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Will El Dorado County effectively govern more MHSA$ ?

By NAMI El Dorado County Board Member
30-July-2019
Will this county be able to effectively govern yet more MHSA$ provisioned and entrusted by the State of California?     
Results of a Grand Jury investigation made recommendations about how to improve MHSA$ spending effectivity.
We are grateful for the Behavioral Health Commission’s leadership in welcoming public and agency perspective.
Ideas/examples within this post are not new to what we have shared in BH Commission meetings.  
In early June 2019, NAMI El Dorado County’s board of directors discussed and summarized perspective about the top 3 low-hanging fruit opportunities.
1) Lack of fiscal responsibility of the MHSA$ spend process; meaning improved governance is essential particularly where MHSA$ are provided.   Learn more by visiting the Mental Health Services Oversight & Accountability Commission mhsoac.ca.gov.
How are agencies and sub-contractors receiving MHSA$ providing evidence that they are helping those with mental illness (or that their prevention services are in fact lending directly towards early intervention with credible measures?). A basic demonstration of knowledge about pre-disposition, symptoms, and the ability to provide evidence that linkages to relevant services occurred is core.
Opportunity exists to leverage content such as but not limited to NAMI El Dorado County’s  Crucial Conversation Brochure.  Understanding genetic underpinning concepts to clinically predicted risk of attempting suicide, of being emotionally vulnerable, of eventually being diagnosed with a mental illness is key.
Opportunity exists for EDC H&HS to require staff and contractors (especially those receiving MHSA$) at least a minimum understanding of heritability and concordance concepts.  Today EDC H&HS county over-over-over-emphasizes trauma (ACES connection) and does not yet seem to comprehend or embrace a primary predictor of mental illness and addiction.   Trauma informed care is critically important but without also understanding basics about heritability vs concordance rates and why we must treat psychosis promptly then those in paid positions are operating with ignorance.
“The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge.”
Does evidence exist that the county is testing staff/contractors for relevant skill as it relates to genetic pre-disposition and prompt treatment of psychosis.   Prompt treatment of psychosis should not equate to waiting weeks/months/years.
Fortunately, the State of CA has hired Dr. Thomas Insel, former Director, NIMH to help raise the performance bar by counties.
County leaders have a great opportunity to hunt for evidence that MHSA$ prevention recipients genuinely provide meaningful service to help with early intervention of mental illness.    HUBS for example were established initially using funding that included approximately 20% MHSA$ with promises of public health nurses available at every hub capable of performing some basic mental health screening and assurances that reporting mh referrals could be demonstrated.
How are HUB workers getting trained?   What skills in mental illness prevention education can be demonstrated?  How are referrals being measured?  These are some of questions asked by BH commissioners and the public (including NAMI) during a recent BH Commission meeting.
The HUB’s evolved dramatically where a perceived (and non-malicious) bait and switch model occurred.  Nurses were assured (the bait) and what the community got was staff workers (the switch.)   HUBS were to be operating at particular locations – now they have evolved to a looser model.    Stating to the community that it is hard to recruit and retain skilled nurses is not an acceptable response.   The Director overseeing First 5 El Dorado has worked diligently and with compassion to bring improvements to our community.     HUBS is just one of those ideas to help EDC’s public health service evolve.
Redistributing MHSA$ back to the state so that they in turn may re-distribute MHSA$ to county’s that are providing evidence of objective data-centric program reporting is an opportunity.     What would Dr. Thomas Insel suggest?
2) Lack of a quality Behavioral Health Court/process. This is especially an issue in South Lake Tahoe where
have not been addressed.  Over 3 years have passed since the issue was brought to the attention of the Director of H&HS, the CAO, the BH Commission, and Assistant Directors of H&HS.   No improvement actions have been publicly conveyed and certainly no action based on the county’s monthly self-reporting to the BH Commission which clearly illustrates a gross under-utilization of BH diversion court month over month.
Is there sufficient information to the public on the county websites (or anywhere in an easy-to-find fashion) providing how/when to request diversion?
Does criteria for those with insurance (private or Medi-Cal) and without insurance well understood?
We find no information to the public stating who performs the MH assessments (in fact attorney’s with decades of experience in SLT are asking NAMI where to find a MH assessor for their client in jail.).
EDC H&HS appears to be excessively inconsistent and overly subjective in their MH assessment process (and lacking in understanding their psychosis must be treated promptly to preserve cognition long-term.).  Where is the core value of early intervention in practice?   How are improvement opportunities being captured and tracked?
  • Is your loved one’s attorney aware of how/when to request diversion to treatment?
  • Do they understand criteria and how those with and without insurance may face parity issues?  Is this criteria clearly posted to the county website and does it appear when the public performs a basic internet search?
  • Does the community understand that the provider of mental health assessments are solely county clinicians operating in a culture where efficient process/procedures are lacking?
  • Does the community understand that the county mh assessors may not be consistently hunting for historical family information and evidence of mental illness already provided to the county in their loose web of systems?
  • Is clear diversion court criteria publicly available on county websites; are county employees and local attorneys both public and private aware of the process?
  • Our affiliate continues to hear families share that sometimes a MH Assessor in EDC feels too subjective and is inconsistent as to when they are leveraging family history that has already been provided to the county’s H&HS AOT team or to other H&HS workers.   The consideration of family history became a CA law in 2001 known as AB 14-24.   This is where there is serious room for improvement in objective procedures where if one employee skilled in MH assessment resigns then there would be procedures for seamless transition.  Imagine your loved one having more than a dozen hospitalizations and multiple medical reports demonstrating they live with schizophrenia and co-occurring addiction.   Then, a crisis hits and an EDC MH Assessment is done indicating for the first time in over a decade that there is virtually no mental illness and yet 90 days prior a different EDC MH assessor concluded a diagnosable serious mental illness.  This is but one example of why families contact NAMI.   Frustrations are high particularly when linkages to services and supports are inconsistent.

Y0u are invited to hear more about the importance of operational definitions for EDC H&HS by the esteemed Dr. Lynn (retired Clinical Psychologist with serious experience in assessing for objectivity as it relates to a mental health assessment process and procedure in general. Come to the 5 p.m. Sep 25, 2019 Behavioral Health Commission meetings are open to the public.  There are 2 Meeting Location options (in person and connected via tele/video-conferencing): • Health and Human Service Agency, 3057 Briw Road, Sierra Room, Placerville, CA • Mental Health Office, 1900 Lake Tahoe Blvd., Suite 103, South Lake Tahoe, CA.

We hear from so many falling through the cracks where early intervention is not being applied.  We grow frustrated that  suggestions from 2016 to leverage more mature county infrastructure/public communication process such as Pathways in San Mateo County (Behavioral Health Diversion Court) has been ignored.       We are encouraged that the BH Commission agreed this month to form a sub-committee to understand more about the BH Diversion court in South Lake Tahoe and summarize concerns using the county’s Board of Supervisor’s meeting process.   Every year the Board of Supervisors receives a summary from the BH Commission; this is not a new topic but will be elevated to their table for action.
NAMI El Dorado County board members have urged broader communication and governance of El Dorado County’s BH diversion program.  In a 2013 TahoeTribune article about this diversion court in South Lake Tahoe it referenced that 30 would be diverted annually and receive services/supports rather than jail.  Today there are 3 in this diversion court (and we continue to receive calls from families who have attorney’s unaware of the criteria for the court or the services offered.).
By addressing the need for procedures and operational deficiencies there is an opportunity to step and repeat lessons learned across county programs.
For example: trying performing a internet search (googling) “El Dorado County Behavioral Health Court,” or “El Dorado County diversion court criteria.” How can local attorney’s or families/caregivers know when to suggest diversion court when the information isn’t readily available on-line…or anywhere.
Try performing an internet search (googling)  “El Dorado County Health and Human Services Grievance Form.”    Training staff to organically anticipate what information a community needs requires experienced leadership.     Asking questions such as “what else might the public ask about this program; how can we provide the information before it is asked; when the public performs a simple internet search will they find this important information?” is a technique that is useful.
  1. Is there sufficient information publicly posted and easy to find on county websites for individuals/families or attorney’s.
  2. Does the information address how the entire bh court process works with various agencies; the benefits; how one gets assessed for consideration; who can do a referral, diagnostic criteria, etc.
  3. How are program offerings communicated as being available and how are suggested improvements for program offerings solicited?
This has been a topic at several Behavioral Health Commission meetings yet minutes from these monthly meetings seem to be county-skewed and often miss the gist of ideas proposed by the community.
We look forward to seeing an improvement in this going forward.  Hope is not a strategy so leaders must lead; they must hunt for coaching opportunities to raise employee performance.
3) Lack of embracing “Early and prompt Intervention”
How do we move from a crisis response and release operation to a measurable early intervention model?
How do we embrace early and prompt intervention especially when loving supportive and skilled family care is available; we request county resources become skilled in providing credible guidance to the family on precisely how the family can best help a loved one not the status quo responses families continue to receive.   This has been a topic at the most recent Behavioral Health Commission meeting.   Too often families feel patronized being told their loved one doesn’t meet criteria for help without provision of here is what you (family/caregiver) can do right now to help provide influence in getting them help. Family involvement continues to be recognized as beneficial in inpatient stabilization and discharge planning and prompt follow-up care. What policies encourage and measure this within our county?
Compare and contrast San Mateo County’s AOT message to the community well documented and welcoming to that of  El Dorado County’s AOT.  This is El Dorado County’s AOT form
  • Which conveys a greater sense of customer service and care?  Which conveys a greater confidence that the family burden will be lifted?
  • The argument that San Mateo and/or Santa Clara are not a fair comparison as they are well-funded serving millions has been played.  Why not leverage what has already been well designed?   Why all the resistance?    Opportunity exists for our local county to transform from “We serve only the severely mentally ill; we don’t do windows; we don’t do floors; you’ll need to call someone else; they don’t look mentally ill….” to “How may we help you?  Help me understand what is going on so we may best support you.”
LEADERSHIP: We believe leadership is essential to move the county forward – to dramatically improve the delivery of services/supports for those living with mental illnesses including co-occurring addiction. We see an opportunity for county leaders to seek out strong mentors/coaches from more robust counties; a theme we have championed for several years. Everyone can benefit from a mentor/coach and radical candor (which simply means to challenge directly with compassion and care!)
CULTURE: Creating a culture that welcomes innovation aimed at improving customer service that represents the needs of families and individuals.
TREATMENT: Psychosis should be treated promptly with measurable linkages to care.
Moving a human being clearly in psychosis to solitary confinement because other human beings believe they are possessed demonstrates ignorance.  While in an incarcerated setting this is sometimes done to protect our loved ones – where is the objective policy guiding how to identify and treat psychosis in jail?   Is there quarterly trend reporting demonstrating the jail’s use of in-patient psychiatric hospital beds for actual treatment? Seeking out an in-patient secure hospital bed that has staff skilled in medication tuning promptly demonstrates an understanding of psychosis and the damage is does long-term to the brain.
We continue to inquire about how many in our jails have been transferred to in-patient hospitalization for short-term stabilization (of psychosis.).  An assistant director of H&HS stated they know of one case in 3 years where an inmate from the jail was taken out of jail and into in-patient care.
Advocate for treatment; lead the change. Of course the existing jail is not designed to accommodate treatment of mental illness. Where is the long-term strategic plan to address this?   How can strategic thinking about healthcare-trends be brought into our local community?  What innovative ideas come to mind?
We are aware of many families that have filed formal grievances about the need for improvements in select county based services/supports.  We know first hand that when a mental health service fails to extreme degrees then it cost enormous angst and can ruin lives. We learned about the Grand Jury complaint form this past month and encourage families to add this option to their toolkit when they have found traditional procedures such as grievances into H&HS, BH or jail commander or Psychiatric Hospital Facility or the like are not being addressed.
What planning is being done?
  • SB-389 is slated to bring funding to our counties to provide treatment/services to those pre- and post-sentencing and for those in diversion courts, on probation/parole.    What strategic planning has occurred?  Where is the county’s strategic plan publicly posted?
  • SB-1045 passed in September 2018 expanding conservatorships to a few large pilot counties.  Where is the county’s strategic plan publicly posted and how can conservatorships be made more readily available?
Many of you have inquired about the definition of PERT: Psychiatric Emergency Response Team (PERT exists on the western slope of the county but not in South Lake Tahoe. Here is San Mateo county’s excellent Facebook description of PERT.   Looking to more robust county’s as “coaches” and leveraging their website communication tips is something we continue to champion.
Greater use of the county website’s and search features are essential communication vehicles grossly underutilized today.   It cost nothing to leverage this existing technology and can go far in helping our community members learn about vital services PERT, HOT, AOT, BH Diversion Court, etc.    When we have suggested this in the past the response has been met with stubborn belief systems that suggest such programs have “already been well communicated” or “it isn’t this department’s responsibility it is that other department’s responsibility” to communicate the programs; essentially a stubborn belief that things are fine status quo.
An Multi-Disciplinary-Team meeting known as MDT is working well on the Western Slope but continues to be broken in South Lake Tahoe where key agencies continue to not participate.
Santa Clara County expanded their mobile mental health services by provisioning 24 hour phone support. Both statewide estimates and a civil grand jury report issued last year estimated that nearly 40 percent of police shootings in the country involved a person who exhibited signs of mental illness. Greater training for first responders in Crisis Intervention is core.
Some of the common and most robust dialogue shared during monthly BH Commission meetings have been around the topic of inadequate planning and oversight of MHSA$ spent and the need for a quality BH Diversion court process and overall basic operational deficiencies.   Thank you volunteers leading this healthy dialogue.   It is egregious that there has been no organic improvements made.   The next step must be the BH Commission requesting an agenda topic with the Board of Supervisors to get them to play their leadership position.    It is truly astonishing how there is no process in place to embrace public concerns and BH Commission concerns and feed them into a strategic planning process.  Leadership opportunity.
We have gone too many years without our concerns about underutilization/availability/awareness of the Behavioral Health court in South Lake Tahoe; lack of sufficient training in crisis intervention as evidenced by families sharing first hand accounts and lack of transparent training completed reporting; a broad lack of relevant education for key workforce in both genetic heritability and the rationale behind the importance of prompt treatment for psychosis; and more.   If there was a genuine acceptance of why prompt treatment of psychosis then wouldn’t county leadership be hunting more closely for where improvements at no cost can be made?
We see inconsistent treatment of psychosis locally but also inconsistency in offering early treatment for psychosis across California. A Psychiatric Emergency Responder may warrant hospitalization as a necessity but a County Behavioral Health assessment clinician may disagree (even when families provide a detailed history of mental illness.). This demonstrated ignorance surrounding the need for prompt treatment for psychosis and disregard for how to interpret AB-1424 (using family history)and how to leverage proactively other county services such as AOT are key areas of opportunity. Similarly law enforcement cannot be the last line of defense as suggested in this article.    We continue to hear from families citing a county mental health assessor found their loved one to not have mental illness (and yet did not look at family history, medical records, and supporting information provided to the county’s H&HS department or the AOT team.). This is an example of an operational gap adversely impacting access to services/supports.
of youth involved in California’s juvenile justice system have unmet behavioral health needs.    Through leadership that is skilled in strategic planning and organically seeking out coaches/mentors (say from county’s such as San Mateo County where NAMI was born in 1979) this county can dramatically improve.    Think of all the improvements that could be made that would cost the county nothing (or minimally) while improving their operation and customer satisfaction simply by asking the right questions.    Where is the strategic plan? Where can we improve? What can we do better?  How can we replicate San Mateo County’s excellent use of their website to convey a welcoming customer oriented approach?

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