NationalAllianceonMentalIllnessofSantaCruzCounty

TaskForceReport

AdvocacyReviewofAcuteCrisisServicesProvidedinSantaCruzCounty

October2017

CarolWilliamson,NAMISCCPresidentandTaskForceChairAdditionalTaskForce/NAMIBoardMembers:SherylLee,NAMIProgramDirector,

BetsyClark,MSW,RamaKhalsa,Ph.D.,HughMcCormickTechnicalAdvisor:MichaelFitzgerald,MS,PMHCNS

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TableofContents

INTRODUCTION-FORMATIONOFNAMI’STASKFORCE 1

NAMITASKFORCECHARGEFORACUTECRISISSERVICES 3

AREVIEWOFMENTALHEALTHACUTECARESERVICES 4

FAMILYENGAGEMENTINTHECSPPROCESS 9

NEEDEDCAREVS.INADEQUATEBEDAVAILABILITY 10

MEETINGSWITHNAMI,COUNTY,TELECARE 10

TELECARECONTRACT 12

AGREATERNEEDFORALTERNATIVEANDTRANSITIONALSERVICES 14

LAWENFORCEMENTANDMENTALHEALTH 15

HOSPITALEMERGENCYDEPARTMENTSANDTHECSP 15

STAFFINGANDCAPACITYINTHECRISISSTABILIZATIONPROGRAM 16

NAMIRECOMMENDATIONS 17

INTRODUCTION-FormationofNAMI’sTaskForceThisreportisasummaryofthefindingsandrecommendationsoftheAcute1CrisisServicesTaskForceformedbySantaCruzNAMImembersinthespringof2017.NAMIisanationalgrassrootsadvocacyandeducationalorganization,withbothstateandcountychapters,whoseprimarymissionisthebuildingofbetterlivesforthoseindividualsinourcountrywithmentalhealthconditions,particularlysevereconditions.NAMI’sroleasanadvocatecantakevariousforms:publicpolicy,supportforresearch,advisoryforlegislativeaction,supportgroups,etc.AcoreresponsibilityisforNAMItolistenandsupportthechallengesfamiliesfaceinseekinghelpfortheirlovedones.Inthisrole,theNAMIchapterhasheardnumerousconcernsregardinghowacutementalhealthcrisisismanagedinthiscommunity.Inparticular,membersoftheNAMIboard(basedontheexperiencesoffamilies)havefeltthattheconditionsandprocessesoftheCrisisStabilizationProgram(CSP),operatedbyTelecareCorporationundercontractandinpartnershipwithSantaCruzCountyMentalHealthServices,wereconcerning.Specifically,theprocessanddecisionsmadeinevaluationofindividualswhoaredetainedinvoluntarilyorwhocomevoluntarilytothefacilitydrewattention.Familieswereexperiencingfrustrationingettingthehelptheyneeded.Theseissuesareaddressedinthisdocument,includingaconcernregardingthereleaseofSeanArlt,wholaterwaskilledbypolice.Amarkedincreaseinepisodesoffamilydissatisfactiondevelopedinlate2016followingtheresignationoftheTelecarefacilityadministrator,alongwithmanyotherstaff.Therehadbeensignificantleadershipturnover;itseemedthatserviceswereindisarray.MoreandmoreconcernsweremadethroughtheNAMIwarm-linefromfamiliesdistressedaboutgettingtreatmentandstabilityfortheirfamilymembers.Wefelturgencyforaction.NAMImemberssubmittedwrittenandverbalstoriesoftheirchallengeswithmentalhealthserviceslocally,andinparticularwiththeCrisisStabilizationProgram.Communityconversations,includingwithelectedofficials,ensuedinordertofindthebestvehicleforadvocacy.Intheend,aTaskForcewascreatedthatwouldfocusonthemostpressingissue,whichwasintheacutementalhealthcrisisarena,andinparticularevaluationandtreatmentservicesprovidedintheCSP.InlateMayofthisyear,NAMIwrotealettertotheCEOAnneBakaroftheTelecareorganization,voicingtheconcernsandrequestingaction.ToTelecare’scredit,Ms.Bakarprovidedaquickresponsetoourrequestformeetings.Ms.Bakaroverseesaverylargeorganization,withprogramsinvirtuallyeverycountyinCaliforniaandinmanyotherstates.Sheexpresseddeepconcernandimmediatelyagreedtoparticipateinthesemeetings,bringingintopleadersoftheTelecareorganization.Theneedsforimprovementweredeterminedtobesignificantandtheservicesnottothestandardsofthecommunity,andasitturnedout,nottothestandardsoftheTelecareCorporationitself.Strongskilledleadershipisimportantforoperatingtheprogram,andthisandotherissuesneededtobe

1Acutereferstosomethingexpressedtoasevereorintensedegree.

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addressed.WewereimpressedTelecare’stransparencyinacknowledgingtheproblems,andtherapidactionofhiringahighlyqualifiedregionaldirectorofacuteservices,whothenhiredbothaclinicaladministratorandadirectoroftheCr,bothalsohighlyqualified.Improvementsinthecultureofcarearenoticeablealready.WeofferappreciationtoSantaCruzCountyMentalHealthDirectorErikRivera,ChiefPsychiatristVanessadelaCruz,AdultServicesManagerPamRogers-Wyman,andQualityImprovementProgramManagerKarolinSchwartz,whoattendedthesemeetingsandwerehelpfulinreinforcingtheneedforimprovements.Thisdocumentwillfocusalsoonwhatwehavelearnedaboutthesystemsdesignthatdrivesthescopeandqualityofthisvitalsafety-netserviceinourcommunity.Webelievethatmanyproblemsinourmentalhealthcarearesystemicandreflectunintendedconsequencesofthecurrentfederalandstatestructuresoffundingandcontrol.Wefoundvalidationforthisintheinvestigationsofothers,includingtheCaliforniaHealthcareFoundation.Thereareflawsinthelocaldesignthataredifficulttoresolveduetoasharpdivisionofservicesfrompublictoprivate–anunnecessaryburdenonourcommunitytotryandnegotiate.Essentially,wefindthementalhealthsysteminCaliforniatobeacomplex,confusing,andpoorlydesignedsystemthatisinneedofchange.Wecallonourcountymentalhealthleadershipandelectedofficialstohelpadvocatewithfederalandstaterepresentativestoaddressthesestructuralproblems.Accesstocareattheappropriatetimeandwithneededsupportssuchashousingandrehabilitationareessential.Theseservicesarecritical;literallylivesareatstake.ItisnottheroleofNAMItoregulatethepracticesnortowritethepoliciesfortreatmentproviders,buttoadvocatefortheirimprovement.Thisreportiswritteninordertofulfilltheadvocacyresponsibilityofourorganization,bysharingtheseconcernsandtheresponsestotheseconcerns.Inthisway,weprovideeducationtothecommunityandhopefullypromoteanongoingdialoguetowardsimprovementinhowindividualsexperiencinganacutementalhealthcrisisarecaredforinSantaCruzCounty.WewouldliketofurtheracknowledgetheprofessionalsandotherstaffatTelecare,CountyHealthandMentalHealthCareServices,localhospitalsandallotherprovidersinourcommunitywhohavededicatedthemselvestothisfield.Ourlovedoneshavebenefittedfromtheirefforts,andwearegrateful.

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NAMITaskForceChargeforAcuteCrisisServices(ReaffirmedSeptember2017byNAMIBoard)

1. Provide awareness to both County and Provider to the areas of dissatisfaction expressed to NAMI by the families and consumers of crisis services in Santa Cruz County.

2. Work collaboratively with those agencies towards building improvement in the service

experience and the quality of care supplied by the Crisis Stabilization Program (CSP), by providing information on current experiences and suggestions for improvement.

3. Through the assistance of a technical advisor, ask questions into the

policies/practices/leadership at the CSP in advocacy of improvement in care.

4. Learn the capacity of treatment at the facility, and the contributing factors to overcrowding, out-of-county placement, and extended stays.

5. Learn about the impact of any workforce issues, including recruitment, pay, turnover,

training and competencies that may impact the quality of services.

6. Review the facility leadership planning for impact on quality of services, culture of care, and adherence to standards.

7. Determine the role of Santa Cruz County in the quality oversight of the CSP/PHF

facility, the day-to-day operations, and funding adequacy for optimal care.

8. Study the level of comfort and dignity in the environment of care and the impact on services provided and the experience of the consumer and family.

9. Examine the relationships of the CSP with other agencies involved in the crisis

management of the consumer: police, sheriff, hospital emergency departments, El Dorado Center, and Telos Crisis Residential Center.

10. Explore the mental health system existing structure for how it impacts provisions of

mental health crisis services.

11. Explore follow-up care for individuals not admitted to, or released from, the CSP.

12. Explore the CSP culture regarding the encouragement of family engagement, and barriers to this engagement.

13. Provide an advocacy-focused report to the NAMI board, membership, and the Santa

Cruz County community on the information above.

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AReviewofMentalHealthAcuteCareServicesHistory&CurrentThereisanincreasedattentionbyourcommunity,andbycommunitieseverywhere,onissuesregardingmentalhealthandaddictionconditions.Moreandmore,individualswho’veexperiencedsevereconditionsandtheirfamilieshavecomeforwardtotalkoftheseexperiences.Manyareparticipatingineffortstoimproveservicesthroughactiveadvocacy.Thishasopenedupthementalhealthdialoguetolookathowthesystemofservicesarestructured,whatthefundingstreamsareandhowtheyarespent,andwhyisitseeminglysohardtogettreatmenttothosewhomostneedit.AtNAMI,weknowthereisagreatamountofneed.Weknowthisfromourpersonalexperiences,themanyphonecallswereceiveonour“warmline,”theobviouspresenceofsomanyindividualswhoarehomelessandmentallyillinourstreetsandparks,theepisodesofdrugoverdosecomingtoouremergencyrooms,andthenumberofmentallyillindividualswhoresideinourjail.Weknowthatthisisnotuniquetoourcommunity,andthatleadersinmultipleagencies--includingpublichealth,mentalhealthandlawenforcement--havebeenworkingtoaddresstheseissues.Theneedthatwehearconstantlyexpressedbyfamiliesisinfindingandreceivingaccessibleandeffectiveinterventionsthatwillhelpourlovedoneshealandmoveforwardwiththeirlives.Thisreportisfocusedontheemergencymentalhealth(crisis)servicesinourcounty,andinparticulartheevaluationandtreatmentservicesprovidedattheonlyfacilityinthecountywith24-hourmentalhealthevaluationcapability.ThePsychiatricHealthFacilityandCrisisStabilizationProgramarethesingledesignatedsettingsformentalhealthassessment(5150/5585W&Icode)andfortreatmentofpeopleonaninvoluntarybasis(WelfareandInstitutesCode5250certificationprocess).DominicanPsychiatricUnithadthisdesignationbeforeitspsychiatricunitclosed.Manythingsareeasiertounderstandwhentheyareplacedincontext,andintermsofacutecrisisthereisahistoricalcontextthatisinformativetothecurrentsituation.Whatwe’vecometorecognizeisthattherearemanyfactorsthatledtothedesignoftheseservices,andthattherearefinancialstructuresinplacethathavedriventhewaycareisprovidedtoday.Wehavelearnedthatthisdesigndoesnotalwaysalignwiththeneedsofpopulationswithinourcommunity,andsignificantchangesareneededinthisdesigninordertobetterfilltheseneeds.Forbetterandforworse,mentalhealthacutecarewasprovideddifferentlyafewdecadesback,withmoreaccessibilitytotreatmentintheacutecaresettingandthecostoftreatmentfarlower(evenafteraccountingforinflation).Itwasnotwithoutflaw:therewasanover-relianceonsedatingmedications,higheruseofrestrictivecarepractices,andlessrecognitionoftheimportanceofthepatient/familyparticipationintreatmentandthevalueofpeersupport.Manythingshaveimproved.InCalifornia,theclosingofstatehospitalbedsbeginninginthe1960swassupposedtobemetwithgreateravailabilityofpsychiatricbedsinlocalcommunitiesandotherservicesthatwouldreplacethelong-terminstitutionalizationofpeoplewithseverementalillness.Communityhospitalsthroughoutthestatedidbegintoprovidepsychiatriccare,andinthateraSantaCruzCountyprovidedinpatientservicesatthehospitallocatedonEmelineStreet.Thecountyeventuallyclosedbothitsmedicaland

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psychiatrichospitalservices,becomingthecontractorratherthantheproviderofacutecaretreatment,andin1983DominicanHospitalopenedupanewinpatientfacilityformentalhealth.Untilthemid1990’s,patientswerebroughtfromtheirhomes,thestreetsandcommunityatlargetotheDominicanmentalhealthunitiftheywereinacrisisstate.Therewere28crisisbeds,(whereasnowthereareonly16).ThestatepaidtheMedi-Calbillsunderafee-for-serviceagreementwithfederalmatchingfunds(50%)andcountyrealignmentfundinghelpeddefraythecost.TheStatedismantledtheStateMentalHealthDepartment,absorbeditunderallHealthCare,andhasnowtransferredthefundsandtheauthoritytotheCountiesDuringthoseyearsDominicantreatedahigherpercentageofprivatelyinsuredpatients,andthoseinsurancecompaniesbegantoaggressivelymanageanddenypaymentforcare.However,becausethereweremorebedsallowedwithinahospitalbasedinpatientprogramtherewasreimbursementthroughMedi-Cal,MediCare,andprivateinsurance.ThestateappliedandwasgrantedafederalMedicaidchangeallowingcountiestobecomemanagedcareplansandhavefullresponsibilityfortheentirecontinuumofcarefromstatehospitalbedstolocaloutpatientcare.Coreelementsoftreatmentaccessarerequired,butmanysmallerandruralcommunitiescouldnotaffordafullrangeoftreatmentoptionsoradequatecapacity.Localcontrolallowedmoredevelopmentofresidentialtreatment,casemanagementandrehabilitationservicesincludingthoseinsupportedhousing.Theseplansvariedcounty-to-county(astheystilldo),withsomecountiestighteninginpatientutilizationandexpandingresidentialtreatmentandarangeofdifferentoutpatientcare.IngeneralSantaCruzisseenashavingarangeofdifferentlevelsofcare,butcapacityisinsufficientatmostlevelsofcare,duetolackofoptionsfordevelopmentofnewhousingbedsbecauseoflossofRedevelopmentFundsandstateallocationsforfunding.LengthofstayinthePHFaverages5-6days.Medicare,Medi-cal,andprivateinsuranceonlyauthorizepaymentforservicesthatmeet“medicalnecessity”.Animprovementhasoccurredindeterminationoflengthofstay.Inthepastthelengthofstaycouldbedictatedbythepaymentsource’sdeterminationof“medicalnecessity”.Currently,thepaymentsources(Medi-Cal,Medicare,Privateinsurance)donotdeterminethelengthofstay.However,itappearsthattheshortageofbedsandsmallspacecreatespressuretomovepeopleoutquicklyortonotadmit,alongwithaprevailingphilosophythathospitalizingshouldbeavoided.Theotherdifficultyisthatthe16bedsareprioritizedtobeavailableforpeoplewhohaveMedi-CalandwhoareintheSCCountysystemofcarealready,oreligible.ApproximatelyonethirdofthepeoplewhocometotheCSP,andaredeterminedtoneedhospitalization,havetobesentoutofourCountytootherlockedfacilitiessuchasFremontHospital.Thejailsandprisonsareacknowledgedtohouselargenumbersofmentallyillinmates,buthowmuchofthisisrelatedtootherfactors?Itisnotdisputedthatnowthereisahigherbarsetforcivilcommitmentinhospitals,buttherearealsomoreoutpatientoptionsforindividualswithseriousmentalhealthconditions,includingcrisisresidentialservices,innovativeprogramsoperatedbyindividualswithlivedexperiences,intensivecasemanagement,etc.Onetruththatindependentanalysts,countymentalhealthdirectors,andothersseemtofullyagreeonisthatthefundingnecessarytoprovideenoughcapacityandflexibilitytomeetindividualpatientneedsfrominpatientcaretocommunityoutpatientserviceshasnotbeensufficient.Thisisespeciallytrueinregardsto

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housingneeds–itisanincrediblydifficultprocessforanindividualwithaseriousmentalillnessandchronichomelessnesstoachieverecovery,absentapathwaytoaffordableandsupportedhousing.Inthe1990’sand2000’s,manypubliccommunityhospitals(highconcentrationsofMedi-Cal)closedtheacutepsychiatricserviceswhichtheyhadopenedinresponsetothecallforclosingstateinstitutions.Eventually,DominicanHospitalannouncedittoowouldcloseitspsychiatricservices.AndwhileDominicanprovidedalongnoticeaswellasacontributionof$5milliondollarstofundanotheroption,thoseoptionswereverylimited.“TheIMDExclusion”,ANationalIssuesince1988:InordertoqualifyforMedi-calandMediCaidreimbursement,thereareonlytwooptionsforinpatientpsychiatricservices(1)Psychiatricunitsthatareinalargegeneralacutecarehospital,and(2)PsychiatricHealthFacilities(PHF)whicharefreestandingsmallhospitals(16beds)whichfocusonacutementalhealthcare.Althoughlicensurewouldallowanysizepsychiatricfacility,Medicaidlawprohibitsuseoffundingtolargerthat16.ThisiscalledtheIMDExclusion.(IMD:InstitutionsofMentalDiseases)Welearnedfromourdiscussionsandreviewthatthisfederalregulationisaseriousissueandtherootcauseofsomeofthestructuralproblemsweseeinourlocalcaresystemandinmanyothercounties.DuringtheObamaadministrationtherewasacalltochangethisIMDexclusion,toallowMedi-Caltobebilledforacutecarefacilitieswithmorethan16beds,andwithlengthsofstayof30daysorless.But,unfortunately,thatconsiderationisnowonhold.DuringthefinalyearsofDominican’soperation,agradualdecreasefrom28bedsto18bedsensued.DominicanBHUoriginallyoperatedwith28beds.In1999Californiapassedalaw,AB394,thatinstitutednursingratiosforvariousmedicalservices,includingpsychiatricsettings.Thenursingratioforapsychiatricunitis1RNregisterednurseto6patients.Dominicanreducedthebedcapacityfrom28to24inresponsetothislaw,in2003.Upto2012theBHUoperatedwith24beds.DominicanHospitalreportedafivemilliondollarayearlossontheBHU,overaseveralyearperiod.ThisultimatelyledDignityHealth,whoacquiredtheDominicanHospital,toclosetheservice.Areviewofbedutilizationoverthepreviousthreeyears2007-2011showedanaveragedailycensusof14.2patientsperday,whichcontributedtoDominicanchoosingtoreduceto18bedsin2012,duetofinancialloss,andalsoledtotheCounty’sconclusionthatthe16bedcapacityofthenewPHFwouldbeadequate.LimitedOptionsforCrisisandInpatientServicesGivenlittlechoice,thecountyturnedtoaPsychiatricHealthFacility(PHF,pronounced“puff”)licensebecauseunderthislicense,itwaspossibletoreceivethefederalmatchingdollarsforthestateMedi-Calexpenses.Thechallengewasthatonly16bedscouldbeprovidedtothecommunity,underfederallaw,andstillbeeligibleforthefederalreimbursement.SinceDominicanhadbeenprovidingcrisisstabilizationservicesaswell,asolutionforthatneededtobefoundalso.Thecountychosetocombinethesetwoneedsintoonebuilding,withside-by-sideservices:aCrisisStabilizationProgram(CSP),alongwiththePHF.ThisprovidedmanyadvantagesintermsofimprovedcoordinationofcarefortheMedi-Calpatient.

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ThePHFshavedifferentlicensingrequirementscomparedwithhospitalsbecausetheyfocusonlyonmentalhealthstabilizationandtreatment,andhavemorerehabilitationandtherapystaffandlessnursingcapacity.PHFscanonlybeopenedwiththepermissionofthecountieswheretheyreside,givingthecountystrongleverageovertheoperations.ADesignthatWorksBetterforSomethanforOthersWheresomeproblemswerebeingsolved,otherswerebeingcreated.Oneproblemwithlessbedavailabilityislimitedaccessforprivateinsurancepatients.Peoplewhoareprivatelyinsuredcanbetreatedifthereiscapacityandtheinsuranceprogramallowspayment;howeverMedi-Calrecipientsareprioritized.IftheyareadmittedtothePHFtherearechallengeswithtransitionstoprivateinsurancefundedcareforaftercare.Someinsuranceprogramshaveclosednetworks,likeKaiserandVAsothosepatientsaresentfromCSPtotheKaiserPHFortheVAhospital.OtherCountyaftercareordiversionprogramsarerarelycoveredbyprivateinsurance,andthecountyisnotsetupforthis.ThesepatientsareoftentransferredoutofcountyduetolackofavailablebedsatthePHF.Theimpactofthisforfamiliesissignificant.Theymusttraveloutofcounty,sometimesgreatdistances,toparticipateinthecareoftheirlovedones.Thesepatientsaresubjecttomultipleambulanceridesattimes:to/fromtheemergencydepartmentforlabdrawsandmedicalclearance,andthenoffonanothertriptoahospitalorPHFwillingtoacceptthem.OutofcountyprogramsmayhavelittleawarenessoftheoutpatientandaftercareservicesavailableintheSantaCruzcommunity.Thismakestransitionsincaredifficultandriskorre-hospitalizationhigher.Becausethe16-bedlimitationonlyappliestothematchingoffederalfundsforthepublicpayMedi-Calpatients,(whichincludesalldisabledindividualsandlowincomeindividual),thishasthegreatestimpactontheavailabilityoftheseservicesforthenon-publicpaypatient.TheStatewaiverandmodelemphasizesprovidingservicestopersonsattheleastrestrictive,appropriatelevelofcare.ThisisbasedonamajorfederalcasecalledtheOlmsteadAct.Theexpectationisthereisarichsetofalternativeservicestolockedcare,andonlywhensafetyisatrisk,wouldsomeonebeputintolockedinvoluntarytreatment.Theassumptionisthereisenoughcapacityandintensivealternativessuchastransitionalresidentialtreatmentwith24hourssupportstooffersoundclinicallyappropriatealternatives.Unfortunatelyaspreviouslydiscussed,therearenotenoughalternativebedsforsmoothtransitionsandlevelsofsupport.Thecountymadeeffortstoaddressthisconcernonthefrontend:requiringthatthecontractor(Telecare)seekcontractswithinsurancepayers,butnotallpayerswillcontractwiththeCountyPHF,forreasonsnotreviewedinthisreport.However,thelargerissueisthattherearesimplynotenoughcrisiscarebedsandnotenoughcapacityatthelowerlevelsofcareforqualityaftercaresupports.A“Two-TieredMedi-CalSystem”Wehaveatwo-tieredsystem.TheMedi-Calpatientswhoareexperiencingamentalhealthcrisisbutwhoarenot“seriouslymentallyill”(SMI),arechallengedbythesystemofcare.Theseindividualsareconsidered“mildtomoderate”intheirseverity,andarenotcandidatesfortheregularCountyprogramswhicharegearedtowardsrecoveryofaseriousmentalillness.TheseMedi-CalpatientswithmildtomoderatetreatmentneedscanbereferredtoBeaconHealthOptionsmentalhealthservices,whichisanetworkoftherapistsandothermentalhealthproviderswhoprovideservicesunderacontractwithCountyBehavioralHealthandfundedthroughtheCentralCaliforniaAllianceforHealth,

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withMedi-Calfunds.BeaconalsooperatesservicesunderCountycontractoutoftheCountyPrimaryCareHealthClinicsinWatsonvilleandSantaCruz.Thisisaveryconfusingsystemforpersonswithmentalhealthneedsandfamiliesandoftenpeople’sneedschangefrommild/moderatetosevereandbackagain.Sothepotentialforbeingbouncedbetweenprovidersandsystemsissignificantandaccesstopsychiatryiscritical.ThiswaspartoftheStateMedi-CalPlanfor2020wheretheywanttoseemorebehavioralhealthintegratedintotheprimarycaresitesandhealthhomes.Whilethevisionispositive,onthegrounditdoesnotworkwellformanypatientsandfamiliesandcausesgreatconfusion.Thissituationisagainwidelyacknowledgedasaseriousproblem,andsoeffortsarebeingmadetocorrectthisatmanylevels.Locally,theCentralCoastAllianceandthecountyMentalHealthPlanhavebeenworkingonsolutions,asthesepatientsmayflowbetweenthetwobasedontheirsymptoms.Theresultofallthisisavariancebetweenwhatthecommunityexpectationsareforservicesandwhatthedesignofservicesis.Thisisattherootofmanycomplaintswereceiveandwebelievethismustbecontinuallyopenlyaddressedasanissue,freeofblame.NAMIencouragesthecommunitytounderstandthatitisnotthefaultofthecountyhealthsystemthattheseproblemsexist.Ourhealthcareleadersareintheunenviablepositionofdoingalltheycantomitigate,astheyareessentiallythe“owners”ofthestatementalhealthsystemforthiscommunity.Thisisnotthesystemanyonewouldhavedesignedfromscratch.ThegoodnewsinSantaCruzCountyisthatthecommunityisengaging.Recentlyleadersfromseveralorganizations,EmergencyRoomphysicians,Telecareleaders,CentralCoastAlliance,primarycarephysiciansandothersmetonabeautifulSaturdaytodiscusswheretheproblemslieandwhattheprioritiesshouldbe.Itwasaninspiringexerciseofcaringforapopulationwhoareamongthemostaffectedbychallengesinthehealthcaresystemandtheeconomy.Therewasnotalkofassigningblame;onlyinunderstandingwhatthesituationisinorderthatsolutionsmaybefound.KeyPoints

1. ThedecisiontobuildtheCSP/PHFmodel,with16beds,wasmadewithlittletonootheroptionavailableforfundingtreatmentofMedi-CalclientsonceDominicandecidedtocloseitspsychiatricunit.FundingofaninpatientunitrequiredthatservicesbeeligibleforMedi-calreimbursement.TheCountybaseddecisionsusingtheaveragedailycensuswhichwas14.2patientsduringthe3yearspriortoDominicanclosing.

2. Thishashadsignificanteffectonthecommunity’scapacityforinpatientservices,whichat16bedsiswellbelowtheaveragenumberofcrisisbedsper100,000residentsinthestateanddrasticallyfewerthanisrecommendedbyTreatmentAdvocacyInc.,anationaladvocacyorganization.

3. Therearelimitedprogramswith24hourtreatmentbedsforout-patientcareinthecontinuum

ofcareforthosewithsignificantmentalillness/chronicallyimpairedandwhoareatriskotherwiseforrepeatedhospitalizations.

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4. ForprivatelyinsuredpatientsandthosewithMedi-Calbutwhoarenotseriouslymentallyill,thesystemhassignificantchallengesinaccommodatingtheirneedsduetocontractingandspaceissues.

5. ThisisnotuniquetoSantaCruzbutisastatewideproblem.

TheCaliforniaHealthcareFoundationin2013notedtheimpactsonthecounty-controlledmentalhealthsystemdesigninaninvestigativepaper.Afewoftheaboveissueswerecalledoutinthisreport:

● Asthemostpopulousstate,CaliforniarankedfirstintheUSfortotalspendingonpublicmentalhealthservicesbut15thforpercapitaspending.

● StatelawsshapeCalifornia'spublicmentalhealthdeliverystructure,butnearlyallfinancialandadministrativeresponsibilityfordeliveringtheseservicesrestsoncounties.Thisdecentralizationhasresultedinwidevariationinprogramoperations,quality,andserviceavailability.

● Asinmanyotherstates,fundingforCalifornia'spublicmentalhealthsystemis"carvedout,"ordisconnected,fromtherestofpublichealthcaresystemfunding.Asaresult,peoplewithmentalhealthneedsoftenmustnavigatetwosystemsforcare.

From: A Complex Case: Public Mental Health Delivery and Financing in California --- CHCF July 2013

ItisofinterestforusasadvocatestolearnandsupportchangesthatwouldimprovethesystemofmentalhealthandaddictioncareforallCalifornians,andthatserviceswouldbereceivedregardlessofwhichinsuranceplanisinvolved.Are-thinkingofthesystemdesign/decentralizedcontrolmaybeinorder.WesupportalleffortsthatSantaCruzCountytakestomitigatetheconsequencesofthementalhealthsystemasitstands,throughcollaborationandthesharedideasofallcommunityagenciesdedicatedtothiscause.

FamilyEngagementintheCSPProcessCountiesthroughoutthestateareinvestinginfront-lineservicesthataredesignedtopreventhospitalizationswhenpossible.Thisleastrestrictiveapproach,however,doesnotworkforeveryone.Thishasdrawnourconcern,incaseswherepatientsarereleasedandthefamilieshavebeenuncleartowhyorwhattreatmenttheirfamilymemberscanaccesstostabilizetheirseveresymptomsandillness.Familieshavebeenfrustratedwhenthebackgroundinformationandhistorytheywishtoexplainhasnotbeenincludedandconsideredintheassessmentprocesses,andtheindividualisnotacceptedfortreatment.Itisusuallyaverytraumatictimethatleadsafamily/friendtoattempthospitalizationoftheirlovedone.Family/friendsalsoneedinformation,support,andmeetingswithdoctorsandsocialworkers.Onlyextremecircumstancesbringabouttheseeffortstogetcareforfamilymembers.ThroughtheprocessofmeetingwithTelecareandcountymentalhealthleadership,therewasmuchdiscussiononhowtoimprovethecommunicationwithfamilieswhilemaintainingthepatient’srighttoconfidentiality.Severalideashavetakenformandsomespecificchangeswerecollaborativelydevelopedinwhathasbeenaverypositiveapproachbetweenthecountymentalhealthteam,

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Telecare,andNAMIrepresentatives.CarolWilliamson,SherylLeeandBetsyClarkfromtheNAMIboardhavetouredandworkedcloselywiththenewleadership,toimproveawarenessoftheprocessforassessmentandthepotentialimpactonfamilies.Newtraining,processes,formsandsignagehavebeenorareintheprocessofbeingimplementedtoreflectare-prioritizationoftheimportanceoffamilyengagementandinformationintheevaluationperiod.NAMIispleasedthatallpartiesrecognizedtheimportanceofthisroleandanticipatesimprovement.Itwasanotherreflectionofthedesireofallpartiestoimprovetheservicecomponentofcare.

NeededCarevs.InadequateBedAvailabilitySomeindividualsneedhospitalizationtomanageandstabilizetheirseriousmentalhealthconditionwhenitisinanacutephase.Theprevalentconceptionthathospitalizationsshouldbeavoidedcarriestheriskthatpatientswhorequirethatlevelofcarewillnotbeconsideredforadmissionwhenitisthebestavailable,clinicallyappropriatelevelofcare.Thisisdonewithallgoodintentions,andthepatientmayevenseeminglybeimprovedwhileintheCrisisStabilizationProgram24hourevaluationperiod.However,apatientadmittedtoacrisisstabilizationunitdoesnotmeanthattheconditioncanberesolvedwithin24hours.ThiswasespeciallyconcerningbecauseoftheSeanArltcasefromOctober2016.Itisnotpossibletostabilizeallpatientswithinanarrowtimewindow,andtherearemanyreasonswhyahospitaladmissionwouldbetherightdecision.CrisisStabilizationshouldbereservedforthosepatientswhoseconditionneedsamorethoroughevaluationtodetermineacuity,andwhosesymptomsindicatethattheycanrealisticallyimproveenoughtobereleasedwithin24hours.OthermoreseriouslysymptomaticpatientsshouldbequicklyadmittedtothePHFortoanotherhospitalifbedsarefull.NAMIisrecommendingthatstrongrelationshipswithregionalpsychiatrichospitalsbeestablished,providingplacementsupportandassistancewhenpatientsaresenttherefromtheCSP,toavoidtreatmentdelayandhelpensureahighstandardofcareisinplace.Lessbedavailabilityincommunitiesimpactshowservicesareprovided.TheaveragenumberofpsychiatricbedsinCaliforniaisapproximately14/100Kpopulation,afigurefarbelowtheTreatmentAdvocacyCenter’srecommendationof50beds/100K.ButinSantaCruzCountytheratioofpsychiatricacutebedsisnow6/100K,lessthanhalfanalreadylowstatewideaverage.Thisisn’tbecauseofalowerneedlevel.Mitigationforthisimpactmustbemadeinwaysthatdonotresultinthedenialofpatientadmissionsortheprematurereleaseofpatients,whenthosepatientsneedadditionaltreatmenttosuccessfullyreturntothecommunity.

MeetingswithNAMI,County,TelecareTheNAMItaskforceonacutecrisisservicesheldseveraldiscussionsonthebestpathforwardtoengageboththeCountyofSantaCruzandtheTelecareCorporation.TwomeetingsincludedmembersofthecountyBoardofSupervisors,andanotherwiththemayorofSantaCruz.Wefelttherewasgoodsupportfortheseefforts,whichweretobefocusedonapurelyadvocacyagenda.ItwasevidentthatthereweresignificantchallengesintheCSP,beginningwithleadership.Thefacilityadministratorpositionwasvacant,aswereotherkeyleadershippositions,includingtheDirectoroftheCSPandtheDirectorofNursing.TheSeniorVicePresidentforAcuteServicesatTelecarewasservingastheactingadministratorofthefacility.Fromthereportsoffamilymembers,manyofthestaffwerenotreceptivetotheinputoffamilymembersduringtheevaluationprocess,wereunfamiliarwiththe

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FamilyInformationForm,andappearedtobewithouttrainingincommunicationskills.Wedeterminedthattherewerenotenoughseatingloungersforpatientsduringhighvolumes,andthattherewasalackofconsistencyinfeedingpatients,aswellasnotableforeating.Therewasnoplacetosleep,excepttheloungechairs,thoughpatientsmayhavetostayevenacoupleofdaysintheCSPiftherearenobedsintheneighboringPHF.Ashowerfacilitywasneeded.Asnotedintheintroductiontothispaper,NAMIPresidentCarolWilliamsonreachedoutandfoundawarmreceptionandaninvitationtomeetfromTelecareCEOAnneBakar.Telecareadministrationwasattentiveandconcerned.OverthefollowingfewmonthsTelecaregraduallyaddedonnewleadersforthefacilityandtheregionwhowerereflectiveofTelecare’sassertionthattheorganizationismission-drivenforqualityofcare.Aremodelwithashowerwasputinplace.IthasbeenobvioustotheNAMIboardmemberswhotouredthefacilityandspokewithstaff,thataculturalchangewasverymuchneededinthefacilityandthatsuchachangewasundertakenthroughtheleadershipofJesseTamplen,MSW,LCSW,MHA,FACHE,anexperiencedclinicalandadministrativehealthcareandmentalhealthcareleaderinthestateovermanyyears.ThestaffreportedtoNAMImembersonwalk-throughsthattheywerereceivingeducationandsupportinwaysthattheyneverhadpreviously.Therewasashiftinfocustothequalityofcareandtheimportanceofprofessionalisminallcommunication,withMr.Tamplenhimselfmodelingthewaybypersonallyevaluatingpatientsandassistingfamilies.

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TelecareContractIntheensuingmeetings,importantissuesofclinicalandadministrativepoliciesremainedevenasotherissuesweretakenoffthetablebecauseofcomingtosatisfactoryresults.We’vedeterminedthattheCounty’scontractwithTelecarerepresentsamostlycapitated(fixedreimbursement)agreement.Itisatruepartnership,andtheCountyofSantaCruz’supportforimprovementsinthefacilitymustbereflectedinthenegotiatedagreement.NAMIrequeststhattheCountyandTelecarenegotiateagreementsthatallowimplementationoftheseimprovementsincrisiscare.ProvidingInvoluntaryCare:ARighttobeTreatedAsnotedearlier,theStatehasimplementedaplanwheretheprovisionofinpatientservicescannotbelimited,butthefundingtopayforthoseservicesislimitedbyfederal,stateandcountybudgets.Thecurrentsystemputsthefinancialriskforallcareincludinginpatientcareonthecounties,whoarechargedwithmanagingthesefundsanddevelopinglessexpensivetreatmentoptionswhenpossible.Whilewedonotdoubttheintegrityoftheleadershiporclinicians,theincentivestofindalternativestohospitalizationhasaknownriskofinfluencingpoliciesanddecisions.Thisriskistrueofanymanagedcaresystem.SantaCruzCountyoperates,underafederalwaiveranddevelopedbytheStateinitsMedicaidplan,amentalhealthmanagedcareplanforMedi-Calrecipientswithmoderatetoseverementalhealthconditions.Involuntarymentalhealthtreatmentisanecessaryservicetoourcommunity.Ithasresultedinthesavingsofcountlesslives.FamiliesdiscussingtheirexperienceswithNAMIreportthattheirlovedoneswerereleasedfromtheCSPwhiletheyremaininanacutecrisisstate.Thestandardsforwhoshouldbehospitalizedonaninvoluntarystatuswillalsoinevitablybeimpactedbytheshortageofbedsforinvoluntarycareinourcommunity.AssessmentsandEvaluationsfor5150TheNAMITaskForcereviewedtheCounty’sTrainingManualforestablishingcriteriafor5150detentionholds,whichisthemanualusedtotrainallpeoplewhocanwritehold,includinglawenforcement.NAMIhasexpressedconcernswithwordingandhasrequestedthatTheCountyincludeNAMIasparticipantsinathoroughreviewandrewrite.TheCountyhaswelcomedNAMItoparticipate.ThecomplaintsreceivedbyNAMIfromfamiliesinourcommunityarenotabouttheirchildorfamilymemberbeingadmittedagainsttheirwill,unnecessarily.Ourcomplaintsaretheopposite–aboutindividualswhoarenothospitalizedatallorreleasedbeforebeingstable,whensometimesveryill,scarytotheirfamiliesandeventothemselves;thattheyarereleasedattimeswithoutthecapacityorinsighttoattendanoutpatientprogram,(whichmaynotevenbeavailabletotheirlevelofneed).Accessto24hourresidentialcapacityisverylimitedasanaftercareoption.CSPEvaluationStaffandPhysicianRolesThemostimportantdecisionintheCrisisStabilizationProgramiswhetherapatientbroughttothefacilityisdetainedforcrisisstabilizationoradmission,orisreleased.ThiscrucialdecisionisthemostimportantpurposeoftheCSP,whichhasapsychiatriston-call24hoursaday.

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Ourcommunityhaslearnedhowimportantthisdecisioncanbe.

SeanArlt,ayoungfatherwholivedwithamentalillness,diedonaverystormynightofOctober16,2016,fromgunshotbyaSantaCruzPoliceOfficer.Ourunderstandingisthatthepolicehadbeencalledagain,becausehewasinadelusionalstateofpsychosis,withaggressivebehaviorsverysimilartobehaviorsthathadjustfivedaysearlierledhimtobecontainedbymultiplepoliceofficersundera5150andtakentotheBehavioralHealthCenter.Unfortunately,inthatfirstincident,hewasreleasedwithineighthours,beforestabilized.Fivedayslater,thesecondincidentofOctober16th,hehadaconfrontationwithlawenforcementthattragicallyledtohisdeath.Mr.Arlt’sdeathhadamajorimpactonthecommunityandhelpedtosparkthisTaskForcereviewofservicesattheCSP.Otherfamiliesreportedproblemswithassessments,andwithquickreleases.Therewerediscussions,informalmeetingsandseparately,betweenTelecareadministrationandNAMIregardingthequalificationsandrequirementsofstaffevaluatingpatientsintheCSP,andtheroleofthepsychiatristinthisprocess.Telecare,withanewlocaladministrationinplace,hasupgradeditsstandardsforreleasesfromtheCSPfacility.Telecarewillnowprovidealevelofserviceabovewhatisminimallyrequired,andinkeepingwiththehigherregionalstandards.PriortoreleaseofaninvoluntarypatientfromtheCSPfollowingevaluation,apsychiatristwillbeconsultedforareviewofthecaseandwillprovideadvisementbasedonwhatheorshehaslearned.Thisisnotanassessmentbythepsychiatrist,butgiventhevolumeofpatientsseenattheCSP,itwouldnotbeastandardinanyknowncommunityofthissizetohaveapsychiatristavailableinpersonatalltimes.Individualsshouldnotbekeptinthefacilityiftheydonotmeetcriteriafollowinganassessmentbyamentalhealthprofessional,butgiventheseriousnessofthisdecision;weappreciateverymuchthischangeinpracticeandcommendtheleadershipofTelecareforthiswillingnesstolistenandtoactonourconcerns.Thebottomlineiswewantourcommunitymemberstobesafeandhaveaccesstotreatment.Weremainconcernedabouttheuseofmaster’sprepared“waived2’3staffevaluationofpatientspresentingtotheCSP,unlesstheyareadditionaltotheprimarylicensedevaluator.WeunderstandTelecarehasrecentlyincreasedpayforSocialWorkersinordertoimproverecruitment.AccreditationandStandardsfortheCSPTheCSPandPHFareaccreditedbytwobodiesthatoverseequalityofcare:CARFandtheJointCommission.TheJointCommissionisahospitalorientedqualitybodyandCARFisformentalhealthandSUDtreatmentandrehabilitation.Comparedtohospital-basedprogramstheregulationsarelean.TheStatedoesnotrequireeitherofthesecertificationsanditispositivetheTelecareandthecountysupportthisworktostayuptostandardsinthefield.Forcontinuityoftreatment,NAMIadvocatesfor

2“Waived”staffmeansthattheyarequalifiedmentalhealthprofessionals,notyetlicensed,whoaretypicallygainingworkinghoursfortheirlicenseandwhomayperformagreatmanyoftheresponsibilitiesthatlicensedstaffperform,undersupervisionbyalicensedstaff.Suchsupervisionconsistsofweeklymeetings.

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theJointCommissiontoevaluateandcredentialboththeoutpatientCSPandtheinpatientPHF.Thiswouldhelptheprogramsbemoreintegratedandseamless.

AGreaterNeedforAlternativeandTransitionalServicesNAMIhasidentifiedthattheavailabilityofalternativestohospitalizationarelimitedandthatmoreprogramsareneeded.Patientswithsevereconditionsneedtimeforpsychiatriccrisisrecovery,formedicationstobeadjustedandevaluatedasneeded,andforafullerunderstandingoftheirneedstoensurecontinuedrecovery(especiallyyoungpeoplewithfirstbreakpsychosis.)Thewholeexperienceasdescribedbyfamiliesistraumatic.CurrentAlternativeandTransitionalServicesTelosCrisisResidential:A10-bedunlockedfacilitywithrobuststaffing,appropriatefordiversionfromhospitalizationforcertainindividuals.TelosisacrucialresourcefortheCSP,todischargeindividualswhodonotmeetthestandardforinpatientcare,orwhoaredeterminedtobeabletosafelybenefitfromthislevelofoutpatientcaretoresolvetheircrisis.Lengthofstayiscurrentlyfrom10-30daysandistightlymanagedinordertomakeroomfornewreferrals.Manyindividualscouldbenefitfromalongerstayinordertostabilizeandbepreparedforalesssupervisedsettingorreturninghome.AnotherfacilitylikeTeloswouldberecommendedforconsideration.ElDoradoTransitionalResidential:A16-bedunlockedfacilityappropriateforindividualswhoare“steppingdown”fromaninpatienthospitalization.ResidentsparticipateinavarietyofrehabilitativeactivitiesandCountypsychiatristsandstaffworkcloselywithresidentsastheycontinuetostabilizeandmoveforwardintheirrecovery.Lengthofstayiscurrentlyupto30days,longerinsomecases.Thecontractallowsforstaysupto90days,butwithgreatdemandonbeds,thislengthofstayisinfrequent.AswithTelos,manyindividualswouldbenefitfromalongerstaytobebetterpreparedforcommunityliving.AnotherfacilitylikeElDoradowouldberecommendedforconsideration.SecondStory:Aninnovative,effectivepeer-operatedresidenceforpeopleinlesspsychiatricdistress,whichhelpsthemheadoffacrisis,andavoidhospitalization.ThisprogramwascreatedwithaSAMHSAgrantandrecentlyhasbeenabletopurchaseahousewithagrant.Currentlyonly6bedsareavailableandlengthofstayisgenerallyuptotwoweeks.Morebedscoulddefinitelybehelpfulintheoverallpictureofcrisiscare.Thereareotherresidentialprogramsinthecommunitywithlongerlengthsofstay,buttheyarenotthefocusofthisreport.Forexample,CasaPacifichasadualdiagnosisfocusandalongerlengthofstay.Inaddition,thereare“boardandcare”homesandpermanentsupportedhousingbeds,whichhaveanindefinitelengthofstay.Theseprogramsareutilizedforindividualswhoareinvariousdegreesofstability,independence,andstagesofrecovery.Theyaredefinitelypartoftheoverlappingsystemofcare,anddoaffecttheavailabilityofthealternativeandtransitionalprograms,aspeopleoftenmovethroughmanyorevenalloftheseprograms,intheirrecoveryprocess.(TheRiverStreetHomelessShelterdoeshavesometemporarymentalhealthbeds,anditissometimes,sadly,theonlyoptionforoutpatientafter-carefromhospitalization,whenotherplacesarefull.)

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SantaCruzCountyMentalHealthandtheircontractorshavedoneanexcellentjobindesigningandimplementinginnovativeandeffectiveprogramstominimizehospitalizationratesandlengthsofstay.Thisnotonlysavesmoney,itcanalsoprovidealesstraumaticexperienceformanyindividualsinacrisisorpre-crisisstage.Theproblemisthatalloftheseprogramsarehighlyimpacted,withwaitinglistsorlackofavailability.Whenindividualsaremovingthroughacrisis,therightlevelofinterventionandcareattherighttimeiscrucialtopreventfurtherdistressandoutcomeslikehomelessnessandmultiplehospitalizations.Weareinasituationwherefamiliesoftendiscoverthattherightlevelofcarecansimplynotbeaccessedatthetimeitisneeded.IncreasingtheavailabilityofalternativeandtransitionalprogramsisanessentialpartofrelievingthepressureontheBehavioralHealthUnitandalsoinimprovingthequalityandresponsivenessofthecrisiscaresysteminthecommunity.

LawenforcementandMentalHealthLocallawenforcementplaysanimportantandkeyroleinthemanagementofAcuteMentalHealthCrisisis.Theyareactiveparticipantsinassistingourfamilies,andhavesharedthattheyexperiencesimilardifficultieswithshortageofcrisisservices,lackofbeds,etc.Duetolitigationregardingrecentcases,andotherconstraintsthatwehave,wehavedeterminedthatthisisnotthetimeforNAMItoaddressprotocolsandprocedures.Werequestanopportunitytoworkwithlocallawenforcementandmentalhealthservicesregardinglawenforcementandmentalhealthprotocolsandproceduresatafuturetime.NAMIrecentlyhasworkedwithSantaCruzCountyMentalHealth,SantaCruzPoliceDepartmentandtheSheriff’sOfficetodevelopcrisisinterventiontrainingforlawenforcementofficerstobetterrespondtoindividualsincrisis.ThishasbeenverysuccessfulandisopeningupimportantcommunicationbetweenNAMIandlawenforcement.Apolicelieutenanthasjoinedourboardwhichhelpswithcommunicationandunderstanding.

HospitalEmergencyDepartmentsandtheCSPNAMIreviewedconcernsexpressedbyfamiliesbasedontheirexperiencesfollowingtheirlovedoneviatheEmergencyDepartmentsorMedicalFloorofregionalhospitalstotheCSP.NAMIinterviewedcliniciansonboththeEmergencyDepartmentandCSPsides,andhavedeterminedthattheprocessofcareisproblematicattimesandcouldbemuchimprovedwithsomechanges.Thegoodnewsisthatatthetimeofthisreport,discussionsareongoingwiththecounty,TelecareandDominicanHospitaltoprovideimprovementinsomekeyareas:

1. WaittimefortransfertoCSPfollowingmedicalclearancebytheEmergencyDepartment.2. LabStudiesnotdoneinEDpriortotransfertoTelecare,orcapabilityatTelecareforthisor

morethoroughlabworkatEDpriortotransfer.

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3. Patients/FamiliesspendinglonghourswaitingtransferfromtheEmergencyDepartmentforassessmentattheCSP.

4. UnpredictableflowofpatientstotheCSPwithlimitationofstaffinglevelsandcomplexityofpatients.

NAMIwouldliketoseetheadministrationsoftheEmergencyDepartments,Telecare,andthecountytomeetandresolvetheseissuesassoonaspossible.

StaffingandCapacityintheCrisisStabilizationProgram

Theinclusionofbothyouthandadultsatthesamesite,albeitinseparateareas,presentsamajorchallengewhenbothpopulationsarepresentunderthecurrentstaffingplanoftheCSP(ourunderstandingisthatthatplanisbasedononlyadultsbeingpresent).Becausetheratiooflicensedstafftopatientsisbuiltwithoutregardtoage,capacitytoprovideevaluationswillbreakdownwhenchildrenarepresent.Whenyoutharebeingassessed,itisamuchlengthierprocessthanforadultsandtheyarehousedbynecessityinaseparateareaofthebuilding.Giventhisinformation,anduncertaintyonhowmanypatientscanbeheldintheCSP,staffingplanningischallenging,solutionsareneeded.Thereisnocapacityinourcountyforyouthhospitalization;ifyoutharedeterminedtoneedhospitalization,theyaresentoutofthecounty.However,theycanbeassessedattheCSP.NAMIsupportsabettersolutionforyouthcrisisservicesandlooksforwardtohearingmoreaboutthecounty’sgoalsforaseparateoutpatienttreatmentandevaluationserviceontheTelecarecampuswhichwouldprovideamoreyouthorientedenvironmentandfocus,and/orotherplans.

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NAMIRecommendations

1. TheCountyofSantaCruzandTelecareAdministrationshouldsupportthenewlyhired,experiencedleadershipattheCSPwiththeresourcesthattheydeterminenecessaryfortheimprovementofcare,includingstaffingallocations.

2. Recommendfurtheradvancedtrainingforthementalhealthprofessionalsdesignatedfortheevaluationofinvoluntarydetainment,includingtraininginsuicideriskassessment.Recommendthatanexperiencedlicensed(ratherthan“waived”)professionaltoconsistentlyperformtheintakecrisisassessment.

3. Ensurestaffevaluatingthepatientreviewsthe5150/5585formtodetermineifpolicearerequestingnotificationforpotentialcharges,priortothepatientbeingreleased.

4. ThecountytoengageNAMIasakeystakeholderinupdatingtheLPS/5150trainingmanualfortheapplicationandevaluationforinvoluntarydetainmentandexploreoptionsforthosenotmeetingcriteriafora5150hold.

5. Standardizebestpracticetoimprovestaffinteractionswithfamiliesandpatients.ConsistentlyusetheAB1424FamilyInformationFormasindicatedinstatelaw.PrioritizecontinuededucationonfamilyengagementwithstaffandactivefeedbackfromNAMI.

6. Providetofamily,asapprovedbythepatient,anaftercareplaninclusiveofmedicationinformation,follow-upservicesatthetimeofrelease,andeducationalmaterialsapplicabletothediagnosis.

7. Provide,withpatientconsent,informationtothefamilyregardingthedecisionaboutthelevelofcare,anddocumentsuchinthemedicalrecord.

8. CountytoprovideCSPpatientswithface-to-faceortelephoneintroductionwhenpossibleforfollow-upcountyservicesrecommendedondischarge.

9. RecommendachangeinaccreditationvendorintheCSPfromCARFtotheJointCommission.

10. Countyshouldexploreincreasingcrisisresidentialresourcesandother24hourtransitionalresidentialtreatmentsimilartoTelos,(only10beds)withstrongstaffingsupport,todecreasedischargestounstablelivingsituationsorhomelessness.

11. WorkingwithCSPsacrossCalifornia,withinputfromconsumersandfamilies,identifyandimplementbest-practicestandards.

12. ImplementchangesinthemedicalclearanceprocessandlabtestingprocesstoavoidunnecessaryandredundanttripstotheEmergencyDepartment.

13. EvaluatecapacityoftheCSPtobedeterminedalongwithadiversionplanorextracapacitythatensuresthepatientsafetyandimprovedservicemodel.

14. ContinueeffortstoreducestaffturnoverintheCSPandPHF,throughimprovementinwagescales,training,andimprovementinthecultureofcare.

15. Empowernursingandsocialwork/therapiststhroughcompetitivewagescales,autonomy/leadershipopportunity.Encourageandreimburseforspecialtycertifications.

16. FosterleadershipstabilityandengagementandinclusionofkeyTelecarestaffinsystemofcarediscussionswithSantaCruzCounty.

DedicatedtothememoryofSeanArltandKeidaJohnson.