HomeMy WebLinkAboutMINUTES - 07201993 - H.3 H3
THE BOARD OF SUPERVISORS OF
CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on,July 20, 1993 by the following vote:
AYES: Supervisors Smith, Bishop, McPeak, and Torlakson
NOES: None
ABSENT: Supervisor Powers
ABSTAIN: None
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SUBJECT: Annual Report of the Contra Costa County Mental Health Advisory Board
Dennis Lepak, Chair of the Mental Health Advisory Board , reviewed the work of the
Contra Costa County Mental Health Advisory Board.
Supervisor Smith urged the Committee to continue telling the community about the
work of the Mental Health Advisory Board.
Mr. Lepak introduced Children's Advocate Cynthia Miller, who gave a short
presentation on children in the mental health program and who urged the Board to keep the
funding for the children"s services in tact.
Mr. Lepak introduced Violet Smith, Chair of the Ad Hoc Planning Committee.
Violet Smith reviewed the report of the Ad Hoc Planning Committee and introduced
the members of the Committee and expressed her thanks and appreciation for their dedication
and fine work, and encouraged the Board to provide for an ongoing planning process.
Board members expressed their appreciation to Violet Smith and the Planning
Committee.
IT IS BY THE BOARD ORDERED that the annual report of the Contra Costa County
Mental Health Advisory Board is ACCEPTED, and the Board urges continuation of the
Commission's long-range planning, its advocacy for mental health and its efforts in educating
the public.
I hereby Certify mLi tri%a w u truu end correct copyot
an action taken and entered on the minutes of the
Board of Super,i rs o the date shown.
ATTESTED: 9513
PHIL BATC ELO ,Clerk f the Board
of supe niso and County Administrator
8y _.Deputy
cc: County Administrator
Health Services Director
CONTRA COSTA COUNTY .
MENTAL HEALTH COMMISSION
595 CENTER AVENUE,SUITE 200
=_ >- MARTINEZ,CALIFORNIA 94553-4639
ofiulli % Phone(510)313-6414
,Sr'q-COUx�
To: Board of Supervisors Date: July 14, 1993
1q�-^
From: De s Lepak, Chair Subject: Ad Hoc Planning
Me tal Health Commission Committee Report
Violet Smihair
Ad Hoc Pla ng Committee
The Ad Hoc Planning Committee of the Mental Health Advisory Board
of Contra Costa County has completed a six-month planning process,
culminating in the publication of the attached report. We are
pleased to send you a copy of the report and look forward to
discussing it with you on July 20.
Thank you for your interest and continued support.
pr
cc: Phil Batchelor
Mark Finucane
Lorna Bastian
A351 (6/93)
tom, 3
REPORT OF "I"DE CONT"O A COSTA COUNTY
MENTAL ITEALTH 4I.DVISORY BOARD
AD HOC PLA 1 TIi'G COMMITTEE
Aclopi-ea by:
595 Center A-venvule, S-i-'te 200
Martinez, CA 9455.E
Fm.e 24, 1993
REPORT OF THE MENTAL HEALTH
ADVISORY BOARD
AD HOC PLANNING COMMITTEE
TABLE OF CONTENTS
I. Executive Summary........................................................................... i
U. Introduction........................................................................................ 1
III. Background........................................................................................ 5
IV. Guiding Principles
V. State Hospitals
VI. IMDs................................................................................................... 19
VII. Local Inpatient Services..................................................................... 23
VIII. Crisis Services.................................................................................... 31
IX. Community Services.......................................................................... 43
X. Financial Commitment....................................................................... 61
XI. Follow-up............................................................................................ 63
XII. Appendices:
A. List of Contributors................................................................. 65
B. Contra'Costa County Mental Health Division Overview and
Philosophy............................................................................... 67
C. Public Law 99-660.................................................................. 69
D. "The Long Journey Home: Accomplishing the Mission of the
Community Support Movement," by Jacqueline Parrish,
Psychosocial Rehabilitation Journal, Volume 12, No. 3:
January, 1989........................................................................... 71
E. Contra,Costa County Health Services Department, Mental
Health FY 92/93 Projection..................................................... 79
F. Trends in Outpatient Services.................................................. 81
G. AMI-CC Housing Survey, 1992, Summary............................. 83
H. Graphic Comparison of Institutional and Community Based Care:
Number of People Served and Costs........................................ 85
NOTE: A complete appendix containg all source documents and computational analyses is on file Mental
Health Division Administration.
EXECUTIVE SUMMARY
OF THE AD HOC PLANNING COMMITTEE REPORT
Approved by the Mental Health Commission, 6/24/93
INTRODUCTION:
The Ad Hoc Planning Committee of the Contra Costa County Mental Health Advisory
Board was formed in early 1993 to provide a vehicle through which a broad array of
mental health constituencies could provide input into planning and developing the
County's mental health services. The full report details the Committee's guiding
philosophy, a description of the County's mental health services for adults*, and
extensive recommendations.
MAJOR FINDINGS:
As a consequence of limited and shrinking resources, the County has restricted the
potential service population to those with the most severe impairment and reduced
community- based services geared to prevention,early intervention and support.
This-has produced a disproportionate reliance on costly,restrictive institution-based
programs and increasingly heavy usage of acute hospital and crisis services. The
projected distribution of expenditures is graphically shown below.
PROJECTED COST OF ADULT PROGRAMS FOR FY 92-93
BY PROGRAM TYPE
Total Costs
Net County Coats
Crisis Community ~�
1396 Crisis Community
Base3
13% Based
28% Matrit}ew 2446
Mcrrit}uw 1546
26% WDs IMDs
State Hospitals 10% State Hospitals i 1396
23% I 35%
PROGRAMS TOTAL COST COUNTY COSI
COMMUNITY BASED SERVICES (County and contractors)including:
Client advocacy/self-help,Case Management,Supported Housing,
Day Treatment/Socialization,Vocational and Employment,
Medication Management,Outpatient Psychotherapy,Board and
Care Supplement,Homeless Services,Residential Treatment,
Forensic and Monolingual/Bilingual Services. .............................$9,046,645 $5,108,562
INSTITUTES FOR MENTAL DISEASE(IMDs)[73 beds] .............................$3,265,479 $2,727,335
STATE HOSPITALS [72 beds] .........................................................................$7,226,900 $7,226,900
MER.R.ITIIEW HOSPITAL(I&J WARDS) [35 licensed beds].............................$8,225,145 $3,069,763
CRISIS SERVICES, including E Ward,Nierika,West County Crisis,and............$4,030,807 $2,735,592
Crisis&Suicide Intervention
*Due to time constraints and the fact that adult services receive nearly 80%of allocated mental health
funds,the Committee elected to focus on this age group. We hope that future planning efforts will address
children's and geriatric programs and follow-up on adult issues not fully covered in this report.
EXECUTIVE SUMMARY
We find the system spending most of its meager resources to care for a relatively small
number of patients in institutions,a form of care that is the least desirable as well as the
most costly. A decade of experience, bolstered by solid research, has shown that
individuals with serious and persistent mental disabilities as well as frequent users of
mental health acute and crisis services,can make successful adjustments to community
living IF they are given adequate supports.
BASIC APPROACH:
Given the current National, State and County fiscal and political realities, the only viable
option is to radically reconfigure existing resources to change the system. These changes
must be accompanied by a corresponding political shift, as stated in the AB904 Master
Plan, that empowers clients,focuses on their strengths and encourages them to live full,
productive lives in the community.
The direction proposed in this report-- MEASURED MOVEMENT AWAY FROM
INSTITUTIONAL CARE AND TOWARD A COMMUNITY SUPPORT SERVICES
SYSTEM -- is fully consistent with National, State and County philosophy and trends. It
holds the promise of providing better services to more people in need at less cost to the
County.
In order to accomplish this goal:
-Mental Health Services must share equal status, priority and financial support
with medical services.
-Dollars saved from the reduction of state hospital and IMD beds must be
designated for local community mental health services in order to avoid repeating
the historical deinstitutionalization disaster.
-A case management system (individual or team) must be proactive in securing,
arranging and/or providing needed services and supports as clients transition to
the community.
Clients must be involved in all decisions affecting their lives.
•A full"range of appropriate housing options with sufficient supports from case
managers and other services must be available within the community.
-Pilot programs -- including proven models like Integrated Services Agency and
Mobile Crisis-- must be implemented as a means of exploring the options for
reconfiguring the system.
These components will make it possible to develop a system which is cost effective,
client centered and community based.
RECOMMENDATION HIGHLIGHTS:
Decrease the reliance on State Hospital and IMD beds:
Work closely with residents to determine their preferences and needs and to
prepare them for returning to the community.
Identify and develop a full range of alternative placements in the community.
ii
Strive to upgrade the services provided in State Hospitals and IMDs for the
benefit of those who will require these services until sufficient and adequate
alternatives are available.
Identify strategies to!reduce the utilization and length of stay on I and J wards in
Merrithew Hospital:
Enhance the system's ability to provide needed supports before the clients'
problems escalate to the acute stage.
Work with other counties to develop specialized facilities for populations that are
not appropriately served by acute inpatient services.
Increase efforts to divert patients to other programs and hospitals.
Begin discharge planning,in cooperation with the patient's case manager, as soon
as possible.
Strive to preserve the client's living situation and ties to the community during
hospital stays.
Expand crisis intervention capability:
Increase crisis residential resources.
Develop a mobile crisis service pilot program.
Retain the West County Crisis Service and pilot a crisis walk-in service in East
County.
Develop a system for sharing Crisis and Suicide Intervention's computerized data
base on community resources.
Consider integrating all crisis services under one administration.
Involve consumers,at all levels of the system,in developing their treatment plans,
evaluating services,working as staff and serving as members of boards and
committees:
Contract with ja consumer group to conduct a survey of State Hospital and IMD
clients and assist in transitions to the community.
Develop an action plan to implement a client-centered service delivery system and
train all staff in client-centered methods. Implement the Coordinated Services
System.
Support the development of a consumer-run self-help center.
Develop a pilot project that adapts the Integrated Service Agency/AB 3777
program to Contra Costa County and include the components necessary to focus
on client needs,choices and wants.
iii
EXECUTIVE SUMMARY
Enhance and strengthen the case management system:
Recognize case management as a therapeutic modality and the case manager as
the advocate and facilitator of the provision of community-based treatment.
Assure system-wide knowledge of expectations and capabilities of case
management services.
Limit case loads to a size that enables staff to meet client needs by increasing
existing case management services.
Augment the case management system to include consumers, contractors and
families.
Provide case management priority access to (and exit from) services needed by
their clients.
Evaluate all current clinic services and day treatment in light of the possibilities
offered by the Rehabilitation Option and other funding sources:
Provide supports necessary to enable clients to remain in their own homes, using
24-hour services only when a person needs a more structured situation.
Assign staff to coordinate and advocate for housing and for vocational and
employment services.
Deep funds saved from reducing hospital,IMD,and local inpatient services
available for the maintenance and development of community services-- for ALL
AGE GROUPS -- to the fullest extent possible.
Develop an integrated system to identify and monitor potential grants and to
coordinate grant-writing and other activities to generate additional revenues.
FOLLOW-UP:
The Ad Hoc Planning Committee recommends that this preliminary planning effort be
followed by a substantial ongoing planning process led by County Mental Health
Administration which includes clients, families,contract administrators, front-line
County and contract staff, and union representatives. One-half of the committee should
be comprised of consumers and families.
A planning process of this nature will enable Contra Costa County to continue to move
toward a more cost effective,client centered,community based system. We look forward
to having a new Mental Health Director who will continue the open door policy of
inclusion and the serious development of ongoing working relationships among all
groups and constituencies. We believe that our County has the will to offer critically
needed support to our most vulnerable population.
iv
REPORT OF THE CONTRA COSTA COUNTY
MENTAL HEALTH ADVISORY BOARD
AD HOC PLANNING COMMITTEE
ADOPTED BY THE CONTRA COSTA COUNTY
MENTAL HEALTH COMMISSION
JUNE 249 1993
I. INTRODUCTION
The Ad Hoc Planning Committee of the Contra Costa County Mental Health Advisory
Board was formed in early 1993 to provide a vehicle through which the various
constituencies in the mental health community could provide input into the planning and .
development of mental health services within Contra Costa County.
Membership of the Committee included the following designated representatives:
Violet Smith,Chair,representing the MHAB
Pat Risser, Mental Health Association
Jack Feldman!Contra Costa Network of Mental Health Clients
Herb Putnam,:CCC-Alliance for the Mentally Ill
Vicki Smith,Contractors and Friends Alliance
Mike Cornwall, Public Employees, Local 1
Sylvia Crout, California Nurses Association
Dr. Barry Miller, Psychiatric Division,Physicians'Union
The Committee's working strategy was open and inclusive: all who wished
to attend were welcome and report drafts were distributed to appropriate
providers (County and contractors) and constituency groups represented by
Committee members.
The breadth of participation, the diversity of Committee membership and the extensive
collaboration, willingness and ability of Committee members to respect and
accommodate each others views exemplifies the positive potential for a continual
planning process that encompasses the entire mental health community.
Introduction
The planning effort was greatly facilitated by the full cooperation, openness and
responsiveness of the Interim Mental Health Director,whose tenure coincided with the
period of the Committee's work. Committee members were heartened by this attitude and
encouraged to plan for cost-effective programmatic changes, despite budgetary
uncertainty and threatened cuts. We look forward to having a new Mental Health
Director who will continue the open door policy of inclusion and the serious development
of ongoingworking relationships with all groups and constituencies. We look forward to
having an administration which will advocate strongly for the mental health services
needed in our community, particularly programs proposed in this report.
The Committee is grateful to Diane Frary,who staffed the Committee, to Mark
Finucane, Health Services Director, for his participation in a number of the Committee's
meetings and to Lorna-Bastian,Interim Mental Health Director, for her support and
cooperation. Numerous staff of the Mental Health Division and contractors provided
substantial and much-appreciated information and assistance. We benefited greatly from
our contacts with representatives of Alameda, Solano and Sacramento counties. These
contributors are acknowledged in Appendix A. The committee extends special thanks to
Jay Mahler of Mental Health Consumer Concerns for organizing the excellent
Sacramento mini-conference.
Due to time limitations, the Committee elected to focus on services to the adult
population (ages 18 - 65)because these services account for approximately 80% of the
Division budget. It is recommended that future planning address children and geriatric
programs and follow up on adult service issues not adequately addressed in this report.
The Committee met twice monthly to review and evaluate the community's mental health
needs, services, and special problems in an attempt to identify strategies for:
1) averting cuts in direct services,
2) increasing revenues, and
3) maximizing the effectiveness of local mental health services.
This report covers the broad perspective developed by the committee to achieve these
goals. It contains an overview of the services as they currently exist and a series of
recommendations for accomplishing measured change from the present emphasis on
institutional care to an increased commitment to community support services. The
2
Introduction
recommendations will,need to be operationalized into specific working plans-- with staff
allocations, budgets and timelines--before they can be implemented.
After detailed plans are developed, a series of concrete actions will be required to achieve
the cost effective, client centered,community based services described in this report.
Implementation depends upon a solid commitment from administration, from all
segments of the mental health community and from the Contra Costa County Board of
Supervisors.
3
II. BACKGROUND
Today's limited mental health resources are directed toward serving those characterized
as having a serious and persistent mental disability, i.e., having a "DSM-HI-R diagnosis
that may lead to chronic disability and functional limitations in major life activities which
require treatment and services over an extended time -- sometimes throughout a
lifetime."'
Estimates of the number of people with Severe and Persistent Mental Illness (SPMI) in
Contra Costa County range from about 5,000 (including only those with a diagnosis of
schizophrenia)to about 14,000 (including affective disorders as well as schizophrenia).
While greater precision in both definitions and numerical estimates would be useful for
subsequent planning, these global figures make it abundantly clear that the current system
cannot provide services even for all who meet the SPMI definition. This is consistent
with estimates from the National Institute of Mental Health (NIMH)2 that present
resources, nationwide, are capable only of meeting less than 50% of the need; and Contra
Costa County's resources prove to be directly proportionate to those described in the
national reports.
As a consequence of limited resources, the County has restricted the potential service
population to those with the most severe impairment. This in turn has produced a
disproportionate reliance on costly,restrictive institutional programs.and an increasingly
heavy usage of acute hospital and crisis services. This was further aggravated by a
reduction in community based services geared to prevention,early intervention and
support.
The first clients eliminated from services were those who were thought to be able to
"make it" on their own, but some could not-- and they fell through the cracks. As
resources continued to shrink, fewer clients were served, yet the need for services
continued to grow. More people appeared in crisis;jail use (with the concomitant use of
law enforcement personnel) increased; the number of homeless grew; and,more people
died.
t Definition in use in Conga Costa County
2 Parrish,Jacqueline, "The Long Journey Home:Accomplishing the Mission of the Community Support
Movement," Psychosocial Rehabilitation Journal,Vol. 12,(3),January, 1989,p.108
5
Background
There are only two reasonable methods of addressing the problem. The first method
requires a massive infusion of new resources to address all of the unmet needs which
have accumulated over the past several years. Given the current National, State and local
fiscal and political realities, this option is not possible.
The remaining alternative is to radically restructure/reconfigure the existing resources to
change the essential shape of the system. These changes must be accompanied by a
corresponding philosophical shift that empowers the client and encourages him/her to live
successfully as a full participant in the community.
During the past decade, there has been a growing body of experience, supported by
research, which has shown that individuals who were deemed to be candidates for
institutional care, as well as frequent users of mental health acute and crisis services,can
make successful adjustments to normal community living IF they are given adequate and
appropriate supports. The average cost of such community supports is estimated at about
$20,000 per person per year, including case management, day programs, short-term acute
care and/or residential treatment,if needed, and other supports. (This is a federal
average, based on the article by Jacqueline Parrish cited above.)The innovative AB3777
programs in California are citing a similar figure. An annual cost of$20,000 per person
is less than half the cost of an Institute for Mental Disease (IMD) bed and less than one-
fifth the cost of a State Hospital bed.
As a result of both the financial considerations and respect for the rights of individuals
with disabilities, there has been a strong national trend away from institutional care and
toward the development of Community Support Systems. This trend makes particular
sense in California today, due to the following:
1) Realignment legislation(under which the County has to pay directly for use of
State Hospital and IMD beds, while the bed rates, set by the state,keep rising);
2) The innovative AB3777 projects which are producing compelling findings in
support of community-based care, and
.3) The new configuration under the Rehabilitation Option, which provides
reimbursement for a broader range of services in the community and more flexible
service delivery approaches.
6
Background
In the past several years,California counties have begun moving people out of the State
Hospitals and IMDs with a resultant increase in the cost of remaining beds in both types
of facilities. The high'cost of institutional beds, Realignment and the Medi-Cal
Rehabilitation Option,' provide counties with opportunities and motivation to move in the
direction of a more community based system of services.
The direction proposed in this report-- MEASURED MOVEMENT AWAY FROM
INSTITUTIONAL CARE AND TOWARD A COMMUNITY SUPPORT SERVICES
SYSTEM-- is fully consistent with National, State and County philosophy and trends. It
holds the promise of providing better services to more of the population in need of
services at LESS cost to the county. It promises, "care that is more humane, more
therapeutic, and less stigmatizing than institutionalization.113
It must be stressed, however, that this approach can only succeed if there are sufficient
resources provided within the communitx. As we shall see, some urgently needed
supports are not now available in Contra Costa County. It is the lack of adequate
supportive services which results in, "...continual readmissions to hospitals, overuse of
emergency rooms,repeated encounters with the correctional system and undue burden on
families...114
3 Stroul,Beth A.,"Community Support Systems for Persons With Long-Term Mental Illness:A
Conceptual Framework," Psychosocial Rehabilitation Journal,Vol. 12,(3),Jan., 1989,pp.9-26.
4 Ibid.
7
II
III. PRINCIPLES GUIDING THE PLANNING PROCESS
The specific principles outlined below grow out of a fundamental first principle that
mental health services must share equal status,priority and financial support with medical
and other health services.
We agree with Tipper,Gore, Chair of the Mental Health Work Group of the White House
Task Force on National Health Care Reform, that those responsible must"Make Mental
Health Disabilities on par with physical disabilities and...help people who for too long
have been ignored."5
We believe that people with mental disabilities are first-class citizens, who must be
accorded the same opportunities as all other people to realize their potential to grow,
thrive and lead full and productive lives.
The principles that follow point the way to a humane and just Health Services response to
the suffering and needs of those with mental disabilities in Contra Costa County:
1. Focus on Client Strengths rather than pathologies;
2. Focus on rehabilitation,not critical incident;
3. Shift the focus of treatment from institutional care to community based care,
in order to
A. Maximize opportunities for normal living experiences; .
B. Provide intervention as early and as effectively as possible;
C. Minimize institutionalization, because:
1) Institutional care is both the most costly and the least desirable;
2) Anyone who is kept in a locked facility for a long period develops
a "mind-set" which makes it difficult to transition back into the
community, and
5American Psychological,Association Monitor,May, 1993.
9
Principles I ,
3) Skills learned in institutional settings are not readily transferable to
a community living situation.
D. Strengthen the ties to support networks,especially families and friends;
E. Save money,which can then be used to serve more of the population in
need of service,and
F. Increase the proportion of resources committed to community based
services.
4. Make the system as "user-friendly" as possible,through the following:
A. Ensure cultural and ethnic sensitivity and representation throughout the
system and
B. Provide maximum accessibility in terms of hours, locations and flexibility
(in relation to appointments and other system demands)..
5. Develop a client-centered system,that is responsive to the needs of clients
rather than the needs of the system.
A. On an individual basis:
1) Understand and respect clients'goals;
2) Plan with clients in accordance with those goals, and
3) Fully involve clients as equal partners in all aspects of treatment.
B. On a system basis:
1) Include consumers as members of key committees throughout the
system;
2) Employ consumers as staff at all levels of the system, and
3) Modify services to better meet the expressed needs of clients.
10
Principles
6. Provide services which will assist clients to live,learn,and work where they
choose,through the following:
A. Encourage the development of needed resources, including supported
independent housing and jobs;
B. Assist clients in securing all the financial benefits to which they are
entitled, and
C. Develop effective working_linkages with other services within the County,
including those dealing with housing,jobs, health,education and social
services, etc.
7. Make the system as cost effective as possible,consistent with the maximum
retention of front-line community services and with the principles identified
above,through the following:
A. Identify savings which can accrue from restructuring existing services;
B. Collaborate with other counties within our region to develop alternative
resources on a regional basis;
C. Shorten the duration of costly hospitalizations;
D. Identify savings in areas which do not impact direct services, and
E. Assess the effectiveness of programs in relation to outcomes.
11
Vo STATE HOSPITALS
A. SlJli'YMARA
The deinstitutionalization movement which resulted in reduction of California's mental
health hospital population from about 37,000 in 1955 to about 2,500 today, was a product
of multiple factors:
1) a belief that patients had rights, including the right to live as normal a life as
possible;
2) the introduction of medications which promised to aid persons with mental
disabilities to function successfully within the community, and
3) an aversion to the dismal conditions which existed in State Hospitals.
The hopes for success were predicated on the assumption that dollars saved would follow
the patients back to the communities to provide needed supports. The dollars for
community services rarely materialized, the drugs frequently were shunned (often because
of their negative side effects) and many discharged hospital patients ended up on the
streets, in jail, or in local equivalents of State Hospitals. This situation has been
exacerbated by federal and state government restrictions on'eligibility for SSI and other
financial assistance and by reduced subsidies for housing.
We are now witnessing a resurgence of interest in moving patients from State institutions
to the community, and the reasons are compelling:
1) while care in State Hospitals has improved, they are still institutions -- people
who reside in them do not have an opportunity to engage in everyday community
life;
2) state hospital residents tend to become habituated to the institution and are less
able to function outside of it;
3)behaviors, including skills, such as cooking, shopping and work, etc., which
may be learned in an institution are not readily transferable,AND
4) institutional care is extremely costly.
13
State Hospitals
Nonetheless, there are several important factors to be considered as we emphasize
the importance of moving away from State Hospital care:
•First, it is essential that the dollars be returned to the community for
development of local community mental health services if we are to avoid
repeating the historical failures;
• Second, client preference, as well as their needs, must be given full
consideration in planning to move people out of the State Hospital, and
•Third, we must have alternative placements which provide supports and services
to meet the rehabilitation and medical needs of the more disabled, self-
destructive, and/or violent persons who remain in State Hospitals. It is the
adequacy, or inadequacy, of such alternatives that is a major concern to family
members,especially those who are concerned that one day they will no longer be
able to care or advocate for loved ones.
Program: State Hospitals currently offer a variety of program levels, including: acute
psychiatric wards,continuing medical care and sub-acute facilities for children,
adolescents and adults. Recently,Napa State Hospital added a program (Wellsprings)
which is described as being "transitional" between institutional care and the community.
In addition, the State Hospitals are planning to broaden the array of services as they
grapple with declining enrollment, including additional transitional programs, partial
hospitalization,board and care residences and other programs. It is anticipated that the
mental health directors in the region will be involved in the planning.
Utilization: Contra Costa currently has 67 adults and four (4)children in Napa and five
(5) adults in other State Hospitals. The total budget for adults in State Hospitals for FY
92/93 is$7,226,900, an average of$100,374 per patient per year.
Costs: The following table shows the daily and annual costs, by type of bed, for each of
the services enumerated above for FY 89/90 and FY 91/92:
14
State Hospitals
COSTS OF STATE HOSPITAL BEDS*
TYPE OF BED COSTS/FY 89/90 COSTS/FY91/92
PER DAY PER YEAR PER DAY PER YEAR
\KL
:' •�iiiiiii:3i:ii:}:ii'riiii
I
Acute 237 86,505 289 105,485
Psychiatric
Continuing 258 94,170 292 106,580
Medical
ICF Sub-Acute 230 83,950 254 92,710
Adolescents 359 131,035 402 146,730
Children 350 127,750 391 142,715
Wellspring"
ICF Sub-Acute 223 81,395 234 85,410
ICF Sub-Acute 2061 75,1901 2481 90,520
* The dollar figures include ancillary costs.
**The Wellspring program was added in 92/93 with a daily rate of$190, including
ancillary costs.
Counties have to pay the full cost of State Hospital beds from Realignment and local
funds, but they have no say about the amounts charged for beds. As shown above, the
costs are very high, and they rose an average of 17% between FY 89/90 and FY 91/92.
For the next year, increases in the amount of 10+% have been proposed, although the
final rate is not yet known. The only control that counties have had has been in
designating the number of beds they intend to purchase. Estimating this number has been
difficult since counties are obligated to commit to a given number of beds in advance
and to pay for all the requested beds, whether they use them or not. Faced with this
extremely difficult fiscal situation and with the goal of bringing clients back to their
communities, counties have been removing patients from State Hospitals at a rapid rate.
15
State Hospitals
The following table shows the reductions in State Hospital bed allocation-requests for a
number of Northern California Counties:
STATE HOSPITAL.
BED ALLOCATION-REQUESTS
COUNTY FY 91/92 FY 92/93 % REDUCTION
Alameda 165 89 46%
Contra Costa* 85 75 12%
Marin 30 17 43%
Sacramento* 48 48 ---
San Francisco 214 172 20%
Solano 48 34 30%
*Contra Costa is planning to remove 13 patients and Sacramento is planning to remove 20 within the next
year;information is not available on reductions being planned by the other counties.
As a result of these actual and threatened reductions, wards have been closed and the
State administration is seeking ways to retain their State Hospital population, including
diversifying programs and trying to limit the amount of rate increases.
B. RECOMMENDATIONS:
1. Continue to decrease reliance on State Hospital beds, because of the high
cost and the adverse effects of institutionalization, as follows:
a. Develop community programs which will help to support clients
and avoid the need for institutional care (see Section IX,
Community Services). This can only occur if savings, which are
realized through decreased use of institutional beds, are transferred
to development of community-based services.
b. Conduct in-depth interviews with State Hospital residents to
determine their housing preferences and what supports they would
require in their preferred placements. Consumer advocates and
conservator staff should work closely with State Hospital residents
to make them aware of alternative placements and to begin to
prepare them for moving to local community based programs, and
16
State Hospitals
C. Identify and develop a full range of alternative placements,
consistent with the needs and desires of State Hospital patients who
are ready to return to the community. Such alternative living
situations might include the following:
•Independent living, with adequate supports;
•Augmented Board and Care, with community supports;
•A Psychiatric Health Facility(PHF), by arrangement with other
counties or by development of a PHF within Contra Costa County,
and
•A substantially upgraded IMD, preferably in County, with time-
limited placements.
2. Recognize that some patients cannot be served in other available facilities
at the present time (in some instances due to medical needs). Additionally
there may be some patients who are too emotionally institutionalized to
want to leave. Both of these situations may change as other options
become available but, it is essential to strive to retain and improve the State
Hospitals for as long as it takes to develop adequate alternatives. This can
best be accomplished through the following:
a. Support the proposal of the Mental Health Directors to "...transfer
management of the state hospital to an alternative governance
structure, while assuring that the land and buildings remain a
resource for the benefit of the seriously mentally ill in
perpetuity...(and assure) that program development and utilization
plans for state hospital resources are based on community mental
health plans developed by counties under Realignment..."6 and
6Proposal of the California Mental Health Director's Association,January, 1993.
17
State Hospitals
b. Encourage the planned development of a broader spectrum of
service programs on the State Hospital grounds to facilitate the
transition of clients to the community.
18
VI. INSTITUTES FOR MENTAL DISEASE (IMDs)
A. SUMMARY
During deinstitutionalization, patients were discharged from State Hospitals and
frequently moved to Skilled Nursing Facilities(SNFs), another type of institution which
had medical supports and the capacity to be locked. In some cases,counties contracted
with the SNFs for augmented services (known as Special Treatment Programs or
STPs). Since SNF services were reimbursed by Medicaid, they were less expensive
alternatives and diminished the counties' motivation to develop residential treatment,
appropriate housing and supports in the community.
In the mid 70's, however, the federal Health Care Financing Agency (HCFA) conducted
audits on some of these programs and determined that they were not eligible for Medi-
Cal reimbursement for persons under the age of 65. Ultimately, federal legislation (P.L.
100-360) stipulated that SNFs would not be eligible for federal reimbursement if:
• More than 50% of all patients had "mental diseases which require
treatment" and
•The average patient age was significantly lower than that of a typical
nursing home.
Based on this legislation, SNF's with these characteristics were designated as Institutes
for Mental Disease (IMDs). They had to be specially licensed and accredited as
psychiatric non-acute 1 facilities; they had to have locked wards; and they were not eligible
to receive Medi-Cal reimbursement.
In 1987, the State allocated funds to replace the lost Medi-Cal revenue and began to
reimburse the IMDs directly. Counties' fiscal motivation to use IMDs continued, despite
the results of studies proving that many people warehoused in these institutions have the
ability, with adequate support, to live in the community.? With Realignment, however,
counties gained control of funds previously allocated to IMDs. Control provided
counties an opportunity to determine how those funds would be expended.
7 Department of Mental Health, State of California,"Summary of Treatment and Placement
Determinations",OBRA Section,May, 1990 and Okin,Robert,M.D.,San Francisco General Hospital, "-
Facility and Residential Client Surveys and Pilot Project Proposal for Comprehensive Community Based
Services for Institutionalized Clients,May 18, 1992.
19
Institutes for Mental Disease
Quality of Service: IMDs are secure (often locked) institutional facilities that provide
food, shelter and minimal programming in an environment that is artificial and culturally.
impoverished. Instead of preparing residents for a more normal life in the community,
IMDs contribute to their institutional mind-set.
A recently completed study highlights the readiness of IMD residents to return to the
community and identifies the supports the residents feel they will need.
In the study, 12 randomly-selected residents of IMDs were interviewed by Mental Health
Consumer Concerns, Inc. (MHCC) in February, 1993. Of these, 11 felt they were ready
to be discharged, but only five said they had been contacted about being discharged.
Needed community supports identified by over half the respondents included help in:
•Obtaining benefits
•Developing a support system
•Using public transportation
•Meeting medical needs
• Finding housing
•Recognizing symptoms
•Developing cooking skills
Locations: The problems associated with IMD placements are exacerbated for residents
of Contra Costa County because facilities are so far from Contra Costa. Residents are
placed in Stanislaus, Santa Clara, San Joaquin,Alameda, Santa Cruz and Solano
Counties. As a result,residents in IMDs are largely isolated from support networks,
including families,conservators, patients rights advocates,case managers and self-help
groups. In addition, the large number of wide-spread locations necessitates a great deal
of travel time and expense to the County and families.
Costs: IMDs are operated by private for-profit corporations and, since Realignment,
augmented rates have been separately negotiated with each County. It is projected that
the County will spend $3,265,479 for 73 IMD beds in FY 92/93. This amounts to
$44,732 per IMD bed per year,including an average base rate of$98.42 per bed per day
PLUS an augmentation ranging from$20 to $80 per bed per day. It also includes the
residents'own SSI contribution of approximately$20 per bed per day. When the-
residents' SSI contribution is deducted, the remaining net county cost is$37,880 per IMD
bed per year. This is substantially less than the cost of placement in a State Hospital.
20
Institutes for Mental Disease
On the other hand, the:same client could live in the community and pay his/her basic
living expenses with his/her SSI check. The funds paid by the County to the IMDs would
be available to provide support services in the community. Since Medi-Cal and
Department of Rehabilitation funds are available as an offset for many community
services, the net cost to the County would be less than the cost of an IMD bed and the
client's situation would be greatly improved.
B. RECOMMENDATIONS:
1. Endeavor to limit the use of IMDs, to the extent possible, as follows:
a. Identify and develop community based alternatives including
supported independent living;
b. Reduce the length of stay in IMDs by taking proactive measures,
including: a) starting discharge planning on the day of admission;
b)explaining to clients on admission what is necessary in order for
them to get out of the institution; and, c) preparing residents for
living in the community by increasing frequency of contacts
'between IMD residents and their conservators, case managers,
consumer advocates and families, and
C. Explore the development of resources to meet special client needs
in collaboration with other counties.
2. Endeavor to improve the quality of IMDs, until sufficient community
alternatives are available:
a. Use the contracting process to strengthen specific treatments,
enhance service quality and stipulate clear, measurable outcome
objectives, and
b. Continue to collaborate with other counties to standardize
augmentation costs and upgrade program quality in IMDs
(negotiations of this type were in progress as this report was being
written).
21
Institutes for Mental Disease
3. Assign a person or team to regularly monitor medication usage/medical
necessity and treatment progress to:
a. Assess the quality of care being provided and
b. Ensure that the plan for reducing stays is adhered to.
4. Use the fewest IMDs consistent with meeting client needs,in order to
facilitate visits by conservators,case managers,client advocates and other
staff. This should make it possible to increase the frequency of contacts
while reducing travel time and costs. At the same time, the ability of
certain facilities to meet particular client needs must be given special
consideration in order to maximize the options available for clients.
22
VIL LOCAL, INPATIENT SERVICES:
MERRITHEW HOSPITAL
Aa SUMMARY
In its description of a comprehensive community support system, the National Institute of
Mental Health (NIMH) has stated that, "Inpatient beds in a protective environment should
be provided for crises which cannot be handled in a natural setting or in crisis residential
settings. Hospitalization is needed for the most severe crises in which clients need
intensive support, structure and supervision during the period of stabilization... These
inpatient beds serve as a back-up to other community support services"8.
Contra Costa County,provides adult inpatient mental health services in two locked units
in the County's Merrithew Hospital,I Ward with 18 beds and J Ward with 17 beds, 9 for
a total of 35 licensed inpatient beds. The primary function of the units, as described in
the Mental Health Advisory Board (MHAB)briefing book, dated 5/92,is the provision of
"psychiatric evaluation and treatment services to seriously and persistently mentally in
(SPMI) clients, mostmeeting the criteria for involuntary hospitalization under Section
5150 of the Welfare and Institutions Code."
Utilization: The following chart portrays the census of H, I and J Wards over a 16 year
period. (Since H Ward's 8 beds are included, the licensed capacity of the three wards
combined is 43 beds). As shown, the three psychiatric wards:
•have had anll average daily census of 40 or more in 13 of the 16 years;
have operated at or above the licensed capacity of 43 in five of the last six years,
and
account for approximately 30% of the hospital's total inpatient census.
8Stroul,Beth A.Community SuMmA Systems for Persons With Long-Term Mental Illness.Questions and
Answers,NIMH, 1988
9There is,in addition,an:8-bed gero-psychiatric ward(H Ward). Because of the focus on adults,not
geriatrics,in the present planning effort,H Ward is not being covered in depth. It is worth noting however,
that a bed on H Ward costs substantially less than beds on I&J Wards(about$37,700 less per bed per
year),and many of the people that we talked with indicated that more H Ward beds would be desirable.
23
Local Inpatient
MERRITHEW MEMORIAL HOSPITAL
AVERAGE DAILY INPATIENT CENSUS
160
140 34
0
W 120
U
021oa
—>-1 100 sa ss ss
MEDICAL
Q89 91 91
64
80 so 7s
W
0
Q 60 S
CLPSYCH 4s
W ,% 47 41._ 49 4P 39 40- 46---47' - -.42-- 43---43
Q 40 -
20
77/78 79/80 81/82 83/84 85/88 87/88 89/90 91192
78/79 80/81 82/83 84/85 86/87 88/89 90/91 7 MO 9V"
FISCAL YEAR
PSYCH INCLUDES H,I&J WARDS INCLUDES NURSERY
(PAT8)
A description of the population being served on 1 and J Wards is contained in the report
of the Safety Task Force, published in January, 1993, as follows:
"The psychiatric patient population of Merrithew is not a homogeneous group. Three
levels of patients are identified within the current patient mix:
-Acute: Patients who are severely and persistently mentally ill with varying
degrees of ability to succeed in an outpatient setting. This population requires
disposition, assessments and concrete goals.
-Sub-acute: These are patients who require...rehabilitative level of care.
-Long-term care: These are patients who are severely compromised...(e.g., Huntington's
patients). Primary treatment objectives are to assist them maintain activities of daily
living (e.g., hygiene, nutritional status, provide some recreation, etc.)...
24
Local Inpatient
"Further adding to the complex nature of the patient population is the fact that the
majority of patients have dual diagnoses", e.g., major mental disorder and substance
use/abuse.
The distribution within these sub-groups is approximately as follows: 1/4 acute; 1/2 sub-
acute; and 1/4 long-term.
Average Length of Stay: The trend with regard to the escalating length of stay in the
psychiatric wards is graphically shown below:
MERRITHEW MEMORIAL HOSPITAL
AVERAGE LENGTH OF STAY
DAYS FISCAL YEAR COMPARISONS
30
2527
25
PSYCH 1.5
2o.7s
2f-�'
20
15 t s.
12.4
10 2
MEDICAL
5.22
5 4.82 5.05 5.03 «4_.78---------4.45 ------.459
0
FY 86/87 FY 87/88. I Y 88/89 FY 89190 FY 90/91 FY 91/92 7 MO 92/93
As shown above, the average Iength of stay has increased from 9.26 days per patient in
FY 86-87 to 25.27 in:the fust six months of the current fiscal year. These figures are for
H,I and J combined; the figured for each ward separately are shown on the next chart.
25
Local Inpatient
LENGTH OF STAY ON H,I AND J WARDS
WARD 88/89 89/90 90/91 91/92 92/93
AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE
H GERO-
PSYCH 15.95 19.56 20.80 21.82 24.44
I PSYCH 10.57 13.73 15.76 16.64 21.64
J PSYCH 24.07 29.77 30.45 30.25 30.96
As shown above, the average length of stay on I and J Wards has increased very
substantially over the last five years. This increase is attributable largely to the
approximately 20% of the population who remain on the wards for a very long time,an
average of 73 days. The remaining 80% are discharged after an average stay of 10 days.
Appropriateness of Persons Served: Retention of long-term patients on the acute ward
means that beds are "frozen", i.e.,filled with patients who are not being discharged.
Hospital staff estimated that approximately 1/3 of the beds are frozen at any given time.
There are a number of contributing factors, as follows:
• On I Ward, some patients are frail and have substantial organic disabilities
in addition to mental illness. (One such patient, with Huntington's Disease
has been on the Ward for more than a year !) Persons with such physical
problems cannot be served adequately in IMDs and they cannot be placed
in Skilled Nursing Facilities since they are not licensed to serve patients
with a primary diagnosis of a mental disability. Until recently, there
were no programs specifically designed to accommodate persons with
organic brain disorders;
• On J Ward, the "frozen" beds are filled with patients suffering from a
multiplicity of disorders and combinations of disorders, including .
developmental disabilities as well as mental illnesses. Some patients have
histories of assaults, so that finding placements that will accept them has
been very difficult;
• Patients with acute problems who might stabilize fairly rapidly often stay
longer than necessary because they have lost their living arrangement and
have nowhere to go, and
26
;j-
Local Inpatient
• Since the erosion of community based intervention programs, there is little
opportunity to intercede with patients before they are in very serious
distress. Once they reach a point where they must be involuntarily
hospitalized,it requires a much longer period of time to achieve stability.
As a result of the "frozen beds" there may not be space available when needed by patients
with acute problems. This has at times,caused patients to be sent as far away as St.
Helena in Napa County, for hospitalization. Removing people from the supports in their
home communities tends to prolong their hospitalizations.
Clearly, the inpatientiunits were not intended to serve large numbers of sub-acute and
long-term patients but, to provide "intensive support, structure and supervision during the
period of stabilization." (Safety Task Force Report) Because a diverse population poses
special problems, the,Safety Task Force concluded..."1)that our current staff is not
trained to handle many of our current patients, and ...2) that there is a lack of an adequate
clinical program and strategy (report emphasis) that addresses the particular needs of our
patient population." Further, acute inpatient care is extremely costly when used to
provide extended care. The problem, which has grown worse over the years, is the lack
of sufficient alternative community resources which would more appropriately meet the
needs of those patients who could/should be referred out.
Cost of Services: The total projected cost for I&J.Wards for FY 92-93 is$8,225,145.
Based on an average utilization of almost 36 beds per day,10 the gross per diem cost is
$626, or$228,476/ye'ar. This is twice the cost of a State Hospital bed and six(6) times
the cost of an DMD bed. These figures are total costs, which are partially offset by
revenues from Medicare, Medi-Cal, private insurance and other revenues.
The net cost to the County is$3,069,763 (including about$1.7,million in Realignment
funds for the Medi-Cal match and$1.37 million in additional Realignment and County
funds). This amounts to an average of$85,271 in County dollars, per bed per year.
This average figure is inflated by the 20% of patients who remain on the wards for an
average of 73 days, including many "administrative days" at a substantially reduced
10 Average actual utilization from 7/1/92 through 1/31/93 was 35.73 per day for I and J Wards—from the
Contra Costa County Health Services Department Program Budget with Workload Statistics,March 15,
1993
27
Local Inpatient
reimbursement rate. If these long-term patients were placed elsewhere,the net cost to the
County for I and J beds would be reduced.
Psychiatric services for persons who are highly agitated and a danger to themselves or
others,especially if they are hospital-based, can be expected to be costly. The question is
whether such services can be limited to only those persons who really must have these
services and only during the short period when no other services will suffice.
E. RECOMMENDATIONS:
1. Identify strategies which would reduce the use of costly inpatient services
when they are not fully appropriate to meet the needs of the clients.
Possible strategies follow:
a. Work with other counties to develop facilities which are appropriate
for specialized populations. The recent collaboration with other
counties in connection with a facility for persons with organic brain
syndrome is an excellent example. Perhaps similar facilities could
be developed for persons with substance abuse and mental illness or
for persons with developmental or physical disabilities and mental
illness;
b. Explore the possibility of developing another type of program as
an alternative to I Ward; for example, a free standing Psychiatric
Health Facility (PHF), a sub-acute program at the former Oak
Grove facility or a combination partial hospital and a protected
living situation. The intent is to staff the program with existing
staff while minimizing the hospital-related overhead and
maximizing flexibility with regard to staff:client ratio and other
programmatic features. This may be a viable option if the new
Federal Health Plan includes support for long-term (or short-term,
non-acute) 24-hour care, or if Medi-Cal becomes available.
28
Local Inpatient
2. Endeavor to shorten the time required to stabilize and discharge patients in
need of acute services:
a. Begin discharge planning upon admission, and include the client's
case manager in the process and
b. Conceptualize and structure the hospital stay as a brief interlude in
the client's life, not as a focal point for providing treatment. To be
successful, such an approach must be coupled with an emphasis on
preserving the client's living/housing situation and ties to the
community. A case manager can be very important in preserving
existing housing and other supports or in arranging for housing for
a client who is homeless or who cannot return to his/her prior
situation.
3. Increase efforts to divert patients from inpatient stays at Merrithew, as
follows:
a. Enhance the system's ability to provide needed supports before the
clients' problems escalate to the acute stage and to break revolving
door patterns. Needed supports may include outpatient therapy,
intensive case management, mobile crisis services, supported
housing,respite housing and other community based programs;
Div 1 who require structured setting, but do not need 24-
b. Divert people o equ e a g,
hour medical supervision, to existing crisis residential services.
Consider contracting for the additional beds for which the existing
provider is licensed. (See Section VIII. Crisis Services), and
29
i
Local Mpatient
C. Since the full cost of fee-for-service patients is covered by the
State and federal government,11 place third-party payor and Medi-
cal patients in need of inpatient care in private hospitals, to the
extent possible. In order to implement this recommendation, it is
vital to help qualify potential patients for all coverages to which
they are entitled since other hospitals generally require such
coverage. It should also be emphasized that this does not obviate
the need for Merrithew as a placement for patients for whom
alternatives are not yet available,or who, for therapeutic reasons,
would be more appropriately hospitalized at Merrithew.
4. Implement the recommendations of the Safety Task Force for training in
safety procedures and program enhancement. Enhancing the clinical
program will enable staff to provide quality treatment during the "window
of opportunity" provided by the period of hospitalization.
11 There will undoubtedly be changes in this regard when managed care becomes a reality in Contra Costa
County.
30
VIII. CRISIS SERVICES
According to the State of California Mental Health Master Plan, "The primary focus of
crisis services is stabilization,crisis resolution, assessment of precipitating and attending
factors, and recommendations for meeting identified needs". NIMH specifies that, "The
primary goal of crisis services is to assist individuals in crises to maintain or resume
community functioning."12. Both of these sources specify that a comprehensive crisis
response system should include:
1. Emergency Services for Evaluation and Treatment
2. Crisis Intervention,Walk-in Services
3. Crisis Intervention,Call-in Services
4. Mobile Crisis and Outreach Services, and
5. A Crisis/Acute Residential Treatment Program.13
The following sections will review the extent to which each of these services exists
within Contra Costa County.
EMERGENCY SERVICES
A. SUMMARY.-
24-hour per day, 7-day a week crisis evaluation and treatment services are provided by
Mental Health Crisis Services (commonly referred to as E Ward) at Merrithew Memorial
Hospital.
Program: Mental Health Crisis Services is "a 5150-designated site14(which) provides:
• "Evaluation, treatment and disposition recommendations to 5150'd patients...
o "Short-term treatment on an outpatient basis....for acute situational crisis.
12Psychosocial Rehabilitation Journal,Vol. 12,No.3,January, 1989.
13The State Plan also includes"Acute,medical,intensive care"as part of crisis services. This form of care
is separately discussed in this report(see Section VII. Local Inpatient Services).
14A 5150-designated site'refers to the section of the Welfare and Institution Code that authorizes
involuntary holds for persons who are a danger to self or others or gravely disabled.
31
Crisis Services -
• "Mental health evaluation for treatment in outlying mental health clinics...
• "Mental health evaluation of detained persons between 11 p.m. and 8 a.m., prior
to entry into Martinez Detention Facility."15
There were an average of 620 client visits per month during the first six months of this
fiscal year. Of these:
30% were hospitalized (one-third in Merrithew and two-thirds in private hospitals
throughout the area). If comprehensive insurance information were available
prior to hospital admission, a still higher proportion of clients would be referred to
private hospitals-- at no cost to the County.
70% were returned to the community and most will require extensive community
supports in order to avert future crises.
It is noteworthy that more than 70% of the people brought to E Ward on a 5150 were
persons who use drugs and/or alcohol. The need for additional specialized services for
this dually diagnosed population is evident.
Staffing and Costs: Mental Health Crisis Services provides 24-hour per day, 7-day per
week coverage with a staff of 29.15 FTEs. Staff includes 10.75 clinical specialists, 8.4
nurses, 3 M.D.s, 1 psychologist, 1 supervisor, 3 clerks and 2 temporary staff. Staff
salaries and benefits account for about 50% of the total operating budget. The projected
budget for FY 92/93 is$3,320,701, including about$1.3 million in Medi-Cal, Medicare
and other revenues, $.3 million for the Realignment Medi-Cal match, and about$1.7
million in additional Realignment and County dollars: The FY 92/93 budget is
substantially higher than the FY 91/92 budget of$2,219,269. The increased budget
reflects substantial increases in revenue, utilization and responsibilities (as described on
the next two pages), but there have been no corresponding increases in staff or space in
the past three years.
15From Mental Health Crisis Service Scope of Service. .
32
Crisis Services
Utilization: The pattern of utilization over a four-year period is shown below:
MENTAL HEALTH CRISIS SERVICES UTILIZATION
FISCAL AVE. VISITS/ AVE. VISITS/ AVE. VISITS/
YEAR DAY MONTH YEAR
89/90 15 456 5,472
90/91 15 441 5,292
91/92 17 520 6,240
92/93 20 620 7,442
This marked increase in the demand for crisis services is particularly
disheartening in light of the County's goal to "measurably reduce use of...crisis
services".16 The increase is attributed to the following:
•A corresponding decrease in the community services which help
prevent crises (such as supported community living, residential
treatment and adult outpatient services) and
-Substantial reductions in mental health services in the jail,
particularly the elimination of the night-time staff which performed the
evaluation function.
The FY 92/93,data displayed in the chart above has been annualized from the first
half of FY 92/93 (7/1/92-12/30/92). During that period the distribution of visits,
by type of activity, was as follows:
16From Overview and Philosophy of CCC-MHD,March, 1992.
33
Crisis Services
DISTRIBUTION OF CRISIS SERVICE VISITS, BY TYPE OF SERVICE
SERVICE VISITS FIRST #VISITS
SIX MONTHS ANNUALIZED
7/1/92-12/30/93 PROJECTION
Assessment 49 98
Individual 89 178
Group 131 262
Medication 82 164
Crisis 3,370 6,740
Total 3,721 7,442
These figures do not adequately reflect a substantial program change which occurred
in November, 1992. At that time, Mental Health Crisis Services began providing
centralized intake services for the mental health system throughout Contra Costa
County. This change was necessitated by budget cuts which drastically reduced the
clinic's psychotherapeutic services for adults. As a result of this change, anyone who
needs a mental health evaluation or is seeking entry into the system must now come
to the Mental Health Crisis Services at Merrithew Hospital in Martinez.
Utilization of this service is increasing substantially in terms of both crisis visits
and assessments, producing a corresponding increase in the demands placed upon
staff and space. During hospital construction, this will be compounded by
difficulties in gaining physical access to the building.
2. RECOMMENDATIONS:
a. Strengthen and develop additional community programs which
help avert crises with particular attention to community services
for clients with a dual-diagnosis and/or other special needs (see
Section X. Community Services).
b. Collaborate with the Department of Social Services to maximize
eligibility determination and access to information relevant to
insurance coverage. Assure that a benefits specialist is assigned to
assist all patients in obtaining the full benefits to which they are
entitled,especially prior to admission.
34
Crisis Services
C. Improve the jail's medical and mental health assessment
capability,17 especially during night hours, by adding a psychiatric
nursing component to relieve some of the burden on Mental Health
Crisis Services and provide substantial savings for the Police and
Sheriffs Departments. Currently, officers transport detainees to
Mental Health Crisis Services, wait while assessments are made,
and then transport them to the jail.
d. Take steps to alleviate the space problem at Mental Health Crisis
Services,especially during construction, through the following:
1) Explore options for additional space such as the addition
of a portable unit, rental of appropriate facilities near the
hospital,or relocation of Mental Health Crisis Services to
another part of the hospital and
2) Consider the possibility of locating some Mental Health
Crisis Services personnel in the jail or the East County
Clinic to relieve the space problem during hospital
construction. This solution requires careful examination of
fiscal and personnel considerations,e.g., no Medi-Cal
reimbursement is available currently for mental health
services provided in the jail but this may be more than
offset by the savings in deputy and police officer time.
Examination of jail diversion and other models would be
useful. Medi-Cal reimbursement is available for East
County Clinic crisis services and the idea merits serious
consideration, since relocation could test the feasibility and
desirability of this programmatic change. Staff could be
given the opportunity of volunteering for relocation.
17The Planning Committee did not study the larger issues in relation to mental health programming in the
jail. However,we believe that this is a very important area for consideration during the next planning
process since SPMl clients very often end up incarcerated when other services are insufficient to meet their
needs.
35
Crisis Services
r
CRISIS INTERVENTION.WALK-IN SERVICES
A. SUMMARY
The California Master Plan states that crisis intervention services,offered during regular
weekday business hours, are to be available to "anyone in the general community with a
psychiatric concern or emergency, including anyone needing information about
services...(or) advice about dealing with someone in a psychiatric emergency."
West County: The West County Crisis Service is located on the same site as the West
County Clinic and Partial Hospitalization so that continuity between crisis services and
on-going treatment is possible. There are three FTE staff members assigned to the crisis
portion of the program. During the first six months of FY 92/93, there were 483 crisis
visits at the West County program, for an annualized total of 966.
East County: There is no structured crisis walk-in service in East County. This gap is
particularly significant in light of the fact that 30% of all of the clients seen by Mental
Health Crisis Services come from East County.
Central County: The Concord Clinic has no structured crisis walk-in services. Clients
in Central County are geographically closer to Mental Health Crisis Services where walk-
in services are available.
B. RECOMMENDATIONS:
1. Retain the West County Crisis Service
2. Add a Crisis Intervention Walk-In Service as part of the East County
Clinic program, so that:
a) East County clients will have greater access to crisis services, in
their own community,and
36
Crisis Services
b) 'There will be increased continuity between crisis intervention, case
management and on-going outpatient treatment.
This could be implemented on a pilot basis with existing staff.
3. If the East County program proves to be cost effective,it should be
replicated in the Concord Clinic.
4. Consider integrating all crisis services under one administration, including
Mental Health Crisis Services, the West County Crisis Service, the East
County crisis walk-in service, if such a service is developed, and
contracted crisis services.
CRISIS INTERVENTION CALL-IN SERVICES
A. SUMMARY
Call in services are to be available 24-hours per day,7-days a week to provide assistance
to anyone with a psychiatric concern or emergency and to offer information and referral
services. The lines are variously characterized as "hotlines" or "warmlines" depending
on whether the caller is (or is not) in crisis. Both types of service are recommended.
Program: There are two programs in the County providing this service. In addition to
their primary crisis intervention and intake functions, Mental Health Crisis Services
provides 24-hour call-in service,receiving about 12,000 calls per year.
Crisis and Suicide Intervention of Contra Costa County(CSI) also provides 24-hour
crisis call-in services, under a County contract. CSI services are available,without
charge and without restrictions, to anyone who calls. Over 35,000 calls are received each
year. Many of the frequent callers are people with serious and persistent mental
disabilities. They are'provided with supportive, active listening -- whenever they feel the
need of such support-- by trained volunteers, working under professional supervision.
The two call-in services are currently discussing strategies for coordinating their services.
However, no provisions are currently in place to link CSI to case managers or other
programs serving the same clients. Linkage would greatly enhance the volunteers' ability
to reinforce the support and assistance being provided by others in the system.
37
Crisis Services
This agency also has developed, and constantly updates, an extensive computerized
system of community resource information.
B. RECOMMENDATIONS:
1. Integrate the CSI crisis intervention call-in service into the Mental Health
System,enhancing the collaboration with Mental Health Crisis Services
and developing operational linkages with case management and other
services.
2. Develop a system for sharing CSI's community resource data base with
Countynand contract staff. Updated computer disks can be supplied on a
regular basis, provided that the systems are (or could be made)compatible.
Initiate a process of collaboration between the County, contract agencies
and CSI to share and update relevant information. Since much of the
work of updating the resource data base is done by CSI volunteers,the
costs should be minimal.
MOBILE CRISIS SERVICE
A. SUMMARY
The State Mental Health Master Plan designates the persons to be served by a mobile
crisis service as "persons experiencing acute psychiatric symptomology who are unable
or unwilling to go to crisis services." This refers to anyone with an emotional crisis, not
just someone who has a severe and persistent mental illness. It is described as a 24-hour,
7-day service which is available "to go wherever a person is in crisis and to work
intensively to resolve the situation without utilizing other emergency settings." The crisis
team works collaboratively with law enforcement when needed, and it uses the home
environment and natural supports to achieve stabilization and prevent the deterioration
which would require involuntary hospitalization. An effective program of this type can
realize substantial cost savings for the system as well as positive outcomes for persons in
crisis.
38
Crisis Services
THERE IS NO MOBILE CRISIS SERVICE IN CONTRA COSTA COUNTY, and this
is probably one of the most significant lacks in a system with a goal to "measurably
reduce use of hospitals, IMD facilities,jail and crisis services".18
B. RECOMMENDATIONS:
1. Make it a priority of the system to develop a pilot mobile crisis service.
Generally crisis teams consist of nurses, mental health professionals, and
consumers. Twenty-four hour capability could be achieved by a
combination of telephone coverage by Crisis &Suicide Intervention and a
beeper relay to an on-call team member (similar to Crisis and Suicide
Intervention's arrangement with Child Protective Services). Planning for
this service should include representatives from all crisis services,
consumers, family members and law enforcement. In assessing the
savings potential, planners will need to examine the positive fiscal impact
for law enforcement as well as for mental health.
2. Implement a mobile crisis service by taking one or more of the following
actions:
•Redirect funds saved from reduction of institutional services;
• Seek special grant funds to fund this as a pilot project,. and/or.
•Develop the program with existing staff. Preference should be given to
those staff members who choose to work in this project, since staff who
are committed to a highly flexible active outreach approach will function
most effectively in a program of this type.
"Contra Costa County Mental Health Division,Overview and Philosophy,March, 1992.
39
Crisis Services
CRISIS/ACUTE RESIDENTIAL TREATMENT PROGRAM
A. SUMMARY:
Contra Costa has a short-term crisis residential treatment program, Nierika House,that
serves as a diversion from hospitalization. The county contracts for nine (9) of the
available 12 licensed beds. This is an unlocked voluntary facility located in Central
County, with services available to all county residents. Staff consists of nine counselors
who provide double coverage 24-hours a day,7-days a week. In FY 91/92, there were
197 admissions,with 160 unduplicated clients,just over 50% from central county.
Referral data shows that the service is being used appropriately as a community based
alternative to divert clients from hospitalization (see following chart):
NIERIKA HOUSE
SOURCE OF REFERRAL FY 91/92
SOURCE NUMBER %OF TOTAL
Psych Emergency 62 31%
Hospital 55 .28%
Self 34 17%
Case Mgr/ 13 7%
Cons/Ther
Shelter 9 5%
Other 24 12%
Clients of the program have multiple problems: in addition to their psychiatric diagnosis,
65% have a history of substance abuse; over 50% have attempted suicide; over 50% are
survivors of abuse, and over 40% are survivors of sexual abuse.
Like other 24-hour services, the length of stay is increasing because of the acute shortage
of appropriate community resources. Almost half of the discharged clients have an
identifiable day time activity upon discharge. In terms of living situations after
discharge, 38% returned to live with their families and 33% moved into independent
living situations or supported housing. In FY91/92,the average length of stay was 13
days. In the first nine months of FY92/93, the average length of stay had increased to 16
40
i.,
Crisis Services
days. The cost per day is$195. With the Rehabilitation Option, available on July 1,
1993, the service will be Medi-Cal reimbursable.
Eo RECOMMENDATIONS:
1. Contract for additional crisis beds, as needed,when more clients are
returned to the community,
2. Designate a liaison between Nierika House and other services (including
Mental Health Crisis Services, I and J Wards, and case management), in
order to more effectively divert clients from hospitalization.
3 Provide administrative oversight to crisis residential services as part of the
integrated crisis system proposed earlier.
41
IX. COMMUNITY MENTAL HEALTH SERVICES
Reducing reliance on costly institutional care can be successful ONLY if adequate and
appropriate community supports are provided. The growing emphasis on and support for
appropriate community services in California is reflected by the recent development of the
Rehabilitation Option and the demonstration Integrated Services Agency programs (ISAs)
under AB3777.
Rehabilitation Option: The Rehabilitation Option is the mechanism whereby federal
Medicaid funds (known as Short-Doyle/Medi-Cal in California) will be used, as of July
1, 1993, to:
•Reimburse specified services wherever in the community they are provided --
e.g., in a coffee shop, a client's home or park bench-- not just in a clinic and
•Provide for reimbursement of residential treatment.
The philosophy of California's Rehabilitation Option plan,based on the AB904
California Mental Health Master Plan, sums up the current shift to community based
services and a client-centered system of services:
"Rehabilitative:Mental Health Services focus on Individual needs, strengths,
choices and involvement in service planning and implementation. The goal is to
help Individuals take charge of their lives through informed decision making.
Services are based on the Individual's long term goals/desired result(s) for his/her
own life and his/her diagnosis, functional impairment(s), symptoms, disabilities,
life conditions and rehabilitation readiness. Services are focused on achieving
specific measurable objectives/personal milestones to support the Individual in
accomplishing his/her desired results. Program staffing should be multi-
disciplinary and reflect the cultural, linguistic,ethnic, age, gender, sexual
orientation and other social characteristics of the community which the program
serves. Families, caregivers, human service agency personnel and other significant
support persons should be encouraged to participate in the planning and
implementation process in meeting the Individual's needs,choices,responsibilities
43
Community Services
and desires. Programs may be designed to use both licensed and non-licensed
personnel who are experienced in providing mental health services."19
Integrated Services Agency model: State support for client centered services is also
demonstrated by the experimental Integrated Services Agency programs (ISAs) funded
by AB3777 in 1989. The ISAs were required to develop a holistic and rehabilitative
approach to community services. Services were to be "client-driven, that is, predicated
upon the goals and needs identified directly by the client".20 The funding was based on a
capitated model, whereby the provider receives a fixed dollar amount for each client
served and provides all of the services needed.
SERVICES/SERVICE DELIVERY AND COORDINATION
A. SUMMARY:
Historically,Contra Costa County has been consistent in its support of community mental
health services as appropriate treatment,so that a range of community based services has
been developed in the County.
Community based services, provided by County and contract agencies, include case
management, outpatient treatment, day treatment, supported housing,residential
treatment, socialization, patient rights and advocacy, vocational and employment
services, services for people who are homeless or at risk of being homeless and some
services that are designed to serve specific ethnic populations.
Nonetheless,community based services are frequently unavailable to the clients who
need them because:
1) Some needed services/are virtually non-existent;
2) Some services have been so reduced in size that they cannot accommodate the
clients who need them, and
3) Some services are not readily accessible to clients in all regions of the County.
19California Rehabilitation Option Plan,Service Definitions,Philosophy,p.2-2
20Kalinowski,M.D.,"Services on the Client's Terms: Experiences at Stanislaus Integrated Services
Agency',January 31, 1992.
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Community Services
While there is increasing interest on the part of the mental health system, providers, staff
and the constituency groups to develop a "client centered" system, there is limited
understanding or consensus as to what client-centered means or how it operates. This
results in a situation where the client has to fit into the system and its services,rather than
the system focusing on developing services to meet client identified needs, choices and
goals.
While many components of a community system are present, the services are not
adequately organized into an integrated and coordinated system. Since individual clients
may use an array of services, increasing coordination among those services would
greatly enhance the effectiveness of the system in meeting the needs of the client.
E. RECOMMENDATIONS:
1. Commit to developing a service delivery system that is responsive to
client needs and wants, as follows:
a) Contract with a consumer group to survey clients (beginning with
NAPA and IMD clients), to determine their needs and wants in
terms of placement and mental health. services and the assistance
they need to make the transition. Focus on medical, as well as
social and psychiatric needs. Include family members in the
interview process after consulting with a client to determine which
of his/her family members may be the most appropriate ones to
involve;
b) Involve consumers, at all levels in the system,including developing
their own treatment plans,evaluating services, working as staff and
serving as members of advisory boards or committees;
c) Develop and adopt principles and an action plan to implement the
client-centered service delivery system;
d) Train all staff(administrative and line, inpatient and community,
County and contractor) in client-centered service delivery and
psychosocial rehabilitation approaches. Emphasize the importance
of relationships in developing a client-centered system. Train
45
Community Services .
supervisors and administrators in the hiring and supervision of staff
with a history of mental disability. Include consumers and families
in developing and providing the training, and
e) Set specific performance objectives for the system and its
component parts to determine the degree to which the system is
fulfilling the mandate contained in P.L. 99-660 to enable
"individuals to function outside of inpatient institutions to the
maximum extent of their capabilities."
2. Develop a pilot project that adapts the Integrated Services Agency(ISA)
concepts to Contra Costa,since the ISA has the necessary components for
a coordinated service delivery system that focuses on client needs,choices
and wants, by the following:
a) Restructure County and contract services, and use existing staff
and resources,to develop this component;
b) Develop a mechanism whereby staff with a special commitment to
this approach can be given an opportunity to volunteer to work on
this project;
c) Include consumers as staff in this project. It would be preferable to
hire more than one consumer so that they can provide mutual
support, and
d) Provide sufficient resources to realistically address client needs,
i.e., an ISA with a large number of"hi-users" will require more
funds and staff than a group serving clients with lesser needs.
3. Implement the Coordinated Services System form of quality assurance and
review developed by the State. Include providers,clients and family
members in designing the process to implement the new system.
•This system requires a Coordinated Service Plan which acts as
the authorization for the client's use of services (except for
emergency services). .
46
Community Services
The Coordinated Service Plan and individual program service
plans will include performance objectives to help measure the
effectiveness of the services provided.
• It also implements a service (utilization)review by client,rather
than provider,so that all the services to one client are reviewed at
the same time enabling the system to understand what is happening
to individual clients. This yields an unduplicated count of clients,
together with information on the cluster and frequency of services
being utilized. It would be helpful to develop a parallel.fiscal
reporting system to show costs by individual client's use of
services.
4. Develop linkages to, and Memoranda of Understanding with, other
agencies that provide services to people with mental disabilities. These
agencies include Conservatorship, Housing and Community Development,
Housing Authority, Social Services, Substance Abuse Services,
Department of Rehabilitation, Shelter, Inc. and Community College
District. Structured relationships would enhance coordination and result
in more effective service delivery.
CASE MANAGEMENT
A. SUMMARY. '
To achieve a coordinated service approach, the case manager role is pivotal. This role
can be fulfilled by an individual case manager,conservator, service coordinator or a case
management team. According to the California Mental Health Master Plan, a key
principle of client-centered service is the recognition, "that the relationship between the
case manager and the client is PRIMARY and essential" 21 (emphasis added). The
critical importance of the case manager's role is recognized in federal statute, P.L.99-660
(see Appendix), and California Legislation AB3777. The central and vital nature of the
case manager's role is also emphasized in Contra Costa County's Philosophy statement, of
March, 1992, "The case manager facilitates the provision of...care and treatment. Case
21AB 904 Plan
47
Community Services
Management is a recognized therapeutic modality... Case managers will work in
Community Living Support Teams, focus on client strengths,set achievable goals with
clients..."
The County has been working toward this goal during the past year, but efforts have been
hampered by several factors:
1. The definition of the target population has not been uniformly and consistently
understood and the role of case managers has not been clearly defined and
communicated throughout the system. Nor has case management been
universally accepted as a priority;
2. Caseload size has been large. Altogether, there are ten case managers for the
whole County. Of these, one and a half are assigned to homeless multiservice
centers. The remaining 8.5 case managers have caseloads of 30 to 40 clients each,
double the recommended ratio of 15 to 20 clients per case manager in an intensive
case management model;
3. Case managers frequently lack full authority to access or terminate services for
their clients, when it is appropriate to do so;
4. There are insufficient services to meet the needs of clients. In addition, there
has been a tendency to depend on only the mental health resources,instead of
accessing a broader range of community resources because linkages to the broader
resources are insufficiently developed;
5. When a conservatee in an IMD is ready for discharge,the practice of
conservatorship is to place them in licensed residential facilities based on a strict
interpretation of the Health and Safety Code, Section 1536.1 which states that,
"conservators place clients who are discharged from IMDs only in licensed Board
and Care facilities." This practice:
a) precludes the use of supported independent living situations
in the community;
b) restricts client choice with regard to living situation, and
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Community Services
c) may delay discharges because of lack of licensed placement
opportunities, and
6. The relationship between conservators and case managers has not been
adequately integrated to ensure continuity of service for the clients as they move
through the system. For example, if a client goes off conservatorship when
he/she moves to the community,the relationship with the conservator ends and a
case manager from mental health is assigned, disrupting continuity of care. Or,in
a worst case scenario, no case manager is assigned.
E. RECOMMENDATIONS:
1. Enhance the case management system, by taking the following actions:
a) Define case management, including case management's reliance on
the relationship between the case manager and the client to
facilitate the client meeting his/her needs,choices and goals.
Outline the services included and the criteria for the service.
Assure system-wide knowledge of expectations and capabilities of
case management services;
b) Define the "high-user" and "at-risk" target populations for system-
wide dissemination, and
c) Increase case management services in three ways:
1) Increase County staff allocated to case management services;
2) As funds are available, add consumers to the case management
teams. Consumer case managers contribute special expertise
derived from their experience, and
3) Incorporate contract services as part of the case management
service delivery system.
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Community Services
2. Support case managers in their work, as follows:
a) Recognize the case manager as the pivotal advocate and facilitator
in the provision of treatment and other services. Provide the
training and support necessary to enable case managers to fulfill
this vital function;
b) Provide case managers priority access to (and exit from) those
services needed by their clients. Assure that the case manager is
the client's primary treatment contact regardless of where .
he/she lives or is being served,e.g. IMD, supported housing, I or J
Ward, or a homeless shelter. Provide case managers with access to
housing and food vouchers. Develop linkages and agreements
which will facilitate access to services outside the mental health
system, and
c) Limit caseloads to a size that enables staff to provide quality cost-
effective services. It may be best to have each caseload include
clients with differing levels of need (to avoid worker burnout) and
determine caseload size in relation to the frequency of visits
needed by each of the clients (e.g., three clients needing daily
visits, plus eight clients needing bi-weekly visits may be a full load
even though there are only 11 different clients involved). It is also
important to take paperwork and resource development time into
consideration.
3. Facilitate the movement of people from institutions to the community by
the following:
a) Address the need for a wider range of housing alternatives,
b) Provide linkages to a locally based self-help group prior to
discharge;
c) Provide needed supports identified by clients, including obtaining
benefits, using public transportation, addressing medical needs and
other activities related to community living;
50
Community Services
d) Identify ways to effectively deal with the problem of switching
from a conservator to a case manager mid-stream. (It has been
suggested that one person perform both functions. Another
suggestion is to involve case managers with institutionalized
clients prior to discharge.), and
e) Seek a clarification of Health and Safety Code Section 1536.1 to
ascertain whether placement in a more desirable,less restrictive
housing situation (such as supported independent living)is
permissible within the meaning of the Code. If not, work to
change the Code,since it contradicts the mandate to house clients
in "least restrictive" settings.
In making these recommendations, we use the term "case management" advisedly as
many clients object to being referred to as "cases" to be "managed".
TREATMENT SERVICES
A. SUMMARY:
Major components of'our community based treatment services are:
• day treatment and socialization programs of various degrees of intensity;
• outpatient services, including therapy, assessment and medication support and
specific services directed toward ethnic and cultural populations, and
•transitional residential treatment program with an emphasis on serving Afro-
Americans and people with a dual diagnosis.
Reductions in these services over the past several years have included the loss of one day
treatment program in Central County, one residential treatment program in West County
(6 beds), supported independent living programs in Central County and substantial
reductions in adult Mental Health Treatment specialists throughout the County.
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Community Services
Day Treatment/Socialization: There are four day treatment programs and one
socialization program in Contra Costa County. The day treatment programs are
structured to meet current Medi-Cal requirements, but under the Rehabilitation Option,
they will have the opportunity to restructure activities so as to increase the services
available. The advent of this new reimbursement, with its less restrictive staffing
requirements, will enable the East County socialization program, Many Hands, which
currently costs$30/day and isnot now Medi-Cal eligible, to provide and bill for day
treatment services as well.
The four day treatment programs-- Partial Hospital, Rubicon Day Treatment and
Rubicon Synthesis in Richmond and Phoenix Center in Concord--currently serve a
range of clients, from those needing rehabilitation to persons needing support during a
more acute period. Partial Hospitalization, currently the only program designed as an
intensive day treatment program,serves 20 clients per day at a cost of$133 per client.
Staff are piloting a project which will reduce the cost per unit and increase the number
who can be served to 30 people per day by.providing a morning and an aftenoon program
at the same site. The other day treatment programs,which are now designed as
rehabilitative cost$60 to$74 per day. The agencies which operate these rehabilitative
day treatment programs (Rubicon and Phoenix) are also considering.the possibility of
operating two programs per day, per site (one intensive and one rehabilitative).
However, there is considerable support for the need to develop a new program category
in which acute and rehabilitative clients can be served in the same program at the same
site in order to promote flexibility and reduce disruption of services for clients. This
issue has been slated for review by the State and the Association of California Mental
Health Directors over the coming fiscal year.
Outpatient Services: Assessment,evaluation,therapy and medication supports are
provided at the County clinics located in each region. Familias Unidas provides
counseling services for Spanish speaking clients in West County under a County contract.
The Asian Mental Health Clinic in Richmond and the Center for New Americans also
provide services for populations with special cultural and language assistance needs.
Over the past two years, nine (9) Mental Health Treatment Specialist positions were cut
at the clinics, substantially decreasing individual and group therapy services. As
treatment options have decreased, there has been a corresponding increase in the use of
medication and crisis services. Outpatient medication visits increased by 34% and
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Community Services
outpatient crisis visits by 17% in the past 3 years. This is in addition to the 35% increase
in crisis visits to Mental Health Crisis Services'. During the same period, outpatient;
individual and group therapy visits declined by 41% and 17%respectively. (See the chart
on the following page.)
Residential Treatment: Nyumba Chuki(now Nevin House),was a transitional
residential treatment program which served clients with a severe mental disability as well
as substance abuse problems. This 12 bed program had the ability to serve people who
would otherwise have been in institutions. The program successfully addressed mental
health and substance abuse issues and was particularly successful in helping Afro-
Americans learn to survive in their own communities by learning ways to cope with their
disability and substance abuse problems. Funding was reduced last year; although there
are still 12 beds, the cut negatively impacted the program's ability to provide the same
level of service and thereby further reduced the options for serving people in the
community instead of institutions.
53
Community Services
CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT'
OUTPATIENT MENTAL HEALTH VISITS BY TYPE
FISCAL YEAR COMPARISONS
j., 342
499
COLLATERAL438
352
282
ASSESSMENT .X 2$1
262
1,482
1,100
INDIVIDUAL 1,081
...........:.
871
312
334
GROUP 320
258
1,137
MEDICATION 1,242
1„332
523
CRISIS 5%
653
;•cn._1
1,Sta
DAY TREATMENT 1,631
Zn
1,676
0 500 1,000 1,500 2,040
NO.OF VISITS
FY 89090 FY 90191 FY 91192 ® 6 MO FY 92193
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B. RECOMMENDATIONS:
1. Evaluate all current clinic services and day treatment in light of the
possibilities offered by the Rehabilitation Option (which stipulates that
services which were previously reimbursable only if they were provided in
a clinic will be reimbursable no matter where they are provided --except
for jail-- as of July 1, 1993).
2. Participate in the State discussion about day treatment and advocate for
one service category with the capacity to serve both acute and
rehabilitative clients.
3. Assess the use of increased reliance on medications as a form of treatment
to determine whether this is appropriate or the result of insufficient
resources. Enhance medication education in conjunction with all services
in the system.
4. Use resources from the Rehabilitation Option to enhance the transitional
residential treatment program, (now known as Nevin House).
Specifically explore using this program in conjunction with West County
Day Treatment programs to help transition IMD clients to the community
and to effectively serve dually diagnosed clients.
CLIENT ADVOCACY/SELF HELP
A. SUMMARY
Statutorily mandated inpatient advocacy and patients rights services are effectively
provided by contract with a consumer-operated agency.
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Community Services
Peer support is increasingly recognized as an important component in providing effective
support for people living in the community. "Self-help groups are the most common
form of peer support and involve groups that meet regularly on a formal or informal basis
to share ideas, information, and mutual support." Peer support is also provided in
consumer-operated services; i.e.,
"service programs that are planned, administered, delivered, and evaluated by
consumers. Consumer-operated services often are organized around a drop-in
center. The peer-run drop-in center provides an open,comfortable setting and
often serves as the nucleus for a wide variety of support, service, and socialization
activities. Services provided by consumer-operated programs include self-help
groups; training in independent living skills; advocacy and assistance in locating
needed community resources and services such as housing and financial aid;
education about patients'rights, psychiatric drugs..."22
The Client Network, and TALLAY (a former self-help organization) have advocated for
several years for the development of a self-help center. While there is a long history of
support for client operated services and the County has contracted with Mental Health
Consumer Concerns, a consumer-operated non profit for 12 years, the tangible support
required for the development of a client-operated self-help center has not been
forthcoming from the County or the community.
E. RECOMMENDATION:
Support the development of a self-help center operated by a consumer run agency,
either through allocation of staff resources to help write grant proposals for start
up funds or by allocating savings from the reduction in institutional beds.
VOCATIONAL AND EMPLOYMENT SERVICES
A. SUMMARY
Several counties have interviewed consumers in locked facilities and in the community to
determine their preferences and needs for services. Employment and vocational services
were often mentioned as desired services by those interviewed. Having a job makes
many things possible -- housing,transportation and social interaction-- and it is one of
the most effective ways of restoring self-confidence and self-esteem in persons with
22PsychoSocial Rehabilitation Journal,Jan. 1989
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Community Services
severe mental disabilities. Going to work every day helps people feel "the same as"
rather than "different from" other citizens in the community.
Contra Costa County is fortunate to have three nationally accredited vocational programs
which provide services to persons with severe mental disabilities. These programs,
operated by non-profit contract agencies, are located in West,Central and East County.
They provide sheltered employment, vocational counseling, work service and adjustment,
job placement and supported employment or follow-up maintenance services for those
placed in community jobs.
These programs are funded by a combination of revenues from County Mental Health,
California State Department of Rehabilitation and revenues generated by agency
businesses. Two of the programs provide employment via Javitts,Wagner and O'Day set
aside contracts at federal government installations. Contra Costa County has funded
vocational services on a consistent basis in the Central and East regions. West County
funding has been negligible for several years. All three organizations, to a greater or
lesser extent,rely on agency businesses to help support their vocational services.
Although the California State Department of Rehabilitation funds job placement
programs at the three agencies, there is not enough money in these contracts to provide
the long term follow-along services needed by many persons with severe mental
disabilities. Another source of funding for vocational services, the Contra Costa County
Private Industry Council, has not allocated funds for services to adults with severe mental
disabilities.
R. RECOMMENDATIONS:
1. Use Medi-Cal Rehabilitation Option funds to provide long term follow-
along services to persons with mental disabilities employed in community
jobs.
2. Develop county-wide support to encourage the Contra Costa County
Private Industry Council to provide funding for vocational employment
services to persons with mental disabilities.
3. Increase funding for vocational services in West County and maintain
funding levels in the other regions.
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Community Services
4. Encourage the California State Department of Rehabilitation to maximize
opportunities for funding co-op placement programs in all regions of the
County.
5. Purchase goods and services from agencies and businesses that employ
people with disabilities. This should be done by Contra Costa County and
other public agencies.
6. Provide employment opportunities for persons with mental disabilities at
all levels in the County's work force.
7. Designate a County staff person to coordinate County vocational and
employment services and advocate for those services within the Mental
Health Division. Perhaps an on-site supervisor whose staff has been
reduced might be available for such an assignment.
HOUSING AND HOMELESS PROGRAMS
A. SUMMARY
Lack of stable living situations exacerbate clients'problems. When people experience a
crisis and are forced to use institutional facilities, their ability to maintain their own
housing is jeopardized. This contributes to the severity of the problem and to the length
of time it takes to help them get back on their feet. Community based housing resources
with supports have taken a tremendous loss in the past few years including:
the elimination of community support and assisted independent living programs
in Central County;
• the inability to replace federal funds used by community agencies to fund
housing supports, and
• the reduction in the number of board and care homes.
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Community Services
Low-income housing is very limited throughout the county. Supported independent
housing (where a person can live independently and receive assistance with household
management and coping with landlords and roommates) is virtually nonexistent but very
much preferred. (See AMI Housing Report in the Appendix.)
As a result of State and national policy and the economic recession, there are increasing
numbers of people with a mental disability who are homeless or at risk of being
homeless. The Homeless Project provides 20 shelter beds and three multiservice centers
which help people access financial assistance, housing and mental health services. The
programs provide outreach to the general shelters in the County to help people with a
mental disability access resources. The problems facing this population in establishing or
reestablishing their lives in the community are horrendous. In addition to acquiring the
necessary financial assistance and housing, tremendous changes are required to enable
homeless people to settle into permanent housing situations. Ideally, transitional housing
resources should be available to help this population make the transition.
B. IIECOMMENDATIONS:
1. Support people in their own housing, using 24-hour services only
when a'person needs a more structured situation that cannot be
provided in his/her own home. Develop a range of services which can
be used to help a person stay in his/her own living situation, with
family,,or with friends during a time of crisis. Expand supported
housing services, so that more emphasis can be placed on prevention
of crises. Establish a fund for housing and utility deposits.
2. Develop strategies to maintain a person's regular living situation
during times when they may need to use 24-hour services. Loss of
community housing makes it extremely difficult to discharge people as
soon as they are ready.
3. Seek funds for housing. Revisit and update the Mental Health
Division Special User Housing Plan, November, 1988. Develop a
joint Housing, Community Development and Mental Health Task
Force to take the lead in developing housing in Contra Costa County
for people with mental disabilities.
59
Community Services
4. Explore the possibility of negotiating Section 8 vouchers from the
Housing Authority to be set aside for people with mental disabilities.
5. Designate a County staff person with responsibility for coordination of
housing activities.
BRIDGING THE GAP FROM ADOLESCENT SERVICES:
A. SUMMARY
There is little coordination between children's and adult services. Consequently, 18 year
olds rely on particular service workers, not the system, to bridge the gap between the two
service delivery systems.
B. RECOMMENDATION:
Assign the task of reviewing this issue to the next planning committee or set up a
small task force of children and adult providers(County and contract),clients who
have had the experience of transitioning from adolescent to adult services and
family members to assess the problem and recommend needed systemic changes
to facilitate meeting the service needs of this population.
60
X. FINANCIAL COMMITMENT
A. SUMMARY:
Recognizing the extraordinary financial crunch facing the County, it is essential to take
certain actions to ensure that our long-term situation is not significantly worsened by
short-term actions.
B. RECOMMENDATIONS:
1. Preserve funds saved from reducing hospital,IMD and local inpatient
services for maintenance and development of community services to the
fullest extent possible. Reallocate these savings to each age group
(children, adult, and geriatric)in the same proportions as their current
allocations.
2. Implement the use of the Rehabilitation Option under Medi-Cal as quickly
as possible, to generate more revenue and increase service flexibility to
meet client needs.
3. Maintain or increase the existing level of Medi-Cal revenue to assure that
Contra Costa County will continue to receive at least the present level of
MediCal reimbursement in anticipation of the forthcoming Medi-Cal
funding cap.
4. Examine all current revenues including Realignment dollars,County
General Fund and SAMHSA funds in terms of their applicability for
funding the proposed expansions, pilots and new programs.
5. Seek new funding and revenues. Develop an integrated system to identify
and monitor potential grants and to coordinate grant writing efforts.
6. Assure clients receive all benefits to which they are entitled.
61
XL FOLLOW-UP
A. SI MNURY
The foregoing recommendations,taken together, comprise a broad-brush plan for shifting
the County's mental health resources from a reliance on institutional care to a client-
centered system of community based care.
Some of the specific recommendations can be immediately implemented while others
will require varying periods of time for development. Some will meet with enthusiastic
response while others may encounter obstacles that were not envisioned. And there
remain several areas which could not be pursued in the limited planning time available.23
For all these reasons,we want this document to be viewed as a living, dynamic work in
progress-- that will encourage and stimulate discussion, and will be debated, improved
and changed.
Rs RECOMMENDATION:
In particular, we strongly recommend that these preliminary planning efforts be followed
by a substantial planning process, a process in which Mental Health administrators,front-
line staff, union representatives, contractors and their staffs, and community
representatives comprise one-half of a committee, with consumers and families making
up the other half. With these participants as the core group of an on-going planning
process, it would be possible to accomplish the following:
•Undertake a comprehensive survey of all of the system's clients, assessing their
needs and wants;
•Consider ALL aspects of the services-- public and private --for possible
modification;
23Children's services,geriatric services,mental health services in the jail,programs for mental health
clients with AIDS,were not addressed in the course of this study. A more in-depth study of services for
clients with special needs would be beneficial. In addition it would be productive to explore model
programs being implemented in other locales.
63
Follow-up
•Review SPECIFIC plans which are being considered with the key groups and
individuals to be impacted,
•Plan and develop a service system which will enable Contra Costa County to
continue to move toward a more cost-effective,client-centered,community-based
model.
As the plan evolves, putting good ideas into practice is critical. Implementing change
will require continuing Mental Health Commission and community advocacy,
wholehearted commitment and leadership on the part of the administrations of the Mental
Health Division and the Health Department,cooperation on the part of all providers and
the support of the County Administration and the Board of Supervisors.
We believe that all of these groups will join together to achieve the fundamental goals
articulated in this report. We believe that our County has the will to provide critically
needed support for our most vulnerable population.
64
APPENDIX A
LIST OF CONTRIBUTORS
The following persons provided client and fiscal data, program descriptions, and other
Valuable information and ideas to aid the Committee in its work:
John Allen
Rick Aubry
Lorna Bastian
Jim Bouquin
Nancy Brewster
Frank Camargo
Max Cowsert
Charles Drolette
Clay Foreman
Pat Godley
Joseph Hartog, M.D.
Essie Henderson
Linda Kirkhorn
Sharon Lundholm
Jay Mahler
Francyn Molina
Eroca Talent
Manuel Velasco
From other counties:
Gale Bataille and staff, Solano County Mental Health Services
Diane.Cunningham, Alameda County Mental Health Services
Lori Shepherd and Beth Stoneking, Sacramento County
Many members of the Alliance for the Mentally Ill,Contra Costa County, Mental Health
Advisory Board and the Client Network attended meetings to share their ideas and
provide feedback. The Committee is deeply appreciative of everyone's cooperation and
assistance.
65
APPENDIX B
CONTRA COSTA COUNTY MENTAL HEALTH DIVISION
OVERVIEW AND PHILOSOPHY
TARGET POPULATION:
Contra Costa County Mental Health will provide services to
targeted populations in accordance with Public Law 99-660, State
Comprehensive Mental Health Services Plan of 1986, the AB 904
California Mental Health Master Plan and AB 1288 Mental Health
Realignment Legislation. The targeted populations are described
in the following three groups:
*Seriously emotionally disturbed children and adolescents under
age is, with active consideration given to the needs of families
of the target populations;
*Seriously and persistently mentally ill (SPMI) adults who are
functionally disabled;
*Older adults, 6G years and over, who require specialized
services due to functional impairment or significant changes in
behavior related to a serious, persistent mental illness or a
dementia.
PHILOSOPHY AND VALUES:
Services will strive to meet. the needs of clients. Mental health
workers will assist clients in identifying and using the spectrum
of mental health and community services. Clients will also be
assisted in "developing the skills and acquiring the supports and
resources they need to succeed where they choose to live, learn,
and/or work; to maintain responsibility, to the greatest extent
possible, for setting their own goals, directing their o-wn lives,
and acting responsibly as members of the community" (CA Mental
Health Master Plan) . Programs will focus on strengthening
skills, and developing environmental supports to sustain clients
in the community. The system of care will acknowledge and
incorporate the importance of culture and language, the value of
cultural diversity, and the adaptation of services to meet
culturally unique needs.
CLIENT-DIRECTED SERVICES:
Based on client strengths and functional and/or organic
disabilities, realistic goals will be set by the client and
mental health worker, in consultation with. family and/or
significant others. Family and community supports will be
identified to assist in meeting goals. service decisions will be
made by the client in consultation with the mental health worker
who will assist the client in making choices about living
environments, social relationships, leisure activities and
housing.
67
CONTRA COSTA COUNTY MENTAL HEALTH DIVISION
OVERVIEW AND PHILOSOPHY
March, 1992
Page 2
For children, realistic goals will be set by mental health staff
in concert with the child, his/her family, and in collaboration
with other child-serving agencies; e.g. , the schools, probation,
social services, etc.
The Mental Health Division will design services that enhance the
quality of life, promote client empowerment, encourage clients'
achievement of potentials, and respond to clients of varied
ethnic and cultural origin.
MENTAL HEALTH GOALS:
For adult clients, the Mental Health .Division will strive to
measurably reduce use of hospitals, IMD facilities, jail and
crisis services; increase length of community tenure; increase
paid and unpaid employment; increase stability in housing;
increase use of nationally recognized intervention methods;
increase symptom management and medication education (pseudo-
educational interventions) ; develop additional service system
components; e.g. , respite for care givers, supported housing and
supported employment; and strive to respond to, and meet, the
culturally unique needs of the ethnically and culturally diverse
client population.
For children and adolescents, the Mental Health Division will
provide high quality family-focused clinical services to an
ethnically and culturally diverse population of children,
adolescents and families throughout the county. Staff will
consult with, collaborate with, and participate in interagency
services and planning with the County departments legally
responsible forthe education, care, and custody of children
(including care-giving county facilities) as well as with
community agencies serving targeted population groups.
Children's services will strive to design programs and provide
treatment and case management services which: (1) maintain
children in the least-restrictive environment; (2) build on
family strengths to prevent acute hospitalization and/or reduce
the length of hospital stay; (3) divert youngsters from
residential treatment, juvenile hall, and crisis services; and
(4) aim to increase the child and family's ability to function
within the home and in the community.
ovandphi
68
100 STAT.3796 PUBLIC LAW 99464—NOV.14,1986
'(7)The State plan may provide for the Implementation of the
requirements of paragraph(6)in a manner which—
"W phaw in,beginning In fiscal year 1989,the provi•
AAPPENDIX
�y ATT v 6,-n to all chronkal mentally ill individuals to which such
PENDIX C Pars�r+Ph applies the case management services required
to be prwnded under such psrs�aph;and
�(B)provides for the subst t- completion of the phas-
ing
in of the provision of such services by the end of fiscal
PUBLIC LAW 99-660 �,",,;ea" I) State p�shall provide for the establishment and
implementation of a program of outreach to,and services for,
chronically meatal) ill Indi 'duals who are homeless.
'(d In dove a State Plan re
9ulred under this section,the
State shall consult with representatives of employers of State
institutions and publicand ppnnvete nursing homes who caro for
chronically mentally III(ndivlduata.
"(d)The Secretary shall provide technical assistance to States In
the development and implementation of State plans which comply
with this section.Such technical assistance shall include the devel-
opment
t and publication�d �4 Secretary of model elements for
plans systems for the collection of data
100 STAT.3794 PUBLIC LAW 99464—NOV.14,1986 concerning the implementation of State plans.
"XNMRCZXCRM
42 USC sons-It "Sac 1920D.W If the Secretary determines that a State has not,
by the end of fiscal year 1989,developed the State plan required
()tsar TITLE V--STATE COMPREHENSIVE
section tm 1�U1e u Secretary I■)nail lyuce the amount of the State
allotment under subpart 1 for Gaul year 1990 by the amount
tC Hh`Z- MENTAL HEALTH SERVICES PLANS •P"Gcd h Secretary determines"Yb)If lhro Secretary determines that a SLito hese not,by the end of
Semim
fis
Plea,Act of 1986. cal year 1990,developed and substantially implemented the State
SEC plan required by section 19200, the Secretary shall reduce the
si t)SC Zlot rote Aare.a TM. amount Orf lbs State's allotment under sub 1 for fiscal 1991
This title may be cited as'the "State Comprehensive Meatal by the amount specified in subsection(d). P� 1
Health Services Plan Ad of 1986". 'Ye)If the Secretary determines that a State has not,by the end of
SCG set.STATE QONPR6HSNSIVEMENTALHEALTHSERVICESPt.AK fixal year 1991,developed and completely implemented the State
a trSC Nov. Part B of title XIX d the Public Health Service Ad L amended plan re9ui+ed by section I920Q the Secretary shall reduce the
(1) by inserting before'the heading for section 1911 the t°f tLe Scalds allotment under
under subpart 1 for fiscal year 1992
following: tion(d1 TbeTbe and each succeeding f shall discocontinuthe amth rat speaGed m'eur his
"SuarAlrr 1—Banca GRANT";and reduction under aria
subsection of a State's allotment under subpart 1 for a fiscal year if
the Seery determines that the State has,in the precedingfiscal
(2)by adding at the end!hereof the following
year, developed and completely implemented the Stae plan
1 wind by sew 19200.
"(d)The amouat referred to in subsections(a1,(b).and(c)with
PUBLIC L.AW 99-660—NOV.14;1986 100 STAT.3795 respect to a State is the total amount expended by the State for
administrative expenses for fiscal year 1986 from amounts paid to
"SvwAET 2—SrAw Cown
atnnsrva MENTAL HEALTH Seevtc is the State under subpart I for such furcal year.
PMN "(d Notwithstanding any other provision of this subpart, the
Secretary shall not require a State government,in carrying out a
'bevELorumm CLAW= State plan submitted under this subpart,to expend an amount for
mental health services for any fiscal year which exceeds the total
`See 1920B.(a)The Secretary shall make graab to States for the tt�ulatioea amount trot would have been expended for such services by such
development of State comprehensive mental health services plans 42 SG sone-lo. government for such fiscal year if such plan had not been
which comply with section 19200.In order W receive a grant under implemente&
this secVwn,a State shall submit an application to the Secretary.
Such application shall be in such form, and shall contain such PUBLIC LAW 99-664—NOV.14,1986 100 STAT.3797
information,as the Secretary may by regulation prescribe
"(bxl)Except an provided in paragraph(2),the amount of a grant
to a State under this section for a furcal year shall be the amount "MODEL sTANDARW FOR THE MOVt910N 0/CARO TO THE CHRONICALLY
which bean the same ratio to the amount approprialed to ce out MENTALLY ILL
this sodion for such fiscal year as the population of the State bears "Sec 1920E(a)Within one year after the date of enactment of 42 USC soot-Is.
to the total of the population of all States which submit applications this subpart, the Secretary shall develop and make available •
nrhderth(asection. model plan for a community-based system of care for chronically
'X*Notwithstanding paragraph(1),the amount of a grant to any mentally ill individuals Such plan shall be developed in consulta-
State under this section shall not be lea than$150,000. tion with State mental health directors,providers of mental health
"(c To carry out this section,there are authorised to be appro- Aup ttine services. chronically mentally ill individuals, advocates for such
pristed $10.000,000 for each of the fiscal years 1988 and 1989. • iO° individuals,and other interested parties.".
-erAlm OOMPwmNSWIS MIMAL HEALTH SERVICES rtwNS SEG 14L STATE MEATAL HEALTH SERVICES PLANNING COUNCILS.
"Sea 192(1G W For each(tees)year.begun with fiscal year t2 Use Soo:-tL Section 1916(()of the Public Health Service Act is amended— 42 USC soot-.
1v8 (1)by striking out "With amounts available under section
1988,each State shall submit a State comprehensive mental health 1915(a),the chief executive officer of the State tray"and insert- 42 USC soot-s.
ps�Vi'oea referred to in this subpart as the 'State ing in lieu thereof'The chief executive officer of the State
shall";and
"(b)A Siete plan shall,for the furcal year for which t mepolare (2)by adding at the end thereof the following new sentence:
submitted and eadl of the 2 succeeding fiscal years. 'The State may use amounts available under section 1915(x)to
fdtovriru More IS: establish and operate such a council.".
"�(ii)The State plan shall provide for the establishment and of
implementation of an o anixed community-based system of SEC."41.DEMON'STRATIOY PROJECTS FOR SERVICES FOR U014CLE.SS
tyre for ehronleally mentally illindividuals.,:. CHRONICALLY MENTALLY ILL INDIVIDUALS.
'M The State plan shall contain uantitative targets to be (a) DrmoNSTRATLOv PEarDcrs.—Section 5040x1) of the Public A ce per>oe.
im tem do f su t cat fire nam Health Service Ad is amended by striking out"and elderly individ. 4Z use 29o..-i
n chronically men individuals resp ' uals"and inserting in lieu thereof"elderly individuals,and home-
to be served under such system. less chronically mentally ill individuals".
13)Tee State plan shall describe services to be provided to (b)AuTHOREz1T10N—Sedion 50400 of such Ad Is amended by
chronically mentally ill individuals to enable such individuals striking out "1985, 19E6.and 1987" and inserting In lieu thereof
to gain aocees to mental health services, including aeoess to "1985 and 1986,and$24,000,000 for fiscal year 1988 .
♦ Saute tan shall estaTbe rhe t Ration services, (c)Atmimi TRATnt ExprNsits.—.Section 504(f)of such Ad is fur-
p Cher amended by adding at the end thereof the following new
paragraph
to i y men- (4KA)Not more than 25 perant of the total amount of a grant for Gnat..
m uals m order to enable such'individuab to tuna fiscal year 1988 made to a State under this subsection for a pro4ed
tion outside of inpatient Institutions to the maximum extent of for services for chronically mentally ill adults(other than a project
tbeir capabilities. I for services for elderly individuals or a project for services'for
*%S)Mie State plan shall provide for activities to Tedi; homeless chronically mentally ill individuals)may be used by the
te of hoe 4-l(tstion of chronically mentally M Individual- State for administrative expenses in carrying out such grant in such
16)kbEcept as provided in paragraph(7),the State PIE shall fiscal year.
(B)Not more than 25 percent of the total amount of any grant
menn m e'; te w o receives made to a State under this subsection for services to chronically
Isubirtantial amounts of public funds or services.For purposes of mentally ill adults for any fiscal year(beginning with fiscal year
elks paragraph, the term chronically mentally ill individual' 1989) may be used by the State for administrative expenses in
mesas a ehronicallr mentally ill individual as defined under carrying out such grant in such fiscal year.".
State laws and regulations.
69
APPENDIX D
PARRISH, JACQUELINE, "THE LONG JOURNEY HOME:
ACCOMPLISHING THE MISSION OF THE COMMUNITY
SUPPORT MOVEMENT"
From the "Psychosocial Rehabilitation Journal", Volume 12, Number 3,
January, 1989
The Long Journey Home: Accomplishing The
Mission Of The Community Support
Movement
Jacqueline Parrish
Jacqueline Parrish,M.S.,R.N.,is Program Director for the National Institute of Mental
Health Community Support Program.The program works with states,communities,national
organizations,:consumers,and family members to stimulate improved community-based ser-
vices and opportunities for people with long-term,severe mental disorders.
Abstract: Although the community support movement has progressed
considerably during the past decade in conceptualizing and promoting ef-
fective community support services for people with severe mental dis-
orders, there continues to be a lack of resources and other major obstacles
impeding the further development of sufficient services and supports for
the entire population. The major obstacles are discussed and four ap-
proaches for overcoming them are presented.
Substantial progress has been made during the past decade toward
helping people with severe mental disorders improve the quality of their
lives. There is increased awareness on the part of legislators, program
planners, and providers of the needs and potentials of these people.There
is a growing consensus, based on research and program experience, that
most can live meaningful and rewarding lives in the community. Many
states have endorsed community support concepts and have designated the
long-term mentally ill as a priority population for services (Brekke &Test,
1987; Goodrick, 1987a; Parrish, 1987).
Although''it is edifying to look back and congratulate ourselves on this
significant progress, we also must look forward and acknowledge that we
and our clients have a long way to go. . . a long journey before reaching
"home." 1 use "home" because I believe it embodies the ultimate goal of
the community support movement. Our intermediate goals are to increase
services and coordinate systems, but our ultimate goal is to help people
with severe mental disorders succeed in living in their own homes in the
community along side other citizens.As is painfully evident from the many
people who are still in institutions,substandard boarding homes,jails,and
from those who are homeless, we are still far from achieving our final
goal.
We in the",Community Support Program (CSP) of the National Institute
of Mental Health (NIMH) have attempted to serve as a focal point for
considering these issues by convening conferences and by undertaking in-
formation-gathering initiatives such as the recently conducted stratcgic 71
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APPENDIX E
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80
APPENDIX F
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81
�I
APPENDIX G
AMI-CC....HOUSING SURVEY...1992
SUMMARY
The study is based upon questionnaires completed by 102 AMI members,a response rate of 65%.
A demographic analysis of the population covered by the study showed that 88%were in the 20-40
age range,75%were male, 96%were single (defined as currently without a partner)and approximately
three-fourths received some form of public financial support for living expenses and health care. This
population profile is very similar to the national distribution of people with mental disability.
Living situations were clustered into rive main categories,with the population distributed as follows:
36 in Independent Living (apartments,single room, mobile homes)
24 in Group,Living(board&care;licensed& unficensed homes)
29 in Family Home,with parent or other family member
10 in Hospital or Institution
I Homeless
2 Unknown
Satisfaction with living arra, gen res ds,distribution by sex and recreationallsocial needs were analyzed
in relation to these housing categories, with the following results:
Overall.36% of the responses showed satisfaction with living arrangements,29%
showed dissatisfaction,and 40% were ambiguous.
According to AMI members, loved ones living independently and with family
tended to be more satisfied than the total population and those living in
group homes were significantly less satisfied(only 8%compared with the 3V.4
overall).
Males were overrepresented in group Wing situations and
underrepiesented in independent Wing;the reverse was true for the
women(�h 50%of women fiving alone).
Over 60%of those who answered the question on social and recreational
needs stated that these needs were not being met;this negative assessment
was true for all riving situations,and most severe in independent living.
Current riving situations were compared with those Judged to be the most beneficial types of housing,
with findings as follows:
Supported independent living was desired by nearly half of all respondents,
but this is,virtually nonexistent in Contra Costa County.
I
Many of the respondents who had loved ones living at home would prefer
other housing but find the alternatives too costly.
I
Halfway housing was desired by many of the respondents,but none is available.
And,finally,more than half of the respondents expressed fear that their mentally disabled loved ones
will become homeless.
83
APPENDIX H
GRAPHIC COMPARISON OF INSTITUTIONAL AND
COMMUNITY BASED CARE: NUMBER OF PEOPLE SERVED
AND COSTS
% of Persons Served Per Day
by Type of Program
crisis 15�
Merrithew 7%
Community Based 51°X.
State Aosgitals13%
2` '\
. WDs 13%
`•,:;�fS�#` �.::fi22 �k� i>#2 4 2f2.
I
% of Projected Total Cost Per Year for FY 92-93
by Type of Program
. . . . .
Oisis 1.3%
community Based 29%
Merrithew 26°b ,.Mu•>.
,;.>....tt':'
State Hosphals 220L
ZL
Y
85
MERRITHEW MEMORIAL HOSPITAL
JOINT CONFERENCE REPORT
July 20, 1993
i
TABLE OF CONTENTS
Average Daily Census . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-3
' Average Monthly Hospital Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Total Hospital Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Discharges by Fiscal Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Average Length of Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
Monthly Births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Admissions from Other Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-15
Outpatient Visits,. . 16-20
Inpatient Days by Payor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Discharges by Payor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
i
Medicare Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Medicare Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Medi-Cal Contract Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Outpatient Visits Iby Payor . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . 26-27
East Bay Hospital Conference Medical Services . . . . . . . . . . . . . . . . . . 28-29
ADC9293 MERRITHEW MEMORIAL HOSPITAL
07/16/93 AVERAGE DAILY CENSUS Prepared By: C. Shevlin
Reviewed By: Bud DeCesare
...............1990--------------- ----------------1991---------------
1990/91
JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE AVERAGE
Medical Care 80 74 79 74 78 78 85 80 94 90 78 78 81
Psychiatric (1) 45 44 41 42 49 44 44 44 40 38 40 39 42
---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- -------
Sub-total 125 118 120 116 127 122 129 124 134 128 118 117 123
Newborn 10 9 9 11 11 11 12 10 10 9 10 10 10
.... .... .... .... .... .... .... .... .... .... .... .... .......
TOTAL 135 127 129 127 138 133 141 134 144 137 128 127 133
==z== ===r zz»z zzzzz zz=» ===== zzzzz zzzzz C=Z====
...............1991............... ................1992---------------
1991/92
JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE AVERAGE
Medical Care 79 82 69 78 93 81 90 83 79 77 83 83 81
Psychiatric (1) 36 39 43 43 41 43 43 45 45 44 44 46 43
--- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- -------
Sub-total 115 121 112 121 134 124 133 128 124 121 127 129 124
Newborn 9 11 11 11 11 9 8 9 8 10 8 8 10
-- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- -------
TOTAL 124 132 123 132 145 133 141 137 132 131 135 137 134
---------------1992--------------- -----------------1993---------------
YTD
1992/93 1992/93
JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE AVERAGE BUDGET
.... .... .... .... .... .... .... .... .... .... .... .... ....... .......
Medical Care 93 87 87 91 88 82 90 83 86 88 85 83 87 81
Psychiatric (1) 40 39 42 44 41 48 47 45 44 44 46 48 44 43
Subtotal 133 126 129 135 129 130 137 128 130 132 131 131 131 124
Newborn 8 9 9 7 8 6 7 7 6 7 9 8 8 10
TOTAL 141 135 138 142 137 136 144 135 136 139 140 139 139 134
===== =a==_ ===z= =___= ===== _____ __=== =a=== __=== z==== =z=== zz==_
(1) INCLUDES H,I 8 J WARD ONLY
PRIOR YEARS HAVE BEEN RESTATED TO INCLUDE H WARD IN PSYCHIATRIC UNIT
FOR COMPARATIVE PURPOSES
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ADMTFAC3.WK1 . MERRITHEW MEMORIAL HOSPITAL
TOTAL ADMISSIONS FROM OUTSIDE FACILITIES
FISCAL YEAR COMPARISONS
YTD JUNE 1993
1989/90 1990/91 1991/92 1992/93
------ --------- --------- ---------
BROOKSIDE 123 169 177 168
DELTA 52 45 51 55
DOCTORS 25 29 39 28
JOHN MUIR 56 80 87 96
KAISER 72 82 78 64
LOS MEDANOS 109 98 130 108
MT. DIABLO 47 75 103 57
OTHER 99 70 73 52
TOTAL ADMISSIONS 583 648 738 628
Prepared By: C. Shevlin
Reviewed By: Bud DeCesare
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• ATTACHMENT L
CONTRA COSTA COUNTY
SIGNIFICANT EVENTS IN COUNTY HOSPITAL PLANNING*
10/78 A Consortium of six hospitals in Contra Costa County proposes to take over
inpatient services of County Hospital, leading to discussion of dosing the
Hospital.
7/80 Supervisor McPeak — as the Board representative to the Consortium —
•reo=rnends that a contract with the consortium is not advisable. The cost
of care at Consortium hospitals is higher than at the County Hospital, and
the Consortium 'hospitals will not agree to be the Vwofers of last resorr.
None of the Consortium hospitals is willing to contract for care at less than
cost. Board of Supervisors orders Health Services Director to study the
feasibility of remodeling or replacing County Hospital.
11/80 Board of Supervisors approves a contract with Amherst Associates to
conduct feasibility study.
7/81 Amherst study finds that other hospitals acknowledge need for County
to Hospital to continue serving its unique population, felt that County Hospital
9/81 should be rebuilt, and that the hospital is functionally obsolete and out of
compliance with standards. Report finds that existing supply of hospital
beds in Central and East County will not be sufficient.
1/82 First meeting of the Board-appointed Committee on the Future of the
County Hospital, established to review Amherst Study results. Committee
is made of 25 members, including representatives of community hospitals,
labor, business, consumers, medical society, and Taxpayers' Association.
4/82 Committee issues final report. The recommendations, adopted by a 20 to
2 vote, include constructing a medical-surgical, psychiatric and
rehabilitation hospital in Central/East County, leasing or purchasing
Richmond Hospital for services in West County, and contracting for
specialty services throughout the County.
8/82 At the Board's request, Health Services Department invites hospitals to
participate in discussions regarding contracting. Although a few hospitals
will contract for selected services, none would serve all indigents referred
to them.
* Although this chronology begins in 1978, debate over the future of the County Hospital
actually began in the late 1940's with the issuance of a Contra Costa County Grand Jury
Report.
2
J
9/82 Board of Supervisors authorizes Health Services Department to develop,
with National Medical Enterprises, a proposal for replacing the County
Hospital. Board also authorizes submission of a Notice of Intent to
construct a 150-bed hospital in Central County.
1/83 Health Services Department staff meet with Mt. Diablo Hospital staff
regarding County's contracting proposal. Mr. Diablo concerned about
receiving a disporportionate share of county patients, especially Indigents. .
6/83 The Health Services Committee of the Grand Jury reports that other
hospitals interviewed expressed willingness to contract for care of County
patients, but not at less than cost. Also recommends that, H a new County
Hospital is built, ft should be located on the existing site.
7/83 Board of Supervisors holds public hearing on options for the County
Hospital.
8/83 Board of Supervisors expresses its intent to build a new County Hospital of
approximately 150 beds. Contra Costa Times publishes an editorial
supporting a new County Hospital.
12/83 Hospital planning put on hold for a year.
7/85 The Contra Costa County Grand Jury urges replacement of "depressing"
County Hospital
11/85 The NBBJ Group finds that Merrithew's buildings and systems are at or
beyond useful life, estimates $11 million maintenance and improvement
costs over five years.
1/86 Health Services Director presents Hospital Options Report to Board. Based
on extensive interviews with community organizations, hospital
administrators and union representatives, the report recommends a new
facility and geriatric institute. Board approves concept 4-0 (one abstention)
and orders facility and design study.
4/86 Health Services Director makes progress report to Board, which includes
comments received in response to the Hospital Options report. Contra
Costa County Legal Services is recorded as supporting the new hospital
and the present location (Martinez).
6/86 Solano County Health Director urges Contra Costa County not to close the
County Hospital.
I .
3
8/86 Board of Supervisors authorizes RFP for strategic,architectural and financial
planning assistance regarding rebuilding Merrithew Memorial Hospital.
12/86 Board of Supervisors approves selection of Arthur Young to determine
feasibility of replacing county hospital.
3/88 Statewide health 'care advocacy coalition releases study criticizing County
Hospital and says, new health facility is desperately needed.
7/88 Merrithew Memorial Hospital is cited by both state and federal regulatory
agencies for lack of compliance with.current physical standards. State
official says, 'The;facility has seen its day".
8/88 Drever and Berkoff estimate $12 to $15 million needed to correct licensing
deficiencies; concurs that hospital has outlived useful life.
10/88 SB 1732 (Presley) passes,which will provide for State reimbursement of the
County's capital 'costs associated with providing services to Medi-Cal
patients. Merrithew Memorial Hospital records the highest census in
history -- 175.
12/88 Board of Supervisors accepts Arthur Young Study regarding the financial
feasibility of replacing Merrithew Memorial Hospital. Study recommends
replacing hospital.,with 227-bed facility. 41
1/89 Board of Supervisors agrees to request. proposals for architectural
drawings. Workshop on the replacement of Merrithew Memorial Hospital.
4/89 Board of Supervisors conducts workshop on the replacement of Merrithew
Memorial Hospital. Receives the ICF/Lewin report confirming the need to
replace the County Hospital based on a financial analysis.
5/89 Contra Costa Grand Jury recommends a smaller replacement hospital(175
beds) and increased contracting with three district hospitals.
7/89 Board of Supervisors approves agreement with KMD Architects for
conducting architectural predesign for replacement hospital.
2/90 Meeting with the Project Oversight Committee, KMD, Bond Council,
Underwriters and MPA to plan development review.
3/90 Monthly meetings take place between KMD, Health Department, County
to Administrator's Office and General Services.
8/90
r
4
9/90 Governor approves SB 2665, which provides for use of General Obligation '
Bonds under SB 1732 program and modifies SB 1732 language to ensure
federal financial participation.
10/90 County Administrator's Office finds that maximum County debt capacity is
$80 million, less than the$126 million needed for full replacement of existing
hospital. KMD revises plan.
2/91 Board of Supervisors receives KMD report. Authorizes preparation of
Schematic Plans for phasing in replacement of hospital.
2/91 Joint Venture Is established with Brookside Hospital under which County
physicians deliver babies for West County women at Brookside Hospital.
3/92 Contra Costa Times endorses rebuilding county hospital.
3/92 Board of Supervisors approves the blended solution: replace hospital with
a new 144-bed hospital and continue working with Los Medanos and
Brookside Hospitals to develop further joint ventures or arrangements.
3/92 Board of Supervisors authorizes a $20 million 'Series B" bond issue for the
• purpose of funding capital improvement projects to support joint ventures
with.District Hospitals or the private sector medical community. These joint
ventures would be directed at improving access to and medical care for
low-income and indigent populations.
5/92 Grand Jury issues report commending the Health Services Department and
Board of Supervisors for a "job well done" on the proposal to replace.
Merrithew, noting that the HSD has worked diligently to increase the use of
contracting with other hospitals and to add clinics In other areas of the
county.
5/92 Certificates of Participation ($125 million) are sold for the Merrithew Hospital
Replacement Project
i
sac CONTRA COSTA COUNTY
_ MENTAL HEALTH COMMISSION
+/• __ = 595 CENTER AVENUE,SUITE 200
__ - MARTINEZ,CALIFORNIA 94553-4639
Phone(510)313-6414
COUIZ
To: Board of Supervisors Date: July 14, 1993
,
From: De ' s Lepak, Chair Subject: Ad Hoc Planning
Me tal Health Commission Committee Report
Violet Smi � hair
Ad Hoc Pla ng Committee
The Ad Hoc Planning Committee of the Mental Health Advisory Board
of Contra Costa County has completed a six-month planning process,
culminating in the publication of the attached report. We are
pleased to send you a copy of the report and look forward to
discussing it with you on July 20.
Thank you for your interest and continued support.
pr
cc: Phil Batchelor
Mark Finucane
Lorna Bastian
A351 (6/93)
REPORT OF THE CONTRA COSTA COUNTY
MENTAL HEALTH ADVISORY BOARD
AD HOC PLANNING COMMITTEE
Adopted bye
THE MENTAL HEALTH COMMISSION
595 Center Avenue
Martinez, CA 94553
June 24, 1993
REPORT OF THE MENTAL HEALTH
ADVISORY BOARD
AD HOC PLANNING COMMITTEE
TABLE OF CONTENTS
I. Executive Summary..................................:........................................ i
U. Introduction........................................................................................ 1
III. Background........................................................................................ 5
IV. Guiding Principles..........................................................
V. State Hospitals.................................................................................... 13
VI. IMDs................................................................................................... 19
VII. Local Inpatient Services..................................................................... 23
VIII. Crisis Services.................................................................................... 31
IX. Community Services.......................................................................... 43
X. Financial Commitment....................................................................... 61
XI. Follow-up............................................................................................ 63
XII. Appendices:
A. List of Contributors................................................................. 65
B. Contra'Costa County Mental Health Division Overview and
Philosophy............................................................................... 67
C. Public Law 99-660.................................................................. 69
D. "The Long Journey Home: Accomplishing the Mission of the
Community Support Movement," by Jacqueline Parrish,
Psychosocial Rehabilitation Journal, Volume 12, No. 3:
January, 1989........................................................................... 71
E. Contra Costa County Health Services Department,Mental
Health,FX 92/93 Projection..................................................... 79
F. Trends in Outpatient Services.................................................. 81
G. AMI-CC Housing Survey, 1992, Summary............................. 83
H. Graphic Comparison of Institutional and Community Based Care:
Number of People Served and Costs........................................ 85
NOTE: A complete appendix containg all source documents and computational analyses is on file Mental
Health Division Administration.
EXECUTIVE SUMMARY
OF THE AD HOC PLANNING COMMITTEE REPORT
Approved by the Mental Health Commission, 6/24/93
INTRODUCTION:
The Ad Hoc Planning Committee of the Contra Costa County Mental Health Advisory
Board was formed in early 1993 to provide a vehicle through which a broad array of
mental health constituencies could provide input into planning and developing the
County's mental health services. The full report details the Committee's guiding
philosophy, a description of the County's mental health services for adults*, and
extensive recommendations.
MAJOR FINDINGS:
As a consequence of limited and shrinking resources, the County has restricted the
potential service population to those with the most severe impairment and reduced
community- based services geared to prevention, early intervention and support.
This-has produced a disproportionate reliance on costly,restrictive institution-based
programs and increasingly heavy usage of acute hospital and crisis services. The
projected distribution of expenditures is graphically shown below.
PROJECTED COST OF ADULT PROGRAMS FOR FY 92-93
BY PROGRAM TYPE
Total Costs
Net County Costs
Crisis Community ��.
1346 Crisis Community
Basta
13% Basta
28% Ifenithew
24%
Ilcrrithm 15%
26% IMDs VVUVUUXXXXXXXIMDs
Stats Hospitals 10% State Hospitals 13%
23% 33% �
PROGRAMS TOTAL COST COUNTY COST
COMMUNITY BASED SERVICES (County and contractors)including:
Client advocacy/self-help,Case Management,Supported Housing,
Day Treatment/Socialization,Vocational and Employment,
Medication Management,Outpatient Psychotherapy,Board and
Care Supplement,Homeless Services,Residential Treatment,
Forensic and Monolingual/Bilingual Services. .............................$9,046,645 $5,108,562
INSTITUTES FOR MENTAL DISEASE(RvfDs)[73 beds] .............................$3,265,479 $2,727,335
STATE HOSPITALS [72 beds] ..........................................................................$7,226,900 $7,226,900
MERRITHEW HOSPITAL(I&J WARDS) [35 licensed beds].............................$8,225,145 $3,069,763
CRISIS SERVICES,including E Ward,Nierika,West County Crisis,and............$4,030,807 $2,735,592
Crisis&Suicide Intervention
*Due to time constraints and the fact that adult services receive nearly 80%of allocated mental health
funds,the Committee elected to focus on this age group. We hope that future planning efforts will address
children's and geriatric programs and follow-up on adult issues not fully covered in this report.
EXECUTIVE SUMMARY
We find the system spending most of its meager resources to care for a relatively small
number of patients in institutions,a form of care that is the least desirable as well as the
most costly. A decade of experience,bolstered by solid research, has shown that
individuals with serious and persistent mental disabilities as well as frequent users of
mental health acute and crisis services,can make successful adjustments to community
living IF they are given adequate supports.
BASIC APPROACH:
Given the current National, State and County fiscal and political realities, the only viable
option is to radically reconfigure existing resources to change the system. These changes
must be accompanied by a corresponding political shift,as stated in the AB904 Master
Plan, that empowers clients, focuses on their strengths and encourages them to live full,
productive lives in the community.
The direction proposed in this report--MEASURED MOVEMENT AWAY FROM
- INSTITUTIONAL CARE AND TOWARD A COMMUNITY SUPPORT SERVICES
SYSTEM-- is fully consistent with National, State and County philosophy and trends. It
holds the promise of providing better services to more people in need at less cost to the
County.
In order to accomplish this goal:
-Mental Health Services must share equal status,priority and financial support
with medical services.
-Dollars saved from the reduction of state hospital and IMD beds must be
designated for local community mental health services in order to avoid repeating
the historical deinstitutionalization disaster.
-A case management system (individual or team) must be proactive in securing,
arranging and/or providing needed services and supports as clients transition to
the community.
-Clients must be involved in all decisions affecting their lives.
-A full range of appropriate housing options with sufficient supports from case
managers and other services must be available within the community.
-Pilot programs-- including proven models like Integrated Services Agency and
Mobile Crisis -- must be implemented as a means of exploring the options for
reconfiguring the system.
These components will make it possible to develop a system which is cost effective,
client centered and community based.
RECOMMENDATION HIGHLIGHTS:
Decrease the reliance on State Hospital and IMD beds:
Work closely with residents to determine their preferences and needs and to
prepare them for returning to the community.
Identify and develop a full range of alternative placements in the community.
lY
Strive to upgrade the services provided in State Hospitals and IMDs for the
benefit of those who will require these services until sufficient and adequate
alternatives are available.
Identify strategies to reduce the utilization and length of stay on I and J wards in
Merrithew Hospital:
Enhance the system's ability to provide needed supports before the clients'
problems escalate to the acute stage.
Work with other counties to develop specialized facilities for populations that are
not appropriately served by acute inpatient services.
Increase efforts to divert patients to other programs and hospitals.
Begin discharge planning, in cooperation with the patient's case manager, as soon
as possible.
Strive to preserve the client's living situation and ties to the community during
hospital stays.
Expand crisis intervention capability:
Increase crisis'residential resources.
Develop a mobile crisis service pilot program.
Retain the West County Crisis Service and pilot a crisis walk-in service in East
County.
Develop a system for sharing Crisis and Suicide Intervention's computerized data
base on community resources.
Consider integrating all crisis services under one administration.
Involve consumers,at all levels of the system,in developing their treatment plans,
evaluating services,working as staff and serving as members of boards and
committees:
Contract with a consumer group to conduct a survey of State Hospital and IMD
clients and assist in transitions to the community.
Develop an action plan to implement a client-centered service delivery system and
train all staff in client-centered methods. Implement the Coordinated Services
System.
Support the development of a consumer-run self-help center.
Develop a pilot project that adapts the Integrated Service A eg_ncy/AB 3777
program to Contra Costa County and include the components necessary to focus
on client needs,choices and wants.
iii
f
EXECUTIVE SUMMARY
Enhance and strengthen the case management system:
Recognize case management as a therapeutic modality and the case manager as
the advocate and facilitator of the provision of community-based treatment.
Assure system-wide knowledge of expectations and capabilities of case
management services.
Limit case loads to a size that enables staff to meet client needs by increasing
existing case management services.
Augment the case management system to include consumers,contractors and
families.
Provide case management priority access to (and exit from) services needed by
their clients.
Evaluate all current clinic services and day treatment in light of the possibilities
offered by the Rehabilitation Option and other funding sources:
Provide supports necessary to enable clients to remain in their own homes, using
24-hour services only when a person needs a more structured situation.
Assign staff to coordinate and advocate for housing and for vocational and
employment services.
Keep funds saved from reducing hospital,IMD,and local inpatient services
available for the maintenance and development of community services-- for ALL
AGE GROUPS -- to the fullest extent possible.
Develop an integrated system to identify and monitor potential grants and to
coordinate grant-writing and other activities to generate additional revenues.
FOLLOW-UP:
The Ad Hoc Planning Committee recommends that this preliminary planning effort be
followed by.a substantial ongoing planning process led by County Mental Health
Administration which includes clients,families,contract administrators, front-line
County and contract staff, and union representatives. One-half of the committee should
be comprised of consumers and families.
A planning process of this nature will enable Contra Costa County to continue to move
toward a more cost effective,client centered,community based system. We look forward
to having a new Mental Health Director who will continue the open door policy of
inclusion and the serious development of ongoing working relationships among all
groups and constituencies. We believe that our County has the will to offer critically
needed support to our most vulnerable population.
iv
REPORT' OF THE CONTRA COSTA COUNTY
MENTAL HEALTH ADVISORY BOARD
AD HOC PLANNING COMMITTEE
ADOPTED BY THE CONTRA COSTA COUNTY
MENTAL HEALTH COMMISSION
JUNE 249 1993
I. INTRODUCTION
The Ad Hoc Planning Committee of the Contra Costa County Mental Health Advisory
Board was formed in early 1993 to provide a vehicle through which the various
constituencies in the mental health community could provide input into the planning and
development of mental health services within Contra Costa County.
Membership of the Committee included the following designated representatives:
Violet Smith,Chair,representing the MHAB
Pat Risser, Mental Health Association
Jack Feldman,Contra Costa Network of Mental Health Clients
Herb Putnam, CCC-Alliance for the Mentally Ill
Vicki Smith,Contractors and Friends Alliance
Mike Cornwall,Public Employees, Local 1
Sylvia Crout California Nurses Association
Dr. Barry Miller, Psychiatric Division, Physicians'Union
The Committee's working strategy was open and inclusive: all who wished
to attend were welcome and report drafts were distributed to appropriate
providers (County and contractors) and constituency groups represented by
Committee members.
The breadth of participation, the diversity of Committee membership and the extensive
collaboration, willingness and ability of Committee members to respect and
accommodate each others views exemplifies the positive potential for a continual
planning process that encompasses the entire mental health community.
Introduction
The planning effort was greatly facilitated by the full cooperation, openness and
responsiveness of the Interim Mental Health Director,whose tenure coincided with the
period of the Committee's work. Committee members were heartened by this attitude and
encouraged to plan for cost-effective programmatic changes, despite budgetary
uncertainty and threatened cuts. We look forward to having a new Mental Health
Director who will continue the open door policy of inclusion and the serious development
of ongoing working relationships with all groups and constituencies. We look forward to
having an administration which will advocate strongly for the mental health services
needed in our community, particularly programs proposed in this report.
The Committee is grateful to Diane Frary,who staffed the Committee, to Mark
Finucane, Health Services Director, for his participation in a number of the Committee's
meetings and to Lorna Bastian,Interim Mental Health Director,for her support and
cooperation. Numerous staff of the Mental Health Division and contractors provided
substantial and much-appreciated information and assistance. We benefited greatly from
our contacts with representatives of Alameda, Solano and Sacramento counties. These
contributors are acknowledged in Appendix A. The committee extends special thanks to
Jay Mahler of Mental Health Consumer Concerns for organizing the excellent
Sacramento mini-conference.
Due to time limitations, the Committee elected to focus on services to the adult
population (ages 18 - 65) because these services account for approximately 80% of the
Division budget. It is recommended that future planning address children and geriatric
programs and follow up on adult service issues not adequately addressed in this report.
The Committee met twice monthly to review and evaluate the community's mental health
needs, services, and special problems in an attempt to identify strategies for:
1) averting cuts in direct services,
2) increasing revenues, and
3) maximizing the effectiveness of local mental health services.
This report covers the broad perspective developed by the committee to achieve these
goals. It contains an overview of the services as they currently exist and a series of
recommendations for accomplishing measured change from the present emphasis on
institutional care to an increased commitment to community support services. The
2
Introduction
recommendations will need to be operationalized into specific working plans-- with staff
allocations, budgets and timelines-- before they can be implemented.
After detailed plans are developed, a series of concrete actions will be required to achieve
the cost effective,client centered,community based services described in this report.
Implementation depends upon a solid commitment from administration, from all
segments of the mental health community and from the Contra Costa County Board of
Supervisors.
3
ILBACKGROUND
Today's limited mental health resources are directed toward serving those characterized
as having a serious and persistent mental disability,i.e.,having a "DSM-III-R diagnosis
that may lead to chronic disability and functional limitations in major life activities which
require treatment and services over an extended time -- sometimes throughout a
lifetime."'
Estimates of the number of people with Severe and Persistent Mental Illness (SPMI) in
Contra Costa County range from about 5,000 (including only those with a diagnosis of
schizophrenia) to about 14,000 (including affective disorders as well as schizophrenia).
While greater precision in both definitions and numerical estimates would be useful for
subsequent planning,(these global figures make it abundantly clear that the current system
cannot provide services even for all who meet the SPMI definition. This is consistent
with estimates from the National Institute of Mental Health (NIMH)2 that present
resources, nationwide, are capable only of meeting less than 50% of the need; and Contra
Costa County's resources prove to be directly proportionate to those described in the
national reports.
As a consequence of limited resources, the County has restricted the potential service
population to those with the most severe impairment. This in turn has produced a
disproportionate reliance on costly,restrictive institutional programs and an increasingly
heavy usage of acute hospital and crisis services. This was further aggravated by a
reduction in community based services geared to prevention, early intervention and
support.
The first clients eliminated from services were those who were thought to be able to
"make it" on their own, but some could not-- and they fell through the cracks. As
resources continued to shrink, fewer clients were served, yet the need for services
continued to grow. More people appeared in crisis;jail use (with the concomitant use of
law enforcement personnel) increased; the number of homeless grew; and,more people
died.
1 Definition in use in Contra Costa County
2 Parrish,Jacqueline,"The Long Journey Home:Accomplishing the Mission of the Community Support
Movement," Psychosocial Rehabilitation Journal,Vol. 12,(3),January, 1989,p.108
5
Background
There are only two reasonable methods of addressing the problem. The first method
requires a massive infusion of new resources to address all of the unmet needs which
have accumulated over the past several years. Given the current National, State and local
fiscal and political realities,this option is not possible.
The remaining alternative is to radically restructure/reconfigure the existing resources to
change the essential shape of the system. These changes must be accompanied by a
corresponding philosophical shift that empowers the client and encourages him/her to live
successfully as a full participant in the community.
During the past decade, there has been a growing body of experience, supported by
research, which has shown that individuals who were deemed to be candidates for
institutional care, as well as frequent users of mental health acute and crisis services,can
make successful adjustments to normal community living IF they are given adequate and
appropriate supports. The average cost of such community supports is estimated at about
$20,000 per person per year, including case management, day programs, short-term acute
care and/or residential treatment, if needed, and other supports. (This is a federal
average, based on the article by Jacqueline Parrish cited above.)The innovative AB3777
programs in California are citing a similar figure. An annual cost of$20,000 per person
is less than half the cost of an Institute for Mental Disease (IMD) bed and less than one-
fifth the cost of a State Hospital bed.
As a result of both the financial considerations and respect for the rights of individuals
with disabilities, there has been a strong national trend away from institutional care and
toward the development of Community Support Systems. This trend makes particular
sense in California today, due to the following:
1) Realignment legislation (under which the County has to pay directly for use of
State Hospital and IMD beds, while the bed rates, set by the state,keep rising);
2) The innovative AB3777 projects which are producing compelling findings in
support of community-based care, and
3) The new configuration under the Rehabilitation Option, which provides
reimbursement for a broader range of services in the community and more flexible
service delivery approaches.
6
Background
In the past several years,California counties have,begun moving people out of the State
Hospitals and IMDs with a resultant increase in the cost of remaining beds in both types
of facilities. The high cost of institutional beds, Realignment and the Medi-Cal
Rehabilitation Option,provide counties with opportunities and motivation to move in the
direction of a more community based system of services.
The direction proposed in this report-- MEASURED MOVEMENT AWAY FROM
INSTITUTIONAL CARE AND TOWARD A COMMUNITY SUPPORT SERVICES
SYSTEM -- is fully consistent with National, State and County philosophy and trends. It
holds the promise of providing better services to more of the population in need of
services at LESS cost to the county. It promises, "care that is more humane, more
therapeutic, and less stigmatizing than institutionalization.113
It must be stressed. however. that this approach can only succeed if there are sufficient
resources provided within the community. As we shall see,some urgently needed
supports are not now available in Contra Costa County. It is the lack of adequate
supportive services which results in, "...continual readmissions to hospitals, overuse of
emergency rooms,repeated encounters with the correctional system and undue burden on
families...114
3 Stroul,Beth A.,"Community Support Systems for Persons With Long-Term Mental Illness:A
Conceptual Framework," Psychosocial Rehabilitation Journal,Vol. 12,(3),Jan., 1989,pp.9-26.
4 Ibid.
7
III. PRINCIPLES GUIDING THE PLANNING PROCESS
The specific principles outlined below grow out of a fundamental first principle that
mental health services must share equal status, priority and financial support with medical
and other health services.
We agree with Tipper Gore,Chair of the Mental Health Work Group of the White House
Task Force on National Health Care Reform, that those responsible must"Make Mental
Health Disabilities on par with physical disabilities and...help people who for too long
have been ignored."5
We believe that people with mental disabilities are first-class citizens, who must be
accorded the same opportunities as all other people to realize their potential to grow,
thrive and lead full and productive lives.
The principles that follow point the way to a humane and just Health Services response to
the suffering and needs of those with mental disabilities in Contra Costa County:
1. Focus on Client Strengths rather than pathologies;
2. Focus on rehabilitation,not critical incident;
3. Shift the focus of treatment from institutional care to community based care,
in order to
A. Maximize opportunities for normal living experiences;
B. Provide intervention as early and as effectively as possible;
C. Minimize institutionalization, because:
1) Institutional care is both the most costly and the least desirable;
2) Anyone who is kept in a locked facility for a long period develops
a "mind-set" which makes it difficult to transition back into the
community, and
5American Psychological Association Monitor,May, 1993.
9
J
Principles
3) Skills learned in institutional settings are not readily transferable to
a community living situation.
D. Strengthen the ties to support networks,especially families and friends;
E. Save money,which can then be used to serve more of the population in
need of service,and
F. Increase the proportion of resources committed to community based
services.
4. Make the system as "user-friendly" as possible, through the following:
A. Ensure cultural and ethnic sensitivity and representation throughout the
system and
B. Provide maximum accessibility in terms of hours, locations and flexibility
(in relation to appointments and other system demands).
5. Develop a client-centered system, that is responsive to the needs of clients
rather than the needs of the system.
A. On an individual basis:
1) Understand and respect clients'goals;
2) Plan with clients in accordance with those goals, and
3) Fully involve clients as equal partners in all aspects of treatment.
B. On a system basis:
1) Include consumers as members of key committees throughout the
system;
2) Employ consumers as staff at all levels of the system, and
3) Modify services to better meet the expressed needs of clients.
10
Principles
6. Provide services which will assist clients to live,learn,and work where they
choose, through the following:
A. Encourage the development of needed resources, including supported
independent housing and jobs;
E. Assist clients in securing all the financial benefits to which they are
entitled, and
C. Develop effective working linkages with other services within the County,
including those dealing with housing,jobs, health,education and social
services, etc.
7. Make the system as cost effective as possible,consistent with the maximum
retention of front-line community services and with the principles identified
above,through the following:
A. Identify savings which can accrue from restructuring existing services;
E. Collaborate with other counties within our region to develop alternative
resources on a regional basis;
C. Shorten the duration of costly hospitalizations;
D. Identify savings in areas which do not impact direct services, and
E. Assess,the effectiveness of programs in relation to outcomes.
11
h
Vo STATE HOSPITALS
A. SUMMARY '
The deinstitutionalization movement which resulted in reduction of California's mental
health hospital population from about 37,000 in 1955 to about 2,500 today,was a product
of multiple factors:
1) a belief that patients had rights,including the right to live as normal a life as
possible;
2) the introduction of medications which promised to aid persons with mental
disabilities to function successfully within the community, and
3) an aversionto the dismal conditions which existed in State Hospitals.
The hopes for success,were predicated on the assumption that dollars saved would follow
the patients back to the communities to provide needed supports. The dollars for
community services rarely materialized, the drugs frequently were shunned (often because
of their negative side effects) and many discharged hospital patients ended up on the
streets, in jail, or in total equivalents of State Hospitals. This situation has been
exacerbated by federal and state government restrictions on eligibility for SSI and other
financial assistance and by reduced subsidies for housing.
We are now witnessing a resurgence of interest in moving patients from State institutions
to the community, and the reasons are compelling:
1) while care in State Hospitals has improved, they are still institutions--people
who reside in them do not have an opportunity to engage in everyday community
life;
2) state hospital residents tend to become habituated to the institution and are less
able to function outside of it;
3)behaviors, including skills, such as cooking, shopping and work,etc.,which
may be learned in an institution are not readily transferable,AND
4) institutional care is extremely costly.
13
State Hospitals
Nonetheless, there are several important factors to be considered as we emphasize
the importance of moving away from State Hospital care:
•First, it is essential that the dollars be returned to the community for
development of local community mental health services if we are to avoid
repeating the historical failures;
• Second, client preference, as well as their needs,must be given full
consideration in planning to move people out of the State Hospital, and
•Third, we must have alternative placements which provide supports and services
to meet the rehabilitation and medical needs of the more disabled, self-
destructive, and/or violent persons who remain in State Hospitals. It is the
adequacy, or inadequacy, of such alternatives that is a major concern to family
members, especially those who are concerned that one day they will no longer be
able to care or advocate for loved ones.
Program: State Hospitals currently offer a variety of program levels, including: acute
psychiatric wards,continuing medical care and sub-acute facilities for children,
adolescents and adults. Recently,Napa State Hospital added a program (Wellsprings)
which is described as being "transitional" between institutional care and the community.
In addition, the State Hospitals are planning to broaden the array of services as they
grapple with declining enrollment, including additional transitional programs, partial
hospitalization, board and care residences and other programs. It is anticipated that the
mental health directors in the region will be involved in the planning.
Utilization: Contra Costa currently has 67 adults and four(4) children in Napa and five
(5) adults in other State Hospitals. The total budget for adults in State Hospitals for FY
92/93 is$7,226,900, an average of$100,374 per patient per year.
Costs: The following table shows the daily and annual costs, by type of bed, for each of
the services enumerated above for FY 89/90 and FY 91/92:
14
State Hospitals
COSTS OF STATE HOSPITAL BEDS*
TYPE OF BED COSTS/FY 89/90 COSTS/FY91/92
PER DAY PER YEAR PER DAY PER YEAR
Acute 237 86,505 289 105,485
Psychiatric
Continuing 258 94,170 292 106,580
Medical
ICF Sub-Acute 230 83,950 254 92,710
Adolescents 359 131,035 402 146,730
Children 350 127,750 391 142,715
Wellspring**
` tea
ICF Sub-Acute 223 81,395 234 85,410
ICF Sub-Acute 2061 75,190 248 90,520
* The dollar figures include ancillary costs.
** The Wellspring program was added in 92/93 with a daily rate of$190, including
ancillary costs.
Counties have to pay the full cost of State Hospital beds from Realignment and local
funds, but they have no say about the amounts charged for beds. As shown above, the
costs are very high, and they rose an average of 17% between FY 89/90 and FY 91/92.
For the next year, increases in the amount of 10+% have been proposed, although the
final rate is not yet known. The only control that counties have had has been in
designating the number of beds they intend to purchase. Estimating this number has been
difficult since counties are obligated to commit to a given number of beds in advance
and to pay for all the requested beds, whether they use them or not. Faced with this
extremely difficult fiscal situation and with the goal of bringing clients back to their
communities, counties have been removing patients from State Hospitals at a rapid rate.
15
State Hospitals
The following table shows the reductions in State Hospital bed allocation-requests for a
number of Northern California Counties:
STATE HOSPITAL.
BED ALLOCATION-REQUESTS
COUNTY FY 91/92 FY 92/93 % REDUCTION
Alameda 165 89 46%
Contra Costa* 85 75 12%
Marin 30 17 . 43%
Sacramento* 48 48 ---
San Francisco 214 172 20%
Solano 481 341 30%
*Contra Costa is planning to remove 13 patients and Sacramento is planning to remove 20 within the next
year;information is not available on reductions being planned by the other counties.
As a result of these actual and threatened reductions, wards have been closed and the
State administration is seeking ways to retain their State Hospital population, including
diversifying programs and trying to limit the amount of rate increases.
B. RECOMMENDATIONS:
1. Continue to decrease reliance on State Hospital beds, because of the high
cost and the adverse effects of institutionalization, as follows:
a. Develop community programs which will help to support clients
and avoid the need for institutional care (see Section IX,
Community Services). This can only occur if savings, which are
realized through decreased use of institutional beds, are transferred
to development of community-based services.
b. Conduct in-depth interviews with State Hospital residents to
determine their housing preferences and what supports they would
require in their preferred placements. Consumer advocates and
conservator staff should work closely with State Hospital residents
to make them aware of alternative placements and to begin to
prepare them for moving to local community based programs, and
16
State Hospitals
C. Identify and develop a full range of,alternative placements,
consistent with the needs and desires of State Hospital patients who
are ready to return to the community. Such alternative living
situations might include the following:
• Independent living, with adequate supports;
•Augmented Board and Care, with community supports;
• A Psychiatric Health Facility(PHF), by arrangement with other
'counties or by development of a PHF within Contra Costa County,
and
•A substantially upgraded IMD, preferably in County, with time-
limited placements.
2. Recognize that some patients cannot be served in other available facilities
at the present time(in some instances due to medical needs). Additionally
there may be some patients who are too emotionally institutionalized to
want to leave. Both of these situations may change as other options
become available but,it is essential to strive to retain and improve the State
Hospitals for as longas it takes to develop adequate alternatives. This can
best be accomplished through the following:
a. Support the proposal of the Mental Health Directors to "...transfer
management of the state hospital to an alternative governance
structure,while assuring that the land and buildings remain a
resource for the benefit of the seriously mentally ill in
perpetuity...(and assure) that program development and utilization
plans for state hospital resources are based on community mental
°health plans developed by counties under Realignment..."6 and
6Proposal of the California Mental Health Director's Association,January, 1993.
17
State Hospitals
b. Encourage the planned development of a broader spectrum of
service programs on the State Hospital grounds to facilitate the
transition of clients to the community.
18
VI. INSTITUTES FOR MENTAL DISEASE (IMDs)
A. SUMMARY
During deinstitutionalization, patients were discharged from State Hospitals and
frequently moved to Skilled Nursing Facilities (SNFs), another type of institution which
had medical supports and the capacity to be locked. In some cases,counties contracted
with the SNFs for augmented services (known as Special Treatment Programs or
STPs). Since SNF services were reimbursed by Medicaid, they were less expensive
alternatives and diminished the counties' motivation to develop residential treatment,
appropriate housing and supports in the community.
In the mid 70's, however, the federal Health Care Financing Agency(HCFA)conducted
audits on some of these programs and determined that they were not eligible for Medi-
Cal reimbursement for persons under the age of 65. Ultimately, federal legislation (P.L.
100-360) stipulated that SNFs would not be eligible for federal reimbursement if:
•More than 50% of all patients had "mental diseases which require
treatment" and
•The average patient age was significantly lower than that of a typical
nursing home:,
Based on this legislation, SNF's with these characteristics were designated as Institutes
for Mental Disease (IMDs). They had to be specially licensed and accredited as
psychiatric non-acute facilities;they had to have locked wards; and they were not eligible
to receive Medi-Cal reimbursement.
In 1987, the State allocated funds to replace the lost Medi-Cal revenue and began to
reimburse the IMDs directly. Counties'fiscal motivation to use IMDs continued, despite
the results of studies proving that many people warehoused in these institutions have the
ability, with adequate support, to live in the community.' With Realignment, however,
counties gained control of funds previously allocated to IMDs. Control provided
counties an opportunity to determine how those funds would be expended.
7 Department of Mental Health, State of California,"Summary of Treatment and Placement
Determinations",OBRA Section,May, 1990 and Okin,Robert,M.D.,San Francisco General Hospital, "L-
Facility and Residential Client Surveys and Pilot Project Proposal for Comprehensive Community Based
Services for Institutionalized Clients,May 18, 1992.
19
Institutes for Mental Disease
Quality of Service: IMDs are secure (often locked) institutional facilities that provide
food, shelter and minimal programming in an environment that is artificial and culturally
impoverished. Instead of preparing residents for a more normal life in the community,
IMDs contribute to their institutional mind-set.
A recently completed study highlights the readiness of IMD residents to return to the
community and identifies the supports the residents feel they will need.
In the study, 12 randomly-selected residents of IMDs were interviewed by Mental Health
Consumer Concerns,Inc. (MHCC) in February, 1993. Of these, 11 felt they were ready
to be discharged,but only five said they had been contacted about being discharged.
Needed community supports identified by over half the respondents included help in:
• Obtaining benefits
•Developing a support system
•Using public transportation
•Meeting medical needs
•Finding housing
• Recognizing symptoms
• Developing cooking skills
Locations: The problems associated with IMD placements are exacerbated for residents
of Contra Costa County because facilities are so far from Contra Costa. Residents are
placed in Stanislaus, Santa Clara, San Joaquin, Alameda, Santa Cruz and Solano
Counties. As a result,residents in IMDs are largely isolated from support networks,
including families,conservators,patients rights advocates,case managers and self-help
groups. In addition,the large number of wide-spread locations necessitates a great deal
of travel time and expense to the County and families.
Costs: IMDs are operated by private for-profit corporations and, since Realignment,
augmented rates have been separately negotiated with each County. It is projected that
the County will spend $3,265,479 for 73 IMD beds in FY 92/93. This amounts to
$44,732 per IMD bed per year, including an average base rate of$98.42 per bed per day
PLUS an augmentation ranging from$20 to $80 per bed per day. It also includes the
residents'own SSI contribution of approximately$20 per bed per day. When the
residents' SSI contribution is deducted, the remaining net county cost is$37,880 per IMD
bed per year. This is substantially less than the cost of placement in a State Hospital.
20
Institutes for Mental Disease
On the other hand, the same client could live in the community and pay his/her basic
living expenses with his/her SSI check. The funds paid by the County to the IMDs would
be available to provide support services in the community. Since Medi-Cal and
Department of Rehabilitation funds are available as an offset for many community
services, the net cost to the County would be less than the cost of an IMD bed and the
client's situation would be greatly improved.
B. RECOMMENDATIONS:
1. Endeavor to limit the use of IMDs, to the extent possible, as follows:
a. Identify and develop community based alternatives including
supported independent living;
b. Reduce the length of stay in IMDs by taking proactive measures,
including: a) starting discharge planning on the day of admission;
b)explaining to clients on admission what is necessary in order for
ahem to get out of the institution; and,c) preparing residents for
living in the community by increasing frequency of contacts
:between IMD residents and their conservators,case managers,
consumer advocates and families, and
C. Explore the development of resources to meet special client needs
in collaboration with other counties.
2. Endeavor to improve the quality of IMDs, until sufficient community
alternatives are available:
a. Use the contracting process to strengthen specific treatments,
enhance service quality and stipulate clear, measurable outcome
objectives, and
b. Continue to collaborate with other counties to standardize
augmentation costs and upgrade program quality in IMDs
(negotiations of this type were in progress as this report was being
written).
21
Institutes for Mental Disease
3. Assign a person or team to regularly monitor medication usage/medical
necessity and treatment progress to:
a. Assess the quality of care being provided and
b. Ensure that the plan for reducing stays is adhered to.
4. Use the fewest IMDs consistent with meeting.client needs, in order to
facilitate visits by conservators,case managers, client advocates and other
staff. This should make it possible to increase the frequency of contacts
while reducing travel time and costs. At the same time,the ability of
certain facilities to meet particular client needs must be given special
consideration in order to maximize the options available for clients.
22
VII. LOCAL, INPATIENT SERVICES:
MERRITHEW HOSPITAL
A. SUMMARY
In its description of a',comprehensive community support system, the National Institute of
Mental Health (NIMH) has stated that, "Inpatient beds in a protective environment should
be provided for crises which cannot be handled in a natural setting or in crisis residential
settings. Hospitalization is needed for the most severe crises in which clients need
intensive support, structure and supervision during the period of stabilization... These
inpatient beds serve as a back-up to other community support services"g.
Contra Costa County provides adult inpatient mental health services in two locked units
in the County's Merrithew Hospital, I Ward with 18 beds and J Ward with 17 beds, 9 for
a total of 35 licensed inpatient beds. The primary function of the units, as described in
the Mental Health Advisory Board (MHAB) briefing book, dated 5/92, is the provision of
"psychiatric evaluation and treatment services to seriously and persistently mentally ill.
(SPMI)clients, most meeting the criteria for involuntary hospitalization under Section
5150 of the Welfare and Institutions Code."
Utilization: The following chart portrays the census of H,I and J Wards over a 16 year
period. (Since H Ward's 8 beds are included, the licensed capacity of the three wards
combined is 43 beds). As shown, the three psychiatric wards:
have had an average daily census of 40 or more in 13 of the 16 years;
have operated at or above the licensed capacity of 43 in five of the last six years,
and
account for approximately 30% of the hospital's total inpatient census.
8Stroul,Beth A.Community Sup=Systems for Persons With Long-Term Mental Illness.Questions and
Answers,NIMH, 1988
971here is,in addition,an 8-bed gero-psychiatric ward(H Ward). Because of the focus-on adults,not
geriatrics,in the present planning effort,H Ward is not being covered in depth. It is worth noting however,
that a bed on H Ward costs substantially less than beds on I&J Wards(about$37,700 less per bed per
year),and many of the people that we talked with indicated that more H Ward beds would be desirable.
23
Local Inpatient
MERRITHEW MEMORIAL HOSPITAL
AVERAGE DAILY INPATIENT CENSUS
160
140 34
Cn
W 120
U1„
02 taa
>- 100
90 MEDICAL 89 94 9S 91 91 96
64
80 80 79
W
0
60 5
W47 PSYCH 46_ 49
`• 41 43 42 39 40'�� �42-�43 --43
40
20
77178 79/80 81/82 83184 85/86 87/88 89/90 91[92
78/79 80/81 82/83 84/85 86/87 88/89 90/91 7 MO 92/93
FISCAL YEAR
PSYCH INCLUDES H,i&J WARDS INCLUDES NURSERY
(PATS)
A description of the population being served on I and J Wards is contained in the report
of the Safety Task Force, published in January, 1993, as follows:
"The psychiatric patient population.of Merrithew is not a homogeneous group. Three
levels of patients are identified within the current patient mix:
-Acute: Patients who are severely and persistently mentally ill with varying
degrees of ability to succeed in an outpatient setting. This population requires
disposition, assessments and concrete goals.
-Sub-acute: These are patients who require...rehabilitative level of care.
-Long-term care: These are patients who are severely compromised...(e.g., Huntington's
patients). Primary treatment objectives are to assist them maintain activities of daily
living (e.g., hygiene, nutritional status, provide some recreation, etc.)...
24
Local Inpatient
"Further adding to the complex nature of the patient population is the fact that the
majority of patients have dual diagnoses", e.g., major mental disorder and substance
use/abuse.
The distribution within these sub-groups is approximately as follows: 1/4 acute; 1/2 sub-
acute; and 1/4 long-term.
Average Length of Stay: The trend with regard to the escalating length of stay in the
psychiatric wards is graphically shown below:
'i�MERRITHEW MEMORIAL HOSPITAL
AVERAGE LENGTH OF STAY
DAYS FISCAL YEAR COMPARISONS
30
25.27
25
20.79 ----
20 ESYCH
15 1s.a
12.4
to
:2
MEDICAL
4.82 5.05 5.03 4.78 5,22
5 ----- �-4==�•=-----------------------.459 --
0
FY 86187 FY 87/88 FY 88/89 FY 89190 FY 90/91 FY 91/92 7 MO 92/93
As shown above, the average length of stay has increased from 9.26 days per patient in
FY 86-87 to 25.27 in the first six months of the current fiscal year. These figures are for
H,I and 3 combined; 'the figures for each ward separately are shown on the next chart.
25
Local Inpatient
LENGTH OF STAY ON H,I AND J WARDS
WARD 88/89 89/90 90/91 91/92 92/93
AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE
H GERO-
PSYCH 15.95 19.56 20.80 21.82 24.44
I PSYCH 10.57 13.73 15.76 16.64 21.64
J PSYCH 24.07 29.77 30.45 30.25 30.96
As shown above, the average length of stay on I and J Wards has increased very
substantially over the last five years. This increase is attributable largely to the
approximately 20% of the population who remain on the wards for a very long time, an
average of 73 days. The remaining 80% are discharged after an average stay of 10 days.
Appropriateness of Persons Served: Retention of long-term patients on the acute ward
means that beds are "frozen", i.e.,filled with patients who are not being discharged.
Hospital staff estimated that approximately 1/3 of the beds are frozen at any given time. ,
There are a number of contributing factors, as follows:
• On I Ward, some patients are frail and have substantial organic disabilities
in addition to mental illness. (One such patient, with Huntington's Disease
has been on the Ward for more than a year !) Persons with such physical
problems cannot be served adequately in IMDs and they cannot be placed
in Skilled Nursing Facilities since they are not licensed to serve patients
with a primary diagnosis of a mental disability. Until recently,there
were no programs specifically designed to accommodate persons with
organic brain disorders;
• On J Ward, the "frozen" beds are filled with patients suffering from a
multiplicity of disorders and combinations of disorders, including
developmental disabilities as well as mental illnesses. Some patients have
histories of assaults, so that finding placements that will accept them has
been very difficult;
• Patients with acute problems who might stabilize fairly rapidly often stay
longer than necessary because they have lost their living arrangement and
have nowhere to go, and
26
Local Inpatient
• Since the erosion of community based intervention programs; there is little
opportunity to intercede with patients before they are in very serious
distress. Once they reach a point where they must be involuntarily
hospitalized,it requires a much longer period of time to achieve stability.
As a result of the "frozen beds" there may not be space available when needed by patients
with acute problems. This has at times,caused patients to be sent as far away as St.
Helena in Napa County,for hospitalization. Removing people from the supports in their
home communities tends to prolong their hospitalizations.
Clearly,the inpatient units were not intended to serve large numbers of sub-acute and
long-term patients but,to provide "intensive support, structure and supervision during the
period of stabilization." (Safety Task Force Report) Because a diverse population poses
special problems, the Safety Task Force concluded..."1) that our current staff is not
trained to handle many of our current patients, and ...2) that there is a lack of an adequate
clinical program and strategy(report emphasis)that addresses the particular needs of our
patient population." Further, acute inpatient care is extremely costly when used to
provide extended care. The problem, which has grown worse over the years,is the lack
of sufficient alternative community resources which would more appropriately meet the
needs of those patients who could/should be referred out.
Cost of Services: The total projected cost for I &J Wards for FY 92-93 is$8,225,145.
Based on an average utilization of almost 36 beds per day,10 the gross per diem cost is
$626, or$228,476/year. This is twice the cost of a State Hospital bed and six (6) times
the cost of an IMD bed. These figures are total costs, which are partially offset by
revenues from Medicare, Medi-Cal,private insurance and other revenues.
The net cost to the County is$3,069,763 (including about$1.7 million in Realignment
funds for the Medi-Cal match and$1.37 million in additional Realignment and County
funds). This amounts to an average of$85,271 in County dollars, per bed per year.
This average figure is inflated by the 20% of patients who remain on the wards for an
average of 73 days, including many "administrative days" at a substantially reduced
10 Average actual utilization from 7/1/92 through 1/31/93 was 35.73 per day for I and J Wards--from the
Contra Costa County Health Services Department Program Budget with Workload Statistics,March 15,
1993
27
Local Inpatient
reimbursement rate. If these long-term patients were placed elsewhere, the net cost to the
County for I and J beds would be reduced.
Psychiatric services for persons who are highly agitated and a danger to themselves or
others,especially if they are hospital-based,can be expected to be costly. The question is
whether such services can be limited to only those persons who really must have these
services and only during the short period when no other services will suffice.
B. RECOMMENDATIONS:
1. Identify.strategies which would reduce the use of costly inpatient services
when they are not fully appropriate to meet the needs of the clients.
Possible strategies follow:
a. Work with other counties to develop facilities which are appropriate
for specialized populations. The recent collaboration with other
counties in connection with a facility for persons with organic brain
syndrome is an excellent example. Perhaps similar facilities could
be developed for persons with substance abuse and mental illness or
for persons with developmental or physical disabilities and mental
illness;
b. Explore the possibility of developing another type of program as
an alternative to I Ward; for example, a free standing Psychiatric
Health Facility (PHF), a sub-acute program at the former Oak
Grove facility or a combination partial hospital and a protected
living situation. The intent is to staff the program with existing
staff while minimizing the hospital-related overhead and
maximizing flexibility with regard to staff:client ratio and other
programmatic features. This may be a viable option if the new
Federal Health Plan includes support for long-term (or short-term,
non-acute) 24-hour care, or if Medi-Cal becomes available.
28
Local Inpatient
2. Endeavor to shorten the time required to stabilize and discharge patients in
need of acute services:
a. Begin discharge planning upon admission, and include the client's
case manager in the process and
b. Conceptualize and structure the hospital stay as a brief interlude in
the client's life, not as a focal point for providing treatment. To be
successful, such an approach must be coupled with an emphasis on
preserving the client's living/housing situation and ties to the
community. A case manager can be very important in preserving
:existing housing and other supports or in arranging for housing for
a client who is homeless or who cannot return to his/her prior
situation.
3. Increase efforts to divert patients from inpatient stays at Merrithew, as
follows:
a. Enhance the system's ability to provide needed supports before the
clients' problems escalate to the acute stage and to break revolving
door patterns. Needed supports may include outpatient therapy,
intensive case management, mobile crisis services, supported
housing,respite housing and other community based programs;
b. Divert people who require a structured setting,but do not need 24-
hour medical supervision, to existing crisis residential services.
Consider contracting for the additional beds for which the existing
provider is licensed. (See Section VIII. Crisis Services), and
29
t
Local Inpatient
C. Since the full cost of fee-for-service patients is covered by the
State and federal government,I I place third-party payor and Medi-
cal patients in need of inpatient care in private hospitals, to the
extent possible. In order to implement this recommendation, it is
vital to help qualify potential patients for all coverages to which
they are entitled since other hospitals generally require such
coverage. It should also be emphasized that this does not obviate
the need for Merrithew as a placement for patients for whom
alternatives are not yet available,or who, for therapeutic reasons,
would be more appropriately hospitalized at Merrithew.
4. . Implement the recommendations of the Safety Task Force for training in
safety procedures and program enhancement. Enhancing the clinical
program will enable staff to provide quality treatment during the "window
of opportunity" provided by the period of hospitalization.
11 There will undoubtedly be changes in this regard when managed care becomes a reality in Contra Costa
County.
30
VIII. CRISIS SERVICES
According to the State of California Mental Health Master Plan, "The primary focus of
crisis services is stabilization,crisis resolution, assessment of precipitating and attending
factors, and recommendations for meeting identified needs". NIMH species that, "The
primary goal of crisis services is to assist individuals in crises to maintain or resume
community functioning."12. Both of these sources specify that a comprehensive crisis
response system should include:
1. Emergency Services for Evaluation and Treatment
2. Crisis Intervention,Walk-in Services
3. Crisis Interrvention,Call-in Services
4. Mobile Crisis and Outreach Services, and
5. A Crisis/Acute Residential Treatment Program.13
The following sections will review the extent to which each of these services exists
within Contra Costa County.
EMERGENCY SERVICES
A. SUMMARY:
24-hour per day, 7-day a week crisis evaluation and treatment services are provided by
Mental Health Crisis Services (commonly referred to as E Ward) at Merrithew Memorial
Hospital.
Program: Mental Health Crisis Services is "a 5150-designated site14 (which)provides:
o "Evaluation, treatment and disposition recommendations to 5150'd patients...
o "Short-term treatment on an outpatient basis....for acute situational crisis.
121'sychosocial Rehabilitation Journal,Vol. 12,No.3,January, 1989.
One State Plan also includes"Acute,medical,intensive care"as part of crisis services. This form of care
is separately discussed in this report(see Section VII. Local Inpatient Services).
14A 5150-designated site refers to the section of the Welfare and Institution Code that authorizes
involuntary holds for persons who are a danger to self or others or gravely disabled.
31
Crisis Services
• "Mental health evaluation for treatment in outlying mental health clinics...
• "Mental health evaluation of detained persons between 11 p.m. and 8 a.m., prior
to entry into Martinez Detention Facility."15
There were an average of 620 client visits per month during the first six months of this
fiscal year. Of these:
30% were hospitalized (one-third in Merrithew and two-thirds in private hospitals
throughout the area). If comprehensive insurance information were available
prior to hospital admission, a still higher proportion of clients would be referred to
private hospitals-- at no cost to the County.
70% were returned to the community and most will require extensive community
supports in order to avert future crises.
It is noteworthy that more than 70% of the people brought.to E Ward on a 5150 were
persons who use drugs and/or alcohol. The need for additional specialized services for
this dually diagnosed population is evident.
Staffing and Costs: Mental Health Crisis Services provides 24-hour per day, 7-day per
week coverage with a staff of 29.15 FTEs. Staff includes 10.75 clinical specialists, 8.4
nurses, 3 M.D.s, 1 psychologist, 1 supervisor, 3 clerks and 2 temporary staff. Staff
salaries and benefits account for about 50% of the total operating budget. The projected
budget for FY 92/93 is$3,320,701, including about$1.3 million in Medi-Cal, Medicare
and other revenues, $.3 million for the Realignment Medi-Cal match, and about$1.7
million in additional Realignment and County dollars. The FY 92/93 budget is
substantially higher than the FY 91/92 budget of$2,219,269. The increased budget
reflects substantial increases in revenue, utilization and responsibilities (as described on
the next two pages), but there have been no corresponding increases in staff or space in
the past three years.
1517rom Mental Health Crisis Service Scope of Service.
32
Crisis Services
Utilization: The pattern of utilization over a four-year period is shown below:
MENTAL HEALTH CRISIS SERVICES UTILIZATION
FISCAL AVE. VISITS/ AVE. VISITS/ AVE. VISITS/
YEAR DAY MONTH YEAR
89/90 15 456 5,472
90/91 15 441 5,292
91/92 17 520 6,240
92/93 20 620 7,442
This marked increase in the demand for crisis services is particularly
disheartening in light of the County's goal to "measurably reduce use of...crisis
services".16 The increase is attributed to the following:
•A corresponding decrease in the community services which help
prevent crises (such as supported community living,residential
treatment and adult outpatient services) and
-Substantial reductions in mental health services in the jail,
particularly the elimination of the night-time staff which performed the
evaluation function.
The FY 92/93 data displayed in the chart above has been annualized from the first
half of FY 92/93 (7/1/92-12/30/92). During that period the distribution of visits,
by type of activity, was as follows:
16From Overview and Philosophy of CCC-MHD,March, 1992.
33
Crisis Services
DISTRIBUTION OF CRISIS SERVICE VISITS,BY TYPE OF SERVICE
SERVICE #VISITS FIRST #VISITS
SIX MONTHS ANNUALIZED
7/1/92-12/30/93 PROJECTION
Assessment 49 98
Individual 89 178
Group 131 262
Medication 82 164
Crisis 3,370 6,740
Total 3,721 7,442
These figures do not adequately reflect a substantial program change which occurred
in November, 1992. At that time,Mental Health Crisis Services began providing
centralized intake services for the mental health system throughout Contra Costa
County. This change was necessitated by budget cuts which drastically reduced the
clinic's psychotherapeutic services for adults. As a result of this change, anyone who
needs a mental health evaluation or is seeking entry into the system must now come
to the Mental Health Crisis Services at Merrithew Hospital in Martinez.
Utilization of this service is increasing substantially in terms of both crisis visits
and assessments, producing a corresponding increase in the demands placed upon
staff and space. During hospital construction, this will be compounded by
difficulties in gaining physical access to the building.
20 RECOMMENDATIONS:
a. Strengthen and develop additional community programs which
help avert crises with particular attention to community services
for clients with a dual-diagnosis and/or other special needs (see
Section X. Community Services).
b. Collaborate with the Department of Social Services to maximize
eligibility determination and access to information relevant to
insurance coverage. Assure that a benefits specialist is assigned to
assist all patients in obtaining the full benefits to which they are
entitled,especially prior to admission.
34
Crisis Services
c. Improve the jail's medical and mental health assessment
capability,17 especially during night hours, by adding a psychiatric
nursing component to relieve some of the burden on Mental Health
Crisis Services and provide substantial savings for the Police and
Sheriffs Departments. Currently,officers transport detainees to
Mental Health Crisis Services, wait while assessments are made,
and then transport them to the jail.
d. Take steps to alleviate the space problem at Mental Health Crisis
Services,especially during construction, through the following:
1) Explore options for additional space such as the addition
of a portable unit, rental of appropriate facilities near the
hospital, or relocation of Mental Health Crisis Services to
another part of the hospital and
2) Consider the possibility of locating some Mental Health
Crisis Services personnel in the jail or the East County
Clinic to relieve the space problem during hospital
construction. This solution requires careful examination of
fiscal and personnel considerations,e.g., no Medi-Cal
reimbursement is available currently for mental health
services provided in the jail but this may be more than
offset by the savings in deputy and police officer time.
Examination of jail diversion and other models would be
useful. Medi-Cal reimbursement is available for East
County Clinic crisis services and the idea merits serious
consideration, since relocation could test the feasibility and
desirability of this programmatic change. Staff could be
given the opportunity of volunteering for relocation.
17The Planning Committee did not study the larger issues in relation to mental health programming in the
jail. However,we believe that this is a very important area for consideration during the next planning
process since SPMI clients very often end up incarcerated when other services are insufficient to meet their
needs.
35
Calsis Services
CRISIS INTERVENTION.WALK-IN SERVICES
A. SUMMARY
The California Master Plan states that crisis intervention services, offered during regular
weekday business hours, are to be available to "anyone in the general community with a
psychiatric concern or emergency,including anyone needing information about
services...(or) advice about dealing with someone in a psychiatric emergency."
West County: The West County Crisis Service is located on the same site as the West
County Clinic and Partial Hospitalization so that continuity between crisis services and
on-going treatment is possible. There are three FTE staff members assigned to the crisis
portion of the program. During the first six months of FY 92/93, there were 483 crisis
visits at the West County program, for an annualized total of 966.
East County: There is no structured crisis walk-in service in East County. This gap is
particularly significant in light of the fact that 30% of all of the clients seen by Mental
Health Crisis Services come from East County.
Central County: The Concord Clinic has no structured crisis walk-in services. Clients
in Central County are geographically closer to Mental Health Crisis Services where walk-
in services are available.
B. RECOMMENDATIONS:
1. Retain the West County Crisis Service
2. Add a Crisis Intervention.Walk-In Service as part of the East County
Clinic program, so that:
a) East County clients will have greater access to crisis services, in
their own community, and
36
Crisis Services
b) There will be increased continuity between crisis intervention,case
management and on-going outpatient treatment.
This could be implemented on a pilot basis with existing staff.
3. If the East County program proves to be cost effective,it should be
replicated in the Concord Clinic.
4. Consider integrating all crisis services under one administration, including
Mental Health Crisis Services, the West County Crisis Service, the East
County crisis walk-in service,if such a service is developed, and
contracted crisis services.
CRISIS INTERVENTION CALL-IN SERVICES
A. SUMMARY
Call in services are to be available 24-hours per day,7-days a week to provide assistance
to anyone with a psychiatric concern or emergency and to offer information and referral
services. The lines are variously characterized as "hotlines" or "warmlines" depending
on whether the caller'is (or is not) in crisis. Both types of service are recommended.
Program: There are two programs in the County providing this service. In addition to
their primary crisis intervention and intake functions,Mental Health Crisis Services
provides 24-hour call-in service,receiving about 12,000 calls per year.
Crisis and Suicide Intervention of Contra Costa County (CSI) also provides 24-hour
crisis call-in services,under a County contract. CSI services are available,without
charge and without restrictions, to anyone who calls. Over 35,000 calls are received each
year. Many of the frequent callers are people with serious and persistent mental
disabilities. They are provided with supportive, active listening -- whenever they feel the
need of such support'-- by trained volunteers,working under professional supervision.
The two call-in services are currently discussing strategies for coordinating their services.
However, no provisions are currently in place to link CSI to case managers or other
programs serving the same clients. Linkage would greatly enhance the volunteers' ability
to reinforce the support and assistance being provided by others in the system.
37
Crisis Services
This agency also has developed, and constantly updates, an extensive computerized
system of community resource information.
B. RECOMMENDATIONS:
1. Integrate the CSI crisis intervention call-in service into the Mental Health
System,enhancing the collaboration with Mental Health Crisis Services
and developing operational linkages with case management and other
services.
2. Develop a system for sharing CSI's community resource data base with
County and contract staff. Updated computer disks can be supplied on a
regular basis,provided that the systems are (or could be made) compatible.
Initiate a process of collaboration between the County, contract agencies
and CSI to share and update relevant information. Since much of the
work of updating the resource data base is done by CSI volunteers, the
costs should be minimal.
MOBILE CRISIS SERVICE
A. SUMMARY
The State Mental Health Master Plan designates the persons to be served by a mobile
crisis service as "persons experiencing acute psychiatric symptomology who are unable
or unwilling to go to crisis services." This refers to anyone with an emotional crisis, not
just someone who has a severe and persistent mental illness. It is described as a 24-hour,
7-day service which is available "to go wherever a person is in crisis and to work
intensively to resolve the situation without utilizing other emergency settings." The crisis
team works collaboratively with law enforcement when needed, and it uses the home
environment and natural supports to achieve stabilization and prevent the deterioration
which would require involuntary hospitalization. An effective program of this type can
realize substantial cost savings for the system as well as positive outcomes for persons in
crisis.
38
Crisis Services
THERE IS NO MOBILE CRISIS SERVICE IN CONTRA COSTA COUNTY, and this
is probably one of the most significant lacks in a system with a goal to "measurably
reduce use of hospitals, IMD facilities,jail and crisis services".18
D. RECOMMENDATIONS:
1. Make it a priority of the system to develop a pilot mobile crisis service.
Generally crisis teams consist of nurses, mental health professionals, and
consumers. Twenty-four hour capability could be achieved by a
combination of telephone coverage by Crisis &Suicide Intervention and a
beeper relay to an on-call team member(similar to Crisis and Suicide
Intervention's arrangement with Child Protective Services). Planning for
this service should include representatives from all crisis services,
consumers, family members and law enforcement. In assessing the
savings potential, planners will need to examine the positive fiscal impact
for law enforcement as well as for mental health.
2. Implement a mobile crisis service by taking one or more of the following
actions:
- Redirect funds saved from reduction of institutional services;
- Seek special grant funds to fund this as a pilot project, and/or:
-Develop the program with existing staff. Preference should be given to
those staff members who choose to work in this project, since staff who
11
are committed to a highly flexible active outreach approach will function
most effectively in a program of this type.
18Contra Costa County:Mental Health Division,Overview and Philosophy,March, 1992.
39
Crisis Services
CRISIS/ACUTE RESIDENTIAL TREATMENT PROGRAM
A. SUMMARY:
Contra Costa has a short-term crisis residential treatment program,Nierika House, that
serves as a diversion from hospitalization. The county contracts for nine (9) of the
available 12 licensed beds. This is an unlocked voluntary facility located in Central
County, with services available to all county residents. Staff consists of nine counselors
who provide double coverage 24-hours a day,7-days a week. In FY 91/92, there were
197 admissions,with 160 unduplicated clients,just over 50% from central county.
Referral data shows that the service is being used appropriately as a community based
alternative to divert clients from hospitalization (see following chart):
NIERIKA HOUSE
SOURCE OF REFERRAL FY 91/92
SOURCE NUMBER %OF TOTAL
Psych Emergency 62 31%
Hospital 55 28%
Self 34 17%
Case Mgr/ 13 7%
Cons/Ther
Shelter 9 5%
Other 24 12%
Clients of the program have multiple problems: in addition to their psychiatric diagnosis,
65% have a history of substance abuse; over 50% have attempted suicide; over 50% are
survivors of abuse, and over 40% are survivors of sexual abuse.
Like other 24-hour services, the length of stay is increasing because of the acute shortage
of appropriate community resources. Almost half of the discharged clients have an
identifiable day time activity upon discharge. In terms of living situations after
discharge, 38% returned to live with their families and 33% moved into independent
living situations or supported housing. In FY91/92, the average length of stay was 13
days. In the first nine months of FY92/93, the average length of stay had increased to 16
40
Crisis Services
days. The cost per day is$195. With the Rehabilitation Option, available on July 1,
1993, the service will be Medi-Cal reimbursable.
Eo RECOMMENDATIONS:
1. Contract for additional crisis beds, as needed,when more clients are
returned to the community,
2. Designate a liaison between Nierika House and other services (including
Mental Health Crisis Services,I and J Wards, and case management), in
order to more effectively divert clients from hospitalization.
3 Provide administrative oversight to crisis residential services as part of the
integrated crisis system proposed earlier.
41
IX. COMMUNITY MENTAL HEALTH SERVICES
Reducing reliance on costly institutional care can be successful ONLY if adequate and
appropriate community supports are provided. The growing emphasis on and support for
appropriate community services in California is reflected by the recent development of the
Rehabilitation Option and the demonstration Integrated Services Agency programs(ISAs)
under AB3777.
Rehabilitation Option: The Rehabilitation Option is the mechanism whereby federal
Medicaid funds (known as Short-Doyle/Medi-Cal in California) will be used, as of July
1, 1993, to:
•Reimburse specified services wherever in the community they are provided --
e.g., in a coffee shop, a client's home or park bench-- not just in a clinic and
•Provide for reimbursement of residential treatment.
The philosophy of California's Rehabilitation Option plan,based on the AB904
California Mental Health Master Plan, sums up the current shift to community based
services and a client-centered system of services:
"Rehabilitative Mental Health Services focus on Individual needs, strengths,
choices and involvement in service planning and implementation. The goal is to
help Individuals take charge of their lives through informed decision making.
Services are based on the Individual's long term goals/desired result(s) for his/her
own life and his/her diagnosis, functional impairment(s), symptoms, disabilities,
life conditions and rehabilitation readiness. Services are focused on achieving
specific measurable objectives/personal milestones to support the Individual in
accomplishing his/her desired results. Program staffing should be multi-
disciplinary and reflect the cultural,linguistic, ethnic, age,gender, sexual
orientation and other social characteristics of the community which the program
serves. Families, caregivers,human service agency personnel and other significant
support persons should be encouraged to participate in the planning and
implementation process in meeting the Individual's needs,choices,responsibilities
43
Community Services
and desires. Programs may be designed to use both licensed and non-licensed
personnel who are experienced in providing mental health services."19
Integrated Services Agency model: State support for client centered services is also
demonstrated by the experimental Integrated Services Agency programs (ISAs) funded
by AB3777 in 1989. The ISAs were required to develop a holistic and rehabilitative
approach to community services. Services were to be "client-driven, that is, predicated
upon the goals and needs identified directly by the client"20 The funding was based on a
capitated model, whereby the provider receives a fixed dollar amount for each client
served and provides all of the services needed.
SERVICES/SERVICE DELIVERY AND COORDINATION
A. SUMMARY:
Historically,Contra Costa County has been consistent in its support of community mental
health services as appropriate treatment,so that a range of community based services has
been developed in the County.
Community based services, provided by County and contract agencies, include case
management, outpatient treatment, day treatment, supported housing,residential
treatment, socialization, patient rights and advocacy, vocational and employment
services, services for people who are homeless or at risk of being homeless and some
services that are designed to serve specific ethnic populations.
,
Nonetheless,community based services are frequently unavailable to the clients who
need them because:
1) Some needed services are virtually non-existent;
2) Some services have been so reduced in size that they cannot accommodate the
clients who need them, and
3) Some services are not readily accessible to clients in all regions of the County.
19California Rehabilitation Option Plan,Service Definitions,Philosophy,p.2-2
2OKalinowski,M.D., "Services on the Client's Terms: Experiences at Stanislaus Integrated Services
Agency',January 31, 1992.
44
Community Services
While there is increasing interest on the part of the mental health system, providers, staff
and the constituency groups to develop a "client centered" system, there is limited
understanding or consensus as to what client-centered means or how it operates. This
results in a situation where the client has to fit into the system and its services,rather than
the system focusing on developing services to meet client identified needs,choices and
goals.
While many components of a community system are present, the services are not
adequately organized into an integrated and coordinated system. Since individual clients
may use an array of services, increasing coordination among those services would
greatly enhance the effectiveness of the system in meeting the needs of the client.
B. RECOMMENDATIONS:
1. Commit to developing a service delivery system that is responsive to
client needs and wants, as follows:
a) Contract with a consumer group to survey clients(beginning with
NAPA and IMD clients), to determine their needs and wants in
terms of placement and mental health services and the assistance
they need to make the transition. Focus on medical, as well as
social and psychiatric needs. Include family members in the
interview process after consulting with a client to determine which
of his/her family members may be the most appropriate ones to
involve;
b) Involve consumers, at all levels in the system,including developing
their own treatment plans, evaluating services, working as staff and
serving as members of advisory boards or committees;
c) Develop and adopt principles and an action plan to implement the
client-centered service delivery system;
d) Train all staff(administrative and line, inpatient and community,
County and contractor) in client-centered service delivery and
psychosocial rehabilitation approaches. Emphasize the importance
of relationships in developing a client-centered system. Train
45
Community Services
supervisors and administrators in the hiring and supervision of staff
with a history of mental disability. Include consumers and families
in developing and providing the training, and
e) Set specific performance objectives for the system and its
component parts to determine the degree to which the system is
fulfilling the mandate contained in P.L. 99-660 to enable
"individuals to function outside of inpatient institutions to the
maximum extent of their capabilities."
2. Develop a pilot project that adapts the Integrated Services Agency(ISA)
concepts to Contra Costa,since the ISA has the necessary components for
a coordinated service delivery system that focuses on client needs,choices
and wants, by the following:
a) Restructure.County and contract services, and use existing staff
and resources, to develop this component;
b) Develop a mechanism whereby staff with a special commitment to
this approach can be given an opportunity to volunteer to work on
this project;
c) Include consumers as staff in this project. It would be preferable to
hire more than one consumer so that they can provide mutual
support, and
d) Provide sufficient resources to realistically address client needs,
i.e., an ISA with a large number of"hi-users" will require more
funds and staff than a group serving clients with lesser needs.
3. Implement the Coordinated Services System form of quality assurance and
review developed by the State. Include providers, clients and family
members in designing the process to implement the new system.
•This system requires a Coordinated Service Plan which acts as
the authorization for the client's use of services (except for
emergency services).
46
Community Services
• The Coordinated Service Plan and individual program service
plans will include performance objectives to help measure the
effectiveness of the services provided.
• It also implements a service (utilization)review by client,rather
than provider, so that all the services to one client are reviewed at
the same time enabling the system to understand what is happening
to individual clients. This yields an unduplicated count of clients,
together with information on the cluster and frequency of services
being utilized. It would be helpful to develop a parallel fiscal
reporting system to show costs by individual client's use of
services.
4. Develop linkages to,and Memoranda of Understanding with, other
agencies that provide services to people with mental disabilities. These
agencies include Conservatorship, Housing and Community Development,
Housing Authority, Social Services, Substance Abuse Services,
Department of Rehabilitation, Shelter, Inc. and Community College
District. Structured relationships would enhance coordination and result
in more effective service delivery.
CASE MANAGEMENT
A. SUMMARY:
To achieve a coordinated service approach,the case manager role is pivotal. This role
can be fulfilled by adindividual case manager,conservator, service coordinator or a case
management team. According to the California Mental Health Master Plan, a key
principle of client-centered service is the recognition, "that the relationship between the
case manager and the',client is PRIMARY and essential" 21 (emphasis added). The
critical importance of the case manager's role is recognized in federal statute, P.L.99-660
(see Appendix), and California Legislation AB3777. The central and vital nature of the
case manager's role is also emphasized in Contra Costa County's Philosophy statement, of
March, 1992, "The case manager facilitates the provision of...care and treatment. Case
21AB 904 Plan
47
l
Community Services
Management is a recognized therapeutic modality... Case managers will work in
Community Living Support Teams,focus on client strengths, set achievable goals with
clients..."
The County has been working toward this goal during the past year, but efforts have been
hampered by several factors:
1. The definition of the target population has not been uniformly and consistently
understood and the role of case managers has not been clearly defined and
communicated throughout the system. Nor has case management been
universally accepted as a priority;
2. Caseload size has been large. Altogether, there are ten case managers for the
whole.County. Of these, one and a half are assigned to homeless multiservice
centers. The remaining 8.5 case managers have caseloads of 30 to 40 clients each,
double the recommended ratio of 15 to 20 clients per case manager in an intensive
case management model;
3. Case managers frequently lack full authority to access or terminate services for
their clients, when it is appropriate to do so;
4. There are insufficient services to meet the needs of clients. In addition, there
has been a tendency to depend on only the mental health resources, instead of
accessing a broader range of community resources because linkages to the broader
resources are insufficiently developed;
5. When a conservatee in an IMD is ready for discharge, the practice of
conservatorship is to place them in licensed residential facilities based on a strict
interpretation of the Health and Safety Code, Section 1536.1 which states that,
"conservators place clients who are discharged from IMDs only in licensed Board
and Care facilities." This practice:
a) precludes the use of supported independent living situations
in the community;
b) restricts client choice with regard to living situation, and
48
Community Services
c) may delay discharges because of lack of licensed placement
opportunities, and
6. The relationship between conservators and case managers has not been
adequately integrated to ensure continuity of service for the clients as they move
i
through the system. For example, if a client goes off conservatorship when
he/she moves to the community, the relationship with the conservator ends and a
case manager,from mental health is assigned, disrupting continuity of care. Or,in
a worst case scenario, no case manager is assigned.
E. RECOMMENDATIONS:
1. Enhance the case management system, by taking the following actions:
a) Define case management, including case management's reliance on
the relationship between the case manager and the client to
facilitate the client meeting his/her needs, choices and goals.
Outline the services included and the criteria for the service.
Assure system-wide knowledge of expectations and capabilities of
case management services;
b) Define the "high-user" and "at-risk" target populations for system-
wide dissemination, and
c) Increase case management services in three ways:
1) Increase County staff allocated to case management services;
2) As funds are available, add consumers to the case management
teams. Consumer case managers contribute special expertise
derived from their experience, and
3) Incorporate contract services as part of the case management
service delivery system.
49
_ I�
Community Services
2. Support case managers in their work,as follows:
a) Recognize the case manager as the pivotal advocate and facilitator
in the provision of treatment and other services. Provide the
training and support necessary to enable case managers to fulfill
this vital function;
b) Provide case managers priority access to (and exit from) those
services needed by their clients. Assure that the case manager is
the client's primary treatment contact regardless of where
he/she lives or is being served,e.g. IMD, supported housing, I or J
Ward, or a homeless shelter. Provide case managers with access to
housing and food vouchers. Develop linkages and agreements
which will facilitate access to services outside the mental health
system, and
c) Limit caseloads to a size that enables staff to provide quality cost-
effective services. It may be best to have each caseload include
clients with differing levels of need (to avoid worker burnout) and
determine caseload size in relation to the frequency of visits
needed by each of the clients (e.g., three clients needing daily
visits,plus eight clients needing bi-weekly visits may be a full load
even though there are only 11 different clients involved). It is also
important to take paperwork and resource development time into
consideration.
3. Facilitate the movement of people from institutions to the community by
the following:
a) Address the need for a wider range of housing alternatives,
b) Provide linkages to a locally based self-help group prior to
discharge;
c) Provide needed supports identified by clients, including obtaining
benefits, using public transportation, addressing medical needs and
other activities related to community living;
50
i
Community Services
d) Identify ways to effectively deal with the problem of switching
from a conservator to a case manager mid-stream. (It has been
suggested that one person perform both functions. Another
suggestion is to involve case managers with institutionalized
clients prior to discharge.), and
e) Seek a clarification of Health and Safety Code Section 1536.1 to
ascertain whether placement in a more desirable, less restrictive
housing situation (such as supported independent living) is
permissible within the meaning of the Code. If not, work to
change the Code, since it contradicts the mandate to house clients
in "least restrictive" settings.
In making these recommendations, we use the term "case management" advisedly as
many clients object to being referred to as "cases" to be "managed".
TREATMENT SERVICES
A. SUMMARY:'!
Major components of our community based treatment services are:
•day treatment and socialization programs of various degrees of intensity;
•outpatient services,including therapy, assessment and medication support and
specific services directed toward ethnic and cultural populations, and
•transitional residential treatment program with an emphasis on serving Afro-
Americans and people with a dual diagnosis.
Reductions in these services over the past several years have included the loss of one day
treatment program in Central County,one residential treatment program in West County
(6 beds), supported independent living programs in Central County and substantial
reductions in adult Mental Health Treatment specialists throughout the County.
51
d
Community Services
Day Treatment/Socialization: There are four day treatment programs and one
socialization program in Contra Costa County. The day treatment programs are
structured to meet current Medi-Cal requirements, but under the Rehabilitation Option,
they will have the opportunity to restructure activities so as to increase the services
available. The advent of this new reimbursement, with its less restrictive staffing
requirements, will enable the East County socialization program, Many Hands, which
currently costs$30/day and is not now Medi-Cal eligible, to provide and bill for day
treatment services as well.
The four day treatment programs--Partial Hospital,Rubicon Day Treatment and
Rubicon Synthesis in Richmond and Phoenix Center in Concord--currently serve a
range of clients, from those needing rehabilitation to persons needing support during a
more acute period. Partial Hospitalization,currently the only program designed as an
intensive day treatment program,serves 20 clients per day at a cost of$133 per client.
Staff are piloting a project which will reduce the cost per unit and increase the number
who can be served to 30 people per day by providing a morning and an afte noon program
at the same site. The other day treatment programs, which are now designed as
rehabilitative cost$60 to$74 per day. The agencies which operate these rehabilitative
day treatment programs (Rubicon and Phoenix) are also consideringthe possibility of
operating two programs per day, per site (one intensive and one rehabilitative).
However, there is considerable support for the need to develop a new program category
in which acute and rehabilitative clients can be served in the same program at the same
site in order to promote flexibility and reduce disruption of services for clients. This
issue has been slated for review by the State and the Association of California Mental
Health Directors over the coming fiscal year.
Outpatient Services: Assessment,evaluation,therapy and medication supports are
provided at the County clinics located in each region. Familias Unidas provides,
counseling services for Spanish speaking clients in West County under a County contract.
The Asian Mental Health Clinic in Richmond and the Center for New Americans also
provide services for populations with special cultural and language assistance needs.
Over the past two years, nine (9)Mental Health Treatment Specialist positions were cut
at the clinics, substantially decreasing individual and group therapy services. As
treatment options have decreased,there has been a corresponding increase in the use of
medication and crisis services. Outpatient medication visits increased by 34% and
52
1
Community Services
outpatient crisis visits by 17% in the past 3 years. This is in addition to the 35% increase
in crisis visits to Mental Health Crisis Services. During the same period, outpatient,
individual and group therapy visits declined by 41% and 17% respectively. (See the chart
on the following page.)
Residential Treatment: Nyumba Chuki(now Nevin House), was a transitional
residential treatment program which served clients with a severe mental disability as well
as substance abuse problems. This 12 bed program had the ability to serve people who
would otherwise have been in institutions. The program successfully addressed mental
health and substance abuse issues and was particularly successful in helping Afro-
Americans learn to survive in their own communities by learning ways to cope with their
disability and substance abuse problems. Funding was reduced last year; although there
are still 12 beds, the cut negatively impacted the program's ability to provide the same
level of service and thereby further reduced the options for serving people in the
community instead of institutions.
I
53
I
Community Services ,
CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT'
OUTPATIENT MENTAL HEALTH VISITS BY TYPE
FISCAL YEAR COMPARISONS
342
499
COLLATERAL .-. a3a
352
24s
282
ASSESSMENT ... :.: 251
262
INDIVIDUAL 1,100
1,081
.................:.:...................:.................:..871.......
312
334
GROUP :. :::. 320
258
.J.Z�. •z.`-.;4 •. :e1. .:z... .1__ -:t: 1,031
1,137
MEDICATION .. 1,242
1,332
S23
CRISIS
653
:;.; ,464
t,sss
DAY TREATMENT 1,631
1.676
0 500 1,000 1,500 2,044
NO.OF VISITS
FY 89190 FY 90191 FY 91/92 6 MO FY 92193
54
•
• Community Services
R. RECOMMENDATIONS:
1. Evaluate all current clinic services and day treatment in light of the
possibilities offered by the Rehabilitation Option (which stipulates that
services which were previously reimbursable only if they were provided in
a clinic will be reimbursable no matter where they are provided -- except
for jail-- as of July 1, 1993).
2. Participate in the State discussion about day treatment and advocate for
one service category with the capacity to serve both acute and
rehabilitative clients.
3. Assess the use of increased reliance on medications as a form of treatment
to determine whether this is appropriate or the result of insufficient
resources. Enhance medication education in conjunction with all services
in the 'system.
4. Use resources from the Rehabilitation Option to enhance the transitional
residential treatment program, (now known as Nevin House).
Specifically explore using this program in conjunction with West County
Day Treatment programs to help transition IMD clients to the community
and to#festively serve dually diagnosed clients.
CLIENT ADVOCAMSELF HELP
A. SUMMARY
Statutorily mandated inpatient advocacy and patients rights services are effectively
provided by contract with a consumer-operated agency.
55
Community Services
Peer support is increasingly recognized as an important component in providing effective
support for people living in the community. "Self-help groups are the most common
form of peer support and involve groups that meet regularly on a formal or informal basis
to share ideas, information, and mutual support." Peer support is also provided in
consumer-operated services; i.e.,
"service programs that are planned, administered, delivered, and evaluated by
consumers. Consumer-operated services often are organized around a drop-in
center. The peer-run drop-in center provides an open,comfortable setting and
often serves as the nucleus for a wide variety of support, service, and socialization
activities. Services provided by consumer-operated programs include self-help
groups; training in independent living skills; advocacy and assistance in locating
needed community resources and services such as housing and financial aid;
education about patients'rights, psychiatric drugs..."22
The Client Network, and TALLAY (a former self-help organization)have advocated for
several years for the development of a self-help center. While there is a long history of
support for client operated services and the County has contracted with Mental Health
Consumer Concerns, a consumer-operated non profit for 12 years, the tangible support
required for the development of a client-operated self-help center has not been
forthcoming from the County or the community.
E. RECOMMENDATION:
Support the development of a self-help center operated by a consumer run agency,
either through allocation of staff resources to help write grant proposals for start
up funds or by allocating savings from the reduction in institutional beds.
VOCATIONAL AND EMPLOYMENT SERVICES
A. SUMMARY
Several counties have interviewed consumers in locked facilities and in the community to
determine their preferences and needs for services. Employment and vocational services
were often mentioned as desired services by those interviewed. Having a job makes .
many things possible -- housing, transportation and social interaction-- and it is one of
the most effective ways of restoring self-confidence and self-esteem in persons with
22PsychoSocial Rehabilitation Journal,Jan. 1989
56
Community Services
severe mental disabilities. (Doing to work every day helps people feel "the same as"
rather than °different from" other citizens in the community.
Contra Costa County]is fortunate to have three nationally accredited vocational programs
which provide services to persons with severe mental disabilities. These programs,
operated by non-profit contract agencies, are located in West,Central and East County.
They provide sheltered employment, vocational counseling, work service and adjustment,
job placement and supported employment or follow-up maintenance services for those
placed in community jobs.
These programs are funded by a combination of revenues from County Mental Health,
California State Department of Rehabilitation and revenues generated by agency
businesses. Two of the programs provide employment via Javitts,Wagner and O'Day set
aside contracts at federal government installations. Contra Costa County has funded
vocational services on a consistent basis in the Central and East regions. West County
funding has been negligible for several years. All three organizations, to a greater or
lesser extent,rely on agency businesses to help support their vocational services.
Although the California State Department of Rehabilitation funds job placement
programs at the three agencies, there is not enough money in these contracts to provide
the long term follow-along services needed by many persons with severe mental
disabilities. Another isource of funding for vocational services, the Contra Costa County
Private Industry Council, has not allocated funds for services to adults with severe mental
disabilities.
B. RECOMMENDATIONS:
i
1. Use Medi-Cal Rehabilitation Option funds to provide long term follow-
along services to persons with mental disabilities employed in community
jobs.
2. Develop county-wide support to encourage the Contra Costa County
Private Industry Council to provide funding for vocational employment
services to persons with mental disabilities.
3. Increase funding for vocational services in West County and maintain
funding levels in the other regions.
57
Community Services ,
4. Encourage the California State Department of Rehabilitation to maximize
opportunities for funding co-op placement programs in all regions of the
County.
5. Purchase goods and services from agencies and businesses that employ
people with disabilities. This should be done by Contra Costa County and
other public agencies.
6. Provide employment opportunities for persons with mental disabilities at
all levels in the County's work force.
7. Designate a County staff person to coordinate County vocational and
employment services and advocate for those services within the Mental
Health Division. Perhaps an on-site supervisor whose staff has been
reduced might be available for such an assignment.
HOUSING AND HOMELESS PROGRAMS
A. SUMMARY
Lack of stable living situations exacerbate clients'problems. When people experience a
crisis and are forced to use institutional facilities, their ability to maintain their own
housing is jeopardized. This contributes to the severity of the problem and to the length
of time it takes to help them get back on their feet. Community based housing resources
with supports have taken a tremendous loss in the past few years including:
• the elimination of community support and assisted independent living programs
in Central County;
• the inability to replace federal funds used by community agencies to fund
housing supports, and
• the reduction in the number of board and care homes.
58
Community Services
Low-income housing is very limited throughout the county. Supported independent
housing (where a person can live independently and receive assistance with household
management and coping with landlords and roommates) is virtually nonexistent but very
much preferred. (See AMI Housing Report in the Appendix.)
As a result of State and national policy and the economic recession, there are increasing
numbers of people with a mental disability who are homeless or at risk of being
homeless. The Homeless Project provides 20 shelter beds and three multiservice centers
which help people access financial assistance, housing and mental health services. The
programs provide outreach to the general shelters in the County to help people with a
mental disability access resources. The problems facing this population in establishing or
reestablishing their lives in the community are horrendous. In addition to acquiring the
necessary financial assistance and housing, tremendous changes are required to enable
homeless people to settle into permanent housing situations. Ideally, transitional housing
resources should be available to help this population make the transition.
B. RECOMMENDATIONS:
1. Support people in their own housing, using 24-hour services only
when a person needs a more structured situation that cannot be
provided in his/her own home. Develop a range of services which can
be used to help a person stay in his/her own living situation, with
family,1 or with friends during a time of crisis. Expand supported
housing,services,so that more emphasis can be placed on prevention
of crises. Establish a fund for housing and utility deposits.
2. Develop strategies to maintain a person's regular living situation
during;times when they may need to use 24-hour services. Loss of
community housing makes it extremely difficult to discharge people as
soon as they are ready.
3. Seek funds for housing. Revisit and update the Mental Health
Division Special User Housing Plan, November, 1988. Develop a
joint Housing,Community Development and Mental Health Task
Force to take the lead in developing housing in Contra Costa County
for people with mental disabilities.
59
Community Services
4. Explore the possibility of negotiating Section 8 vouchers from the
Housing Authority to be set aside for people with mental disabilities.
5. Designate a County staff person with responsibility for coordination of
housing activities.
BRIDGING THE GAP FROM ADOLESCENT SERVICES:
A. SUMMARY
There is little coordination between children's and adult services. Consequently, 18 year
olds rely on particular service workers, not the system,to bridge the gap between the two
service delivery systems.
B. RECOMMENDATION:
Assign the task of reviewing this issue to the next planning committee or set up a
small task force of children and adult providers (County and contract),clients who
have.had the experience of transitioning from adolescent to adult services and
family members to assess the problem and recommend needed systemic changes
to facilitate meeting the service needs of this population.
60
X. FINANCIAL COMMITMENT
A. SUMMARY:I
Recognizing the extraordinary financial crunch facing the County, it is essential to take
certain actions to ensure that our long-term situation is not significantly worsened by
short-term actions.
B. RECOMMENDATIONS:
1. Preserl e funds saved from reducing hospital, IMD and local inpatient
services for maintenance and development of community services to the
fullest I'extent possible. Reallocate these savings to each age group
(children, adult, and geriatric)in the same proportions as their current
allocations.
2. Implement the use of the Rehabilitation Option under Medi-Cal as quickly
as possible, to generate more revenue and increase service flexibility to
meet client needs.
3. Maintain or increase the existing level of Medi-Cal revenue to assure that
Contra'I Costa County will continue to receive at least the present level of
MediClal reimbursement in anticipation of the forthcoming Medi-Cal
funding cap.
�I
4. Examine all current revenues including Realignment dollars,County
General Fund and SAMHSA funds in terms of their applicability for
funding the proposed expansions, pilots and new programs.
5. Seek new funding and revenues. Develop an integrated system to identify
and monitor potential grants and to coordinate grant writing efforts.
Assured clients receive all benefits to which they ey are entitled.
61
I
XI. FOLLOW-UP
A. SUMMARY:
The foregoing recommendations, taken together,comprise a broad-brush plan for shifting
I
the County's mental health resources from a reliance on institutional care to a client-
centered system of community based care.
Some of the specific recommendations can.be immediately implemented while others
will require varying periods of time for development. Some will meet with enthusiastic
response while others may encounter obstacles that were not envisioned. And there
remain several areas which could not be pursued in the limited planning time available.23
For all these reasons, we want this document to be viewed as a living, dynamic work in
progress-- that will encourage and stimulate discussion,and will be debated,improved
and changed.
B. RECOMMENDATION:
In particular, we strongly recommend that these preliminary planning efforts be followed
by a substantial planning process, a process in which Mental Health administrators, front-
line staff, union representatives,contractors and their staffs, and community
representatives comprise one-half of a committee, with consumers and families making
up the other half. With these participants as the core group of an on-going planning
process,it would be possible to accomplish the following:
•Undertake a comprehensive survey of all of the system's clients, assessing their
needs and wants;
•Consider ALL aspects of the services-- public and private -- for possible
modification;
23Children's services,geriatric services,mental health services in the jail,programs for mental health
clients with AIDS,were not addressed in the course of this study. A more in-depth study of services for
clients with special needs would be beneficial. In addition it would be productive to explore model
programs being implemented in other locales.
j 63
Follow-up
•Review SPECIFIC plans which are being considered with the key groups and
individuals to be impacted,
•Plan and develop a service system which will enable Contra Costa County to
continue to move toward a more cost-effective,client-centered,community-based
model.
As the plan evolves,putting good ideas into practice is critical. Implementing change
will require continuing Mental Health Commission and community advocacy,
wholehearted commitment and leadership on the part of the administrations of the Mental
Health Division and the Health Department,cooperation on the part of all providers and
the support of the County Administration and the Board of Supervisors.
We believe that all of these groups will join together to achieve the fundamental goals
articulated in this report. We believe that our County has the will to provide critically
needed support for our most vulnerable population.
64
APPENDIX A
LIST OF CONTRIBUTORS
The following persons provided client and fiscal data, program descriptions, and other
Valuable information and ideas to aid the Committee in its work:
John Allen
Rick Aubry
Lorna Bastian _
Jim Bouquin
Nancy Brewster
Frank Camargo
Max Cowsert'
Charles Drolette
Clay Foreman
Pat Godley
Joseph Hartog, M.D.
Essie Henderson
Linda Kirkhorn
Sharon Lundholm
Jay Mahler
Francyn Molina
Eroca Talent
Manuel Velasco
From other counties:
Gale Bataille and staff, Solano County Mental Health Services
Diane.Cunningham, Alameda County Mental Health Services
Lori Shepherd and Beth Stoneking, Sacramento County
Many members of the Alliance for the Mentally Ill,Contra Costa County, Mental Health
Advisory Board and the Client Network attended meetings to share their ideas and
provide feedback. The Committee is deeply appreciative of everyone's cooperation and
assistance.
65
APPENDIX B
CONTRA COSTA COUNTY MENTAL HEALTH DIVISION
OVERVIEW AND PHILOSOPHY
TARGET POPULATION:
Contra Costa County Mental Health will provide services to
targeted populations in accordance with Public Law 99-660, State
Comprehensive Mental Health Services Plan of 1986, the AB 904
California Mental Health Master Plan and AB 1288 Mental Health
Realignment Legislation. The targeted populations are described
in the following1three groups:
*Seriously emotionally disturbed children and adolescents under
age 18, with active consideration given to the needs of families
of the target populations;
*Seriously and persistently mentally ill '(SPMI) adults who are
functionally disabled;
*Older adults, 60 years and over, who require specialized
services due tolfunctional impairment or significant changes in
behavior related to a serious, persistent mental illness or a
dementia.
PHILOSOPHY AND VALUES:
Services will strive to meet. the needs of clients. Mental health
workers will assist clients in identifying and using the spectrum
of mental health !and community services. Clients will also be
assisted in "dev6lloping the skills and acquiring the supports and
resources they need to succeed where they choose to live, learn,
and/or work; to maintain responsibility, to the greatest extent
possible, for set'I ting their own goals, directing their .o-.m lives,
and acting responsibly as members of the community" (CA Mental
Health Master Plan) . Programs will focus on strengthening
skills, and developing environmental supports to sustain clients
in the community. ' The system of care will acknowledge and
p
incorporate the imp,
ortance of culture and language, the value of
cultural diversity, and.the adaptation of services to meet
culturally unique/, needs.
CLIENT-DIRECTED SERVICES:
Based on client strengths and functional and/or organic
disabilities, realistic goals will be set by the client and
mental health worker, in consultation with. family and/or
significant others. Family and community supports will be
identified to assist in meeting goals. Service decisions will be
made by the client, in consultation with the mental health worker
who will assist the client in making choices about living
environments, social relationships, leisure activities and
housing.
67
CONTRA COSTA COUNTY MENTAL HEALTH DIVISION
OVERVIEW AND PHILOSOPHY
March, 1992
Page 2
For children, realistic goals will be set by mental health staff
in concert,-with the child, his/her family, and in collaboration
with other child-serving agencies; e.g. , the schools, probation,
social services, etc.
The Mental Health Division will design ,services that enhance the
quality of life, promote client empowerment, encourage clients,
achievement of potentials, and respond to clients of varied
ethnic and cultural origin.
MENTAL HEALTH GOALS:
For adult clients, the Mdntal Health Division will strive to
measurably reduce use of hospitals, IMD facilities, jail and
crisis services; increaselengthof community tenure; increase,
paid and I unpaid employment; increase stability in housing;
increase use of nationally recognized intervention methods;
increase symptom management and medication education (pseudo-
educational interventions) ; develop additional service system
components; e.g. , respite for care givers, supported housing and
supported employment; and strive to respond to, and meet, the
culturally unique needs of the ethnically and culturally diverse
client population.
For children and adolescents, the Mental Health Division will
provide high quality family-focused clinical services to an
ethnically and culturally diverse population of children,
adolescents and families throughout the county. Staff will
consult with, collaborate with, and participate in interagency
services and planning with the County departments legally
responsible for the education, care, and custody of children
(including care-giving county facilities) as well as with
community agencies serving targeted population groups.
Children's services will strive to design programs and provide
treatment and case management services which: (1) maintain
children in the least-restrictive environment; (2) build on
family strengths to prevent acute hospitalization and/or reduce
the length of hospital stay; (3) divert youngsters from
residential treatment, juvenile hall, and crisis services; and
(4) aim to increase the child and family's ability to function
within the home and in the community.
ov=dpW
68
100 STAT.3796 PUBLIC LAW 99460—NOV.14,1986
'(7)The State plan may provide for the Implementation of the
requirements o(paragmph(6)in a manner which—
"W phases in,beginning in furcal year 1989,the proA-
ATT v sic°to all chronically mentally ill individuals to which such
APPENDIXC paraCraph oppliar the cue management servicer required
to be provided under such paragraph and
_W)provided for the
subetantlal Dom
ppletion of the pphas-
ine 19 f the provision of such services by the end of tura)
"o°'vle" 'rM) State plan shall provide for the establishment and
PUBLIC LAW 99-6'60
re/v°" implementation of a program of outreach to,and services for.
ehreaically memtall)ill individual who are homeless.
'(c)In dem each State plan,"uired under this section.the
State shall consult with representatives of employees of State
Institutions and public and ppnnvale nursing homes who caro for
chronically mentally ill Indivldwl.
"(d)The Secretary shall provide technical assistance to States In
the development and implementation of Statelana which complyr
with this section.Such technical assistance shall include the devel-
opment and publication by the Secretary of model elements for
Slate plans and model data systems for the collection of data
100 STAT.3794 PUBLIC'LAW 99460—NOV.14,1986 concerning the implementation of State plana
"KIMRCDAJM .
42 USC sofa-IL "see 1920D.(a)If the Secretary determines that a State ha not,
by the end of fiscal year 1989,developed the Stale plan required 7 ,
socGo°1920C,the Secretary shall reduce the amount of the Stat!7.
&ao TITLE V--STATE COMPREHENSIVE allotment under subpart 1 for fiscal year 1990 by the amount
W H*z1 MENTAL HEALTH SERVICES PLANS •p�Gcd h subsection(d)
'Yb)If the Secretary determines that•SLtte has not,by the end of
Act of 1986. fiscal year 1990.developed and substantially Implementod the State
Pfan A
tt A tot rota SEG set.SHORT LL plan required by section 19200, the Secretary shall reduce the
the 'State Comprehensive Meatal Aair.p'1794' amount of the State's allotment under subpart 1 for fiscal year 1991
Thio title may be cited a
Health Services Plan Art of 1986". by the amount r edfied is subsection(d1
'Yd H the SecreLvy determines that a State has not,by the end of
SEC_64LSTATE CDNPREHEN91V914EWALHEALTH SERVICES PLAK ficial year 199L developed and completely implemented the State
plan42 Use soot. Part B of title XIX of the Public Health Service Act is amended amount
rt of thered to section lent a the Secretary shall reduce the
(1) b inserting before the heading for section 1911 the amount of the State's allotment under subpart 1 for fiscal rear 1992
y and each seiooeediag fiscal year by the amount spea�ied m subeec
following: tion(d).The Secretary shall discontinue the reduction under this
"SuarART l-Stats GRANT":and subsection of a State's allotment under subpart 1 for a fiscal year if
the Secretary determines that the State has,in the preceding fiscal
(2)by adding at the end thereof the following: year, developed and completely implemented the State plan
1 aired by section 1920C.
"(d)The amount referred to in subsections(at(b),and(c)with
PUBLIC LAW 99460—NOV.14,1986 100 STAT.3795 reaped to a Slate is the total amount expended by the State for
administrative expenses for fiscal year 1986 from amounts paid to
'SURPAtr 2--.4rATs COMPLEHICHOV11 MICKTAL HRALTH Sxtvtcra the State under subpart 1 for such fiscal year.
Pu►N (e) Notwithstanding any other provision of this subpart, the
Secretary shall not require a State government,in carrying out a
"OxvII4PURNT GuN State plan submitted under this subpart,to expend an amount for
mental health services for any fiscal year which exceeds the total
"SM 19208.(a)The Secretary shall make greats to States for the Rqu4tiw.a amount that would have bees expended for such services by such
development of State comprehensive mental health services plans s2 SC 6001-to. government for such fiscal year if such plan had not been
which comply with section 1920( In order to receive a grant under implemented.
this sediom,a State shall submit an application to the Secretary.
Such application shall be in such form, and'shall contain such PUBLIC LAW 99-660--NOV.14,1986 100 STAT.3797
Lnformalnon,as the Secretary may by regulation prescribe.
'(b)(1)Except as provided in paragraph(24 the amount of a grant "MODLL STANDARDS rot THx PROVISION Or CARR TO THC CHRONICALLY
to a State under this section for a focal year shall be the amount
which bears the same ratio to the amount appropriated to caout unarrAUY It1
this section for such focal year as the population of the State bears "SEs. 1920E.(a)Within one year alter the date of enactment of 42 USC sone-u.
to the total of the population of all Stated which submit applications this subpart, the Secretary shall develop and make available a
euderthis section. II modellan for a community-based system of care for chronically
"(2)Notwithstanding paragraph(1),the amount of a grant to any mentally ill individuals Such plan shall be developed in consulta-
State under this section shall not be less than$150,000. tion with State mental bealth directors,providers of mental health
"(d To carry out this section,there are authorized to be ceppro- Appropristioa xrvien, chronically mentally ill individuals advocates for such
priated $10.000.000 for each of the fiscal yeas s 1988 and 1989. .4 services.
individuals,and other interested parties.".
"frATt OOMPRDRNEIVa MENTAL UZALTH srZTIC7a r1ANa SEC.SM STATE MENTAL HEALTH SERVICES PLANNING COUNCILS.
1 Section 1916(0 of the Public Health Service Ad is amended— 42 USC 30ft-4.
'Sea 192DC.W For each focal year,beginningwith focal year r2 USC sons-1L
(1)by striking out "With amounts available under section
1988)each State shall submit a State nomyr�erisrae meatal health 1915(a),the chief executive officer of the State may"and insert- 42 USC 300.-3.
p�vrt'o a t�(hereafter referred to Ice tbia s pa t as the 'State ing in lieu thereof"rhe chief executive officer of the State
to s« ry. I shall";and
"(b)A State plan shall,for the fiscal year for which the plan i. (2)b adding at the end thereof the following new sentence:
submitted and each of the 2 succeeding focal yews. meet the 'The State may use amounts available under section 1915(a)to
follovvi regmremenla: establish and operate such a council.".
"(1)The State plan shalt provide for the establishment and of
Implementation of sm o�'Banlhad community-based system of SEG bar.DEMON'ST UTION PROJECTS FOR SERVICES MR HOMEt—
Care for chronically mental),ill individuals.{ CHRONICALLY MENTALLY LLL INDIVIDUALS
-(2)The State plea shall eemiatn uantitative tata to be (a) DEMomsrRATion PRwErn.—Section 504(11(1) of the Public A rem
��1h��i� ed ten tem ratio f su m u Ing cum, Health Service Ad is amended by striking out"and elderly individ- i2 u1�;
ego a man y men individuals to the area uals"and inserting in lieu thereof"elderly individual,and home-
to be served under such system. leu chronically mentally ill individuals".
"($)The State plan shall describe services to be provided to I (b)AUTHORIZATION.—$edion 504(1X3)of such Ad Is amended by
chronically mentatly ill individual to enable such individuals striking out "1985. 1916. and 1987" and inserting in lieu thereof
to gain access to mental health services. Including access to "1985 and 1986,and 124,000,000 for faecal year 1988 .
4 State lea shall eecnbe ha n Ration services, (c)ADMINIsnrAW.It ExPoascs—Section 504(0 of such Ad is fur-
"(4) Ther amended by adding at the end thereof the following new
23pm.t Be houning services te,al 4W"I'M paragra h•
to ni y men. (4KA)Not more than 25 percent of the total amount.of a grant for Gr+�
individuals In order to enable such individual to funs fiscal year 1988 made to a State under this subsection for a project
tka outside of inpatient Institutions to the maximum extent of for services for chronically mentally ill adults(other than a project
theireapabUitiea J for services for elderly Individual or a project for serviom'for
101 The State plan shall provide for activities to 1� homeless chronically mentally ill individual)may be used by the
ante of hosvitalization of chronically mentally ill In iv i State for administrative expenses In carrying out such grant in such
1 cep a prove ed In paragraph(7),the State DIV shill fiscal year.
YB)Not more than 25 rant of the total amount of any grant
chronicaUx mentall In te who receives made to a State under this subsection for services to chronically
amounts0
pis is n or servioes.For purposes of mentally ill adults for any fiscal year(beginning with fiscal year
this paragraph, the term chronically mentally Ill individual' )989) may be used by the State for administrative expenses in
means a chronical l} mentally ill individual as defined under carrying out such grant in such fiscal year.".
State laws and regulations.
69
�I
APPENDIX D
PARRISH, JACQUELINE, "THE LONG JOURNEY HOME:
ACCOMPLISHING THE MISSION OF THE COMMUNITY
SUPPORT MOVEMENT''
From the "'Psychosocial Rehabilitation Journal", volume 12, Number 3,
January, 1989
The Long Journey Home: Accomplishing The
Mission Of The Community Support
Movement
Jacqueline Parrish
Jacqueline Parrish,M.S.,R.N.,is Program Director for the National Institute of Mental
Health Community Support Program.The program works with states,communities,national
organizations,consumers,and family members to stimulate improved community-based ser•
vices and opportunities for people with long-term,severe mental disorders.
Abstract: Although the community support movement has progressed
considerably during the past decade in conceptualizing and promoting ef-
fective community support services for people with severe mental dis-
orders there continues to be a lack of resources and other major obstacles
impeding the further development of sufficient services and supports for
the entire population. The major obstacles are discussed and four ap-
proacbes,for overcoming them are presented.
Substantial progress has been made during the past decade toward
helping people with severe mental disorders improve the quality of their
lives. There is increased awareness on the part of legislators, program
planners, and providers of the needs and potentials of these people.There
is a growing consensus, based on research and program experience, that
most can live meaningful and rewarding lives in the community. Many
states have endorsed community support concepts and have designated the
long-term mentally ill as a priority population for services (Brekke &Test,
1987; Goodrick, 1987a; Parrish, 1987).
Althoughi it is edifying to look back and congratulate ourselves on this
significant progress, we also must look forward and acknowledge that we
and our clients have a long way to go. . . a long journey before reaching
"home." I use"home" because I believe it embodies the ultimate goal of
the community support movement. Our intermediate goals are to increase
services and,coordinate systems, but our ultimate goal is to help people
with severe mental disorders succeed in living in their own homes in the
community along side other citizens.As is painfully evident from the many
people who Are still in institutions,substandard boarding homes,jails,and
from those who arc homeless, we are still far from achieving our final
goal.
We in the Community Support Program (CSP) of the National Institute
of Mental Health (NIMH) have attempted to serve as a focal point for
considering these issues by convening conferences and by undertaking in-
formation-gathering initiatives such as the recent.ly conducted strategic 71
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78
APPENDIX E
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80
APPENDIX F
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81
APPENDIX G
AMI-CC....HOUSING SURVEY...1992
SUMMARY
The study is based upon questionnaires completed by 102 AMI members,a response rate of 65%.
A demographic analysis of the population covered by the study showed that 88%were in the 20-40
age range,75% were male, 96%were single (defined as currently without a partner)and approximately
three-fourths received some form of public financial support for living expenses and health care. This
population profile is verysimilar to the national distribution of people with mental disability.
Living situations were clustered into five main categories,with the population dstnbuted as follows:
36 in Independent Living (apartments,single room, mobile homes)
24 in Group Living (board&care; frcensed& unlicensed homes)
29 in Family Home,with parent or other family member
10 in Hospital or Institution
1 Homeless
2 Unknown
Satisfaction with living arrangements,distnbution by sex and recreationaltsociat needs were analyzed
in relation to these housing categories,with the following results:
Overall, 30%of the responses showed satisfaction with living arrangements,29%
showed dissatisfaction,and 40% were ambiguous.
According to AMI members, loved ones riving independently and with family
tended to be more satisfied than the total population and those living in
group homes were significantly less satisfied (only 8%compared with the 30°,6
overall).
Males were overrepresented in group living situations and
underrepresented in independent living; the reverse was true for the
women(with 50%of women living alone).
Over 60%of those who answered the question on social and recreational
needs stated that these needs were not being met;this negative assessment
was true for all living situations,and most severe in independent living.
Current riving situations were compared with those judged to be the most beneficial types of housing,
with findings as follows:
Supported independent living was desired by nearly half of all respondents,
but this is virtually nonexistent in Contra Costa County.
Many of the respondents who had loved ones living at home would prefer
other housing but find the alternatives too costly.
Halfway housing was desired by many of the respondents,but none is available.
And,finally, more than half of the respondents expressed fear that their mentally disabled loved ones
will become homeless.
83
t ,1
APPENDIX H
GRAPHIC COMPARISON OF INSTITUTIONAL, AND
COMMUNITIY BASED CARE: NUMBER OF PEOPLE SERVED
AND COSTS
% of Persons Served Per Day
by Type of Program
Gisis 15%
Merrithew
Stats Hospital: tbmtnunity Based 51%
13°aL ..
UdDs 13%
% of Projected Total Cost Per Year for FY 92-93
by Type of Program
Gisis 13% ~1~
Qammunity Based 29%
Meniithew 26%
"ns w>, 11Y1Ds 10%
swe Hospitals 2346
• "x : s ,a4s} ,:
'tom''�•3 ti�
i
85