnosed with mental illness, including treatment, counseling, emergency shelter, case management, outreach and education, permanent supportive housing, and transitional housing.

Some interviewees noted the lack of step-down facilities, and the consequent need for BHD to repeat treatment because the patient relapses.

Behavioral Health’s Draft Three-Year Plan notes that for people with serious mental illness, a lack of enough beds in higher-level care facilities can lead to a “revolving door of insecurity, including jail and street life.” Some patients are sent to other California counties, which is expensive. Others are released from in-patient psychiatric care with no follow-up care.

Homelessness

About 37% of BID clients are homeless. There were 2,167 people unhoused in Santa Cruz County in 2019, and 2,299 people unhoused in 2022.

Nationally, 26% of homeless people self-identify as severely mentally ill.

Locally, 67% are experiencing chronic substance abuse. Just being homeless is associated with declines in mental and physical health.

Homeless persons experience high rates of HIV infection, tuberculosis, and other conditions as well as the mental illness and substance use disorder that contributed to their homelessness.

A homeless person may enter mental health treatment, but have nowhere to live upon completion if an inpatient, or during treatment if an outpatient.

Being homeless is a full-time job; just getting food, shelter, bathroom access, medical and dental care, and access to whatever limited services local government or nonprofits provide is all consuming.

A person needs secure housing before they can be expected to take an active role in dealing with their mental health. There is a huge need for permanent supportive housing.

In their Draft Three-Year Plan, BHD reports that “some of those with the least financial resources are those who need services the most.” They identify “unhoused populations” among their service gaps.

Newly Released Inmates

Some 43% of BHD substance use patients are involved with the criminal justice system.

About 40% of jail inmates have been diagnosed with mental illness.The jail provides some discharge care for released inmates and may coordinate with BHD if the inmate was a former patient.

The 6-7 month wait for a bed in the state mental health system means an inmate needing in-patient care is out of luck.

The Public Defender’s Office runs some programs to help inmates get the services they need. They also coordinate with BHD, but the effort is severely underfunded.

In their Draft Three-Year Plan, BHD identifies “ Incarcerated or formerly incarcerated people with mental health needs” among their service gaps. They further state there is a lack of coordination with other county systems, such as law enforcement or the jail, and a lack of warm handoff to outpatient providers and ensuring a sufficient amount of medication until a pharmacy is open. This is in spite of the “mental health liaison program to local law enforcement” and “Jail mental health program” they claim on their website. (A warm handoff means that jail staff introduces the inmate to the outpatient provider rather than just providing a referral. A lack of warm handoff to therapists, outpatient providers, and ensuring sufficient medications can pose challenges to clients’ continuity of care.

This year’s Civil Grand Jury investigated Santa Cruz County’s jails and found a high recidivism rate — around 60% — for individuals released from jail. Released inmates with mental illness or SUD have much higher recidivism rates than those without.

Many released inmates get in trouble with the law again and go right back into the criminal justice system because that is the only easy option for them. Anti recidivism programs do work, but are underfunded and inadequate. The Jail report recommends increased funding for anti recidivism programs, including increasing funding for Behavioral Health to support released inmates.

Latino/a Use of Services

Latinos/as in South County Santa Cruz have experienced mental health problems due to lower incomes, housing uncertainty, documentation status, language barriers, and cultural differences. Nevertheless, according to Medi-Cal data, the percentage of Latinos/as in Santa Cruz County seeking mental health services is less than any other ethnic group and lower than the state average for this ethnic population.

There are probably multiple factors involved, but historically, investment in South County has been less than in North County. South County previously used a converted building with no private space for treatment. However, an outpatient building for mental health services in Watsonville was opened in 2018.

The new Sí Se Puede Behavioral Health Center in Watsonville will make the distribution of mental health facilities in the County more equitable.

Outreach to the Latino/a community has historically been less successful than to other populations. While outreach efforts have improved for South County in the recent past, more could be done. The limited availability of bilingual and bicultural services is the main issue.

Cultural competency, as well as language, is important in encouraging people to seek and undergo needed mental health treatment.

Currently, the County provides an increase in pay of $1. per hour for Level One bilingual services and $1.35 per hour for Level Two bilingual services.

Level One is the ability to converse in the second language and to translate English into the second language. Level Two is the ability to converse in the second language, to read the second language, to translate the second language orally into English, and to write in the second language. At the present time this bilingual pay differential is available only for Spanish.

Unfortunately, in spite of this pay incentive, the County has a shortage of practitioners who are bilingual Spanish speakers. Some of the farmworkers are indigenous immigrants from southern Mexico and speak Mixteco, which is different from Spanish.

The Grand Jury understands that covering all languages is impossible but more qualified interpreters are needed.

In North County, homelessness plays a big role in the services needed, while in South County the focus is more likely to be on youths and families. Understanding the family unit is important in providing mental health services, especially in South County. This emphasizes the importance of bicultural awareness beyond bilingual services.

Mental Health Conclusion

The longstanding and serious staffing shortage at the Behavioral Health Division is a contributing factor to all the issues in this report, such as lack of step-down capability, services for marginalized groups including homeless persons, those involved with the criminal justice system and racial minorities.

Until the staffing level is significantly improved, expecting improved service in any of these areas is unreasonable.

The Grand Jury typically recommends an increase in funding when an agency has more responsibilities than budget, even while understanding that if there were funding available to increase the budget, this would already have been done.

In this case, however, not only are County residents not getting adequate mental health services, the cost to the County is also higher because patients sometimes need to repeat treatment.

Recommendations

Staffing

Competitive salaries and hiring incentives should be put in place for all vacant Behavioral Health Division (BHD) positions that don’t already have them. The BHD should consider the salaries and hiring incentives offered by Santa Clara County as a guide — such as hiring bonuses, loan repayment, public service loan repayment, and workforce tuition. The Personnel Department must plan for increases in salary and incentives by the end of 2023 with the goal of including them in the next budget cycle.

The County Personnel Department should:

• Plan to do an analysis of the hiring process for BHD positions and put measures into place to reduce the time it takes to hire by at least half. They should streamline the process and make use of up-to-date automated processes by the end of 2023.
• Institute an annual competitive analysisby th end of 2023 for all open BHD positions that includes consideration of the extraordinarily high cost of living in Santa Cruz, benefits and incentives.
• Develop connections and internships with nearby universities that have Psychology and Social Work programs to groom a clinical workforce. A plan should be completed by the end of 2023.

Crisis Stabilization

To eliminate the frequent offloading of the Behavioral Health Division clients to local hospital emergency departments, the Board of Supervisors and BHD should by the end of 2023 evaluate ways to increase the number of Crisis Stabilization Program chairs and psychiatric beds available, which may include planning for another adult Psychiatric Healthcare Facility.

The Behavioral Health Division should:

• Improve staffing and expand coverage to 24/7 by the Mobile Emergency Response Team and the Mobile Emergency Response Team for Youth by the end of 2023.
• Ensure a smooth transition plan and back-up plan for the treatment of children and youths from the current Crisis Stabilization Program to the planned new facility in Live Oak other than diverting them to emergency departments. This should be completed by Sept. 30.

Step-Down

The Behavioral Health Division should request sufficient funding from the County to provide adequate step-down care so patients do not relapse and need yet more care. This request should be in place by the end of 2023.

Latino/a Services

The Behavioral Health Division should continue to improve bilingual/bicultural outreach to the Latino/a population, including whether any language besides Spanish reaches the threshold to warrant offering the bilingual pay differential. Improvements should be in place by the end of 2023.

The Behavioral Health Division should review recruitment and retention of bilingual staff, including an increase to the current bilingual pay differential by the end of 2023.

Commendations

The Grand Jury commends the Behavioral Health Division:

For development of a psychiatric healthcare facility for children and youths which will provide much needed mental health services for this population.

For efforts to develop a wide range of crisis care services not routinely offered in similar-sized counties, including Mobile Emergency Response Teams for adults and youth, a Crisis Services Program, and a Psychiatric Health Facility.