Title
Consider an updated preliminary analysis report in response to Board Referral No. 2023.12 seeking collaboration between County of Monterey and City of Salinas on a pilot crisis response program.
Report
RECOMMENDATION:
It is recommended that the Board of Supervisors:
a. Receive an updated preliminary analysis report in response to Board Referral No. 2023.12;
b. Provide direction on a preferred referral processing option:
i. Proceed with completion of referral as outlined in preliminary report;
ii. Proceed with completion of referral based on modifications by Board;
iii. Return to Board with a more comprehensive analysis of referral and anticipated effort for completion; or
iv. Rescind referral.
c. Provide further direction, as appropriate.
SUMMARY:
Behavioral Health Bureau (BHB) has been participating in meetings and discussions with the City of Salinas regarding Mobile Crisis Services for over a year. BHB presented on mobile crisis at the May 23, 2022 Salinas Valley City Managers and Mayors meeting held in Greenfield where City of Salinas representative was in attendance. Following that presentation on the existing BHB Mobile Crisis Services that have been operating in Monterey County since November 2015, City Manager outreached to BHB and a follow-up discussion occurred on June 21, 2022. On July 5, 2022, BHB presented on Mobile Crisis Services to additional representatives of the City of Salinas to initiate further discussion and exploration of possible opportunities for City / County collaboration. This was followed by additional discussion on August 18, 2022, and BHB provided a presentation to the Salinas City Council on September 6, 2022 at the request of the City Manager. BHB has also presented on our Mobile Crisis Services to the Health, Housing and Human Services Committee of the Board of Supervisors on May 6, 2022, and the Board of Supervisors on September 13, 2022. BHB joined a follow-up discussion on exploration of adding a mobile crisis unit specifically for the City of Salinas at the City’s Ad Hoc MOU Committee meeting on March 2, 2023. Upon receipt of this referral from the Board of Supervisors, BHB outreached to the City of Salinas and has participated in eight (8) additional meetings (June 5, 2023, June 21, 2023, June 22, 2023, June 29, 2023, July 18, 2023, August 1, 2023, August 14, 2023, and August 31, 2023) to further explore a potential pilot crisis response program. Additional county partners have been brought into the discussion specifically, Emergency Communications Department (ECD) and Emergency Medical Services (EMS). Programs operating elsewhere such as CAHOOTS in Eugene Oregon, and the inRESPONSE Mental Health Support Team model in Santa Rosa have also been reviewed and discussed.
Under the American Rescue Plan Act (ARPA), states are eligible for an 85% enhanced Federal Medical Assistance Percentage (FMAP) for qualifying mobile crisis services for twelve (12) quarters between April 2022 and April 2027. The State of California Health and Human Services Agency Department of Health Care Services (DHCS) submitted a State Plan Amendment (SPA) to Centers for Medicare and Medicaid Services (CMS) that established a new Medi-Cal mobile crisis benefit. DHCS issued Behavioral Health Information Notice (BHIN) 22-064 on December 19, 2022, and a revised BHIN 23-025 on June 19, 2023 which supersedes BHIN 22-064, regarding the new Medi-Cal Mobile Crisis Services Benefit Implementation to provide guidance regarding implementation of the Medi-Cal Community-Based Mobile Crisis Intervention Services benefit by county mental health plans (MHPs), Drug Medi-Cal (DMC) counties and Drug Medi-Cal Organized Delivery System (DMC-ODS) counties. This guidance states, “No sooner than January 1, 2023 and upon receiving approval from DHCS, county MHPs, DMC counties, and DMC-ODS counties (collectively, “Medi-Cal behavioral health delivery systems”) shall provide, or arrange for the provision of, qualifying mobile crisis services in accordance with the requirements set forth in this BHIN. Medi-Cal behavioral health delivery systems shall have the benefit fully implemented by December 31, 2023. Mobile crisis services are an integral part of California’s efforts to strengthen the continuum of community-based care for individuals who experience behavioral health crises, including through implementation of the 988 Suicide and Crisis Lifeline and the Crisis Care Mobile Units Program Grant.” BHIN 23-025 outlines the specific requirements and service components that need to be met to ensure all Medi-Cal members have access to coordinated crisis care 24 hours a day, 7 days a week, 365 days per year. County behavioral health plans are required to submit their implementation plan to DHCS by October 31, 2023 and have full implementation of this new benefit by December 31, 2023.
Developing a pilot program with the City of Salinas that would meet the DHCS requirements is essential to not only develop but help sustain the program over time. Given workforce shortage challenges and the specific requirements outlined by DHCS requiring at least a two-person team comprised of “Qualified Mobile Crisis Team Members” as defined by DHCS (please refer to pages 8-9 of the attached BHIN), consideration has been given to exploring the viability of partnering BHB clinicians with City of Salinas paramedic units given the DHCS restrictions regarding law enforcement involvement in mobile crisis response (please refer to pages 20-21 of the attached BHIN). Crisis services are provided irrespective of ability to pay or payor source. Under such a jointly staffed model, BHB would be requesting the City of Salinas share some of the cost associated with services provided to the uninsured and privately insured to go towards offsetting staffing cost for the program as Medi-Cal reimbursement would not be received for these groups. There are state and local EMS regulations that make effectively and efficiently operating a co-responder model partnering BHB clinicians with City of Salinas paramedic units challenging that would need to be addressed / resolved and Memorandums of Understanding (MOUs) would have to be established to move this forward.
BHB has continued to explore all viable solutions to meet DHCS requirements and implementation deadlines despite current workforce shortage and hiring challenges to include contracting out for additional resources as Community Based Organizations (CBO) have greater flexibility in staffing and scheduling than do county entities and their staff would be able to work alongside and augment the existing mobile crisis services already being provided by our County BHB staff and County contracted provider Seneca who operates the Children and Youth Mobile Response Team and Family Urgent Response System (FURS) in Monterey County. On August 18, 2023 BHB received sole source approval to contract with Sierra Mental Wellness Group (SMWG) for mobile crisis dispatch and field response. We are presently working on the contract to add mobile dispatch and a two-person team available for in person mobile crisis field response countywide 24 hours a day, 7 days a week, 365 days a year. Additionally, on August 30, 2023, BHB received sole source approval to contract with Family Service Agency of the Central Coast (FSA-CC) Suicide Prevention Service, the established 988 provider for the tri-county area of Monterey, Santa Cruz, and San Benito counties, to answer calls to our public facing BHB Community Crisis “Warm Line” 24/7. We are presently working on the contract amendment with FSA-CC to add this scope of work.
BHIN 23-025 states, “Medi-Cal behavioral health delivery systems shall identify and post a single telephone number that Medi-Cal beneficiaries who may require mobile crisis services can call. This number can be the same as the county’s 24/7 access line, or an existing crisis line, if the Medi-Cal behavioral health delivery system ensures the line has the capacity to respond to beneficiaries in crisis and to dispatch mobile crisis teams when appropriate. Medi-Cal behavioral health delivery systems shall coordinate with the 988 Suicide and Crisis Lifeline, local law enforcement and 911 systems, the Family Urgent Response System (FURS), and community partners to ensure beneficiaries have information about mobile crisis services” (please refer to page 5 of the attached BHIN).
BHB having the ability to contract with both FSA-CC and Sierra Mental Wellness Group (SMWG) serves to take a big step to truly start integrating our crisis system of care and brings us significantly closer to the national best practice standards for behavioral health crisis care as well as meets DHCS mandates. SMWG is already operating a similar model in San Luis Obispo County where they partner with County Behavioral Health and another non-profit agency who answers the crisis warm line in that county, so this is in keeping with a proven model that is quite familiar to them already. SMWG has expertise in mobile dispatch and response while FSA-CC has expertise in operating a 24/7 crisis call center / warm line. Both agencies are ready and eager to partner with the County and expand their staffing to meet this need. They share BHB’s enthusiasm to be at the forefront of County Behavioral Health, mobile crisis dispatch / field response and 988 coordination in the state. Not only will this meet our state mandate, but it will also be a game changer locally. While there is still much work to do on a very expedited timeline, this is a big step forward and lays the foundation to make possible excellent coordination of crisis services through phone, text, chat, and mobile crisis in person field response for our Monterey County community.
Given the steps BHB is already putting in place to meet our state mandate with the contracts referenced above, there is an opportunity for the City to consider contracting with County and for BHB to add a two-person team specifically for the City of Salinas pilot project to the contract currently under development with SMWG. This was proposed to the City in the most recent meeting on August 31, 2023. For this pilot, BHB proposed having a team Monday - Friday for 8-hour shifts (i.e., 9-6 or 10-7) to augment the other existing mobile crisis services as a reasonable starting point for phase one. BHB would contract with the City for the cost to provide these services and roll this scope of work into the contract we are currently negotiating with SMWG.
PRELIMINARY ANALYSIS:
Background: Behavioral Health is in receipt of Referral no. 2023.12, assigned by the Board on 5/23/2023, requesting the Behavioral Health Bureau collaborate with City of Salinas and explore launching a joint model crisis response pilot program.
Project Description: BHB understands the collaborative effort required for this project and is committed to that. BHB and City of Salinas have had several meetings to explore viability of launching a joint model crisis response pilot program and that has been met with some barriers. Additional partners (ECD and EMS) have also been brought into the discussion as critical partners as we have explored the viability of partnering BHB clinicians with City of Salinas paramedic units. Doing so, identified certain challenges and barriers that would need to be addressed and overcome to have a truly efficient and effective service model using a clinician / paramedic team, specifically related to current EMS regulations and local dispatch capacity.
BHB has however identified a viable path forward for this pilot project. Specifically, for the City to contract with BHB to provide a two-person team for the City of Salinas. As phase one of this pilot, we could start with the team operating Monday - Friday for an 8-hour shift (i.e., 9am - 6pm or 10am - 7pm). BHB in turn would add this to the contract currently in the works with SMWG and BHB would oversee the provision of these services along with the rest of our countywide mobile crisis services. Given the challenges and barriers outlined by the City, this appears to be the most feasible path forward to bring these additional services to the City in a reasonable timeframe. Partnering with BHB for these services would integrate the services into our behavioral health system of care in a manner that is in-line with best practice standards and state requirements to leverage the new Medi-Cal Mobile Crisis Services benefit and help connect individuals and families in crisis to care.
Estimated Project Cost: A preliminary budget estimate for the City Pilot is $390,000 annually. Per City Manager, City has an established budget for this project that would be able to cover the cost for multiple years.
Staffing Level Estimate: Two-person team with one person on-call as backup/fill-in and includes the licensed clinician and administrative support for the team.
Departmental Challenges: BHB has historically been successful in collaborating with the City of Salinas. Challenges with this project: a.) Finding and hiring qualified personnel to fill the positions, however County contracted providers have greater flexibility in hiring and scheduling staff than does the County which will be invaluable for this project. b.) Securing sustainable funding over time. The revenue from billing under the new Medi-Cal Mobile Crisis Services Benefit will be able to offset the cost of this project, however this is a new benefit and the amount of revenue that will be generated is not yet known.
Proposed Response Date: BHB intends to continue communication and collaboration with the City of Salinas and is scheduled to return to the Board on September 19, 2023 for the joint City Council and County Board of Supervisors meeting.
BOARD OF SUPERVISORS STRATEGIC INITIATIVES:
Improve health and quality of life through County supported policies, programs, and services, promoting access to equitable opportunities for healthy choices and healthy environments in collaboration with communities.
Mark a check next to the related Board of Supervisors Strategic Initiatives:
__Economic Development
__Administration
x Health & Human Services
__Infrastructure
__Public Safety
Prepared by: Melanie Rhodes, Deputy Director Behavioral Health, 796-1742
Jon Drake, Assistant Bureau Chief, 755-4357
Approved by:
_________________________________Date ___________________________
Elsa Mendoza Jimenez, Director of Health Services, 755-4526
Attachments:
BHIN 23-025
Draft budget estimate