Title
Receive a presentation from the Health Department’s Behavioral Health Bureau staff regarding availability of mobile crisis services throughout the County.
Report
RECOMMENDATION:
It is recommended that the Board of Supervisors:
Receive a presentation from the Health Department’s Behavioral Health Bureau staff regarding availability of mobile crisis services throughout the County.
SUMMARY/DISCUSSION:
Behavioral Health (BH) launched the County’s first Mobile Crisis Team (MCT) services in November 2015 and the team remains operational to date. MCT services were disrupted in mid-March 2020 due to the COVID-19 pandemic and staff were reassigned to support other critical and essential services within BH. The MCT was reactivated in April 2021.
The MCT is staffed with licensed / licensed eligible clinicians and are based out of the Salinas, South County and Peninsula regions of the County. Program hours of operation are Wednesday through Saturday from 12:30 pm to 10:00 pm and every other Tuesday from 1:30 pm to 10:00 pm.
BH, in partnership with our contracted services provider Seneca Family of Agencies (Seneca), also developed the Mobile Response Team (MRT) for Children and Youth which launched during the pandemic in July 2020. MRT’s focus is on children and youth ages 0-21 and their families. MCT and MRT communicate and refer to each other as clinically appropriate.
The MCT provides law enforcement and other treatment providers with specialized assistance in responding to individuals and families in crisis. They collaborate to recognize the signs of psychiatric distress; work to de-escalate a mental health crisis, provide available resources and link people with voluntary outpatient services and/or treatment as appropriate. The team seeks to provide the support to stabilize the situation in the community to avoid unnecessary hospitalizations and divert from emergency resources (hospital/jail) when appropriate while providing the linkage to ongoing care as needed. They facilitate involuntary hospitalization when clinically indicated and act as the liaison with emergency personnel as well as the receiving hospital/providers for continuity of care. They also provide follow-up outreach and engagement services in the community.
The MCT responds to calls for service that come through County Communications Computer-Aided Dispatch (CAD) system at the request of responding law enforcement personnel to assist by providing behavioral health expertise to situations involving some sort of behavioral health crisis. They conduct risk assessments in the community to determine if WIC 5150 criteria is met and if hospitalization is needed. If it is, then they work with law enforcement to facilitate that. If the criterion for an involuntary hold is not met, then the mobile crisis staff provide brief crisis intervention and safety planning with the individual and/or family in crisis in addition to referrals to appropriate voluntary services in the community. They can link existing system of care clients immediately back to their treatment team or other community resources in some cases. The MCT provides consultation support to law enforcement as well as other service providers throughout our BH System of Care and County contracted providers of mental health and substance use disorder services. They also receive non-urgent referrals for outreach and follow-up from law enforcement. County contracted service provider Sun Street Centers operates a Sobering Center for adults which opened in December 2017. Hours of operation are Thursday starting at 3pm to Monday at 8am. As the Sobering Center only admits individuals referred by law enforcement, this is an example of another resource the MCT may suggest to law enforcement partners when clinically indicated as a diversion from the hospital or jail.
The BH System of Care provides services to all age groups. As a safety net provider, we work to align the services with the needs of the general Medi-Cal population and strive to provide community-based services that equitably engage our community members. The 10-year service trend data shows an overall increase in demand for services and then a leveling off. In Fiscal Year 2021-22 (FY 21-22), our BH System of Care served a total of 13,150 clients for a total service value of $102,851,037.80. The average service value per client was $7,821.37 and the average age was 30 years old. In FY 21-22, there were 4,389 new clients admitted to the system of care and 7,440 discharged.
Review of MCT program utilization data from program inception through June 2022 reflects a total of 4,333 calls for service throughout Monterey County. Approximately a third of the calls came from the Salinas/North County Region, a little more than a third from the South County Region, and a little less than a third from the Peninsula Region. Most of the calls (41%) were initiated through the County Communications Computer-Aided Dispatch (CAD) system, followed by Consultations from BH and Other Agencies (29%), then Consultation from Law Enforcement (26%) and the remaining 4% from other sources. Most calls for service were for the adult population (18+), with 15% for Transition Aged Youth (TAY) ages 18-24, and 67% for those age 25 and over. 16% of the total calls for service were regarding an older adult (60+), and 15% were for children and youth ages 0-17. Call disposition data reflects that 78% of the time when MCT is involved the outcome is something other than arrest or involuntary hospitalization. The call is more often resolved with brief crisis intervention services and referrals (36%), and diversion by immediate linkage to outpatient or community resources (10%). Please see Attachment: Mobile Crisis Team Frequency Report for additional MCT utilization data points.
The Substance Abuse and Mental Health Services Administration (SAMHSA) National Guidelines for Behavioral Health Crisis Care specifically identify what crisis services are and are not, and state, “Crisis services are for anyone, anywhere and anytime. Crisis services include (1) crisis lines accepting all calls and dispatching support based on the assessed need of the caller, (2) mobile crisis teams dispatched to wherever the need is in the community (not hospital emergency departments) and (3) crisis receiving and stabilization facilities that serve everyone that comes through their doors from all referral sources. These services are for anyone, anywhere and anytime.”
Based on the SAMHSA definition (above) our current crisis continuum has some service gaps. Specifically, MCT operational hours are not 24/7, Sobering Center operational hours are not 24/7, there is a lack of Crisis Receiving and Stabilization Units for all age groups, and more alternatives to jail and hospitals are needed within Monterey County.
There are some significant challenges as we strive to meet the SAMHSA best practice guidelines. There continues to be a local and statewide workforce shortage. According to a report by CalMHSA on the Behavioral Health Workforce Shortage, the average position vacancy rate in California counties is 20% while Medi-Cal enrollment is up 16% since the pandemic. Despite our ongoing recruitment efforts, it is difficult to fill vacant clinical and specialized positions within BH such as those with crisis services, and it takes longer to fill positions overall. We continue to lose some of our more experienced staff who move on after gaining some experience with BH to pursue other employment opportunities with employers that pay more or to work that is less challenging. Additionally, there are funding challenges as based on the nature of crisis work, BH serves anyone in the community regardless of payor source or ability to pay. MCT finance data shows programmatic costs continue to rise each year while reimbursement for services provided continues to decline and the long-term funding situation is unclear. We have been successful in obtaining some grant funding, but it is not sufficient to sustain / grow our crisis services programs as some grant opportunities are identified as specifically for equipment or infrastructure and cannot be used for salaries and benefits. We are also faced with legislative changes and unfunded mandates that impact our system, most recently CalAIM, 988 Implementation, and Care Court.
BH has continued to adjust and adapt to face these challenges and the increasing demands on our System of Care. Strategic efforts include: (1) Continuing to seek out and apply for grant funding opportunities to support our programs and continued program development. (2) Continuing to nurture existing relationships, and build new ones, with our community partners and stakeholders to work collaboratively with and across disciplines to be responsive to the needs of the community. We have also engaged in some preliminary discussions regarding potential City/County collaborations in this area. (3) There has been some significant restructuring. As of April 1, 2022, the BH Crisis Team is no longer co-located in Natividad Hospital as is not the provider of hospital-based crisis services in the Emergency Department, this function has transitioned to Natividad personnel. This transition enables us to shift our efforts to development of a more community facing and responsive BH Crisis Team that is integrated with BH Mobile Crisis services. Community members, new clients, existing clients, and significant support persons can speak to a BH crisis worker by calling the 24/7 Access to Treatment number at 888-258-6029 and selecting the prompt for the Crisis Team (prompt 5). Hospital providers may also call 888-258-6029 and select “hospital provider” (prompt 6) for discharge coordination for new clients, Short Doyle authorization for inpatient care, and to request collateral information for continuity of care for all BH clients presenting in a hospital emergency department for psychiatric emergency care.
In April 2019, the Monterey County Board of Supervisors passed a Stepping Up resolution joining a national movement to reduce the number of people in the local jail who have mental illnesses and co-occurring substance use disorders. BH contracted with the Council of State Governments (CSG) Justice Center to work with stakeholders on a large system mapping project co-led by Behavioral Health, Sheriff’s Office, and Probation Department. A key CSG recommendation that came out of that effort specifically identified the need for mobile crisis services and the need to expand non-emergency room options for crisis response and stabilization.
There are a few projects underway currently to build out the crisis continuum for specific groups. Seneca is working on developing a Child / Adolescent Crisis Stabilization Unit (CSU) & Crisis Residential Services Facility, and Community Hospital of the Monterey Peninsula (CHOMP) is developing a Crisis Stabilization Unit (CSU) projected to open in Fall 2022. However, these projects are not designed to meet the larger needs of the Adult Specialty Mental Health and Safety Net population. Once these projects are completed, the gap in these services will remain for our Adult Specialty Mental Health and Safety Net population and this disparity is of significant concern. This, in addition to the absence of a Crisis Receiving Center alternative to hospital emergency departments for this population and the lack of 24/7 Mobile Crisis response, does not meet the SAMHSA National Best Practice Guidelines for Crisis Care.
While developing a plan to address these gaps and disparities is critical and should be a part of the long-term plan, there are other strategies that can be considered to maximize the resources we currently have available. First, providing training for our first responder partners in curriculum such as Mental Health First Aid (MHFA) for Public Safety and Fire (8-hour course) and Crisis Intervention Team (CIT) Academy for Law Enforcement (40-hour / one week) can provide important foundational training (MHFA) and more enhanced skills (CIT) for personnel throughout the County so they are better prepared to handle calls involving those with behavioral health issues. Advocate for the MHFA training to be added into law enforcement and fire basic academy curriculum. Second, explore opportunities for City/County collaborations to expand mobile crisis services and consider the viability of strategically adding dedicated co-responder units. Third, employ technology that can extend the reach of office-based crisis trained personnel to support responders in the field throughout the County. Fourth, pilot a model of embedding crisis trained staff at County Communications, and train all County Communications call takers in the new CIT International online curriculum specifically designed for 911 call takers (8-hours). Finally, we can continue to address a key factor contributing to the current workforce shortage issue in the state by advocating for universities to increase the capacity in their schools of social work and other related licensure fields to address the bottleneck at the university level as schools are not turning out students at a rate that keeps up with the demand.
OTHER AGENCY INVOLVEMENT:
BH collaborates with a variety of stakeholders including all County Law Enforcement agencies, Emergency Communications Center (911), County and County contracted providers of behavioral health services, Hospitals, Adult Protective Services, Child Protective Services, and Consumer Advocacy Groups such as the National Alliance on Mental Illness (NAMI) and the Recovery Task Force, and the Family Service Agency of the Central Coast Suicide Prevention Services who will operate the 988 call center for our region.
This work supports the Monterey County Health Department 2018-2022 Strategic Plan Goals: 2. Enhance community health and safety by emphasizing prevention; and 3. Ensure access to culturally and linguistically appropriate, customer-friendly, quality health services. It also supports one of the ten essential public health services, specifically: 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
FINANCING:
Receiving this report will have no impact on the Health Department Behavioral Health Bureau’s
Budget nor to the General Fund.
BOARD OF SUPERVISORS STRATEGIC INITIATIVES:
Check the related Board of Supervisors Strategic Initiatives:
☐Economic Development:
• Through collaboration, strengthen economic development to ensure a diversified and healthy
economy.
☐ Administration:
• Promote an organization that practices efficient and effective resource management and is recognized for responsiveness, strong customer orientation, accountability, and transparency.
☒Health & Human Services:
• 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.
☐Infrastructure:
• Plan and develop a sustainable, physical infrastructure that improves the quality of life for County residents and supports economic development results.
☐Public Safety:
• Create a safe environment for people to achieve their potential, leading businesses, and communities to thrive and grow by reducing violent crimes as well as crimes in general.
Prepared by: Melanie Rhodes, Deputy Director, 796-1742
Approved by:
______________________________Date: ____________
Elsa Mendoza Jimenez, Director of Health, 755-4526
Attachments:
PowerPoint Presentation
Mobile Crisis Team Frequency Report