HomeMy WebLinkAboutMINUTES - 03202001 - D.2 TO: BOARD OF SUPERVISORS
e-s .. Contra
FROM: Mark DeSaulnier t
Costa
DATE: March 20, 2001 County
°6y
SUBJECT: Mental Health Services
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
REFER to the Family and Human Services Committee a request to return to the Board within 60
days with a proposal for program and budget strategies to implement priorities identified by the
Mental Health Coalition. The proposal will also identify state legislative priorities to improve local
mental health systems and funding.
REQUEST that the Family and Human Services Committee, the Mental Health Coalition and the
County Police Chiefs' Association make a joint presentation to the County Mayors' Conference and
to the County Public Managers' Association to provide information on local mental health
priorities, issues and needs.
ADOPT RESOLUTION to proclaim May as Mental Health Month in Contra Costa County.
CONTINUED ON ATTACHMENT: \ YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ON March 2 0 , 2 0 0 1 APPROVED AS RECOMMENDED XX OTHER XX
The Board discussed the issues. Public comment was opened,and the following person appeared to speak: Mike Cornwall,
representing himself and others on the Mental Health Coalition,no one else desiring to comment,the Board continued their
discussion,and took the following action:
IT IS BY THE BOARD ORDERED the above recommendations are APPROVED; and the Health Services
Department is DIRECTED to complete a feasibility study for the Board's future consideration regarding a Geary Road,
Walnut Creek,structure for use as a County mental health facility.
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
_XX_UNANIMOUS(ABSENT — — — ) AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
ATTESTED March 20 , 2Q01
JOHN SWEETEN,CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
Contact: CAO
Cc: F&HS staff
Sheriff Warren Rupf
Bill Walker,MD
Donna Wigand
BY A. DEPUTY
BACKGROUND
In November 2000 the Little Hoover Commission released its study of the organization, funding
and delivery of mental health services in California, Being There:Making a Commitment to Mental Health.
The Executive Summary (attached) asserts that the cost savings from the closing of State mental
health institutions some 30 years ago did not follow citizens with mental illness back to their home
communities to provide needed services:
A generation ago, California decided that people with mental illness should live in
their communities rather than locked in institutions. They had a right to a more
everyday life,and it was determined they would benefit from community-based
treatment. It is painfully clear that we have failed to follow through with all that
was required by this noble decision (little Floover Commission 2000).
The Commission estimates that today, the public adult system of mental health care in California is
under-funded by at least 50%.
This ongoing shortfall has required prioritization of needed services by a key constituency group,
the Mental Health Coalition (summary of all priorities is attached). The Mental Health Coalition
comprises the Contra Costa Client Network, the Contractors' Alliance, Local 1, the Mental Health
Association, the Mental Health Commission, and the National Alliance for the Mentally Ill-Contra
Costa. Working together from July to December 2000, these organizations have identified the
following top service priorities for the near future:
• Consumer-run community centers—Self-help is a primary tenet of the recovery vision
approach to mental health service delivery that is being adopted by the County Mental Health
Division. Self-help is at the heart of consumer-run community centers. Three fledging centers
are now located in the East and Central regions of the County. West County has no program.
• Affordable housing—Safe and appropriately supportive housing is essential for consumers of
mental health services to sustain their recovery and for the system of care to protect its
investment in their services.
• Services for transition-age (17-25) young adults—Seriously emotionally disturbed (SED)
youth require specialized attention as they move out of the children's system of care, both for
their own stability and to maintain the investment of the services they have already received.
Transition-age services are extremely limited in Contra Costa County.
• Residential treatment facilities—Some consumers will occasionally require highly structured
living situations for limited periods of time.This may happen as they leave acute inpatient
psychiatric care at Contra Costa Regional Medical Center. It may happen when their conditions
improve beyond the level of care they currently receive, but they are not yet ready for
independent living. Such structured residential services are more effectively and efficiently
provided close to the home communities of consumers. Contra Costa Mental Health Division
has been granted resources to establish one residential treatment facility in the County, but
siting it has proven challenging.
Contra Costa County needs to make an implementation and budget commitment to its residents
with mental illness and their families that will:
reflect priorities and best practices identified by the Mental Health Coalition
take advantage of any non-County funding opportunities that appear
IN THE BOARD OF SUPERVISORS
OF
CONTRA COSTA COUNTY, STATE OF CALIFORNIA
In the Matter of Proclaiming the Month )
Of May, 2001 as Mental Health Month )
In Contra Costa County ) RESOLUTION NO. 2001/
WHEREAS, mental illness affects millions of adults, adolescents, children and their families
and causes much stress and suffering as well as.costing our nation billions of dollars annually for
lost.productivity, economic dependence and health care; and
WHEREAS, mental illness is a physical and emotional condition that is treatable, with recovery
possible through appropriate medical, social and support services; and
WHEREAS, people. with mental .disabilities share with all people a desire and need for
.interpersonal acceptance and support, decent housing and an opportunity to be productive; and
WHEREAS, through the prevention and treatment of mental and emotional disorders we can
return individuals to productive and successful lives; and
WHEREAS, the commitment must begin at the local community level to increase awareness of
mental illness and to promote the understanding that people with mental disorders can and do
lead productive and satisfying lives;
NOW, THEREFORE, BE IT RESOLVED by the Board of Supervisors that May, 2001 be
proclaimed as Mental Health Month in Contra Costa County.
PASSED AND ADOPTED ON March 20, 2 00 1, by a unanimous vote of the Board members present.
Mark DeSaulnier
John Gioia Gayle B. Uilkema
Donna Gerber Federal Glover
I hereby certify that the foregoing is a true and correct copy of an order entered on the Minutes of said Board of
Supervisors.on the aforesaid date.
Witness my hand and the Seal of the Board of Supervisors
affixed this twentieth day of March, 2001.
JOHN SWEETEN, Clerk of the Board of
Supervisors and County Administrator.
By
Deputy Clerk
Introduced by Supervisor
Mark DeSaulnier, District IV
IN THE BOARD OF SUPERVISORS
OF
CONTRA COSTA COUNTY, STATE OF CALIFORNIA
In the Matter of Proclaiming the Month )
Of May, 2001 as Mental Health Month )
In Contra Costa County ) RESOLUTION NO. 2001/ 107
WHEREAS, mental illness.affects millions of adults, adolescents, children and their families
and causes much stress and suffering as well as costing our nation billions of dollars annually for
lost productivity, economic dependence and health care; and
WHEREAS, mental illness is a physical and emotional condition that is treatable, with recovery
possible through appropriate medical, social and support services; and
WHEREAS, people with mental disabilities share with all people a desire and need for
interpersonal acceptance and support, decent housing and an opportunity to be productive; and
WHEREAS, through the prevention and treatment of mental and emotional disorders we can
return individuals to productive and successful lives; and
WHEREAS, the commitment must begin at the local community level to increase awareness of
mental illness and to promote the understanding that people with mental disorders can and do
lead productive and satisfying lives;
NOW, THEREFORE, BE IT RESOLVED by the Board of Supervisors that May, 2001` be
proclaimed as Mental Health Month in Contra Costa County.
PASSED AND ADOPTED ON March 20, 2 00 1, by a unanimous vote of the Board members present.
Mark DeSaulnier ,
Joh Gayle B. Ui ema
DonnGe er. Federal. Glover
1 hereby certify that the foregoing is a true and correct copy of an order entered on the Minutes of said Board of
Supervisors on the aforesaid date.
Witness my hand and the Seat of the Board of Supervisors
affixed this twentieth day of March, 2 00 1.
JOHN SWEETEN, Prk of t Board of
SuViso s and of n stra r.%
By
Deuty Clerk
Introduced by Supervisor
Mark DeSaulnier,District IV
l
Slate of California
LITTL E HOOVER COMMISSION
November 20, 2000
The Honorable Gray Davis
Governor of California
The Honorable John Burton The Honorable James Brulte
President pro Tempore of the Senate Senate Minority Leader
and members of the Senate
The Honorable Robert Hertzberg The Honorable Scott Baugh
Speaker of the Assembly Assembly Minority Leader
and members of the Assembly
Dear Governor and Members of the Legislature:
Just over a year ago the Commission began to study the quality and availability of
mental health services for California's adults. We discovered something that sets
mental health policies apart from others: Despite programs and promises, California
explicitly rations care to only those with the most extreme needs - and even then we
turn people away.
California's mental health policy lacks something fundamental: a clear commitment to
provide mental health services to people who need assistance. The goal of mental
health reform should be that simple - ensuring that all Californians who need mental
health services receive care.
The Commission also discovered that we spend billions of dollars dealing with the
consequences of untreated mental illness - rather than spending that money wisely on
adequate services. We pay for jail space and court costs that we incur because mental
health clients do not receive care and treatment. We pay for redevelopment and
struggle to revitalize our inner cities, but we pretend we cannot do anything to keep
people with mental health needs from sleeping in the doorways of downtown homes and
businesses.
We have, in effect, criminalized mental illness. State law instructs counties to turn
away those in need because funding is limited. But law enforcement is expected to
respond to every call, to keep every peace, and to ensure everyone's safety. Absent
adequate mental health services, the cop has become the clinician. The jail has become
the crisis center.
There is, of course, a moral imperative for caring for those who cannot care for
themselves, and on that basis alone we should change our policies. But there is also a
fiscal imperative to mental health reform. The public and private sectors share the
costs of failed policies: lost productivity and business, lower property values and quality
of life, and increased costs of criminal justice, public health and safety programs.
To curb these uncontrolled costs we must develop policies that proactively help people
maintain their functionality - to keep their jobs and homes, their ambition and
independence. Ensuring that everyone receives care would require a substantial up-
front expenditure. It also may take years to build the public support and to build the
system capacity to provide services. Still, this investment has been shown to yield a
positive return: including lower criminal justice costs and healthy business districts,
and more importantly a renewed hope for Californians who are too often viewed as a
liability rather than an asset.
Moreover, as with the physical health care system, the value of quality mental health care is
shared throughout our communities. Providing quality care therefore is a community
responsibility. The State must create the foundations for stable, successful private sector
mental health coverage and nurture the expansion of the private market. With a strong private
system in place, the public system can be the safety net for those without private coverage.
California has started down this road with the recent parity legislation. But we have not
committed to providing minimum basic services to all who need care, and the consequences of
inaction are tragic.
Californians have shown a willingness to spend if they see promise. Therefore, the first step to
reforming mental health policy is for all Californians to understand fully the costs and
consequences of failed programs and the responsibility we share to care for people with mental
illness. We can then commit to building a mental health service system that emphasizes
preventive care and intervention programs for all people needing services. We can ensure that
no one ends up in the criminal justice system, on the streets or in the emergency room solely
because treatment services were unavailable.
Too many Californians have lost their hope. Years of inadequate treatment, homelessness and
jail time have stripped them of their self-esteem and their confidence that their productive lives
can be restored. Too many business owners have steeled their hearts against the mentally ill
individuals who scare away their customers. Too many neighborhoods have rejected treatment
centers and supportive housing. Too many families have lost their sense of hope that a
mentally ill child, parent, friend or neighbor will recover.
Importantly, the Commission found reason to be hopeful. We found an unwavering resolve on
the part of many who have worked to provide the highest quality care possible, to push against
the bureaucracy and do what they know is necessary and right. We found innovative,
energized individuals who have built world-renowned models of care. They envision a
California mental health system that ensures those in need can live the most fulfilling lives
possible as they recover from their illnesses.
We can solve the problems facing California's mental health system. We have taken the initial
steps and we are making progress. But there is more work to do. We must recognize that
sound mental health policy is about compassion for human suffering and the quality of life in
our communities, our neighborhoods and in our homes.
In recent months the attention on mental health reform has focused on California's involuntary
commitment laws- the Lanterman-Petris-Short Act. Involuntary treatment plays an important
role in providing the highest quality of mental health care. But voluntary treatment should be
the initial response. California needs a continuum of care in which involuntary treatment is
the last and final resort - only appropriate when no other form of treatment is effective - and
implemented in a way that guarantees and respects the rights of individuals.
When we declared that people with mental illness have a right to treatment in their
communities we made a promise. It's time we kept our word. We need to provide adequate
housing, training, employment and counseling- services that were provided in institutions and
need to be provided in our communities. People with mental illness need to be invited back
from the edges of our society, out from under bridges and the margins of our conscience.
Sincerely,
Richard R. Terzian
Chairman
Being There
Making a Commitment to Mental Health
November 2000
EXECUTIVE SUMMARY
Executive Summary
A generation ago, California decided that people with mental illness
should live in their communities rather than locked in institutions. They
had a right to a more everyday life, and it was determined they would
benefit from community-based treatment. It is painfully clear that we
have failed to follow through with all that was required by this noble
decision.
Mental health clients have in fact been integrated into our communities;
we see them on the street corners and sleeping in parks. They are
integrated into our jails and prisons; many are behind bars on what
officers call "mercy bookings" — jailed for their protection, not the
public's. They are disproportionately represented among the poor, the
victims of crime, the unemployed and the homeless. A majority of people
erroneously sees them as "dangerous, dirty, unpredictable and
worthless"—better shunned than embraced.1
Many of us are uncomfortable with what we see and are not sure how to
respond. We too often avert our eyes from the face of mental illness.
And our public policies reflect this discomfort: Mental health programs
are the chronic losers in budget debates. Community officials verbally
scuffle with service providers. Neighbors complain about programs sited
near their homes. And funds are increasingly siphoned away from the
hundreds of thousands who want help leading productive lives to
address the small minority of those who are ill and also dangerous.
T66:
66 Lanterman Pefris-Short Act(LPS)
' California's involuntarycommitment:law': ;the.:LPS Act-.is one of-the rriostcontroversial.mental
health-issues of the:qday. :but ffie'Commission found the:most,important and immediate concern to.be
l;,5 millionGaliforniars;wtio;.need help .but:do not..rece.ive it:.:Moreover,"before meaningful'.
....;
reforrris`to.:the•:L. :Act co:ul.d.;b'e considered the Commission:fiel.ieves.the.following analyses are
. needed: . >.
❑ An.assessment of how the current..LPS law.:is.administered across counties.
❑ An:assessment.of.how improved access to voluntary treatment could diminish.the need for
involuntary.treatment: ..
0 .The dimensions.of the:problem that LP.S reform.would-address:.:.. . �
❑ The capacity of'state and local authorities'.to.:better serve.existing clients.through other
;. .:. .
'involuntary" models.;
❑ .The:ability::of.the State:to..im4provethe. ualityof!involuntarycare:...
;.
j,
In.Finding.2, the.Commission identifies'.a number of"leadership" challeriges:.facing;the State, :
including the needs,to..better.understand':the.:tole`of involuntary:treatment:before the Governor and
the:Legislature can thoughtfully and compassionatelyconsider amending the LPS Act.
�a
i
EXECUTIVE SUMMARY
Executive Summary
A generation ago, California decided that people with mental illness
should live in their communities rather than locked in institutions. They
had a right to a more everyday life, and it was determined they would
benefit from community-based treatment. It is painfully clear that we
have failed to follow through with all that was required by this noble
decision.
Mental health clients have in fact been integrated into our communities;
we see them on the street corners and sleeping in parks. They are
integrated into our jails and prisons; many are behind bars on what
officers call "mercy bookings" — jailed for their protection, not the
public's. They are disproportionately represented among the poor, the
victims of crime, the unemployed and the homeless. A majority of people
erroneously sees them as "dangerous, dirty, unpredictable and
worthless"— better shunned than embraced. I
Many of us are uncomfortable with what we see and are not sure how to
respond. We too often avert our eyes from the face of mental illness.
And our public policies reflect this discomfort: Mental health programs
are the chronic losers in budget debates. Community officials verbally
scuffle with service providers. Neighbors complain about programs sited
near their homes. And funds are increasingly siphoned away from the
hundreds of thousands who want help leading productive lives to
address the small minority of those who are ill and also dangerous.
The Lanterman=Petris-Short-Act(LPS)
California's involuntarycommitmerit law:.-.the:.LPS Act=.:is one;:.of.;the most`controversial mental.
I health issues.of•tlie'd.ay. But the,Commissio.nnfound the.:most.important and immediate concern to.be
the.1.5 million:Californians:.who.;need.help;`but do not receive:it. Moreover;.:before meani.ngfUl
:reforms-to the LPS`Act:coyld b:econsidered''the:Co"m.missiontiefieVes tfie.followin anal ses are
i g: y
needed: `
0... Awa.sses.sment of hovi the.current LPS'law is administered`across:::counties:.'7: .;;:,,.
i.•❑.:..Ari assessment of.how:improved access-to voluntary treatment:could=:diminish the.need for
I.. involuntary:treatment,.: '
❑ :The;dimensions_:of:the. .roblem,that_LPS:'reform would address.:::u; .
P
❑ The,capacity-.of,:state'an:d'local:authorities to tietter:.serve,existing;clients through other.
InvolUnta . " models..
j 0. i.The.ability:of;th'e;'State.to improve',the;.qualityof involuntary.,care.
In.Finding=2,;.the,Commissionidentifjes.d number of."leadership":.cFiallenges facing.the.State,
1. including the needs'to better understand the. role of involuntary.treatment before:the Governor'and.:
I.Ahe.Legislature can thoughtfully,and:compassionately consider'amending•the.LPS Act.:
i
LITTLE HOOVER COMMISSION
An estimated 1.5 million Californians are in need of help, but do not
receive it.2 Many of those who need help do not reflect the stereotypes.
They struggle to hold jobs, maintain friends and care for children - often
burdened as much by stigma as disease.
Fortunately the plight of those with mental illness - and their families
and the neighborhoods where they live - are receiving renewed attention.
And in these times of plenty, leaders are able to commit more resources
to provide help. The neglect of the past provides the opportunity of a
generation to implement fundamental reforms to the community mental
health system - reforms that may outlast the current empathy and
budget surplus.
The overriding goal of reform is clear: No one who needs mental health
care should be denied access to high quality, tailored services. To
transform this system, California needs to develop leadership capacity at
two levels. First, community leaders need to define for the State a public
commitment to serve those with mental illness and advocate for that
commitment until it is fulfilled. What sets mental health apart from
other social and medical causes is that we do not share a collective
expectation or sense of responsibility - and as a result there is little
outrage when mental health programs fail.
_..._..._...._.-._.....................---- ---.._.._.._._....---------------
Second, we need to fortify institutional
- _ WhO;N@@dS C8a'@_
___ leadership - at the Department of Mental
The Commis.siori's central.recommendation for Health and in communities - to create a
reforming mental health policy is.that no one system where barriers to improvement are
.who needs.care should be;denied access•t.b : identified and lowered, where the best
services-California currentlyrations access to:.
care, first based:on the`severity of an illness and strategies are replicated and improved, and
then by providing services `only to the'extent where the public and state and local
resourees.aresavailatile." leaders are confident to invest additional
resources.
To remove the funding barrier,.the public and ..
private sectors:need to commit resources to
ser`v`e all of those eligible based on the Severity Mental health clients and service providers
of their illness."'B.y::urging the State:to go further are justifiably frustrated. For years
-to set agoal of otoviding care to:all who.need wholesale reforms have been discussed and
it-.the:Commission:is acknowledging the.:
human.and fiscal benefits of preventative and then shelved. In California there are model
..::early intervention services:: providers offering comprehensive and
integrated services. Experts from around
=How to specifically limit care is an irnportant:and:Y the world come to visit these operations.
difficult issue that' eeds.to.be explored by But California has not replicated their
policy-makers—;c and business
leaders, mental health:;professionals and of successes; the knowledge they have
course, clients-, produced has not been infused into state
policies.
ii
LITTLE HOOVER COMMISSION
An estimated 1.5 million Californians are in need of help, but do not
receive it.2 Many of those who need help do not reflect the stereotypes.
They struggle to hold jobs, maintain friends and care for children - often
burdened as much by stigma as disease.
Fortunately the plight of those with mental illness - and their families
and the neighborhoods where they live- are receiving renewed attention.
And in these times of plenty, leaders are able to commit more resources
to provide help. The neglect of the past provides the opportunity of a
generation to implement fundamental reforms to the community mental
health system - reforms that may outlast the current empathy and
budget surplus.
The overriding goal of reform is clear: No one who needs mental health
care should be denied access to high quality, tailored services. To
transform this system, California needs to develop leadership capacity at
two levels. First, community leaders need to define for the State a public
commitment to serve those with mental illness and advocate for that
commitment until it is fulfilled. What sets mental health apart from
other social and medical causes is that we do not share a collective
expectation or sense of responsibility - and as a result there is little
outrage when mental health programs fail.
Second, we need to. fortify institutional
WhorNeed§ Care
leadership - at the Department of Mental
The;`Qomrn.ission's,central recommendation
for Health and in communities - to create a
reforming mental`health'policy is that no one. .';: system where barriers to improvement are
who:needs.care.stiouldbe.;:d...W access 1 identified and lowered, where the best
services',.,alifornia:'cur�ently rations access.to
care;:first based on the.severity of an illness:an_d strategies are replicated and improved, and
then.by prowi.ding services 'only.to::the extenf` ' ! where the public and state and local
resources'are:'availab.le"'..•;' leaders are confident to invest additional
resources.
.,Tod.remove:the funding:barrier;:the,public and `
private:secfors`nee(1o.'cornmit:resources.to;,;
serve all of:those:eligible,tiased on`the'severity
I Mental health clients and service providers
of,their,.illnessByFurging;tYie State to gd.further are justifiably frustrated. For years
to set`a'goal;`of:;providing,care to;,all who:;need: wholesale reforms have been discussed and
it the.Commis§ion s.acknowledging the then shelved. In California there are model
human:.andfiscal benefits;of;preve,ntative. and
early.Finteryention.services: .:.:';: , providers offering comprehensive and
integrated services. Experts from around
.How to sped fic211y,-1imit care..is.animportant and . the world come to visit these operations.
difficult%issuet....at'.needs:to t 6:'ei x lobed by But California has not replicated their
policy=makers,:community,:ard business
leaders,,mental health professionals.a.nd, of successes; the knowledge they have
produced has not been infused into state
::courseclients :< :
policies.
ii
EXECUTNE SUMMARY
Rather, in most communities, care is rationed to those with severe
mental illness. Even then, the system seldom recognizes that some
clients need a home, others need a job and all need respect- in addition
to medication.
We do not tell cancer patients to come back if and when their disease has
metastasized. But we turn mental health clients away and tell them to
return when their symptoms are so severe and persistent that they
cannot meet their own needs, and may no longer recognize that they
even need care.
The commander of the Los Angeles County jail testified that he operates
the largest mental institution in the nation-an indicator that the system
is broken and is exacting moral, as well as monetary costs.3 Clearly
some criminals, who also have mental illnesses, warrant incarceration.
But law enforcement officials are now advocating that jail and prison
should not be used to house those who have
not received adequate care from the mental
Living.with Mental Illness
health system.
. When John was 16 he tried to kill himself. He:".
While we need to dedicate more resources to didn't lose.fiis life, but lost his sight: While in
his native:Massachusetts tie:ezperienced...
mental health services, there is reason to mental health care that he found:to.be
believe that this investment will produce rinhumane- so heyavoided care and struggled"
positive returns. Researchers are just ( •:to.survive::
beginning to tally the costs of unaddressed i Homeless..in:Califorriia, he.was encouraged to:
mental illness - lost productivity, income and seek'.help;and he did: Mith.,treatme.nt.he.grew
:.
tax revenues, as well as increased criminal stronger.. He graduated:from California .state
justice and emergency medical expenditures. University,.Sacramento.and;McGeorge School
_of Law...
Evidence also is mounting that early
intervention and more comprehensive services He is'practicing;law,on medication;and:in
recove.ry.: Nis;life..is:a testameiit:to the value of
can preserve and restore functionality - appro`priate,.quality me.ntal.h:ealth care_and.the
providing human, as well as monetary promise of recovery,:: .`. . . .;
benefits.
The intangible consequences must be considered: the turmoil and grief of
families, friends and clients who struggle to find assistance and answers.
In 1997, 3,430 Californians committed suicide, the leading cause of
preventable death.4
Importantly, thousands of individuals are well-served. But credit goes to
the dedication of compassionate staff and a growing number of policy-
makers who have come to understand this public obligation. Overall,
however, the State has not developed or supported management and
service systems that encourage continuous improvements in the breadth
and quality of services.
iii
EXECUTNE SUMMARY
Rather, in most communities, care is rationed to those with severe
mental illness. Even then, the system seldom recognizes that some
clients need a home, others need a job and all need respect- in addition
to medication.
We do not tell cancer patients to come back if and when their disease has
metastasized. But we turn mental health clients away and tell them to
return when their symptoms are so severe and persistent that they
cannot meet their own needs, and may no longer recognize that they
even need care.
The commander of the Los Angeles County jail testified that he operates
the largest mental institution in the nation-an indicator that the system
is broken and is exacting moral, as well as monetary costs.3 Clearly
some criminals, who also have mental illnesses, warrant incarceration.
But law enforcement officials are now advocating that jail and prison
should not be used to house those who have
not received adequate care from the mental '
::Living with Mental lllness ` ::, :•
health system. "•
When John was :161he::thed`to kill Himself. He
didn't lose-his life;:but"lost his sight. While in,
While we need to dedicate more resources to his.native.Massachusetts Fie experienced
mental health services, there is reason to mental healthcare that>he:found to be
believe that this investment will produce inhumane-so he avoided care and struggled
positive returns. Researchers are just to survive:
beginning to tally the costs of unaddressed Homeiess;in California,,he•:was-encouraged to .
mental illness - lost productivity, income and seek,help,::and he did.. With%treatment he grew
tax revenues, as well as increased criminal stronger: He;.graduated:from.California..State-
justice and emergency medical expenditures. University, Sacramento::and McGeorge.Sch661
Evidence also is mounting that early of`Law: :•`;: '
intervention and more comprehensive services lie;is'"practicing law,,on=medi6btion and:in
recovery.: His;life1s.a testament to the value of
can preserve and restore functionality - appropriate, quality mental:Health care'and tFie
providing human, as well as monetary promise:of'recovery..;:':'
benefits.
The intangible consequences must be considered: the turmoil and grief of
families, friends and clients who struggle to find assistance and answers.
In 1997, 3,430 Californians committed suicide, the leading cause of
preventable death.4
Importantly, thousands of individuals are well-served. But credit goes to
the dedication of compassionate staff and a growing number of policy-
makers who have come to understand this public obligation. Overall,
however, the State has not developed or supported management and
service systems that encourage continuous improvements in the breadth
and quality of services.
iii
LITTLE HOOVER COMMISSION
The challenge is to capture the growing concern, knowledge, resources
and goodwill to make fundamental reform to policies and programs that
have been neglected for so long that they cannot be fixed by marginal
changes. Rather, we need to support fundamental change that
ultimately will transform our image of people with mental illness from
community liabilities into an accurate reflection of those individuals as
our neighbors, family members and loved ones.
The Little Hoover Commission has identified four core areas of reform
that together can move California's response to mental illness from one
driven by fear, stigma and lost hope to one offering treatment, success
and recovery to those living with mental illness.
❑ Expectations and Leadership. public policy is driven by public
expectations. To raise the public's expectations for mental health
services, programs must be able to communicate reliably and clearly
their performance and their potential. The Department of Mental
Health also needs to step up its efforts to be a statewide leader of the
community-based mental health system.
❑ Comprehensive Services and Resources. In many cases,
mental health treatment is limited to medication, when what is really
needed is help with housing, substance abuse and other problems.
While California hosts world-renowned service providers, they are
islands of success in a sea of rationed care. Mental health and
related programs have been plagued by a lack of resources. Reforms
should promote early intervention and more comprehensive services,
as a way of preserving functionality and holding down costs for acute
care. Over the long term, the State needs to capture funds now spent
housing clients in jails to provide better services through the mental
health system.
❑ Criminal Justice. Law enforcement officials say they have become
the safety net for the failing mental health system. California is just
beginning — and needs to do much more — to make sure that people
do not land in jail because of limited mental health treatment
options. And when mental health clients are jailed and released, far
more can be done to reintegrate them into communities and prevent
their reincarceration.
❑ Accountability.Concern alone for the welfare of people with mental
health needs is inadequate to motivate change. Clients, taxpayers,
policy-makers and the public must understand how policy and
funding decisions move the State closer to realizing their new
expectations. Without clear and constant accountability, mental
health will continue to reflect an inadequate and forsaken component
of California's social service programs.
iv
LITTLE HoovER COMMISSION
The challenge is to capture the growing concern, knowledge, resources
and goodwill to make fundamental reform to policies and programs that
have been neglected for so long that they cannot be fixed by marginal
changes. Rather, we need to support fundamental change that
ultimately will transform our image of people with mental illness from
community liabilities into an accurate reflection of those individuals as
our neighbors, family members and loved ones.
The Little Hoover Commission has identified four core areas of reform
that together can move California's response to mental illness from one
driven by fear, stigma and lost hope to one offering treatment, success
and recovery to those living with mental illness.
❑ Expectations and Leadership. Public policy is driven by public
expectations. To raise the public's expectations for mental health
services, programs must be able to communicate reliably and clearly
their performance and their potential. The Department of Mental
Health also needs to step up its efforts to be a statewide leader of the
community-based mental health system.
❑ Comprehensive Services and Resources. In many cases,
mental health treatment is limited to medication, when what is really
needed is help with housing, substance abuse and other problems.
While California hosts world-renowned service providers, they are
islands of success in a sea of rationed care. Mental health and
related programs have been plagued by a lack of resources. Reforms
should promote early intervention and more comprehensive services,
as a way of preserving functionality and holding down costs for acute
care. Over the long term, the State needs to capture funds now spent
housing clients in jails to provide better services through the mental
health system.
❑ Criminal Justice. Law enforcement officials say they have become
the safety net for the failing mental health system. California is just
beginning - and needs to do much more - to make sure that people
do not land in jail because of limited mental health treatment
options. And when mental health clients are jailed and released, far
more can be done to reintegrate them into communities and prevent
their reincarceration.
❑ Accountability.Concern alone for the welfare of people with mental
health needs is inadequate to motivate change. Clients, taxpayers,
policy-makers and the public must understand how policy and
funding decisions move the State closer to realizing their new
expectations. Without clear and constant accountability, mental
health will continue to reflect an inadequate and forsaken component
of California's social service programs.
iv
EXECUTIVE SUMMARY
The Commission believes that successful mental health reform will
require systematic change in how mental health policies are conceived,
funded and administered. It will require California's community,
business and political leaders to understand the costs and consequences
of success and failure, and it will require them to drive the reform
process.
Fundamental reform will move California toward I. -.....:. :" ' 4m►r►ediate$fees:.
a system of care that has as its goal ensuring I Fundamental,mental.h.e.alth,;.reform.v✓ill
access to care and tailoring mental health require:a sustained.commitm.ent to
services for those with debilitating mental continuously improving how m.enta.l.healtli
services are:o.rganized; managed and
illness. But the thousands of Californians in funded;
need of services today should not have to wait
But.Iongourne s.be with:' .sin le'step
for fundamental reforms to be achieved. Along .ly 9In a9
. Beside each:.:recommendation for
with recommendations for transforming the fundamental.reform, the Commission has
mental health system, the Commission is urging F)dentified immediate steps.that.would.begin
State and community leaders to take immediate building the common:uriderstanding and
steps to expand and improve care. j public support necessaryfor:.California,.to-: ;
I..fulfill,its obligation to help people,with:::mental'
illness:.::�'. :.,::•:. ,
The goal of ensuring that people who need care These..immediate steps.can'be;,taken through
have access to high quality, tailored mental existing.legal authority or with.executive
health services is achievable. It will require orders; by reallocating current:resources or
strategically expanding access and the capacity I tapping into.:the resources of non-
of the system over time - enough time to do it i"governmental organizations that should be
right, but not so long as to lose our way again. part Of the:solutions.
Toward this end, the Commission offers the following findings and
recommendations:
Building Public Support for the Mental Health Service System
Finding 1: No one who needs care should be denied access to high quality,
tailored mental health services. Open access cannot be achieved until the public
and policy-makers have a shared commitment to care for people with mental
illness.
Mental health clients have many champions. But they have been unable
to make their voices heard in the broader public and policy arena.
Without a shared sense of responsibility, the public and their political
leaders cannot create expectations, set goals and measure progress.
The Surgeon General asserts that stigma is a primary reason why mental
health problems are not adequately funded.5 The antidote for stigma is
accurate information. The faces of those with mental illness are diverse
and cross all social boundaries. Mental health clients who receive
v
EXECUTIVE SUMMARY
The Commission believes that successful mental health reform will
require systematic change in how mental health policies are conceived,
funded and administered. It will require California's community,
business and political leaders to understand the costs and consequences
of success and failure, and it will require them to drive the reform
process.
Fundamental reform will move California toward Immed►a#e:Sfeps:.
a system of care that has as its goal ensuring ..Fundamental mental health reform will-.
(. require.a;sustained commitment to
access to care and tailoring mental health ;:..
services for those with debilitating mental
continuously.,:improving how menfal:;heal.th.
i services:.are:organized; managed,anci
illness. But the thousands of Californians in .funded:. ..
need of services today should not have to waitBut lo ;
ng. journeys begin with:a single.,step:;..;..
for fundamental reforms to be achieved. Along I Beside:each recommendation for..-
with
or..with recommendations for transforming thefundamental.reform,.:the;Commission has .:. a.
mental health system, the Commission is urging I. identifiedm
_:.. mediate ste.ps:thatwould .begin: W
State and community leaders to take immediate .building the common:understanding and :,'..
steps to expand and improve care. I
public`Support necessary for.California to
1.fulfill its:obl.igation to"help people with mental
`..illness. .
The goal of ensuring that people who need care
These immediate steps.can be.faken;throudti
have access to high quality, tailored mental existing`legal authority orwith:
health services is achievable. It will require i orders, by.rea.11ocating:current resources or
strategically expanding access and the capacity I tapping:into the.resources.of non- .
of the system over time — enough time to do it govern mental.organizations thateshouId.be.
right, but not so long as to lose our way again. Part'of,the solutions:.:. ..._.
Toward this end, the Commission offers the following findings and
recommendations:
Building Public Support for the Mental Health Service System
Finding 1: No one who needs care should be denied access to high quality,
tailored mental health services. Open access cannot be achieved until the public
and policy-makers have a shared commitment to care for people with mental
illness.
Mental health clients have many champions. But they have been unable
to make their voices heard in the broader public and policy arena.
Without a shared sense of responsibility, the public and their political
leaders cannot create expectations, set goals and measure progress.
The Surgeon General asserts that stigma is a primary reason why mental
health problems are not adequately funded.S The antidote for stigma is
accurate information. The faces of those with mental illness are diverse
and cross all social boundaries. Mental health clients who receive
v
LITTLE HOOVER COMMISSION
The faces of those with mental adequate treatment are no more violent than other
illness are diverse and cross all people.6 And failing to provide adequate mental
social boundaries. Mental health health care leads to higher social, personal and
clients who receive adequate economic costs.
treatment are no more violent than
other people.And failing to provide Californians must understand the social costs and
adequate mental health care leads to
social, personal and personal consequences of mental illness. They
increased
economic socialcosts. need to know that people with mental illness can
lead fulfilling, productive lives and they need to
recognize that mental illness affects everyone.
Defining expectations for mental health care will be a challenge. Mental
health policy is complicated and reflects diverse and competing interests.
The science of mental illness is also complex and continues to evolve.
The policy-making process is most challenged by topics that fit this
description - intricate policies based on competing interests and
incomplete knowledge.
Nevertheless, the multiple interests must be brought together to develop
a shared understanding of the problems and the possibilities. Creating a
California Mental Health Advocacy Commission could assist policy-
makers in making a commitment, providing direction and pushing for
fundamental reform. The Commission should include a broad range of
stakeholders, particularly interests not historically involved in mental
health discussions, such as business, labor, taxpayer and education
groups. The Advocacy Commission could immediately begin to raise
public awareness and over time provide detailed proposals to policy-
makers.
Recommendation 1: The Governor and the Legislature should ensure that no one
who needs care is denied access to high quality, tailored mental health services.
The first step is to establish a California Mental Health Advocacy Commission to
serve as a catalyst for change, set expectations and establish responsibility for
mental health services. Specifically, the Commission should:
❑ Be of limited term and funded from public and private sources.
To ensure against unnecessary bureaucracy, the Commission should
be of limited term. To improve accountability, it should be jointly
---------- - funded from public and private sources. And to
_ mme Late- (eps I demonstrate clear expectations for outcomes, the
The Governor should oint a::'` l Commission should issue periodic reports and a
pp ."... final summa of its activities and
per.sc)hal'Mental Health:Ad.vocate summary
charged:.with buildi6g the'networks.and;",I accomplishments.
partnerships necessary to form the
Merital'Health.Advocac Commission. ❑ Develop 9 9 strategies to overcome stigma. The
public and policy-makers need an improved
understanding of mental health, mental illness and
vi
LITTLE HOOVER COMMISSION
The faces of those with mental adequate treatment are no more violent than other
illness are diverse and cross all people.6 And failing to provide adequate mental
social boundaries. Mental health health care leads to higher social, personal and
clients who receive adequate economic costs.
treatment are no more violent than
other people.And failing to provide Californians must understand the social costs and
adequate mental health care leads to
creased social, personal and personal consequences of mental illness. They
in
economic creased costs. need to know that people with mental illness can
lead fulfilling, productive lives and they need to
recognize that mental illness affects everyone.
Defining expectations for mental health care will be a challenge. Mental
health policy is complicated and reflects diverse and competing interests.
The science of mental illness is also complex and continues to evolve.
The policy-making process is most challenged by topics that fit this
description - intricate policies based on competing interests and
incomplete knowledge.
Nevertheless, the multiple interests must be brought together to develop
a shared understanding of the problems and the possibilities. Creating a
California Mental Health Advocacy Commission could assist policy-
makers in making a commitment, providing direction and pushing for
fundamental reform. The Commission should include a broad range of
stakeholders, particularly interests not historically involved in mental
health discussions, such as business, labor, taxpayer and education
groups. The Advocacy Commission could immediately begin to raise
public awareness and over time provide detailed proposals to policy-
makers.
Recommendation 1: The Governor and the Legislature should ensure that no one
who needs care is denied access to high quality, tailored mental health services.
The first step is to establish a California Mental Health Advocacy Commission to
serve as a catalyst for change, set expectations and establish responsibility for
mental health services. Specifically, the Commission should:
O Be of limited tern and funded from public and private sources.
To ensure against unnecessary bureaucracy, the Commission should
be of limited term. To improve accountability, it should be jointly
--- — funded from public and private sources. And to
/mmediafeSteps " ! demonstrate clear expectations for outcomes, the
■ The do vernot should appoint a :..:.;:.;.;;:;
EXECUTNE SUMMARY
Imdiate
...,;.:.:.,
the role of public policy in providing quality `� meSte p ..s•. -�.
mental health care. i':'■ ;The Governor:'s Men"tal Health:
46ocat6"should:,convene a:serie`s:qof �:```..
El Detail need. The public and policy-makers ; -..
tal:Health"'S.unimits4itli business ::,
need to understand how Californians are
''
education', labol,ah&mental-health::;:.:":,
affected by mental health policies, the leaders.to:build'.ari`agenda for<-., fi
adequacy of existing programs and the ':FA ::"`.''::.;` `;..:'°.•`:
■ Draft legislation should16e;prepared fob
magnitude of additional need. introductio.n.:in'January.to;fu,iii;and'
LI
Assess costs of failure. The public and formalize the:Commission:; •:.;; ;; ' ':•
policy-makers need to understand the trade-off
between investing in adequate mental health services and failing to
provide appropriate care.
❑ Provide for on-going policy advice. The Commission should
propose strategies for providing the Legislature and Governor on-
going direction and advice on mental health policy, and in particular,
strategies for understanding the complex and evolving science of
mental health and mental illness.
Strengthening Statewide Leadership
Finding 2: The state Department of Mental Health is not organized or funded to
ensure that all Californians have access to mental health services when they
need care.
The Department of Mental Health is charged with ensuring that targeted
mental health clients have access to adequate, appropriate care through
a culturally competent system within their communities.
The State faces significant barriers to improved care that require the
department to exercise this leadership: Care is limited by chronic
underfunding and critical shortages of mental health professionals.
Stigma and fear limit support for community-based services. Local
mental health agencies often do not adopt best practices. Family and
client organizations battle over attempts to reform
involuntary commitment laws, threatening years of good Distribution of DMH
relations. There is contentious disagreement over the Personnel
success or failure of f
managed care. Clients ace an 2000-01
g Departmental
increasing shortage of affordable housing. Over 30,000 Administration
people in California's jails and prisons need mental health 2%
services - many are incarcerated because they failed to
receive adequate community care? (/
Community Long Term
Services Care Services
While each of these issues is challenging, the department's 2% ss^r
attention is divided between leading a statewide
community-based system of care and managing a growing
vii
EXECUTIVE SUMMARY
the role of public policy in providing quality i lm'media.te:�Sfeps
mental health care. ■: :The`dovernor's;Mental Health.
❑ Detail need. The public and policy-makers ;. :. :;;Advocate should co.nvene�asenesof !' t
Mental I-lea.Itf1 Summits":w...l business;.`•..::
need to understand how Californians are
M. .. ..
education, labof a nd:;mentalhealth.
affected by mental health policies, the :':.leac.ers-to
build an a ebna"for c,han e s;
adequacy of existing programs and the ..''
legislation sho•uld¢:tie prePa,�ed for;;:.
magnitude of additional need. ;int[oduction:in January to;'fund:and
❑ Assess costs of failure. The public and formalize:the;Commission:;
policy-makers need to understand the trade-off
between investing in adequate mental health services and failing to
provide appropriate care.
❑ Provide for on-going policy advice. The Commission should
propose strategies for providing the Legislature and Governor on-
going direction and advice on mental health policy, and in particular,
strategies for understanding the complex and evolving science of
mental health and mental illness.
Strengthening Statewide Leadership
Finding 2: The state Department of Mental Health is not organized or funded to
ensure that all Californians have access to mental health services when they
need care. ,
The Department of Mental Health is charged with ensuring that targeted
mental health clients have access to adequate, appropriate care through
a culturally competent system within their communities.
The State faces significant barriers to improved care that require the
department to exercise this leadership: Care is limited by chronic
underfunding and critical shortages of mental health professionals.
Stigma and fear limit support for community-based services. Local
mental health agencies often do not adopt best practices. Family and
client organizations battle over attempts to reform
involuntary commitment laws, threatening years of good Distribution of DMH
relations. There is contentious disagreement over the Personnel
success or failure of managed care. Clients face an 2000-01
Departmental
increasing shortage of affordable housing. Over 30,000 Administration
people in California's jails and prisons need mental health 2%
services — many are incarcerated because they failed to
receive adequate community care? (/
Community Long Term
Services Care Services
While each of these issues is challenging, the department's 2% 96% f"
attention is divided between leading a statewide
community-based system of care and managing a growing " -�
vii
LITTLE HOOVER COMMISSION
penal code population in state hospitals. As the chart shows, over 95
percent of the department's staff is dedicated to operating institutions;
less than 2 percent is available for leadership activities.
California will not be able to provide adequate, appropriate mental health
care to its citizens without reorganizing state resources to provide
leadership and guidance to community mental health systems.
Recommendation 2: The Department of Mental Health needs to become the
State's mental health champion. The department needs the resources and the
political support to ensure that California's mental health system continuously
improves. Specifically, the department should:
❑ Advocate and provide policy guidance. The department should be
an advocate for mental health clients. It should provide direction and
advice to the Legislature and Governor on a policy framework that
results in continuous improvement in the availability and quality of
mental health care.
❑ Advocate for local mental health programs. The department must
ensure that local providers have the support they need from local,
state and federal agencies to provide needed care. The department
should pay particular attention to the need for housing, employment
and substance abuse treatment.
I ❑ Identify barriers and promote change. The
Immediate 3fe s;
department should identify statewide and local
■ The.Governor should reassign 10 barriers to improved care and recommend state
"staff persons from other departments and local strategies to overcome those barriers.
tolhe`Department:of Mental Health The department should explore strategies to
to im:medi.ately. provide additional
support.for community mental health" motivate improvement through funding, promote
programs: best practices and improve state and local
The:Department of Finance:and the
accountability.
Legislative Analyst's.Office should ❑ Develop mental health workforce. The
begin the detailed analyses department must ensure that California has an
necessary to redesign the
Department of Mental Health. adequate workforce capable of providing culturally
competent, professional mental health services
The department should.convene a
tsthroughout the state. The department should
ak force of countymental':health ;. :..
officials and national mental health•:.; partner with state and federal agencies involved in
experts to identify barriers to education and workforce development to meet this
improvement and strategies to need.
promote change.:..,. .
■ The department should convene a Ll Assess options for managing state hospital
summit of public and private experts system. The department should determine
in'h`uman resources and workforce whether providing long-term care services detracts
development to begin assessing: from its leadership responsibilities. It should
human resource needs and crafting assess alternatives for the long-term operation and
short-term and long-term pla_ns:to.
address the shortage of qualified management of state hospitals.
mental health.professionals.. .
Viii
LITTLE HOOVER COMMISSION
penal code population in state hospitals. As the chart shows, over 95
percent of the department's staff is dedicated to operating institutions;
less than 2 percent is available for leadership activities.
California will not be able to provide adequate, appropriate mental health
care to its citizens without reorganizing state resources to provide
leadership and guidance to community mental health systems.
Recommendation 2: The Department of Mental Health needs to become the
State's mental health champion. The department needs the resources and the
political support to ensure that California's mental health system continuously
improves. Specifically, the department should:
❑ Advocate and provide policy guidance. The department should be
an advocate for mental health clients. It should provide direction and
advice to the Legislature and Governor on a policy framework that
results in continuous improvement in the availability and quality of
mental health care.
❑ Advocate for local mental health programs. The department must
ensure that local providers have the support they need from local,
state and federal agencies to provide needed care. The department
should pay particular attention to the need for housing, employment
and substance abuse treatment.
-- - ❑ Identify barriers and promote change. The
_ Immediate Steps i department should identify statewide and local
■ TheTGoverno.r.should reassign 1.0 ( barriers to improved care and recommend state
staff persons..from other:departments. and local strategies to overcome those barriers.
to:the•Department of.Mental.Health I The department should explore strategies to
to immediatety,`provi.d.e.add.itional
support:for community mental health motivate improvement through funding, promote
programs. best practices and improve state and local
■ Th:e Dep artment.of.Finance and the
accountability.
Legislative Analyst's Office should ❑ Develop mental health workforce. The
begin tlie;detailed analyses department must ensure that California has an
necessary to,redesigri.the
Department of Mental Health: i adequate workforce capable of providing culturally
competent, professional mental health services
■ The department-should convene a I throughout the state. The department should
task force of county mental health, i
offcials and national mental heal#h ,. partner with state and federal agencies involved in
.experts to identify.barriers to.: .'. education and workforce development to meet this
improvement:and strategies°to.:. need.
promote chan..ge.
The department should.convene a
i ❑ Assess options for managing state hospital
summit of public and.private experts system. The department should determine
in human resources and workforce whether providing long-term care services detracts
developmentto:begiri assessing i from its leadership responsibilities. It should
human resource needs and crafting . assess alternatives for the long-term operation and
short-term and long-term plans,to
address the shortage of qualified management of state hospitals.
mental health professionals. j
viii
EXECUTIVE SUMMARY
Developing Comprehensive Services
Finding 3: Ensuring access to high quality mental health care means that each
community must provide a comprehensive array of mental health and support
services. Yet the rule-bound mental health system offers fragmented and poorly
coordinated care.
Like all people, mental health clients face multiple challenges every day.
Some are more prepared — and some less — to provide for their housing,
health care, employment and independent living needs. Some are unable
to provide for themselves because of their mental illness.
Although the mental health system is organized around a rehabilitation
model, the majority of people served do not receive comprehensive
services. California has over 500,000 mental health clients in need of
substance abuse treatment, but treatment services do not begin to meet
the need.H Over 75,000 clients need some form of housing assistance?
But the mental health system and community programs have a limited
supply of temporary and permanent housing. Employment presents an
even greater challenge. The majority of people with serious mental
illness are capable of working with support, but 80 to 90 percent are
unemployed. 10
Improving access to services often requires additional funding, but it can
also be done by breaking through bureaucratic barriers. The highly
regarded program offered by the Village Integrated Service Agency in
Long Beach reveals the results of removing institutional barriers. Other
agencies, such as Baker Places and the Progress Foundation in San
Francisco, have been able to provide integrated services because
administrators have the support of local authorities to work through
licensing regulations. Jonathan Vernick, director of Baker Places,
explains:"
The mental health system unintentionally contrives against service
integration. I tried to shop around for a license that would allow
the organization to provide mental health and substance abuse
treatment services under one roof. There is no license that will
allow me to offer both services in a single residential program.
As the mental health leader, the State must make a concerted effort to
motivate local agencies to provide comprehensive services — by lowering
barriers to integrated services, promoting cost-effective strategies and
encouraging innovation. California's Mental Health Planning Council,
representing an array of State departments and client and family
advocacy organizations, could assist the department in its efforts.
ix
EXECUTIVE SUMMARY
Developing Comprehensive Services
Finding 3: Ensuring access to high quality mental health care means that each
community must provide a comprehensive array of mental health and support
services. Yet the rule-bound mental health system offers fragmented and poorly
coordinated care.
Like all people, mental health clients face multiple challenges every day.
Some are more prepared - and some less - to provide for their housing,
health care, employment and independent living needs. Some are unable
to provide for themselves because of their mental illness.
Although the mental health system is organized around a rehabilitation
model, the majority of people served do not receive comprehensive
services. California has over 500,000 mental health clients in need of
substance abuse treatment, but treatment services do not begin to meet
the need.$ Over 75,000 clients need some form of housing assistance?
But the mental health system and community programs have a limited
supply of temporary and permanent housing. Employment presents an
even greater challenge. The majority of people with serious mental
illness are capable of working with support, but 80 to 90 percent are
unemployed.10
Improving access to services often requires additional funding, but it can
also be done by breaking through bureaucratic barriers. The highly
regarded program offered by the Village Integrated Service Agency in
Long Beach reveals the results of removing institutional barriers. Other
agencies, such as Baker Places and the Progress Foundation in San
Francisco, have been able to provide integrated services because
administrators have the support of local authorities to work through
licensing regulations. Jonathan Vernick, director of Baker Places,
explains:]1
The mental health system unintentionally contrives against service
integration. 1 tried to shop around for a license that would allow
the organization to provide mental health and substance abuse
treatment services under one roof. There is no license that will
allow me to offer both services in a single residential program.
As the mental health leader, the State must make a concerted effort to
motivate local agencies to provide comprehensive services - by lowering
barriers to integrated services, promoting cost-effective strategies and
encouraging innovation. California's Mental Health Planning Council,
representing an array of State departments and client and family
advocacy organizations, could assist the department in its efforts.
ix
LITTLE HOOVER COMMISSION
Recommendation 3: The State must assertively promote cost-effective, efficient
approaches to providing care. The Department of Mental Health must ensure that
local mental health programs have the tools and assistance necessary to improve
the cost-effectiveness of their programs. Specifically, the department should:
--- --- ----- -- -- ❑ Utilize the resources of the Planning
_ Immediate S Council. The department should seek assistance
�. The F%nning Cpuncil should convene from the Planning Council for each of the
public.hearinds aroundthe state to continuous improvement efforts outlined below.
identify and document potential best
practice models. I ❑ Identify barriers. The department should
■ :The department should prepare a actively identify the barriers that discourage local
budget.change proposal to.create and ) mental health systems from providing
staffa,unitcharged with identifying i comprehensive, integrated services that can be
and promoting cost-effective practices tailored to individual needs.
F that.improve outcomes. .
■ The department should convene;a.:. ❑ Identify best practices. The refocused
working group..ofinental health i department should create and staff a unit charged
professionals and evaluators charged with identifying and promoting cost-effective
with developing a protocol for Jpractices that improve individual and system
evaluating the effectiveness of service: If
outcomes.
models.
❑ Explore incentives. The department should
explore funding, reporting or other mechanisms
that can create incentives for state and local mental health officials
and service providers to continuously identify and remove barriers to
more efficient and effective care.
❑ Evaluate innovate programs. The department should evaluate
promising and innovative practices that have the potential to improve
services.
❑ Reportprogress. The department and the Planning Council should
annually report to the Legislature, local agencies and the public on
their activities, progress and on-going challenges to providing
comprehensive services.
Providing Adequate Mental Health Resources
Finding 4: Mental health funding is inadequate to ensure all Californians who
need mental health services have access to care. Furthermore, existing
resources fail to create uniform incentives for improvement and can prevent local
authorities from providing cost-effective, efficient care.
Community mental health services are funded through an array of local,
state and federal funds. Realignment provides dedicated revenue. Medi-
Cal, Medicare and Social Security programs provide reimbursements and
x
LITTLE HOOVER COMMISSION
Recommendation 3: The State must assertively promote cost-effective, efficient
approaches to providing care. The Department of Mental Health must ensure that
local mental health programs have the tools and assistance necessary to improve
the cost-effectiveness of their programs. Specifically, the department should:
--- _ ❑ Utilize the resources of the Planning
Irr►mediafe.StepS.:. Council. The department should seek assistance
■ The.Flan.ning Council sl ould Convene, from the Planning Council for each of the
e p.utilic',heafings`around the sfate to;:: continuous improvement efforts outlined below.
identify,and docurrient:,potential best,
pract16e`,models'.. ❑ Identify barriers. The department should
activelyidentify the barriers that discourage local
■. The departurent:shoul..d;prepa"re.a;:..;::':: =:.. y g
tiudget:ctiange.prbposal:to create and: mental health systems from providing
staff.,4.,unit cia.rged;with'.identifying, comprehensive, integrated services that can be
and promoting cost-effective practices: tailored to individual needs.
`that improve o..utcom.es::'::,
■
the:deparfinent.shouldconvene a
❑ Identify best practices. The refocused
wo. e'.;group of.mental.healtli'., department should create and staff a unit charged
professionals:and eValuato.rs ch"aged" with identifying and promoting cost-effective
with:devel`oping:a°protocol or...... practices that improve individual and system
evaluating=.the,effectiv.eness of service,="- outcomes.
... models: :: . ; . .
.... ❑ Explore incentives. The department should
explore funding, reporting or other mechanisms
that can create incentives for state and local mental health officials
and service providers to continuously identify and remove barriers to
more efficient and effective care.
❑ Evaluate innovate programs. The department should evaluate
promising and innovative practices that have the potential to improve
services.
❑ Reportprogress. The department and the Planning Council should
annually report to the Legislature, local agencies and the public on
their activities, progress and on-going challenges to providing
.comprehensive services.
Providing Adequate Mental Health Resources
Finding 4: Mental health funding is inadequate to ensure all Californians who
need mental health services have access to care. Furthermore, existing
resources fail to create uniform incentives for improvement and can prevent local
authorities from providing cost-effective, efficient care.
Community mental health services are funded through an array of local,
state and federal funds. Realignment provides dedicated revenue. Medi-
Cal, Medicare and Social Security programs provide reimbursements and
x
EXECUTIVE SUMMARY
direct payments for people who qualify. Categorical funds, grants and
pilot projects allow some communities to provide additional services.
The result of having multiple funding streams is that local mental health
authorities must patch together services, and the breadth and quality of
programs vary from county to county. Overall, mental health agencies
are forced to ration care to only those with the greatest needs and often
cannot provide the support services needed to keep individuals stable.
One advisory committee member noted that he could not get help until
he attempted suicide. Another argued that the only way she can improve
the quality of her care is to move to a county that offers better services.
California should reexamine how it funds mental health programs.
When funding and efficiency levels vary across the State, access and
quality also vary. Some counties are able to provide a range of services
to many, while others provide more limited services and place greater
restrictions on access. Access to high quality mental health services
should not be determined by a person's zip code.
Other states use funding to promote program effectiveness and efficiency.
To promote improvements, Pennsylvania provides additional funds to
local agencies willing to adopt programs that have been proven to work.
The Pennsylvania funding model is based on a clear assessment of needs
and the demonstrated effectiveness of a service approach. The
Pennsylvania Partnership for Safe Children has used this model to
support youth violence prevention programs.12 It provides incentives to
communities to adopt cost-effective programs.
California could incorporate a practice similar to the Pennsylvania model
as part of an overall funding strategy. The majority of mental health
funding, perhaps 90 percent, should be stable, provide incentives that
promote efficiency and effectiveness and give local agencies discretion to
tailor programs to meet individual needs. In addition, the State should
provide incentive funding, perhaps 5 percent of all funding, that the
Department of Mental Health could allocate to motivate local authorities
to adopt practices proven to enhance services. A third tier of funding
should promote innovation, perhaps 5 percent, as well. This funding
should encourage counties to invest in approaches that hold the promise
of increasing the efficiency and effectiveness of mental health programs.
With three tiers of mental health funding, each with explicit incentives,
the State can provide stable, discretionary funding while motivating
counties to adopt best practices and continuously explore innovative
approaches to improving outcomes.
xi
EXECUTNE SUMMARY
direct payments for people who qualify. Categorical funds, grants and
pilot projects allow some communities to provide additional services.
The result of having multiple funding streams is that local mental health
authorities must patch together services, and the breadth and quality of
programs vary from county to county. Overall, mental health agencies
are forced to ration care to only those with the greatest needs and often
cannot provide the support services needed to keep individuals stable.
One advisory committee member noted that he could not get help until
.he attempted suicide. Another argued that the only way she can improve
the quality of her care is to move to a county that offers better services.
California should reexamine how it funds mental health programs.
When funding and efficiency levels vary across the State, access and
quality also vary. Some counties are able to provide a range of services
to many, while others provide more limited services and place greater
restrictions on access. Access to high quality mental health services
should not be determined by a person's zip code.
Other states use funding to promote program effectiveness and efficiency.
To promote improvements, Pennsylvania provides additional funds to
local agencies willing to adopt programs that have been proven to work.
The Pennsylvania funding model is based on a clear assessment of needs
and the demonstrated effectiveness of a service approach. The
Pennsylvania Partnership for Safe Children has used this model to
support youth violence prevention programs.12 It provides incentives to
communities to adopt cost-effective programs.
California could incorporate a practice similar to the Pennsylvania model
as part of an overall funding strategy. The majority of mental health
funding, perhaps 90 percent, should be stable, provide incentives that
promote efficiency and effectiveness and give local agencies discretion to
tailor programs to meet individual needs. In addition, the State should
provide incentive funding, perhaps 5 percent of all funding, that the
Department of Mental Health could allocate to motivate local authorities
to adopt practices proven to enhance services. A third tier of funding
should promote innovation, perhaps 5 percent, as well. This funding
should encourage counties to invest in approaches that hold the promise
of increasing the efficiency and effectiveness of mental health programs.
With three tiers of mental health funding, each with explicit incentives,
the State can provide stable, discretionary funding while motivating
counties to adopt best practices and continuously explore innovative
approaches to improving outcomes.
xi
LITTLE HOOVER COMMISSION
Recommendation 4: California should provide adequate funding to ensure those
who need care have access to services. The first step is for the Governor and the
Legislature to reform the present funding streams. Specifically the legislation
should:
❑ Provide stable base funding that motivates quality outcomes.
The lion's share of mental health funding should include incentives
for local mental health agencies to continuously improve services.
Funding should reward local programs that
improve system outcomes and generate savings
_ Immediate Sfeps associated with reduced mental health costs, as
■ The Department of Finance and:the I well as reductions in the costs of other public
Legislative Analyst's Office should services, such as public safety and health care.
analyze the.cost of fully funding .
realignment. ❑ Provide incentive funding for the adoption
■ In January, the. .egislature.shoOld of best practices. In addition to base funding,
introduce a bill to fully fund the State should develop supplemental incentive
realignment and remove language that i funding that encourages local agencies to adopt
C
limits access."to the extent:resources
are availableproven best practices.
:"
10The Governor-should direct"the ❑ Provide innovation funding to encourage
Departments of Mental Health and I new experimentation and risk taking. Mental
Managed`Care to assess the impact of health funding should also include resources in
parity legislation and constantly, . . addition to base and incentive funding that
identify strategies for expanding promote innovation and risk taking to encourage
access to.care through public and.. local agencies to explore new approaches.
private.-sector mental health programs.
■ The Department of Finance and the ❑ Document the effectiveness and promote
Legislative Analyst's.Office should. mental health parity. Providing all who need
develop a transition plan to move.'.:.::.::.; :; services unrestricted access to mental health care
away from 19°.major funding,streams
toward amore"rational
means expanding access through the private sector
approach to.
funding mental.health services.. as well as expanding the safety net offered by the
public sector. The effect of mental health parity
legislation must be understood, and parity should
be expanded to improve access to quality care.
Decriminalizing Mental Illness
Finding 5: One consequence of an inadequate mental health system is the
criminalization of behavior associated with mental illness. The criminal justice
system is too often the only resource — the only safety net — available to mental
health clients and their families in times of crisis.
California's mental health system is designed to ensure that people have
access to emergency mental health care. State and local psychiatric
facilities provide round-the-clock services for individuals in need of
emergency mental health services. But non-emergency services are more
xii
LITTLE HOOVER COMMISSION
Recommendation 4: California should provide adequate funding to ensure those
who need care have access to services. The first step is for the Governor and the
Legislature to reform the present funding streams. Specifically the legislation
should:
❑ Provide stable base funding that motivates quality outcomes.
The lion's share of mental health funding should include incentives
for local mental health agencies to continuously improve services.
Funding should reward local programs that
improve system outcomes and generate savings
'Immediate Steps,.. associated with reduced mental health costs, as
0<. The Departme:nt.of:Finance and the:: '.:: well as reductions in the costs of other public
Legislati.ve'Analystl.s`Office,shou.ld:..:;':` '. services, such as public safety and health care.
analyze,the cost of fullyfund'ing.
realignment' ❑ Provide incentive funding for the adoption
..ln. 'January, the Legislature..should,;.
of best practices. In addition to base funding,
introduce'a:bill to.fully:fund. the State should develop supplemental incentive
realignment and-remove language that funding that encourages local agencies to adopt
limits access "to.the extent resources . proven best practices.
are available."
The Governor should direct the ❑ Provide innovation funding to encourage
. Departments of.Mental Health'and • new experimentation and risk taking. Mental
Managed Care.to assess theimpact of health funding should also include resources in
..p.2rity legislation and constantly. addition to base and incentive funding that
. identify strategies for:expand'iig promote innovation and risk taking to encourage
access:to:care through`putilic and
private sector mental health>p'rograms. local agencies to explore new approaches.
.:
The Department of Finance.and the ❑ Document the effectiveness and promote
Legislative:Analyst's Officeshould: mental health parity. Providing all who need
develo:p:a tiarisition`plan:to move services unrestricted access to mental health care
away:`from19:major:funding.'streams,
.: means expanding access through the private sector
toward a-=w rational:approach to
funding mental:health services:..;;..
as well as expanding the safety net offered by the
public sector. The effect of mental health parity
ter.. legislation must be understood, and parity should
be expanded to improve access to quality care.
Decriminalizing Mental Illness
Finding 5: One consequence of an inadequate mental health system is the
criminalization of behavior associated with mental illness. The criminal justice
system is too often the only resource — the only safety net — available to mental
health clients and their families in times of crisis.
California's mental health system is designed to ensure that people have
access to emergency mental health care. State and local psychiatric
facilities provide round-the-clock services for individuals in need of
emergency mental health services. But non-emergency services are more
xii
EXECUTIVE SUMMARY
limited. People who need assistance, but who are not a danger to
themselves or others, are often ineligible for immediate inpatient care,
and outpatient assistance may not be available.
If every community had a 24-hour assistance .center, a safe haven
offering care, individuals needing assistance could contact a center for
immediate support, while avoiding the high cost of hospitalization or
incarceration. In the majority of California communities, however,
clients, family members and concerned neighbors have limited options
when seeking assistance. In most cases, law enforcement is the only
resource available, every day, all day.
The majority of law enforcement contacts with
people with mental health needs do not result in Jails Have Become Treatment
Centers.....
an arrest.13 Most client-police interactions
involve officers facilitating access to mental 'Aftei:several'.days:of taking over-the:-counter..
health services, mediating disputes, calming antifiistamines, Ron was manic. His.`father...
•describes.fiim as "bouncing.off:the Ovalis:and
situations or otherwise responding in waysslamming doors:
other than to arrest and jail. Police officers,
however, are not routinely trained to interact Atone.p.o.int his father called 91'1 because.':..
with the specialized needs and concerns of 'Ron was making noise,•it,was.late;;and he
. was.concerned about the neighbors and:his
clients in crisis.14 And when community mental
health resources are not available, arrest can be ' son's safety:, When the police responded.,
Ron,:walked out the front door, raised:his:
the only option. ,;:arms;straight in the.air and.said-to.the`police;
"I will (expletive).kill,you."
Of the 30,000 seriously mentally ill people in
After.spcaying:;.Ron with p.epper spray.and..
California's jails and prisons, the majority are �. handcuffing hirh,:the.:police officers ca.11i the'..'
thought to be nonviolent, low-level offenderscounty. mental health facifity.to:see;.if th•ere..
who landed in the criminal justice system in ! was.room for Ron:::There.was no space.
part because they did not receive appropriate Theji.called:the.psycliiatric.hospital.in: the
community treatment.15 Unstable housing and neighboring county, no.space:`; They called..
facility`two counties:over;,ho.space.,With.no .
limited substance abuse treatment are ,other optiony ch
.thearged;Ron,,.with assault {
particularly associated with the likelihood and took`him.to jail:.:.
clients will become involved in the criminal
justice system.16 The State needs to better understand which people are
in jail or prison because they were unable to access mental health care
and which should be incarcerated and receive treatment while they serve
time.
California has begun to identify ways to divert people needing care out of
the criminal justice system and into treatment. The Legislature has
invested over $160 million in the Mentally Ill Offender Crime Reduction
Grant and the Integrated Services to Homeless Adults programs. Both
are designed to reduce the number of mental health clients sent to jail.]7
xiii
EXECUTIVE SUMMARY
limited. People who need assistance, but who are not a danger to
themselves or others, are often ineligible for immediate inpatient care,
and outpatient assistance may not be available.
If every community had a 24-hour assistance center, a safe haven
offering care, individuals needing assistance could contact a center for
immediate support, while avoiding the high cost of hospitalization or
incarceration. In the majority of California communities, however,
clients, family members and concerned neighbors have limited options
when seeking assistance. In most cases, law enforcement is the only
resource available, every day, all day.
The majority of law enforcement contacts with '..`
Jails Have"Become Treatment
people with mental health needs do not result in
Centers
an arrest.13 Most client-police interactions j..,,,... .; ;•:. .
involve officers facilitating access to mental After.seyeral:days of.faking over-the-counter .
health services, mediating disputes, calming ! antihistamines; Ron-was manic:: His fattier
describes'.him as:"bouncing:off the.walls and.
situations or otherwise responding in ways :slamming doors.°
other than to arrest and jail. Police officers,
however, are not routinely trained to interact Atone°point his.father::called 911:because
,Ron;was.making noise,'it was late and he
with the specialized needs and concerns of r
Was concerned.about the neighbors.and his
clients in crisis.14 And when community mental
son's safety: When.the police responded
health resources are not available, arrest can be Ron.walked out.thefront door, raised his
the only option. arms.:straight in:the.air and said to.the police,
i..°I will.(expletive).kill you." .
Of the 30,000 seriously mentally ill people in
.After:spraying Ron with,pepper:spray and
California's jails and prisons, the majority are
handcuffing him, the:police officers called`the
thought to be nonviolent, low-level offendersI.#unri mental;;health-facilitY.:to::see:if.::there;
who landed in the criminal justice system in was:roornfor::,Ron: :T.h:erewas.riospace.
part because they did not receive appropriate I They called.the.`psychiatric hospital,in
community treatment.15 Unstable housing and neighboring.county;:no;space:. 'They,-called a
facilitytwo counties.over, no.space::. With no:
limited substance abuse treatment are other.option'they charged Ron with assault,..::
particularly associated with the likelihood !. and..tooli:him to jail:
clients will become involved in the criminal
justice system.16 The State needs to better understand which people are
in jail or prison because they were unable to access mental health care
and which should be incarcerated and receive treatment while they serve
time.
California has begun to identify ways to divert people needing care out of
the criminal justice system and into treatment. The Legislature has
invested over $160 million in the Mentally Ill Offender Crime Reduction
Grant and the Integrated Services to Homeless Adults programs. Both
are designed to reduce the number of mental health clients sent to jail.17
xiii
LITTLE HOOVER COMMIssioN
But these programs are limited and may not provide the most cost-
effective services to those who can most benefit. The bulk of California's
diversion and intervention efforts focus on clients after they have been
arrested and jailed. Greater savings may result from providing
alternatives to arrest, such as improved police training, more 24-hour
assistance centers and the expansion of supportive housing programs.
Recommendation 5: The State needs to decriminalize mental illness by ensuring
that no one ends up in the criminal justice system solely because of inadequate
mental health care. The Governor and the Legislature should improve and
expand mental health crisis interventions. Specifically, the Department of Mental
Health, the Attorney General and the Board of Corrections should:
------ - - ❑ Use data to improve services. The State
Immediate Steps should analyze criminal justice and mental health
The.Department:of Mental Health data to identify priorities, develop promising
should query the Department-of. . programs and inform policy decisions that will
Justice.database to determine how reduce the number of mental health clients who
and where clients come into contact end up in the criminal justice system.
with the criminal justice system.. ::.:.:>: ::
■ The Legislative Analyst`s..Office ❑ Identify needs. The State should document
should review;criminal justice diversion I the need in each county for services that would
..and. intervention'programs and ! prevent people from ending up in the criminal
determine..if the State is making the Ijustice system, such as 24-hour crisis programs,
best use of`ez.isting investments:. : I supportive and affordable housing, substance
■
Legislation should be drafted for abuse treatment and other services.
introduction in January to:ezpand
facility funding available through the. : ❑ Evaluate intervention programs. The State
Board of..Corrections and permit ... should determine whether the Mentally III Offender
co unties.to seek funds fro.m.the.:Board Crime Reduction Grant and Integrated Services to
to.:build. 24hour assistance centers or
jails..;, Homeless Adults programs represent the greatest
opportunities to reduce client involvement in the
criminal justice system.
Coordinating Mental Health and Criminal Justice Services
Finding 6: Local and State agencies have failed to integrate and coordinate
mental health and criminal justice services — and as a result people with mental
health needs leaving jails and prisons do not receive adequate services and are
too often rearrested.
Even if substantial efforts are made to ensure that no one is incarcerated
solely because of mental illness, some persons suffering from mental
illness will end up in jail or prison for crimes of survival. The criminal
justice system also must continue to respond to people with mental
illness who have committed serious crimes. In both cases, it must be
xiv
LITTLE HOOVER COMMISSION
But these programs are limited and may not provide the most cost-
effective services to those who can most benefit. The bulk of California's
diversion and intervention efforts focus on clients after they have been
arrested and jailed. Greater savings may result from providing
alternatives to arrest, such as improved police training, more 24-hour
assistance centers and the expansion of supportive housing programs.
Recommendation 5: The State needs to decriminalize mental illness by ensuring
that no one ends up in the criminal justice system solely because of inadequate
mental health care. The Governor and the Legislature should improve and
expand mental health crisis interventions. Specifically, the Department of Mental
Health, the Attorney General and the Board of Corrections should:
777------
- - -
❑ Use data to improve services. The State
p.. should analyze criminal justice and mental health
.mme Tate to s
■ The Department of Me6taJ..Health data to identify priorities, develop promising
should query the Depaitment of.. programs and inform policy decisions that will
Justice:datatiase.to..determine.how ' reduce the number of mental health clients who
and where clients come.into.contact end up in the criminal justice system.
with the criminal justice system::.
■ The Leg islative.Analyst's Office ❑ Identify needs. The State should document
should:review criminal justice diversion: the need in each county for services that would
and:intervention programs and ,.;. prevent people from ending up in the criminal
determine if the State-is making the. ' . justice system, such as 24-hour crisis programs,
best:use of existing investments... supportive and affordable housing, substance
■ Legislation should..be drafted for abuse treatment and other services.
introduction.in January to expand
facility;furding available through the ° ❑ Evaluate intervention programs. The State
".:Board of Corrections:=and permit; : should determine whether the Mentally I11 Offender
counties to seek funds from the Board'..,..
to build24-hour:assistance centers-or Crime Reduction Grant and Integrated Services to
Jails. Homeless Homeless Adults programs represent the greatest
. . I opportunities to reduce client involvement in the
criminal justice system.
Coordinating Mental Health and Criminal Justice Services
Finding 6: Local and State agencies have failed to integrate and coordinate
mental health and criminal justice services — and as a result people with mental
health needs leaving jails and prisons do not receive adequate services and are
too often rearrested.
Even if substantial efforts are made to ensure that no one is incarcerated
solely because of mental illness, some persons suffering from mental
illness will end up in jail or prison for crimes of survival. The criminal
justice system also must continue to respond to people with mental
illness who have committed serious crimes. In both cases, it must be
xiv
EXECUTIVE SUMMARY
remembered that nearly everyone in the criminal justice system will be
released and re-enter their communities.
Yet clients leaving the criminal justice system face ;=;^: : : :.: .':
multiple barriers to community re-integration. = ::`:' .,>:Serv�ee:Coord�nation::Can:.
...... ..
Im rove�.Treatdii6h
They may require housing, employment, substance ! p..:=.; :.
P.P.
. .
abuse treatment and independent living services to O .
prevent their return to custody. Many :In Just''.one..:.of CD.C's:fve parole',�regioris;.
communities fail to offer these services. Where 69 peicerit of mentally ill,parolees;fail to.
these services are available, it may not be clear
sli'ow up for mandatory: menta.l'tiealth,
;services:'. Alm( 100;percent of clients
how to access them.
i..paroled.into'Sacramento.C,ounty,have a-
history of contact wi0'c1 ou*. mental.::`;' .
The biggest barrier to successfully re-integrating .health services; Yet•'parole and:;
mental health clients back into their communities is.comm unity mentar.e.alt.. services do.not. .
is a lack of cooperation among multiple community `'coordinate care; share treatrrient history,. +
information..or•collal ora te.on:;d•ischarde
and state agencies. The evidence is compelling planning;
that participation in treatment services is
Source: California Deparirrierit:of Corrections:
increased and recidivism is reduced when
community criminal justice and mental health services are consistent
and coordinated. 18 Yet the State offers limited direction or incentive to
support collaboration. Resolving this problem is relatively inexpensive,
but essential to improving the lives of these mental health clients.
The Texas Council on Offenders with Mental Impairments provides an
example of state and community leaders from multiple service areas
collaborating to identify strategies to improve services to mentally ill
offenders and reduce costs. The National GAINS Center in Delmar, NY,
represents a national investment in research, technical assistance and
information dissemination to improve community responses to mentally
ill offenders.
California should explore the potential of these models and develop
strategies to realize similar goals: improving program quality, efficiency
and research, enhancing education and technical assistance and
increasing the ability of the State to draw upon federal resources to
provide services to offenders with special needs.
Recommendation 6: The State should establish a California Council on Offenders
with Special Needs to investigate and promote cost-effective approaches to
meeting the long-term needs of mentally ill offenders. The council, comprised of
state and local officials, should:
❑ Identify treatment strategies. The council
should propose policies for improving the cost- Immediate
effectiveness of services for offenders with ::By Executive O.rder;�.th'e,,Governor'
special needs within jails and prison s, should..establi_sh'the,California.Council.
on.Offenders:with%Special.Needs.
xv
EXECUTIVE SUMMARY
remembered that nearly everyone in the criminal justice system will be
released and re-enter their communities.
Yet clients leaving the criminal justice system face
I,. :Service.Coordination`Can.:
multiple barriers to community re-integration.
Improve
They may require housing, employment, substance
Treatmenf;:
abuse treatment and independent living services to Opp0ltunl0es:.:: :::::.;
prevent their return to custody. Many In just one.of.CDC.:s five parcle' regions;:'
communities fail to offer these services. Where 69. petcent of::mentally_ill.parolees fa.i(to..
� °
these services are available, it may not be clear
show`up,for mandatory:mental,health., ..::
services:':Almost;100:percent ofxcferits
how to access them. i::.:::::.: ... .. :.
!.:'paroled:into Sacramento County have a. ,
histo.ry�of'contact with:courity
The biggest barrier to successfully re-integrating health.services.. Yefyparolei'and
mm
mental health clients back into their communities ! co .unity mental health services do not,
is a lack of cooperation among multiple community ; in
o.rma io care,share:treatment history
information.:or;:.ollaborate;on;discharge::
and state agencies. The evidence is compelling 1 .planning: :. T
that participation in treatment services is .Source: Califomia;Department of Corrections:
increased and recidivism is reduced when 779-7
community criminal justice and mental health services are consistent
and coordinated. 18 Yet the State offers limited direction or incentive to
support collaboration. Resolving this problem is relatively inexpensive,
but essential to improving the lives of these mental health clients.
The Texas Council on Offenders with Mental Impairments provides an
example of state and community leaders from multiple service areas
collaborating to identify strategies to improve services to mentally ill
offenders and reduce costs. The National GAINS Center in Delmar, NY,
represents a national investment in research, technical assistance and
information dissemination to improve community responses to mentally
ill offenders.
California should explore the potential of these models and develop
strategies to realize similar goals: improving program quality, efficiency
and research, enhancing education and technical assistance and
increasing the ability of the State to draw upon federal resources to
provide services to offenders with special needs.
Recommendation 6: The State should establish a California Council on Offenders
with Special Needs to investigate and promote cost-effective approaches to
meeting the long-term needs of mentally ill offenders. The council, comprised of
state and local officials, should:
❑ Identify treatment strategies. The council
should propose policies for improving the cost- _ Immediate Steps:` .
effectiveness of services for offenders with E. gy'-Ezecutye Order;`the Governor
special needs within jails and prisons, should estatilish'the:California:Council
..: on Offenders:with.Special.Needs '
T 4
xv
1
LITTLE HOOVER COMMISSION
including service coordination and data sharing
Immediate Steps
among community mental health and criminal
justice programs.
;The Legislature6'should call.for;an. :,.
independent:eyaluation.of contracts: L3 Promote coordination. The council should
between�theCalifornia.Dep artment.of. .,:. document the need to coordinate mental health
Corrections.and lbcal.mental healtfi":::: services and improve the ability of clients to
agencies to provide care to parolees.,:..: transition successfully between corrections-based
■. The.LegWature,should direct the and community-based treatment programs.
California Department.bf Corrections.
to.expand;to all:counties.contracts,';: ❑ Provide technical assistance. The council
proven to.successfully provide.quality;.,; should develop a technical assistance and resource
mental health care to parolees., center to document best practices and provide
■ ..The Legislative Analyst's Office should °? information and training to improve the efficiency
analyze the:`State's response to..:.'. ;`.. . :. and effectiveness of state and local programs
incentive".'programs.offere.d.:.by.'the.:' serving mentally ill offenders.
federal Social S:ecurity Administration
and.promote the-use of.incentive.,' ❑ Develop incentives. The council should
payments to fund.pre-authorization '`:' identify incentives that will motivate State and
efforts that speed up.benefits to.clients .
leaving jailor.prison. local agencies to coordinate mental health and
._ J criminal justice services.
Creating Accountability: Monitoring the Mental Health
System
Finding 7: California will never be able to ensure that all Californians have access
to mental health care without clear and continuous accountability for outcomes.
When realignment shifted responsibility for care to counties, client
advocates were concerned that local agencies would limit their
investment in services and the quality of care would suffer. In response,
the Department of Mental Health was required to develop a reporting
system to assess the performance of counties.19 But it has struggled
with the requirements and the reporting system is not fully operational.
The department envisions a data-based reporting system that tracks
outcomes for all mental health clients receiving services for 60 days or
more each year— some 25,000 children and 185,000 adults.20 Data for
each individual will track the services used, costs and outcomes. Despite
sound planning and pilot testing, the department is challenged by the
enormity of the task. There is no unequivocal agreement or standard for
measuring the effects of mental health services. There is no clear
measure for evaluating the impact of treatment.21
xvi
LITTLE HOOVER COMMISSION
including service coordination and data sharing
linmediate Steps
among community mental health and criminal
justice programs.
;N The Legislature shou.ld6all::.for.:an:..
independent evaluation.:of"contracts ❑ Promote coordination. The council should
between'the.California;Departrhent:of document the need to coordinate mental health
Corrections::anti.local mental health'...... services and improve the ability of clients to
I agencies to provide care:to:;paro.lees....... transition successfully between corrections-based
The Legislature should.direct°the:;' ''`: : and community-based treatment programs.
Ca.lifornia'..Department.of Correct'ionsl`.
to.expand to all,counties.contracts . ❑ Provide technical assistance. The council
proven to successfully:provide quality should develop a technical assistance and resource
mental health.ca re to parolees`. center to document best practices and provide
■ The Legislative Analyst's Office should ' information and training to improve the efficiency
analyze the State's response to and effectiveness of state and local programs
incentive.programs offered.by the`. .: serving mentally ill offenders.
federal Social Security:Administration
and promote the.use'of incentive ❑ Develop incentives. The council should
payments to fund pre-authorization identify incentives that will motivate State and
efforts that" speed: up.,benefits to clients
local agencies to coordinate mental health and
leaving jail o.rprison: ..
criminal justice services.
Creating Accountability: Monitoring the Mental Health
System
Finding 7: California will never be able to ensure that all Californians have access
to mental health care without clear and continuous accountability for outcomes.
When realignment shifted responsibility for care to counties, client
advocates were concerned that local agencies would limit their
investment in services and the quality of care would suffer. In response,
the Department of Mental Health was required to develop a reporting
system to assess the performance of counties.19 But it has struggled
with the requirements and the reporting system is not fully operational.
The department envisions a data-based reporting system that tracks
outcomes for all mental health clients receiving services for 60 days or
more each year— some 25,000 children and 185,000 adults.20 Data for
each individual will track the services used, costs and outcomes. Despite
sound planning and pilot testing, the department is challenged by the
enormity of the task. There is no unequivocal agreement or standard for
measuring the effects of mental health services. There is no clear
measure for evaluating the impact of treatment.21
xvi
EXECUTNE SUMMARY
Supporters of the department argue it is difficult to develop a system
when the science of performance measurement is still evolving. Critics
contend that a lack of progress is a result of the department's interest in
ensuring that the data favorably represent all county mental health
agencies. The reality is likely somewhere in the middle. Similar efforts
in other states have shown that data systems often fail to capture the
value of local mental health programs. Preliminary data are often
suspect, and it can take years of fine tuning to build a reliable
measurement and reporting system 22
Despite these challenges, California needs to make progress. The
department needs to take first steps regardless of how unstable those
steps may be. The department could bolster its efforts by involving
nationally recognized experts in outcome reporting and encouraging
public awareness and critique of its process and progress.
Further, the department should develop data sharing protocols with
other state and local agencies to encourage collaborations that can
improve the quality of services and client outcomes. Data sharing should
explore potentials for organizational improvement by encouraging data-
based research on the mental health service delivery system. Outcome,
assessment and financial data should be widely available and permit
mental health stakeholders and the general public to understand the
adequacy and efficiency of local mental health programs.
Recommendation 7: Improvement, public understanding and support for mental
health programs depend on an accurate assessment of California's progress
toward its goals. As the State's mental health leader, the Department of Mental
Health must continuously inform the public, program administrators and policy-
makers on the performance of the system, whether quality and access are
improving and how they could be enhanced. Specifically, the department should:
❑ Inform decision-makers. The department _-
should provide information that can help the Ilnll7edlate.;Steps'.;;7
general public, policy-makers and program :. ",:•.; : :
■ TFie department:should publicly;,report•;:
administrators understand the availability,
-,aggregated;info�mation`'fo�eacti �:'.�";';�'
quality and cost-effectiveness of mental :,'county Ion:tfie?,types:of Californians'=
health services. who"are�bein9 S.erved''and the'unhiet ,lig"
need:::.
❑ Provide benchmarks. The department
should provide information that compares
E..The.department`shoul' commit to;<:; :•;':
`.developand"publicisebenchmarks'.:
performance with expectations. It should j at;outline`:ann:ual'goals for'ezpanding.,
reveal variations across programs, counties 2ccess.;to.mental:health:.c2re;:='.;: ,
and over time. E JlieLegislatuFe shouldrect"ttie"
De.partmenteof Mental.%Health to:;;-
complete the.;%atewide performance%.
reporting s.yMem: .::;..
xvii
EXECUTNE SUMMARY
Supporters of the department argue it is difficult to develop a system
when the science of performance measurement is still evolving. Critics
contend that a lack of progress is a result of the department's interest in
ensuring that the data favorably represent all county mental health
agencies. The reality is likely somewhere in the middle. Similar efforts
in other states have shown that data systems often fail to capture the
value of local mental health programs. Preliminary data are often
suspect, and it can take years of fine tuning to build a reliable
measurement and reporting system 22
Despite these challenges, California needs to make progress. The
department needs to take first steps regardless of how unstable those
steps may be. The department could bolster its efforts by involving
nationally recognized experts in outcome reporting and encouraging
public awareness and critique of its process and progress.
Further, the department should develop data sharing protocols with
other state and local agencies to encourage collaborations that can
improve the quality of services and client outcomes. Data sharing should
explore potentials for organizational improvement by encouraging data-
based research on the mental health service delivery system. Outcome,
assessment and financial data should be widely available and permit
mental health stakeholders and the general public to understand the
adequacy and efficiency of local mental health programs.
Recommendation 7: Improvement, public understanding and support for mental
health programs depend on an accurate assessment of California's progress
toward its goals. As the State's mental health leader, the Department of Mental
Health must continuously inform the public, program administrators and policy-
makers on the performance of the system, whether quality and access are
improving and how they could be enhanced. Specifically, the department should:
❑ Inform decision-makers. The department
should provide information that can help the Immediate-Si
.„;: :•:.';1 .:
general public, policy-makers and program
.Thedepartment sho.utd:publiclyrepgrt-;;"
administrators understand the availability, `;` aggregatedinformation..foveach.`":: `..
quality and cost-effectiveness of mental noun,ty on'.tl e;types of,C.aI fornians:.
health services. A6i are being.served;and,tfie"unmet
need. `
❑ Provide benchmarks. The department
should provide information that compares
;:. .';The department:should:commitfo ::.::.: ::;
develop`and'publicize.benchmarks ,•;
performance with expectations. It should that:outline;annu:al goal.s..for.expanding-:..
reveal variations across programs, counties access to mental health.care'.;'.;.
and over time. The Legislature should direct`tFie
Department'-of,Mental;Health
.complete i66,: tatew18Wbe'ormance;.::":
reporting,systerm
xvii
LITTLE HOOVER COMMISSION
❑ Reveal barriers. The department should
Immediate Steps,�; provide data to permit administrators and
�. The departments"should"provide: researchers to identify barriers to program
;.quarterly reportsjo the.Legislature:andimprovement and alert policy-makers when and
the'publicon progress:
in, where policy changes are necessary.
developing.the reporting system:
i n,..,• . Ll Encourage broad access. all data and
ii, the b
mentsliould; egputting.
data.on line for.easy patilic.access.. information on mental health programs should be
readily accessible to the public, the press,
The:depa:rtmentshould:publicize the>
conditions under whicli^:it:will intervene: i researchers and others whose analyses could lead
to ensure::Mental.health services are. . to better public understanding, program
available iii ever] community,;. management and policy making.
❑ Provide standards. Performance data should
be structured to indicate to state and local
administrators and policy-makers when mental
health services are so inadequate that intervention
is warranted.
xviii
LITTLE HOOVER COMMISSION
,... .. .. ;• : : ❑ Revealbarriers. The department should
1►rimediate'Steps 'xss provide data to permit administrators and
■ The departmentshddld provide `'' researchers to identify barriers to program
q uarterlyre.ports to.the'Legislature,and. improvement and alert policy-makers when and
tlie.;public on its progress,in. where policy changes are necessary.
:.gres . ,.. P Y g
developing thc'Qeportmg.syStem:'.""
Thede a.rtmentxshoUId be in. Uttin :. ❑ Encourage broad access. All data and
P ..r 9i .P 9
data on=line-f oreasy;public,:access: information on mental health programs should be
a; .. . readily accessible to the public, the press,
;.The department;.shoUld;pUblicize.,the.
conditions:under wlicfi'it.wi.11.iriteni6he researchers and others whose analyses could lead
to`'ensure mentaI f ealtFi senrice.s are. to better public understanding, program
available in�eve.ry;,community..•%., management and policy making.
KPOW2118WER�j , OM ❑ Provide standards. Performance data should
be structured to indicate to state and local
administrators and policy-makers when mental
health services are so inadequate that intervention
is warranted.
xviii
"YEAR 2001—YEAR OF MENTAL HEALTH"
Mental Health Coalition Priorities
Our Mental Health system.is currently significantly underfunded (50%) and fails to
meet the needs of some of our most vulnerable citizens. The members of the Mental
Health Coalition feel very strongly that the "Year of Mental Health" should be about
focus on systemic changes, both in terms of the specific service areas presented below
and in terms of a broad public education campaign and overarching philosophy.
As we add services to try to meet the mental health needs of our community, we
want to emphasize the need for all current and new programs to do the following:
e Provide community education that will help to reduce or eliminate the stigma
associated with mental illness
e Address divers ity®cultural and language competency and capacity; gender;
age/generation issues; parent/family/child issues; access barriers; etc.
♦ Ensure that services are available both across the continuum and in all geographic
regions
o Insist on collaboration, cooperation, and participation of ALL county departments,
especially Substance Abuse; but also including Health, Public Health, Community
Services, Employment and Human Services, and Law Enforcement and Juvenile
Justice—as well as community based organizations, city government, education,
and other advisory boards and commissions
We have agreed that the following four areas of service needs are our top priorities:
y Client-run community centers (establish a center in West County and fully fund the
other 3 existing centers in East and Central County)
A full array of housing available through out the county
Services for transition aged (17-25) youth
Residential Treatment Facility(ies)
There are also many other services, which we consider are needed to fully serve our mentally
ill community members. They.are as follows:
• Transportation
• Mobile Response Teams (Mental Health and Law Enforcement)
• Intensive case management upgrades, especially in West County
• Vocational/employment/education services
• Expanding TBS (therapeutic Behavioral Services) to non-MediCal clients
• Family advocacy, in particular special education and AB3632
• 5150 form revision
• Increasing the service capacity of community based organizations
• Cost of Doing Business increases on contracts with non-profit health providers.
• Some percentage of new monies be RFP'd
The Mental Health Coalition is composed of representatives from each of the primary
mental health constituencies, including:
• The Contractors' Alliance
• Local 1 • The Mental Health Commission
• National Alliance for the Mentally III • The Mental Health Association
(NAMI) 0 The Client Network
�-a
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