Status  Report  on  Integrating  Medical  Care  with  Mental  Health  and  Substance  Use  Disorder  Services  in  L.A.  County  

 October  2012  

                   

 

  Special  recognition  to  our  funders  (The  California  Endowment,  Blue  Shield  of  California  Foundation,  and  Weingart  Foundation)  and  to  Marvin  Southard,  Robin  Kay,  and  Kumar  Menon  (Los  Angeles  County  Department  of  Mental  Health),  Albert  Senella  (Tarzana  Treatment  Centers),  Mandy  Johnson  (Integrated  Behavioral  Health  Project),  Chad  Costello  and  Richard  Van  Horn  (Mental  Health  America  of  Los  Angeles),  Cynthia  Carmona  (Community  Clinic  Association  of  Los  Angeles  County),  Thomas  Freese,  Sherry  Larkins,  Howard  Padwa,  and  Rick  Rawson  (UCLA  Integrated  Substance  Abuse  Programs),  Jaime  Garcia  (Hospital  Association  of  Southern  California),  and  Lucien  Wulsin  and  John  Connolly  (Insure  the  Uninsured  Project)  for  their  invaluable  guidance  and  insight,  without  whom  this  project  would  have  been  impossible.      

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Table  of  Contents  

Executive  Summary  .............................................................................................................................  3  

Opportunities  and  Barriers  to  Achieving  Integration  .............................................................  6  Revenue  Streams  ..................................................................................................................................  9  

Policy  Context  ......................................................................................................................................  10  California  Health  and  Human  Services  Agency  Reorganization  .....................................................  11  Medi-­‐Cal  Managed  Care  and  Behavioral  Health  ..................................................................................  11  Patient  Protection  and  Affordable  Care  Act  (ACA)  ..............................................................................  13  “Bridge  to  Reform”  Waiver  .........................................................................................................................  14  2011  Realignment  .........................................................................................................................................  15  Implications  ....................................................................................................................................................  15  

L.A.  County  Health  and  Behavioral  Health  Systems  ................................................................  16  L.A.  County  Departments  of  Health,  Mental  Health,  and  Public  Health  .........................................  16  Medi-­‐Cal  Managed  Care  and  the  Two-­‐Plan  Model  ...............................................................................  18  Community  Health  Centers  and  Clinics  ...................................................................................................  19  Inpatient  and  Emergency  Services  ...........................................................................................................  20  School  Health  Centers  ...................................................................................................................................  22  

Vulnerable  Populations  ...................................................................................................................  23  Homelessness  ..................................................................................................................................................  23  Jail  Reentry  ......................................................................................................................................................  24  Alcohol  and  Other  Drug  Use  .......................................................................................................................  26  

Integration  Examples  ........................................................................................................................  27  Mental  Health  Services  Act  .........................................................................................................................  27  Integrated  Behavioral  Health  Project  .....................................................................................................  29  Low  Income  Health  Program:  Healthy  Way  LA  Matched  ...................................................................  29  Delivery  System  Reform  Incentive  Pool:  Co-­‐location  of  Mental  Health  and  Physical  Health  Services  .............................................................................................................................................................  31  Integrated  School  Health  Centers  .............................................................................................................  32  Emergency  Services  ......................................................................................................................................  33  Homeless  Initiatives  ......................................................................................................................................  36  Jail  Reentry  ......................................................................................................................................................  38  Seniors  and  Persons  with  Disabilities  Transition  and  Duals  Demonstration  .............................  39  Federal  Initiatives  .........................................................................................................................................  41  

Discussion  .............................................................................................................................................  41  Conclusion  ............................................................................................................................................  43  

Appendix  A.    Timeline  of  Mental  Health  Care  Development  in  L.A.  County  ...................  44  

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Executive  Summary   An opportunity exists to integrate mental health and substance use disorder (SUD) services with medical care in a patient-centered manner under the Patient Protection and Affordable Care Act (ACA) and federal parity requirements. Survey results on health care preferences of low-income Californians suggest that the safety net should provide more patient-centered, responsive services to compete in an environment with significantly increased consumer choice post-reform. Providing bidirectional integrated care, which means offering mental health/SUD services in primary care settings as well as primary care in mental health/SUD settings, will be required to meet the Triple Aim to improve the patient experience of care, improve population health, and reduce costs in order to optimize system performance. Mental health and SUD services are fragmented and poorly coordinated with physical health services due to structural, financial, clinical, and operational barriers. Although L.A. County faces challenges in achieving integration, it has the opportunity to lead and shape behavioral health policy in order to promote patient self-determination and dignity. This report will review what integration means; provide information on revenue streams, the policy context, and key behavioral integration examples in L.A. County; and offer recommendations moving forward as full implementation of the ACA approaches. Integrating services has various meanings given the differing orientations within the health, mental health, and SUD systems and other barriers that have resulted in siloed care. In moving towards a managed care environment in which decreasing costs while improving patient outcomes will be rewarded, the goal should be clinical integration. While many people with mild to moderate mental health and SUD issues seek care in a primary care setting, individuals in behavioral health settings often experience medical and public health issues. Addressing issues including but not limited to financing and reimbursement mechanisms, confidentiality of patient information, workforce issues, and practice settings, and using new technologies such as telehealth will be required. California has a complicated patchwork of funding for health, mental health, and SUD services, spending $41.3 billion for Medi-Cal and indigent health care and an additional $5.5 billion on mental health and SUD treatment. While 11% of total expenditures are allocated towards mental health, only 1% is spent on SUD treatment. While California will benefit from significant federal dollars once ACA takes full effect, it will continue to struggle with persistent state deficits. Counties have been facing budget deficits. The Mental Health Services Act has been a crucial source of funding for public mental health services to create a state-of-the-art, culturally competent system that promotes recovery, wellness, and resiliency for unserved and underserved population. Mental Health America of Los Angeles played an instrumental role in the Act’s development and passage. While the Act’s revenue has supported integration of mental health and some SUD services into other care settings, a comparable SUD funding stream does not exist. An overview of the dynamics currently influencing the future role of counties in achieving behavioral health policy integration, including the interactions among these multiple forces, is provided. The state has been awaiting federal guidance on the Medicaid Benchmark Benefit and Medicaid Behavioral Parity before several key ACA implementation decisions are made; these regulations should be released by the end of the year. Governor Brown announced to California’s leadership his intention to convene a special legislative session to address issues related the California Health Benefit Exchange and the Medicaid expansion once federal guidance is received. While California has enacted laws that provide mental health parity, a similar requirement does not exist for SUD treatment. The ACA presents an opportunity to upgrade the SUD benefit. However, parity language is somewhat vague and allows considerable discretion to states. Counties have additional revenue through the “Bridge to Reform” waiver and the 2011 realignment of financing and responsibility for behavioral health and community corrections from the state level. It is possible that the Medi-Cal could have two tiers of benefits post-reform, one for the newly eligible and another for individuals eligible under traditional rules. Counties will have to carefully calibrate the managing of funds for federal entitlements and construction of provider networks, while health plans will become the accountable entity for patients under ACA coverage expansions. Background information on L.A. County’s major systems that provide physical health, mental health, and SUD services to low-income communities is provided, including the L.A. County Departments of Health, Mental Health, and Public Health; Medi-Cal managed care plans (L.A. Care Health Plan and Health Net);

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community health centers and clinics; inpatient and emergency services; and school health centers. These public and private providers offer a patchwork of safety net services to different but overlapping populations. While planned collaboration does exist, services are often provided in a fragmented and poorly coordinated manner, which will need to evolve to develop patient-centered, high quality care in an environment of increased consumer choice. In addition, populations in L.A. County that encounter high rates of a combination of physical health, mental health, and SUD conditions are described, including the homeless, persons exiting the corrections system, and individuals with SUD disorders. These individuals are expected to represent a significant portion of the Medicaid expansion due to the ACA’s new eligibility rules. They will require a special focus to ensure enrollment into coverage and integrated care happens to manage their complex conditions while improving health outcomes and controlling costs L.A. County has embarked on a number of efforts to integrate care. Often, the focus has been on piloting approaches in certain areas and particular populations given the geographic variation throughout the county, high levels of unmet need, and pronounced differences in regional delivery systems, rather than on building an integrated system of care. An overview of integrating care in order to improve outcomes and reduce costs in L.A. County is provided. This includes efforts funded by the Mental Health Services Act, the Integrated Behavioral Health Project, the “Bridge to Reform” waiver’s Low Income Health Program and Delivery System Reform Incentive Pool project, integrated school health centers, emergency services, homeless initiatives, jail reentry, transitions into managed care including Seniors and Persons with Disabilities with Medi-Cal only coverage and persons dually eligible for Medicaid and Medicare, and federal initiatives. While this review is not meant to be an exhaustive one, it is intended to bring to light major initiatives that involve cross-sector collaboration, promising results, and potential for replication. At the crossroads of systems transformation as full ACA implementation approaches in 2014, L.A. County has the opportunity to begin the safety net transformation process towards patient-centered, bidirectional, integrated care. L.A. County’s goal should be clinical integration that increases patient satisfaction and promotes consumer self-determination. While significant progress made in the last few years under L.A. County’s dynamic leadership supported by financing streams such as the Mental Health Services Act and the “Bridge to Reform” waiver, additional planning and collaboration will be required to ensure that the L.A. County safety net system will be a provider of choice post-reform. Based on the review of the policy environment, L.A. County’s physical health, mental health, and SUD systems, and integration efforts taking place, the following recommendations are offered: • Patients should be involved in integrating and transforming safety net systems into high quality,

responsive providers of choice in a post-reform world.

• L.A. County should design a system of integrated care to serve patients regardless of the door through which they enter.

• The expansion of managed care in public health coverage provides an opportunity to provide high quality, integrated care that improves patient outcomes and reduce costs.

• Detection and early intervention of mental health and SUD issues should be incorporated into the primary care setting, which may be particularly important in providing care to underrepresented racial/ethnic groups.

• Particular attention should be paid to integrating SUD services.

• Training and practice should evolve towards integrated care.

• Care coordination and management, information exchange mechanisms, and new technologies should be maximized to facilitate and promote the delivery of patient-centered care.

• Financial and reimbursement incentives should be aligned to ensure the goal of achieving clinical integration.

Significant planning and collaboration efforts will be required to transform local safety net systems in order to become a provider of choice for patients post-reform. Integration may offer a chance to learn from the strengths that each of the three systems of physical health, mental health, and SUD treatment has to offer and move to a person-centered, recovery-oriented wellness model that promotes two-way communication to support the provider-patient relationship.

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Introduction

An opportunity exists to integrate mental health and substance use disorder (SUD) services with medical care in a patient-centered manner under the Patient Protection and Affordable Care Act (ACA) and federal parity requirements. The Institute of Medicine’s definition of high quality care includes patient-centeredness and a focus on recovery and self-management as key attributes.1, 2 The development of patient-centered medical homes and person-centered health homes have emerged as new paradigms to address disparities and move towards meeting patient needs.3 The Triple Aim is a leading approach to improve the patient experience of care, improve population health, and reduce costs in order to optimize system performance. Although no universally accepted definition exists, patient-centered care is about the healing relationships among clinicians and patients and patients' families that is grounded in a two-way dialogue, sharing information, exploring patients' values and preferences, and helping patients and families make clinical decisions.4 Survey results on health care preferences of low-income Californians suggest that the safety net should provide more patient-centered, responsive services to compete in an environment with significantly increased consumer choice post-reform.5 As an integral part of L.A. County’s safety net systems transformation efforts, the L.A. County Department of Health Services (LADHS) created a separate strategic plan on improving the patient experience within its ambulatory care network.6 While L.A.’s mental health providers have adopted a client-focused model and agreement on the approach exists among SUD providers, these services are not well integrated with LADHS on a clinical level with a few exceptions on a provider-by-provider basis. Although the mental health system has made progress on integrating care due to support from the “Bridge to Reform” waiver and Mental Health Services Act, this has not occurred for SUD care due to lack of a comparable financing stream. Mental health and SUD services are fragmented and poorly coordinated with physical health services due to structural, financial, clinical, and operational barriers. L.A. County faces challenges in achieving integration given its size, geographic and racial diversity, the large numbers of individuals estimated to benefit from the ACA’s Medicaid expansion and the California Health Benefit Exchange, and level of unmet need. The prevalence of mental health diagnoses in L.A. County ranged from 19% using a broad definition to 8% including only persons with serious and persistent mental illness; 3 in 10 California adults under 200% FPL with mental health needs reside locally.7, 8 A significant proportion of L.A. County residents under 200% FPL have alcohol and other drug use diagnoses at 9.4%.9 Only 10% of total California health, mental health, and alcohol and drug funds are spent on indigent, non-Medi-Cal persons, but this group represents 39% of those served.10 Providing bidirectional integrated care means offering mental health/SUD services and the reverse, which will be required in order to reduce costs and improve outcomes.11 A ranking of preventive services found that alcohol screening and intervention rated at the same level as colorectal cancer and hypertension screening and treatment, while depression screening and intervention was equal with osteoporosis and cholesterol screening and treatment.12

                                                                                                               1 Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century, Washington: National Academy Press, 2001. 2 Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions, Washington: National Academies Press, 2005. 3 Institute for Healthcare Improvement, The IHI Triple Aim, http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx. 4 Epstein RM, Fiscella K, Lesser CS, and Stange KC, :Why the Nation Needs a Policy Push on Patient-Centered Health Care,” Health Affairs, Aug. 2010 29(8):1489–95. 5 Langer Research Associates, On the Cusp of Change the Healthcare Preferences of Low-Income Californians, Blue Shield of California Foundation, June 2011. 6 LADHS, Los Angeles County Department of Health Services Strategic Plan Update, August 15, 2011. 7 Grant D, Padillo-Frausto I, Aydin M, Streja L, Aguilar-Gaxiola S, Patel B, and Caldwell J, Health Policy Fact Sheet: Adult Mental Health Needs and Treatment in California, UCLA Center for Health Policy Research, November 2011. 8 Human Services Research Institute, Technical Assistance Collaborative, and Expert Consultation From Charles Holzer, California Mental Health Prevalence Estimates, January 30, 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/California%20Prevalence%20Estimates%20-%20Introduction.pdf. 9 Human Services Research Institute, Technical Assistance Collaborative, and Expert Consultation From Charles Holzer, California Mental Health Prevalence Estimates, January 30, 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/California%20Prevalence%20Estimates%20-%20Introduction.pdf. 10 Jarvis D and Freeman J, Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net, California Institute for Mental Health, June 2011 11 Mauer B, The Business Case for Bidirectional Integrated Care, California Integration Policy Initiative, June 2010, accessed at http://ibhp.org/uploads/file/Business_Case_for_Integration_Summary_6-10_Mauer.pdf. 12 Ibid.

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Counties like L.A. may provide significant leadership in achieving integrated care and shaping policy to promote patient self-determination. The public and private safety net delivery networks, which have operated siloed systems, are undergoing rapid change. Services will be largely organized through managed care arrangements, which today carve out mental health and SUD services. Counties are creating pre-reform expansion programs and moving complex, high-cost patients into mandatory managed care through California’s “Bridge to Reform” waiver. L.A. County operates three separate departments that provide medical, mental health, and SUD services to different but overlapping populations. Almost one-third of individuals statewide who are eligible for the Medicaid expansion reside in L.A. County; those with the most severe physical health and behavioral health service needs are likely to have already enrolled in Medi-Cal and will not be heavily represented in the projected growth.13 Individuals with mild and moderate mental health issues may be identified and treated in the primary care setting especially given the co-occurrence of chronic diseases. This may be especially true with certain populations, such as Asian Pacific Islanders and Latinos who are low utilizers of mental health services due stigma issues but may find it more acceptable to seek medical care. Adults with mental health needs were 1.5 times more likely to have a co-occurring chronic disease (high blood pressure, heart disease, or asthma) or to be diagnosed with two or more of these chronic conditions, as compared to the general population.14 While community clinics and free health centers have begun to weave mental health services into primary care now that there is payment from LADMH, an organized effort to integrate SUD services does not exist. This report will review what integration means; provide information on revenue streams, the policy context, and key behavioral integration examples in L.A. County; and offer recommendations moving forward as full implementation of the ACA approaches. A timeline of key developments in L.A. County’s behavioral health services history is provided in Appendix A.

Opportunities  and  Barriers  to  Achieving  Integration   Integrating services has various meanings in the field. It may refer to integration occurring at either the financial, structural, or clinical practice levels, or some combination of the above. Although often focused on integrating care between and among systems, developing patient-centered models will be important in a post-reform environment. Table 1 provides some examples of ways in which services may be integrated. Numerous options exist, some of which allow coordination, such as referral arrangements, and others that promote integration, such as services delivered through the auspices of a single agency. Table 1. Examples of Integration Efforts

Level Examples Financial • Benefit packages

• Carve-ins • Shared risk pools • Other incentives • Mental health and primary care services under a common funding stream that can be used potentially to promote

any other activities Structural • Services delivered under the umbrella of the same organization

• Behavioral health specialty services co-located with primary care services • Behavioral and primary care services under a common administrative authority, which can create standards for

collaboration and clinical integration Clinical • Referral arrangements

• Co-location of physical health, mental health, and/or SUD services • Dually trained interdisciplinary teams including primary care, mental health and/or SUD professionals, formal

collaboration and consultation mechanisms, required screening practices, collaboration practices built into service protocols, and a combined health record, and regular case conferencing for care coordination

Sources: Mauer BJ, Background Paper: Behavioral Health/Primary Care Integration Models, Competencies, and Infrastructure, National Council for Community Behavioral Healthcare, May 2003, accessed at http://www.ibhp.org/uploads/file/Mauers%20Behav%20Health%20Models%20Competencies%20Infra.pdf.

                                                                                                               13 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 14 Jarvis D and Freeman J, Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net, California Institute for Mental Health, June 2011

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In moving towards a managed care environment in which decreasing costs while improving patient outcomes will be rewarded, the existing financial and clinical models must change. Each system is summarized below: • Health systems have provided services under a medical model. Providers are more familiar with

managed care arrangements and payment methodologies such as capitation, which are intended to incentivize primary, preventive care and control costs. In California, many health systems hold managed care contracts, have administrative infrastructure to manage care and comply with contracts, and employ or contract for the required licensed staff. Additionally, health systems routinely utilize evidence-based practices and IT infrastructure for collecting data, reporting health outcomes, and billing.

• Mental health systems have employed a person-centered, recovery-oriented approach. This model is

grounded in the belief that recovery is a possible and expected outcome of treatment, and that the full range of comprehensive services and supports that an individual needs to meet his or her recovery goals should be accessible, flexible, individualized, and coordinated.15 In the past decade, a push to deliver evidence-based practices in public mental health systems has been growing. Some evidence-based practices such as cognitive-behavioral therapy, dialectical behavior therapy, motivational interviewing, and treating depression in a primary care setting are widely accepted. A barrier to having these practices more readily available stems from the need to incorporate them into the teaching curriculum, both in school and continuing education, coupled with a shortage of mental health professionals.16 Public systems have limited their services to the seriously mentally ill population, largely due to budget issues. County mental health systems operate county Mental Health Plans that contract with counties and private providers for the seriously mentally ill population. Thus, county mental health systems have specialty mental health expertise needed as parity and coverage expansion happen. However, county and county contractor administrative infrastructure to meet Medi-Cal and commercial health plan requirements may not be in place to bill and collect and report health outcome data.

• SUD providers have moved towards a recovery-oriented, clinical model similar to mental health

services. However, a portion of the SUD system still uses the social model, which uses a peer-oriented process focusing on behavior change through experimental learning and shared responsibility.17 Well-established evidence-based practices to treat alcohol and other drug use have been developed. These include Screening, Brief Intervention, and Referral to Treatment (SBIRT), contingency management, case management, continuing care, and medication-assisted therapies such as Vivitrol and buprenorphine.18 Pressure exists to incorporate medication-assisted treatments in SUD settings in the same or similar fashion to primary care or mental health. Infrastructure will be required to meet managed care requirements, which includes having licensed clinicians and the information technology infrastructure to report outcomes and do billing.

The majority of people with behavioral health problems seek assistance in the primary care setting, with half of all care for common psychiatric disorders delivered by a primary care provider. Mild to moderate behavioral health issues are observed routinely, presenting a prevention and early intervention opportunity. Common behavioral health issues among adults in a primary care environment include anxiety, depression, and SUD, while ADHD, anxiety, and behavioral problems are seen often in children.

                                                                                                               15 Felton MC, Cashin CE, and Brown CE, What Does It Take? California County Funding Requests for Recovery-Oriented Full Service Partnerships under the Mental Health Services Act, Community Mental Health Journal, (2010) 46:441-451, accessed http://www.springerlink.com/content/7841734p65563267/fulltext.pdf. 16 Surface D, Understanding Evidence-Based Practice in Behavioral Health, Social Work Today, Vol. 9 No. 4, accessed at http://www.socialworktoday.com/archive/072009p22.shtml. 17 The continuum of programs offered under the social model includes detoxification from alcohol and drugs, primary recovery, secondary supportive recovery, and recovery sustenance, or lifelong support for recovering persons who are fully integrated with society. See Kaskutas LA, The Social Model Approach to Substance Abuse Recovery: A Program of Research and Evaluation: Part I, Center for Substance Abuse Treatment, SAMHSA, April 1999, accessed at http://numerons.files.wordpress.com/2012/04/7the-social-model-approach-to-substance-abuse-recovery.pdf. 18 Padwa H and Rawson R, A New Medi-Cal Benefit is Needed to Effectively Address the Patient and System Needs Associated with Substance Use Disorders, UCLA Integrated Substance Abuse Programs, September 2012.

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People with common medical issues have high rates of behavioral health issues. Adults with mental health needs were 1.5 times more likely to have a co-occurring chronic disease (high blood pressure, heart disease, or asthma) or to be diagnosed with two or more of these chronic conditions, as compared to the general population.19 Conversely, individuals in behavioral health settings often experience medical and public health issues. The severely mentally ill population served by public mental health systems has rates of co-occurring chronic conditions two to three times higher than the general population, with a corresponding life expectancy of 25 years less.20 Medical treatment of these chronic conditions is often substandard, with many receiving no treatment at all.21 The majority of care received is from ER visits and inpatient stays, as opposed to primary, preventive treatment.22 The rates of mortality of the severely mental ill from diseases including cardiovascular disease, diabetes, respiratory disease, and infectious diseases are several times higher than the general population.23 The average age of death of those with co-occurring mental health and SUD was 45 years, and 53 years for individuals with severe mental health illness.24 Addressing confidentiality of patient information to allow care coordination among physical health, mental health, and SUD providers remains a major stumbling block. A myriad of laws governs privacy of information of different types. In addition, consumers are concerned about how the information will be used, especially for mental health and SUD treatment where a great deal of stigma exists around these issues.25 In addition to federal law governing the sharing of information from a health record (Health Insurance Portability and Accountability Act or HIPAA), a different regulation (CFR 42 Part II) dictates disclosure of mental health and SUD information. Another layer of laws exist since each state has its own statutes. While these multiple regulations are often contradictory and open to interpretation, they are further complicated by the emergence and evolution of health information technology and health information exchange.26 While providers may request client permission for disclosure, other options exist to share information for the purposes of care coordination. For example, HIPAA permits partnering organizations to become Organized Health Care Delivery Systems while CFR 42 Part II allows providers to enter into a Qualified Service Agreement to share SUD information.27 As a result of these complexities, proponents of integrated behavioral care have maintained a single medical chart as a necessary precursor for intra-agency collaboration.28 These legal requirements will need to be addressed in order to create a patient-centered experience with the goal of achieving clinical integration that is bidirectional in nature, in either the primary care or behavioral health setting. Attaining integration in a medical home model in the absence of appropriate financing mechanisms and structures will be challenging, combined with workforce challenges and differing practice settings.29 For example, reimbursement limitations have hampered new technologies such as telehealth, which provides the capability of providing mental health evaluation and consultation remotely to maximize constrained resources. Although telehealth has grown in popularity in both urban and rural areas, use of this technological solution among behavioral health programs has been extremely

                                                                                                               19 Grant D, Padillo-Frausto I, Aydin M, Streja L, Aguilar-Gaxiola S, Patel B, and Caldwell J, Adult Mental Health Needs in California: Finding from the 2007 California Health Interview Survey, UCLA Center for Health Policy Research, November 2011. 20 Jarvis D and Freeman J, Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net, California Institute for Mental Health, June 2011 21 Ibid. 22 Ibid. 23 Parks J, Svendsen D, Singer P, Foti ME, and Mauer B, Morbidity and Mortality in People with Serious Mental Illness, Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors Medical Directors Council, October 2006. 24 Ibid. 25 Integrated Behavioral Health Project, Confidentiality of Client Information and Records, accessed at http://ibhp.org/index.php?section=pages&cid=188. 26 Clark HW, 42 CFR Part 2, June 16, 2011, Presentation to the 2011 Health Information Technology Regional Forum, accessed at http://www.cihs2.browsermedia.com/workforce/Clark_Westley_II_508_Read-Only_Compatibility_Mode.pdf. 27 Reynolds, Kathy, Don’t Be Spooked: Navigating Confidentiality Challenges When Integrating Mental Health, Substance Abuse, and Primary Care, SAMHSA-HRSA Center for Integrated Health Solutions eSolutions Newsletter, October 2011, accessed at http://www.integration.samhsa.gov/about-us/esolutions-newsletter/october-2011#spooked. 28 Ibid. 29 Mauer BJ, Background Paper: Behavioral Health/Primary Care Integration Models, Competencies, and Infrastructure, National Council for Community Behavioral Healthcare, May 2003, accessed at http://www.ibhp.org/uploads/file/Mauers%20Behav%20Health%20Models%20Competencies%20Infra.pdf.

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limited. 30 Workforce issues will be an ongoing challenge, especially with shortages of particular behavioral health professionals.31 In some cases, the setting in which services are provided may be another issue warranting consideration, such as a health center located on a school campus. As a result, numerous models have developed with varying degrees of success. Some of the more successful programs have focused on specific populations, integrated delivery systems, or geographic areas. Financing continues to be a major barrier, especially for integrating SUD care. California has secured newer revenue streams facilitating integration efforts, which are described in the next section.

Revenue  Streams   California has a complicated patchwork of funding for health and behavioral health services, spending $41.3 billion for Medi-Cal and indigent health care and an additional $5.5 billion on mental health and SUD treatment. 32 While 11% of total expenditures are allocated towards mental health, only 1% is spent on SUD treatment. 33 California will benefit from significant federal dollars once the ACA takes full effect in 2014, while it will continue to struggle with persistent state budget crises. Medi-Cal, the largest state program for public mental health and SUD services, has been a target for budget cutters, experiencing a $1.2 billion reduction in FY 2012-13.34 Counties have been facing their own budget deficits, experiencing challenges in proving the State’s match for Medi-Cal. Table 2 summarizes the major funding streams supporting behavioral health services. Since county-level expenditures are not readily available, the amount of statewide funding is provided where possible. Table 2. Summary of Mental Health and SUD Funding Streams

Funding Stream Description and Revenue Amount

Medi-Cal Funds specialty mental health services provided through a Medi-Cal carve-out to a county Mental Health Plan, and SUD services provided through a Medi-Cal fee-for-service carve-out program. • $3.4 billion annually on mental health • $406 million annually on SUD, with $167.2 million for the specialty Drug Medi-Cal program

Substance Abuse and Mental Health Services Administration (SAMHSA)

Supports treatment and recovery services • $250 million annually from the Substance Use Prevention and Treatment Block Grant • $53 million annually from the Community Mental Health Block Grant • $198 million annually from other formula/discretionary grant funds

Realignment

Includes sales tax and vehicle license fees from 1991 legislation and the recent 2011 package of bills that transfer from state to local responsibility various behavioral health services including Drug Medi-Cal, EPDST, Medi-Cal Mental Health Managed Care, and others. Increasingly used for local matching funds to draw down Medi-Cal federal dollars. • $842.9 to Community Corrections and $964.5 to Behavioral Health subaccounts in FY 2012-13 (projected)

Mental Health Services Act (MHSA)

Provides funding for community mental health services, which requires a state maintenance of existing funds and prohibits supplanting state or local funds. Increasingly used for local matching funds to draw down Medi-Cal federal reimbursement. • $900 million to $1.5 billion annually

Early Periodic Screening, Diagnosis, and Treatment (EPDST) Program

Provides Medi-Cal recipients under age 21 with medically necessary mental health services, which has been delegated to county Mental Health Plans. The eligibility and scope of services is determined by state and federal policy. • $900 million baseline

Healthy Families

Provides services to children with serious emotional disturbances. AB 1494, which moves children in Healthy Families to Medi-Cal no sooner than January 1, 2013, will result in eligibility for EPDST services and will require a time-limited, problem-specific evidence-based treatment.

CalWORKs

Includes funding for SUD and mental health services for program recipients to whom a barrier to employment exists

Sources: Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment Final Report, DHCS, February 2012 and Kelch DR, The Crucial Role of Counties in the Health of Californians: An Overview, California HealthCare Foundation, March 2011.

                                                                                                               30 Sarasohn-Kahn J, The Online Couch: Mental Health Care on the Web, California HealthCare Foundation, June 2012, accessed at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/O/PDF%20OnlineCouchMentalHealthWeb.pdf. 31 Foster G, Shilton A, and Keefer B, Mental Health Workers: Future Growth and Critical Shortages, National Association for Rural Mental Health Conference, 2011. 32 Jarvis D and Freeman J, Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net, California Institute for Mental Health, June 2011. 33 Ibid. 34 Fujioka, William. “State Budget – Preliminary Analysis of the FY 2012-13 State Budget Act” County of Los Angeles Chief Executive Office, June 29, 2012, Memorandum, Web.

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The Mental Health Services Act has been a crucial source of funding for public mental health services given declining state budget support. Enacted through a ballot initiative (Proposition 63) voted into law in November 2004, the Act imposed a 1% tax on high-income earners, which increased funding, personnel, and other resources to expand county mental health services. A local agency, Mental Health America of Los Angeles (MHA), played an instrumental role in the development and passage of the Act. Considered a leader in the field of recovery-based mental health care, MHA pioneered two person-centered projects that are viewed as national models and have received numerous accolades. Founded in 1990, the MHA Village in Long Beach is credited as the inspiration for the Mental Health Services Act and projects funded through AB 34 (described on page 25). An integrated services center that provides psychiatric services, counseling, and social model services, the Village assigns clients through a team that works in collaboration to help manage their case, find them housing, help them with employment, deal with financial planning, and help them make friends and develop hobbies through community integration. MHA initiated Project Return Peer Support Network in 1980 as California’s first staff-facilitated peer support program for people with mental illness, which transitioned to a client-operated program in 1992 and to an independent nonprofit organization in 2012.35 As a result of MHA’s leadership, the Mental Health Services Act focused on creating a state-of-the-art, culturally competent system that promotes recovery, wellness, and resiliency for unserved and underserved populations. Progress was monitored toward statewide goals for children, transition age youth, adults, older adults, and families, with funds allocated in six components: 1) Community Program Planning, 2) Community Services and Supports, 3) Workforce Education and Training, 4) Capital and Technology, 5) Prevention and Early Intervention, and 6) Innovation. Each county developed a local plan through an extensive stakeholder process that guided the disbursement of each component. A cornerstone of the Act is the person-centered Full Service Partnership, which uses a team approach to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support toward recovery and resilience for target populations. Full Service Partnerships may provide housing, employment, peer support, wellness centers, crisis stabilization, food, clothing, respite care, and other services necessary to meet individual recovery goals.36 Employment has been the least robust service offered, due to difficulties in drawing down and leveraging Department of Rehabilitation funds and programs. While Mental Health Services Act dollars have supported integration of mental health services into other care settings, a comparable SUD funding stream does not exist, although some Full Service Partnerships provide SUD services as part of their core programs. In addition, federal threats loom to reduce SUD funding.37 For example, under the Budget Control Act, California’s SAMHSA Substance Abuse Prevention and Treatment Block Grant may be subjected to a $19.4 million reduction effective January 2013 if the U.S. Congress does not enact a plan to reduce the national debt by $1.2 trillion. This block grant supports treatment and recovery services for those impacted by alcohol and drug addiction. Research has found that every $1 spent on quality treatment results in at least $12 in reduced SUD-related crime and criminal justice and health care costs.38 Changes to other revenue steams, such as the Governor Brown’s 2011-12 realignment, are described in further detail in the following sections, given the implications and interactions with other policy changes.

Policy  Context   In this highly fluid environment, many policy and organizational changes have shaped the future role of counties in California and their ability to achieve service integration. The California Department of Health Care Services (DHCS) has been awaiting federal guidance on the Medicaid Benchmark Benefit and

                                                                                                               35 Project Return Peer Support Network, About Project Return, accessed at http://www.prpsn.org/index.php/about-project-return. 36 Evidence on the Effectiveness of Full Service Partnership Programs in California’s Public Mental Health System, UC Berkeley School of Public Health, May 2010, accessed at http://www.dmh.ca.gov/prop_63/MHSA/Publications/docs/PetrisCenter_ExecSummaryReport_Final.pdf. 37 Senator Tom Harkin, Under Threat: Sequestration’s Impact on Nondefense Jobs and Services, Chairman, Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education, and Related Agencies, July 25, 2012, accessed at http://www.harkin.senate.gov/documents/pdf/500ff3554f9ba.pdf. 38 Ibid.

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Medicaid Behavioral Parity before several key ACA implementation decisions are made; these regulations should be released by the end of the year.39 Governor Brown announced to California’s leadership his intention to convene a special legislative session. The purpose will be to address issues related the California Health Benefit Exchange and the Medicaid expansion once federal guidance is received.40 Slated to begin in December 2012 or January 2013, the special session will occur simultaneously with the regular legislative session. Any laws enacted will take effect in 90 days, instead of January 2014 at the time that ACA would take full effect.41 Stakeholders speculate that more details on the specific legislation to be considered should be forthcoming following the November 2012 election. In addition, while California has enacted laws that provide mental health parity, a similar requirement does not exist for SUD treatment. The ACA presents an opportunity to upgrade the SUD benefit. However, parity language is somewhat vague and allows considerable discretion to states. With these future changes on the horizon, this section provides an overview of the dynamics currently influencing behavioral health policy integration, including the interactions among these multiple forces. California  Health  and  Human  Services  Agency  Reorganization   The California Health and Human Services Agency officials took several actions towards establishing a uniform approach to overseeing behavioral health services, primarily driven by the state’s budget deficits. Officials created a new Department of State Hospitals to oversee the state’s five mental health hospitals, and reorganized the functions of the California Department of Mental Health and Department of Alcohol and Drug Programs into other departments.42 As a result of these changes, the California Department of Health Care Services (DHCS) started overseeing Medi-Cal mental health coverage and developed a new deputy director position responsible for overseeing mental health and SUD services effective July 2012.43 The Legislature deferred the transfer of the Drug Medi-Cal program to DHCS oversight until July 2013.44 County mental health programs have been granted significant autonomy in providing Medi-Cal specialty mental health treatment. The carve-out and realignment of Medi-Cal behavioral health services from managed care have resulted in a great deal of service-level variation provided across counties. However, the statewide advisory board established to oversee the implementation of Mental Health Services Act (Mental Health Services Oversight and Accountability Commission) has been given a legislative mandate to lead evaluation efforts across the mental health systems. The consolidation of behavioral health oversight into DHCS holds the potential to increase: 1) Standardization and accountability of county mental health and SUD systems; 2) Financing and service delivery, 3) Integration of management and policy across these systems; and 4) Collection and dissemination of previously unavailable data across populations.45 Medi-­‐Cal  Managed  Care  and  Behavioral  Health   Mental health and outpatient SUD services are carved out from Medi-Cal managed care, with county departments providing services. Carve-outs, which first emerged in commercial plans in the early 1990s, spurred the development of a managed behavioral health care industry consisting of firms specializing in this service.46 For example, L.A. Care Health Plan, L.A. County’s public health plan, contracts with

                                                                                                               39 DHCS, 1115 Waiver Behavioral Health Services Needs Assessment Plan, accessed at http://www.dhcs.ca.gov/provgovpart/Pages/FinalBehavioralHealthServicesNeedsPlan.aspx. 40 Siders D, “Jerry Brown to Call Special Legislative Session on Health Care,” The Sacramento Bee, August 17, 2012. 41 Ibid. 42 DHCS, Departments and Programs Transitioning into the Department of Health Care Services, accessed at http://www.dhcs.ca.gov/Pages/DepartsTransitioning-DHCS.aspx. 43 Office of Governor Edmund G. Brown, Governor Brown Announces Appointments, July 27, 2012, accessed at http://gov.ca.gov/news.php?id=17652. 44 California Department of Alcohol and Drug Programs, Transfer of ADP Functions to Other Departments, accessed at http://www.adp.ca.gov/transfer.shtml. 45 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 46 http://content.healthaffairs.org/content/17/2/53.full.pdf.

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CompCare to provide inpatient and outpatient mental health services and SUD treatment for members in its non-Medi-Cal product lines.47 To tackle cost control in the public sector, more than 20 states had developed carve-outs to manage mental health and SUD care in their Medicaid programs by 1999.48 While the carve-out of specialty mental health services has been shown to be successful in addressing cost and efficiency concerns, limited evidence exists on its impact on the quality of care rendered.49 We provide an overview of how California’s Medi-Cal carve-out of these services operates below. From 1995 to 1997, California consolidated Medi-Cal funding streams for specialty mental health services through a Freedom of Choice 1915(b) waiver in order to increase access to services, improve care coordination, and reduce administrative costs. County mental health departments were provided an option of operating a county Mental Health Plan, which most counties have elected to provide. The county Mental Health Plan makes a distinction in the severity of mental illness and the level of care that should be provided. It is responsible for providing specialty mental health services to Medi-Cal beneficiaries who meet medical necessity criteria of having a serious and persistent mental illness, and includes inpatient and outpatient services. Medical necessity includes a clearly identified set of diagnoses, functional impairments, and intervention criteria. The services must be delivered by or under the direction of a specialist in the mental health field, such as a psychiatrist, a psychologist, a Licensed Clinical Social Worker, or Marriage and Family Therapist. The service must also be a mental health service, such as medication management of psychotropic medications, individual therapy, and psychological testing. Patients with moderate to mild mental health issues receive services in a primary care setting by providers who are directly contracted with the managed care plan. County Mental Health Plans receive a fixed annual allocation of state General Funds based on the historical cost of services formerly provided through the fee-for-service system. Although outpatient specialty mental health services provided through the EPSDT program to Medi-Cal beneficiaries under 21 years has not been capped, the county Mental Health Plans receive realignment funds, which have funded services since 1991 and under new rules as part of the Governor’s FY 2011-12 state budget. More information is provided about these changes on page 15. These funds are transferred by the state to each county and may be used to draw down federal reimbursement. The relationship between SUD services and Medi-Cal managed care is more complex as compared to mental health care. Inpatient services are provided by the health plan.50 Outpatient services provided through Drug Medi-Cal are carved out in a similar manner to specialty mental health services, with health plans assessing members’ need for SUD treatment and referring them to county programs. Drug Medi-Cal covers an extremely limited set of benefits, is underfunded, and suffers from poor financial management due the lack of utilization review. The state certifies Drug Medi-Cal facilities. While some counties play a role in overseeing Drug Medi-Cal contracts, certified agencies may have a direct contracting relationship with the state that circumvents the county. In addition, counties provide other SUD outpatient services funded through the SAMHSA Substance Abuse Prevention and Treatment Block Grant, which may or may not be coordinated with Drug Medi-Cal and mental health services. SUD evidence-based treatments exist that are not included in the Drug Medi-Cal benefit. These include Screening, Brief Intervention, and Referral to Treatment (SBIRT), contingency management, case management, continuing care, and medication-assisted therapies such as Vivitrol and buprenorphine.51 California started a large Medi-Cal managed care expansion in the mid-1990s. The Temporary Assistance to Needy Families (TANF)-linked population was enrolled into mandatory managed care using a few models depending on county size and infrastructure. The State is continuing to expand the role of

                                                                                                               47 These lines of business are Healthy Kids, Healthy Families, and Medicare Advantage HMO Special Needs Plan. See L.A. Care Health Plan, Mental Health Resources, accessed at http://www.lacare.org/providers/resources/mentalhealth. 48 Busch AB, Frank RG, and Lehman AF, The Effect of a Managed Behavioral Health Carve-Out on Quality of Care for Medicaid Patients Diagnosed as Having Schizophrenia, Archives of General Psychiatry, 2004;61(5):442-448, accessed at http://archpsyc.jamanetwork.com/article.aspx?articleid=481996#ref-yoa30190-1. 49 Patel KK, Butler B, and Wells KB, What Is Necessary To Transform The Quality Of Mental Health Care, Health Affairs, May 2006, Vol. 25 No. 3:681-693. 50 L.A. Care Health Plan, Health Families, Healthy Kids, and Medi-Cal Direct (MCLA) Provider Manual, June 2012, accessed at http://www.lacare.org/sites/default/files/files/HF-HK-MC_Provider Manual_Final_June2012(1).pdf. 51 Padwa H and Rawson R, A New Medi-Cal Benefit is Needed to Effectively Address the Patient and System Needs Associated with Substance Use Disorders, UCLA Integrated Substance Abuse Programs, August 2012.

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managed care to high-cost patients with complex care needs, including Seniors and Persons with Disabilities with Medi-Cal coverage, California Children’s Services, and persons dually eligible for Medicare and Medicaid, in selected counties with significant Medi-Cal managed care presence. As a result, the health plan will become the accountable entity for creating a patient-centered experience, managing care, reimbursing providers, improving quality, and controlling costs. Patient  Protection  and  Affordable  Care  Act  (ACA)   The ACA builds upon previous legislation requiring parity between mental health/SUD and medical benefits by extending the application of the Mental Health Parity and Addiction Equity Act of 2008. This legislation requires that group health plans with 50 or more employees provide equal coverage for medical/surgical and mental health/SUD services. The ACA requires that Essential Health Benefits must provide services within 10 defined categories, including mental health and SUD. California passed legislation (AB 1453 and SB 951) that sets the Essential Health Benefits package as the Kaiser Permanente Small Group HMO 30 Plan.52 The ACA’s vision is that Medi-Cal’s SUD services will be included in the managed care model, along with SAMHSA block grants for non-medical treatment. While the Kaiser Permanente plan provides a good starting point, the addition of medication-assisted therapies would provide a more comprehensive SUD benefit, as advocated by the California Coalition for Whole Health.53 The parity act applies to both California’s commercial and Medi-Cal managed care plans.54 With the ACA’s coverage expansions beginning in 2014, 1.5 million individuals statewide are projected to be newly eligible for Medi-Cal, many of whom will have mild to moderate mental health and SUD needs and will receive care through their primary care physician.55 Although the prevalence of serious behavioral health disorders is predicted to be lower among the Medicaid expansion population, the majority of which will be enrolled in managed care plans, adverse selection may bring in individuals with higher levels of co-occurring physical health and mental health or SUD issues in the initial enrollment phases.56 As a result, the need for multi-system approaches and integrated care coordination models will be more pronounced than for the current non-disabled Medi-Cal population.57 Federal guidance on Medicaid Behavioral Health Parity, which is expected by the end of 2012, may result in changes in covered benefits. Unlike specialty mental health services, Drug Medi-Cal offers an extremely narrow set of benefits, is extremely underfunded, and lacks utilization review that leads to fraud and services not being provided based on medical necessity. The majority of services provided are methadone maintenance and awareness programs to middle and high school age children. 58 An opportunity exists with ACA and parity requirements to upgrade the benefit.59 The result of the limited SUD treatment services available to Medi-Cal beneficiaries may have been up to $1.4 billion in costs for the hospitalization of individuals due to SUD diagnosis, which exceeds the amount budgeted to Drug Medi-Cal statewide.60

                                                                                                               52 Fujioka W, Sacramento Update, Memorandum from LACEO to the Board of Supervisors, October 1, 2012. 53 54 However, parity provisions do not extend to the traditional fee-for-service Medi-Cal population, creating bifurcated coverage that will be challenging to plans and providers. Personal communication with Mandy Johnson, Integrated Behavioral Health Project, October 26, 2012. 55 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 56 Ibid. 57 Ibid. 58 Presentation by John Viernes, Director, LADPH Substance Abuse Prevention and Control, to LA Health Action workgroup, August 26, 2012. 59 Jarvis D, Paying for Integrated Services: FQHC, Medi-Cal and Other Funding Strategies, June 24, 2010, Webinar presentation sponsored by California Institute for Mental Health, Alcohol and Other Drug Policy Institute, and Integrated Behavioral Health Project, accessed at http://www.uclaisap.org/Affordable-Care-Act/assets/documents/health%20care%20reform/Financing/Paying%20for%20Integrated%20Services-%20FQHC,%20Medi-Cal%20and%20other%20Funding%20Strategies.pdf. 60 California Legislative Analyst’s Office, "Remodeling" the Drug Medi-Cal Program, February 11, 2004, accessed at http://www.lao.ca.gov/2004/drug_medi-cal/021104_drug_medi-cal.htm.

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Medi-Cal mental health services may be expanded to individuals with moderate and mild mental illness who are receiving services in a primary care setting once the Medicaid expansion commences.61 An example in which this will be taking place is the transition of children enrolled in the Healthy Families program into Medi-Cal in 2013 as required by AB 1494. Under Medi-Cal, children with moderate mental illness will be receive EPSDT services and will be eligible to receive a limited mental health benefit. As a result, LADMH is planning to offer an evidence-based practice treatment that is time limited and tailored to the mental health issue, much like the benefit offered to Healthy Way LA Matched patients with moderate mental illness, which is discussed starting on page 29. Lastly, particular racial/ethnic and vulnerable populations representing a significant portion of the Medicaid expansion will require a special focus to ensure they enrolled into coverage and receive integrated care. Although Asian Pacific Islanders and Latinos have the lowest overall mental health and SUD participation rates in Medi-Cal and public behavioral health systems, these groups are predicted to represent a large share of the Medicaid expansion group. Given the cultural barriers and stigma associated with accessing mental health and SUD treatment, integrating care into the primary care setting would be one approach to meeting their needs. In addition, the homeless, individuals with SUD, and persons exiting the corrections system will comprise a portion of persons newly eligible for Medi-Cal.62 For these groups, who are often frequent users of multiple systems of care, a more intensive set of services such as permanent supportive housing or comprehensive reentry programs would be warranted. “Bridge  to  Reform”  Waiver   Intended to prepare California for ACA implementation, the Section 1115 Medicaid waiver approved by the federal government in November 2010 aims to assist counties in transforming their delivery systems. The waiver includes several components, preparing for the evolution of behavioral health services that will occur under ACA. One component includes moving patients, such as the Seniors and Persons with Disabilities, California Children’s Services, and persons dually eligible for Medicaid and Medicare populations, into mandatory managed care. The waiver includes several components supporting integration. Pre-reform coverage (Low Income Health Plan or LIHP) included a limited mental health and an optional SUD benefit. Only nine contracts have exercised the SUD benefit on a limited basis.63 The Delivery System Reform Incentive Pool offers possibilities for public hospitals to incorporate physical health services into mental health and SUD treatment.64 The impacts of the LIHP and the Incentive Pool on mental health and SUD treatment are described Due to concerns raised by advocates, DHCS included a requirement in the waiver to conduct a behavioral needs assessment and create a plan describing how the Medicaid expansion population will be served.65 While the needs assessment was submitted to CMS in March 2012, DHCS received an extension until April 2013 to complete the plan. The extension was requested because federal guidance on the Medicaid Benchmark Benefit and Medicaid Behavioral Health Parity will not be released until the end of 2012.66 As a result, DHCS sent CMS a draft outline providing a framework to guide the plan’s creation.67

                                                                                                               61 Jarvis D and Freeman J, Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net, California Institute for Mental Health, June 2011 62 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 63 These contractors include Alameda, CMSP (County Medical Services Program), Kern, Orange, Riverside, San Francisco, San Mateo, Santa Clara, and Santa Cruz Counties. See County LIHP applications, accessed at 64 Graves S and Sellers S, Finishing the Job: Moving Realignment Toward Completion in 2012, California Budget Project, June 2012. 65 Lauer G, Mental Health, Substance Abuse, Treatment Changing, California Healthline, September 17, 2012, accessed at http://www.californiahealthline.org/features/2012/mental-health-substance-abuse-treatment-changing-on-two-fronts.aspx. 66 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment Final Report, DHCS, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Pages/FinalBehavioralHealthServicesNeedsPlan.aspx. 67 Ibid.

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2011  Realignment   As part of the Governor’s 2011-12 budget, the California Legislature passed a realignment of state program responsibilities and funds to county governments. This recent realignment provided $6.3 billion to counties to oversee certain criminal justice, public safety, and health and human service programs in FY 2011-12, and ongoing funding projected to increase to $6.9 billion in FY 2013-14.68 Proposition 30, which will appear on the November 2012 ballot, would lock in existing sales tax and Vehicle License Fee revenues and provide constitutional protections for counties under realignment if passed, among other things.69 Realignment represents a significant change for counties for criminal justice and public safety responsibility, which is described in greater detail in the jail reentry section that begins on page 24. However, the financial impact of realignment is greater on health and human services. Two-thirds of overall funds are dedicated to these services with an increasing county role for particular populations with significant behavioral health needs.70 Realignment dollars are allocated into several subaccounts, one of which is the Behavioral Health subaccount. This subaccount includes Drug Courts; Drug Medi-Cal; Non-Drug Medi-Cal; and Medi-Cal specialty mental health services provided through the EPDST program and the county Mental Health Plan, and is projected to receive $964.5 million in 2012-13.71 Counties will be responsible for administration of funds and services, while distribution of dollars to the subaccount’s various programs is yet to be determined. Funding allocations to each subaccount are based on current spending levels within each program, while benefits may be expanded dependent on pending federal guidance on parity. This may be problematic for certain programs such as Drug Medi-Cal, which been underfunded and suffers from poor financial management due to the lack of utilization review. Some programs within the subaccount such as Medi-Cal and EPDST are federal entitlements. Counties have the flexibility of moving dollars across programs within each subaccount, which will allow counties to increase funding based on locally defined priorities but require careful calibration.72 Even though the state ceased providing General Fund dollars for the realigned programs, it will still play a role in oversight and technical assistance and ensuring counties follow federal regulations.73

Implications   These policy shifts have several implications for counties. With federal guidance pending on the Medicaid Benchmark Benefit and Medicaid Behavioral Health Parity, it is possible that Medi-Cal could have two tiers of benefits post-reform, one for the newly eligible and another for individuals eligible under traditional rules. The design of benefits will need to be carefully considered in the context of the redistribution of behavioral health funding to the county level under realignment. While counties will have increased flexibility in how they spend funds in the behavioral health subaccount, careful calibration may be required among the federal entitlement programs such as the county Mental Health Plan and Drug Medi-Cal to ensure overspending does not occur locally, for which counties will be liable.74 The Medicaid expansion will result in the full federal match for the newly eligible Medicaid population for the first three years and decrease gradually to 90% starting in 2020.75 At that time, counties will be required

                                                                                                               68 Graves S and Sellers S, Finishing the Job: Moving Realignment Toward Completion in 2012, California Budget Project, June 2012. 69 Connolly J, Proposition 30: Options and Consequences, Insure the Uninsured Project, August 3, 2012, accessed at http://itup.org/legislation-policy/state/2012/08/03/proposition-30-options-and-consequences/. 70 Graves S and Sellers S, Finishing the Job: Moving Realignment Toward Completion in 2012, California Budget Project, June 2012. 71 Ibid. 72 This flexibility could result in discontinuation of programs that counties operate at their discretion, particularly if a county needed to address a funding shortfall affecting a federal entitlement program. The Governor’s proposal also would allow counties to transfer funds once per year between the Protective Services and Behavioral Health subaccounts. The size of this shift, however, could not exceed 10 percent of the value of the smaller subaccount. Counties argue that this flexibility is “absolutely critical” because “it will allow counties to move funds in situations where caseloads may be declining within one subaccount, while increasing in the other subaccount. For more information, see Graves S and Sellers S, Finishing the Job: Moving Realignment Toward Completion in 2012, California Budget Project, June 2012. 73 Lauer G, Mental Health, Substance Abuse, Treat Changing, California Healthline, September 17, 2012, accessed at http://www.californiahealthline.org/features/2012/mental-health-substance-abuse-treatment-changing-on-two-fronts.aspx. 74 Since the State certifies Drug Medi-Cal facilities, it may contract directly with providers. As a result, the State will withhold a portion of Drug Medi-Cal funds transferred to counties from the behavioral health subaccount so that payment may occur. Personal conversation with John Viernes, Director, SAPC, October 10, 2012. 75 Cohen A, Driscoll K, Vane C, and Dougherty A, Health Reform Timeline – Key Dates for L.A. County, Insure the Uninsured Project, November 23, 2010, accessed at http://www.lahealthaction.org/library/LA_County_Implementation_Timeline.pdf.

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to provide 10% local match, using funds from the behavioral subaccount. However, these funds may already be allocated for other federally mandated services. At the same time, while federal Medicaid law requires the freedom of choice of providers, counties would like to be able to select which providers will be able to participate in their networks. This is especially true with SUD treatment due to large variations in the development and efficacy of evidence-based treatments offered. The health plan will become the accountable entity for patients under ACA managed care expansion. As California continues to expand the role of managed care in Medi-Cal, more consumers with multiple, high-cost health and human services needs are being moved into these arrangements. The nature of the behavioral health services carve-out will require providing patients with specialized services, navigation, care coordination, and culturally and linguistically appropriate services in order to access care and reduce disparities. A focus on measuring and improving quality across systems will be required, which will require a robust electronic health record and information exchange. With increased revenue anticipated to states and counties through the ACA’s coverage expansion, it is possible that systems may change their funding priorities. On the federal level, SAMHSA plans to alter how it will allocate the Community Mental Health Services Block Grant and Substance Use Prevention and Treatment Grant, focusing on persons who remain uninsured or experience breaks in coverage; certain treatment and support services not covered by Medicaid, Medicare or private insurance; primary prevention; and performance and outcome measurement.76 On the county level, LADMH is considering new populations such as the residually uninsured for its Mental Health Services Act dollars, which will not be required as the local match for newly eligible Medicaid recipients for the first three years. The new Medicaid eligibles will receive a benchmark level of SUD and mental health services. This should allow counties that are currently expending state and county General Fund and federal block grant dollars on these types of services to re-deploy these resources into safety net and best practices services and care coordination efforts that cannot wholly be funded with Medi-Cal under the benefit design in the benchmark plan.77

L.A.  County  Health  and  Behavioral  Health  Systems   L.A. County’s major systems that provide physical health, mental health, and SUD services to low-income communities are described below. These public and private providers provide a patchwork of safety net services to different but overlapping populations. While planned collaboration does exist, services are often provided in a fragmented and poorly coordinated manner, which will need to evolve to develop patient-centered, high quality care in an environment of increased consumer choice. L.A.  County  Departments  of  Health,  Mental  Health,  and  Public  Health   In L.A. County, responsibility for physical health, mental health, and SUD services is trifurcated among three departments, with the structure changing over the years. Before the turn of the 20th century, public health departments were organized for L.A. County, as well as for the Cities of L.A., Pasadena and Long Beach.78 In the late 1960s, the L.A. County Department of Public Health (LADPH) absorbed the L.A. City Department of Health. In 1972, in an effort to rationalize care for the uninsured, the L.A. County Departments of Hospitals, LADPH, and Mental Health (LADMH) and the County Veterinarian’s Office were combined into the Department of Health Services (LADHS), with service integration as its primary goal.79 In response to concerns raised by mental health advocates, LADMH was re-established as a separate department in 1978. Mental health responsibility was split between the two departments. Outpatient care, including psychiatric and case management services, was assigned to LADMH, while

                                                                                                               76 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 77 Ibid. 78 The Long Beach and Pasadena departments of public health are still operational. In addition, several cities in the South Bay area are organized into the Beach Cities Health District. 79 Tranquada R, Vera Y, Gupta N, and Quinn H, Sick System: A 10-year Look at the Los Angeles Health Care System and Its Current State of Health, LA Health Action, November 2005.

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emergency and inpatient services were designated to LADHS.80 Faced with similar concerns, LADPH was separated from LADHS in 2005.81 The Substance Abuse Control and Prevention division, housed within LADPH and started over 30 years ago, oversees L.A. County’s publicly funded SUD services. The integration of services has not occurred due to siloed systems of care and institutional and financial disincentives. While other California counties operate behavioral health services under the auspices of one department, L.A. County is the only county that has separated mental health and SUD service provision and oversight. For indigent health services, counties outside of L.A. may have a separate structure, or they may be integrated into a single health services agency. New revenue streams have provided financial incentives to facilitate integration on a clinical level and create a more patient-centered, responsive system in preparation for full ACA implementation. L.A. County leadership has made the integration of services a top priority in order to serve its vulnerable patient population more effectively. In addition, given the scope of unmet need, L.A. County partners with other nongovernmental organizations on several key integration projects, which are described in the next section. An overview of the three L.A. County departments is provided below. With origins dating back to 1880, LADHS has evolved into the second largest health system in the country. LADHS has an annual budget of $3.3 billion and employs a workforce of 22,000 individuals. Providing the majority of all uncompensated medical care to a largely uninsured population, LADHS serves approximately 800,000 patients annually. LADHS operates four hospitals (LAC+USC Medical Center, Harbor-UCLA Medical Center, Olive View-UCLA Medical Center, and Rancho Los Amigos National Rehabilitation Center), two multi-service ambulatory care centers (MACCs), six comprehensive health centers, and 10 health centers. LADHS has experienced persistent annual budget deficits since the mid-1990s, resulting in the receipt of two unique county-only Section 1115 waivers from 1995 to 2004 to sustain its delivery system.82 One outcome of these waivers was the formation of a contracted community clinic network in 1997 to increase the department’s capacity to deliver primary care services, fostered by the Community Clinic Association of Los Angeles County.83 This network has evolved since its inception into the Community Partners program. Due to financing infused from the “Bridge to Reform” waiver, LADHS reported a positive fiscal outlook in FY 2011-12 for the first time in nearly two decades. Realignment has brought new funds to counties that may be used to draw down federal reimbursement in order to provide behavioral health services to at-risk populations such as AB 109 parolees through new partnerships with the criminal justice system. However, these dynamics may change once the Medicaid expansion occurs and patients have an increased choice of providers. Based on recommendations from an assessment of the department’s managed care operations completed on the eve of federal health reform passage nearly three years ago, LADHS took two actions. First, the department developed a formal relationship with the local safety net health plan (L.A. Care Health Plan) to strengthen managed care operations. Second, the department elevated its ambulatory care operations to be on par with the public hospitals within its organizational structure to place greater emphasis on primary care services. As a result, LADHS is strengthening its relationship with the Community Partners clinics and engaging in joint system transformation efforts. LADMH operates the largest county mental health system in the nation, established in 1960. LADMH’s services are grounded in the recovery model like many other public mental health departments. With an annual budget of $1.9 billion, LADMH serves 250,000 children, adolescents, adults and older adults through a network of over 120 contracted agencies and 35 directly operated outpatient clinics with a qualified staff of clinicians. LADMH operates the county’s Mental Health Plan for Medi-Cal’s specialty mental health carve-out services through California’s 1915(b) Freedom of Choice waiver.

                                                                                                               80 Ibid. 81 Gupta N, Creating a Separate Los Angeles County Public Health Department: Maximizing the Opportunity to Integrate Services with Personal Health, LA Health Action, November 2005.. 82 Tranquada R, Vera Y, Gupta N, and Quinn H, Sick System: A 10-year Look at the Los Angeles Health Care System and Its Current State of Health, LA Health Action, November 2005. 83 Community Clinic Association of Los Angeles County, Quality Improvement, accessed at http://www.ccalac.org/i4a/pages/index.cfm?pageid=3308.

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In order to deliver integrated primary care and mental health services, LADMH employs evidence-based practices, care coordination, and workforce enhancement, which are described in greater detail in the integration examples section on page 23. As the primary provider of services for individuals with serious mental illness, co-occurring mental health and SUD disorders, and integrated care, LADMH delivered Mental Health Services Act-funded Full Service Partnership services to 3,180 children and 1,620 adolescents with serious emotional disturbances, and 4,672 adults and 406 older adults with serious and persistent mental illness in FY 2010-11. Documented results include decreased hospital costs, lowered rates of incarceration for youth and adults, and a dramatic decrease in homelessness for all age groups with a corresponding increase in the ability of clients to live independently.84 LADPH’s Substance Abuse Prevention and Control (SAPC) division provides an array of alcohol and drug prevention, treatment and recovery programs and services to L.A. County residents, particularly the uninsured or underinsured. In FY 2009-10, SAPC served over 60,000 individuals who were admitted to publicly funded treatment programs with an annual budget of more than $200 million.85 SAPC contracts with a provider network of 185 agencies. Some of SAPC’s contracted agencies provide integrated mental health services or primary care, which may be the only time that patients receive SUD treatment. In addition to its contractors, SAPC operates the Antelope Valley Rehabilitation Center (AVRC) to help participants engage in the recovery process. The residential program, the Acton Rehabilitation Center, provides services to up to 300 adult men and women. High Desert Recovery Services, located in Lancaster, is a low-cost, comprehensive, adult outpatient SUD treatment program. Drug Medi-Cal comprises 40% of the SAPC budget, while SAMHSA block grants make up an additional 25%. The remainder includes funds for delivering care for CalWORKs, Department of Children and Family Services (DCFS), and General Relief populations, and prevention services.86 Medi-­‐Cal  Managed  Care  and  the  Two-­‐Plan  Model   California started a major expansion of Medi-Cal managed care in the mid-1990s when enrollment of the Temporary Assistance to Needy Families-linked population was required. This approach was implemented in the 12 largest counties throughout the state according to the Two-Plan Model. In L.A., the State contracted with two managed care plans: a public health plan representing safety net providers (L.A. Care Health Plan) and a commercial plan (Health Net). In 2010, over 1.2 million people were enrolled between the two plans, with approximately two-thirds of beneficiaries receiving services from L.A. Care Health Plan to assist in sustaining the safety net.87 Specialty mental health and SUD services operate as a carve-out, as described in the section on behavioral health and Medi-Cal managed care plans on pages 9-10. LADMH runs the county’s Mental Health Plan under the 1915(b) Freedom of Choice waiver. Health plan beneficiaries diagnosed with a serious and persistent mental illness are referred to LADMH for treatment. Those beneficiaries with moderate to mild illness receive care from the primary care provider to whom they are assigned by the health plan. For SUD care, inpatient services are provided by the health plan.88 Outpatient services provided through Drug Medi-Cal are carved out in a similar manner to specialty mental health services, with health plans assessing members’ need for SUD treatment and referring them to county programs. The state certifies Drug Medi-Cal facilities. While LADPH SAPC administers $80 million in Drug Medi-Cal counties contracts, certified agencies may have a direct contracting relationship with the state that circumvents SAPC. L.A. County provides other SUD outpatient services funded through the SAMHSA Substance Abuse Prevention and Treatment Block Grant, which are not coordinated with Drug Medi-Cal and mental health services. While less of an evidence base exists in SUD care, several successful treatments are not

                                                                                                               84 LADMH, White Paper: The Los Angeles County Mental Health Network of Care: The Provider of Choice in the Era of Health Reform, Draft #2. 85 LADPH Substance Abuse Prevention and Control Program, Strategic Plan 2011-2016, February 2011, accessed at http://publichealth.lacounty.gov/sapc/Plan/SAPCStrategicPlanFinal062011.pdf. 86 Freedman J, Presentation from LADPH to LA Health Action Workgroup, March 28, 2011. 87 DHCS, Research and Analytic Studies Section, Medi-Cal Population by County, July 2010, accessed at http://www.dhcs.ca.gov/dataandstats/statistics/Documents/18_Medi_Cal_population_by_County_2010.pdf 88 L.A. Care Health Plan, Health Families, Healthy Kids, and Medi-Cal Direct (MCLA) Provider Manual, June 2012, accessed at http://www.lacare.org/sites/default/files/files/HF-HK-MC_Provider Manual_Final_June2012(1).pdf.

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included in the Drug Medi-Cal benefit. These evidence-based treatments include Screening, Brief Intervention, and Referral to Treatment (SBIRT), contingency management, continuing care, case management, and medication-assisted therapies such as Vivitrol and buprenorphine.89 ACA provides an opportunity to upgrade the SUD benefit.

Community  Health  Centers  and  Clinics   Serving about 3 million patients throughout California each year, community health centers and clinics (CCHCs) are expected to play a central role in the identification and treatment of mental health and SUD in the safety net.90 The ACA provides incentives for FQHCs and behavioral health providers to promote improved integration of primary care and behavioral health services. FQHCs receive enhanced funding through Medicare and Medicaid91, and Section 330 grants from the federal government for providing care to the uninsured.92 The National Association of Community Health Centers’ 2010 Assessment of Behavioral Health Services found that over 70% of FQHCs provide mental health services, 55% provide SUD services, and 65% provide components of integrated care, such as a shared treatment plan.93 FQHCs and community clinics have a variety of mechanisms through which they can collaborate with behavioral health providers, including community mental health centers, which range from referrals to co-location of services to establishing new FQHC sites with partnering providers.94 Other CCHCs play an important role in the health care safety net but do not receive enhanced The Community Clinic Association of Los Angeles County represents 47 member clinics operating over 150 sites in L.A. County.95 These clinics provide primary health care, including medical, dental, and mental health services, for 700,000 uninsured and medically underserved patients each year.96 In L.A. County, 122 primary care clinic sites were designated with FQHC or FQHC lookalike status in 2010.97 Clinics participating in the LADHS contracted community clinic network (Community Partners) and the Healthy Way LA Matched program serve a percentage of uninsured patients (63.5%) nearly two times higher than a financially sustainable FQHC.98 L.A. County’s free and community clinics serve an impoverished population with 70% of patients at or below 100% FPL.99 FQHCs and community clinics face several barriers to integrating behavioral health services. First, federal law does not allow Marriage and Family Therapists (MFTs) to bill for behavioral health visits. While Licensed Clinical Social Workers and psychologists may be reimbursed, a shortage of mental health professionals exists. Second, California does not allow same-day billing for medical and mental health/SUD visits under Medi-Cal. As Medicaid reimbursement varies across state programs, 28 states permit same-day billing. Third, reimbursement for case management and care coordination between

                                                                                                               89 Padwa H and Rawson R, A New Medi-Cal Benefit is Needed to Effectively Address the Patient and System Needs Associated with Substance Use Disorders, UCLA Integrated Substance Abuse Programs, August 2012. 90 Urada D, Integration of Substance Use Disorder Treatment with Primary Care in Preparation for Health Care Reform, Presentation to California Program Access for Care Capitol Briefing, Laying The Groundwork for Health Reform: Challenges and Opportunities, August 22, 2012. 91 California has a wraparound process for the Prospective Payment System (PPS) rate, which is a reconciliation process for backfilling the difference between the PPS rate and what ended up being paid during the year through Managed Care, CHDP, and Medicaid/Medicare dual eligibles. For more information see Jarvis D, Paying for Integrated Services: FQHC, Medi-Cal and Other Funding Strategies, June 24, 2010, Webinar presentation sponsored by California Institute for Mental Health, Alcohol and Other Drug Policy Institute, and Integrated Behavioral Health Project, accessed at http://www.uclaisap.org/Affordable-Care-Act/assets/documents/health%20care%20reform/Financing/Paying%20for%20Integrated%20Services-%20FQHC,%20Medi-Cal%20and%20other%20Funding%20Strategies.pdf. 92 Brolin M, Quinn A, Sirkin J, Horgan C, Parks J, Easterday J, and Levit K, Financing of Behavioral Health Services within Federally Qualified Health Centers, Brandeis University, July 23, 2012, accessed at http://www.integration.samhsa.gov/Financing_BH_Services_at_FQHCs_Final_7_23-12.pdf. 93 Ibid. 94 Ibid. 95 Community Clinic Association of Los Angeles County, About Us, accessed at http://www.ccalac.org/i4a/pages/index.cfm?pageid=3277. 96 Ibid. 97 California Office of Statewide Health Planning and Development, Healthcare Information Division, Primary Care and Specialty Clinics Annual Utilization Data, Primary Care Clinics 2010 Final Database, accessed at http://www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/PC_SC_Utilization.html. 98 Gupta N. 2011 LA Health Collaborative Executive Summary, LA Health Action, April 3, 2011, accessed at http://lahealthaction.org/library/LAHC_Executive_Summary_2011_final.pdf. 99 Ibid.

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primary care and mental health services does not exist.100 In addition, FQHCs receive reimbursement through their enhanced rate from the state, as opposed to county government. While L.A. community clinics and FQHCs have integrated mental health treatment into the primary care setting, supported by various Mental Health Services Act and other philanthropic funds, which are described in the integration examples section on page 22, SUD service integration has not taken place to the same extent. This may be attributed in part to limited funding streams to support SUD treatment. Inpatient  and  Emergency  Services   The utilization of inpatient and emergency services by patients with mental illness in L.A. County has been well-above optimal levels over the last decade. Hospital ERs are required by law to serve everyone regardless of a patient’s ability to pay. Frequent users of emergency services are a small group of chronically ill individuals who use ERs and hospitals repeatedly for medical issues that could be prevented with more appropriate ongoing care that is more cost-effective. Many frequent users have mental illness, SUD, and/or are homeless, and they lack social supports, which affects their ability to get continuous, coordinated care.101 ER patients experiencing a mental health crisis require rapid evaluation and management, presenting a challenge for public and private hospitals to transition them efficiently through inpatient and outpatient systems of care. A great deal of variation exists among Psychiatric Emergency Services (PES) structures, including the number and expertise of staff, whether a separate space exists for people experiencing a mental health crisis, and the level of support services.102 PES are meant to identify mental health issues, stabilize and refer patients to outpatient services, or admit them into inpatient psychiatric care.103 By 1980, PES evolved into the main entry point into services for large numbers of chronically mentally ill individuals nationally.104 This shift may be attributed to an increase in the volume and complexity of emergency presentations, reductions in inpatient beds, and a surge in mental health patients in the community due to deinstitutionalization and more rigorous cost containment in managed care arrangements.105 Insufficient capacity at lower levels of care leaves ERs as the only providers available to psychiatric patients requiring immediate attention, which has been exacerbated by cuts in public mental funding due to the state’s persistent budget deficits.106, 107 PES overcrowding leads to privacy issues, reduces the ability to address patient needs, and results in expensive, inefficient care.108 The evolution of PES in L.A. County’s public sector has its origins in the separation of LADMH from LADHS in 1978, when the mental health responsibility was split between the departments. Outpatient care, including a range of psychiatric and case management services, was assigned to LADMH, while emergency and inpatient services went to LADHS. However, payment and coordination mechanisms were not clearly delineated. To address increases in hospital-based PES utilization, LADMH developed an Emergency Outreach Bureau in 2000 and Alternative Crisis Services in 2006 to organize and coordinate services with law enforcement, criminal justice, and ERs. Despite the creation of these services and increases in community-based outpatient beds, PES overcrowding persisted for a variety of reasons.

                                                                                                               100 Urada D, Integration of Substance Use Disorder Treatment with Primary Care in Preparation for Health Care Reform, Presentation to California Program Access for Care Capitol Briefing, Laying The Groundwork for Health Reform: Challenges and Opportunities, August 22, 2012. 101 Linkins KW, Brya JJ, and Chandler DW, Frequent Users of Health Services Initiative: Final Evaluation Report, The Lewin Group, August 2008. 102 Allen M et al., Report and Recommendations Regarding Psychiatric Emergency and Crisis Services, American Association for Emergency Psychiatry, August 2002. 103 Fujioka W, “Psychiatric Emergency Services Decompression Plan (Budget Deliberations, Agenda of June 25, 2012)” Los Angeles County Chief Executive Office, June 8, 2012, Web. 104 Michael Allen et al. “Report and Recommendations Regarding Psychiatric Emergency and Crisis Services” American Association for Emergency Psychiatry, August 2002. 105 Fujioka, William. “Psychiatric Emergency Services Decompression Plan (Budget Deliberations, Agenda of June 25, 2012)” Los Angeles County Chief Executive Office, June 8, 2012, Web. 106 Gorman, Anna. “ERs are becoming costly destinations for mental disturbed patients” Los Angeles Times, September 5, 2011, Web. 107 Gorn, David. “Organizing the Mental Health of California” California Healthline, March 2, 2012, Web. 108 Fujioka, William. “Psychiatric Emergency Services Decompression Plan (Budget Deliberations, Agenda of June 25, 2012)” Los Angeles County Chief Executive Office, June 8, 2012, Web.

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LADHS offers PES through specialized ERs at three of the county-operated hospitals: Harbor-UCLA Medical Center, LAC+USC Medical Center, and Olive View-UCLA Medical Center.109 While the combined LADHS PES bed capacity is 39, the daily census exceeds 60-90 patients regularly.110 The monthly census has remained high (~1,900 per month) over the last six years.111 The majority of patients entering the PES are adults (91%) and males (61%). Law enforcement and LADMH’s Psychiatric Mobile Response Teams, described in greater detail below, are the mode of arrival for over half of PES patients (55%). The homeless population represents a significant proportion of PES users at 13 percent.112, 113 Private hospitals with ERs have been struggling with an uptick in uninsured psychiatric patients coupled with an erosion of services. Mental health-related ER usage increased at a higher rate (38%) versus overall ER visits (8%) from 1992 to 2001.114 Federal law (the Emergency Medical Treatment and Active Labor Act) requires any ER patient, including the mentally ill, to receive a medical screening examination and be stabilized prior to being transferred regardless of insurance status.115 Many ERs without specialized PES may lack a separate area in which agitated or distressed patients may have a quiet, secluded, secure, and hazard-free environment.116 While a consulting psychiatrist or a contracted psychiatric facility may provide PES evaluation and referral, state law does not require non-designated hospitals to have psychiatric staff. LADMH’s Psychiatric Mobile Response Teams respond to calls for assistance, which are staffed by clinicians who have legal authority per the Lanterman-Petris-Short (LPS) Act to perform evaluations for the involuntary detention of mentally disordered adults and children. While Psychiatric Mobile Response Teams usually arrive within 60 minutes of the initial referral, they often encounter difficulty given the high demand for services.117 Even when LADMH can dispatch a Psychiatric Mobile Response Team to a hospital and a hold is placed on an ER patient, inpatient psychiatric beds may not be available to initiate transfer.118 , 119 In L.A., 2,145 inpatient psychiatric beds existed in 2010, with the County operating 257 beds and the remainder in private hospitals.120 , 121 However, this number has decreased since Cedars-Sinai Medical closed its outpatient and inpatient psychiatry programs last year, which eliminated 51 beds.122 , 123 Boarding of psychiatric patients in the ER may occur until an inpatient bed becomes available, which may not occur for several days.124 Not only are hospital employees obligated to act as sitters during this timeframe, which prevents them from performing day-to-day duties, but the psychiatric patient also occupies an ER bed that could be used by someone with an emergent need.125 Hospitals have suggested

                                                                                                               109 Michael Allen et al. “Report and Recommendations Regarding Psychiatric Emergency and Crisis Services” American Psychiatric Association, August 2002. 110 Fujioka, William. “Psychiatric Emergency Services Decompression Plan (Budget Deliberations, Agenda of June 25, 2012)” Los Angeles County Chief Executive Office, June 8, 2012, Web. 111 When the former Martin Luther King, Jr., Medical Center’s Psychiatric ER closed in 2006, a redistribution of volume occurred among the remaining three LADHS facilities. See Ghaly C and Shaner R, Psychiatric Emergency Services in LA County, Presentation to the LA Health Collaborative, July 26, 2012, accessed at http://lahealthaction.org/library/3-Dr._Ghaly_and_Dr._Shaner.pdf. 112 Ibid. 113Nationally approximately 20-25% of homeless individuals are estimated to have SMI. “Mental Illness and Homelessness” National Coalition for the Homeless, June 2006, Web. 114 Stone A, Rogers D, Kruckenberg S, and Lieser K, Impact of the Mental Healthcare Delivery System on California Emergency Departments, Western Journal of Emergency Medicine, 2012 February; 13(1): 51–56. 115 Ibid. 116 Michael Allen et al. “Report and Recommendations Regarding Psychiatric Emergency and Crisis Services” American Psychiatric Association, August 2002. 117 Gorman, Anna. “ERs are becoming costly destinations for mental disturbed patients,” Los Angeles Times, September 5, 2011. 118 LADMH, Emergency Services, accessed at http://losangeles.networkofcare.org/mh/emergency.cfm#1. 119 Gorman, Anna. “ERs are becoming costly destinations for mental disturbed patients,” Los Angeles Times, September 5, 2011. 120 Office of Statewide Health Planning and Development, Health Care Information Division, Hospital Annual Financial Data, 2010, accessed at http://www.oshpd.ca.gov/HID/Products/Hospitals/AnnFinanData/PivotProfles/default.asp. 121 As the local Mental Health Plan (MHP) for L.A. County, LADMH authorizes reimbursement for acute inpatient psychiatric services provided to Medi-Cal beneficiaries. See LADMH, Local Mental Health Plan, Medi-Cal Fee-For-Service Inpatient Provider Manual, Second Edition, May 2011, accessed at http://file.lacounty.gov/dmh/cms1_159848.pdf. 122 Lauer G, Two Faces of Mental Health Treatment in California, California Healthline, December 12, 2011, accessed at http://www.californiahealthline.org/features/2011/two-faces-of-mental-health-treatment-in-california.aspx 123 In California’s five state mental hospitals, 92% of beds are occupied by patients from the criminal justice system. See California Healthline, Treatment of Patients in Psychiatric Hospitals Down, Report Finds, July 20, 2012. 124 Psychiatric boarding is defined as psychiatric patients waiting in hallways or other emergency room areas for inpatient beds. For more information, see Alakeson, Vidya et al. “A Plan to Reduce Emergency Room ‘Boarding’ of Psychiatric Patients” Health Affairs, September 2010, 29:9, 1638, Web. 125 Personal communication with Jaime Garcia, Hospital Association of Southern California, August 15, 2012.

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that Psychiatric Mobile Response Team should use telehealth to perform psychiatric assessments remotely in order to maximize efficiency of limited resources.126 Furthermore, the seriously mentally ill population may be receiving ongoing intensive outpatient services through a Mental Health Services Act-funded Full Service Partnership, with evaluation results demonstrating that clients using these services for 18 months had 78% lower odds of using mental health ER services.127 Psychiatric ER patients receiving services from a Full Service Partnership may not have a membership card or be able to recall the name of their provider, especially those arriving an unstable mental condition. As a result, hospital staff may not be able to easily contact local Full Service Partnerships to link individuals with community-based care.

School  Health  Centers   Many schools and school districts acknowledge the social, emotional and physical factors that shape student behavior.128 School Health Centers (SHCs) provide important access to primary care and can provide mental health specialists to identify the underlying causes of a student’s disruptive behavior, leading to the implementation of alternative behavioral interventions.129 Mental health services received in a SHC setting have been shown to improve users’ “health-related quality of life” and to be more efficacious than those provided in community settings.130, 131 The ACA includes provisions to increase the number and operations of SHCs in order to serve additional students, increase health care access for children, and provide funding for capital needs.132 SHCs have been growing rapidly in L.A. County since the mid-1980s, operated by community health centers, hospitals, school districts and others. Each employs various staffing models and disparate services depending on local resources, and all have struggled financially. Operating both full and part-time, SHCs focus on prevention and early intervention strategies. Well child and sports physical exams comprise a large portion of their services along with reproductive health care that are consistent with school health policy and state minor consent and confidentiality laws. In clinics that offer mental health services as a part of their array, as many as 40 percent of all visits were mental health related. While SHCs primarily deliver medical care, students and families also need mental health, family violence and substance abuse services, particularly at the secondary school level. Although many schools have site-based Early Periodic Screening, Diagnosis, and Treatment program services provided by school staff or mental health agencies through County contracts, those services are frequently not well integrated with the SHCs. Consequently, some SHCs have not been well positioned to provide or access behavioral health services when issues are identified during a medical visit. Some SHCs have struggled financially to sustain licensed mental health staff at their sites due to the lack of county mental health contracts. Particularly at the high school level, where students present frequently in crisis, this siloed approach is not effective. The most difficult integration issues are among mental health providers and SUD services. In particular, SUD providers are certified counselors who are typically adults recovering from SUDs. They provide treatment to students, with almost no evidence to suggest that this approach works effectively. Mental health professionals are seldom part of the SHC provider team, even though depression, anxiety, or other co-occurring disorders are part of the presenting picture. Furthermore, a disconnect exists

                                                                                                               126 Gorman, Anna. “ERs are becoming costly destinations for mentally disturbed patients” Los Angeles Times, September 5, 2011. 127 Brown TT, Buckner TA, Chung JC, Choi S, Felton M, Scheffler RM, The Impact of the Mental Health Services Act on Emergency Interventions and Involuntary Hospitalizations, Nicholas C. Petris Center on Health Care Markets and Consumer Welfare, University of California, Berkeley, May 2010. 128 Research has demonstrated that school health centers (SHCs) can support improved learning behavior and influence academic achievement. See California School Health Center Association, Ready, Set, Success! How to Maximize the Impact of School Health Centers on Student Achievement, November 2010. 129 California School Health Center Association, Ready, Set, Success! How to Maximize the Impact of School Health Centers on Student Achievement, November 2010. 130 Guo, JJ, Wade, TJ, and Keller KN, Impact of School-Based Health Centers on Students with Mental Health Problems, Public Health Reports, (2008) 123: 768-780. 131 Daniel, PID, Treatment Efficacy of School-Based Mental Health Clinics as Compared to Community-Based Mental Health Clinics, 2008, Dissertation, Northcentral University School of Psychology. 132 Los Angeles County Education Foundation, Education + Health = The Critical Combination for Student Success: Policy Summit Findings and Next Steps, April 2012.

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between County-contracted and FQHC-delivered mental health services because they are funded through different siloed public entities. L.A. County’s 62 SHCs are not sufficient to meet the needs of its 1.5 million public school students. Only 10 percent of the County’s 80 school districts have a SHC. 133 As the second largest school district in the nation educating one-half of L.A. County’s K-12 population, the Los Angeles Unified School District (LAUSD) operates many SHCs that provide EPDST/Childhood Health Disability and Prevention (CHDP) assessment services and access other funding streams 134 . LAUSD maintains a health insurance enrollment program for its large uninsured population, but the revenue generated does not meet its operational costs. Founded a century ago, LAUSD’s School Mental Health Program provides students with early identification and intervention, promotes mental health, and prevents more serious disability. In 1993, LADMH contracted with LAUSD, signifying the first blended funding, full-scope school-based Medi-Cal child psychiatry clinics in the nation. 135 In 1991, LAUSD authorized the creation of a nonprofit organization, the LA Trust for Children’s Health, to foster and sustain school health programs. The LA Trust is a convener of partners, an advocate for children’s health, and fosters planning and resource development. Other school districts are smaller, and many do not offer EPDST services. All schools are facing large budget deficits and challenges to maintain priority programs. Partnering with FQHCs that have access to enhanced Medi-Cal reimbursement has become increasingly popular as schools seek to sustain SHCs. However, the lack of funding for services that make a collaborative service model work, such as case management, care coordination, and health promotion and education, remains a significant barrier to long-term sustainability.

Vulnerable  Populations   Populations in L.A. County that encounter high rates of a combination of physical health, mental health, and SUD conditions are described below, including the homeless, persons exiting the corrections system, and individuals with SUD disorders. These individuals are expected to represent a significant portion of the Medicaid expansion due to the ACA’s new eligibility rules. They will require a special focus to ensure enrollment into coverage and integrated care happens to manage their complex conditions while improving health outcomes and controlling costs.136

Homelessness   L.A. County is referred to as the homeless capital in the nation, a substantial proportion of whom have mental health and SUD issues. More than 51,000 individuals are homeless on any given night in the region, including 12,560 who are chronically homeless.137 Chronic homelessness is defined as being homeless for a year or more and having a disabling mental health, SUD and/or physical health condition. L.A.’s public systems invest $875 million annually to manage homelessness, including ERs, jails, shelters, and other crisis services.138 The chronically homeless population uses three-quarters of these resources while comprising only one-quarter of all homeless persons, dying at a much younger age (30-40 years).139

                                                                                                               133 Ibid. 134 Other funding sources including Local Educational Agency Medi-Cal programs and Medi-Cal Administrative Activities claiming, Mental Health Rehabilitation Program, EPDST mental health, AB 3632, Health Net fee-for-service contracts, L.A. Care reimbursement contract for CHDP services, and other partnerships for vision and oral health services. 135 Los Angeles Unified School District, Complete History of School Mental Health, accessed at http://notebook.lausd.net/pls/ptl/PTL_EP.wwv_media.show?p_id=1057527&p_settingssetid=1&p_settingssiteid=33&p_siteid=33&p_type=basetext&p_textid=1057528. 136 Technical Assistance Collaborative and Human Services Research Institute, California Mental Health and Substance Use System Needs Assessment: Final Report, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf. 137 Rapport S, LA Health Collaborative Meeting: Homeless Health Care Policy Opportunities, Corporation for Supportive Housing, presentation to the LA Health Collaborative, February 23, 2012. 138 United Way of Greater L.A. and L.A. Area Chamber of Commerce, Home For Good: 2012 Update, 2012, accessed at http://www.unitedwayla.org/wp-content/uploads/pdfs/HomeForGood_Action_Plan.pdf. 139 Ibid.

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In particular, the chronically homeless are expensive to L.A.’s health care systems, given the barriers not having a residence creates to accessing services. The homeless use acute care services at high rates. Approximately 2,300 individuals who are homeless use LADHS inpatient services each year at an average annual cost of $30,000 per patient and an average length of stay at one and half time longer than someone who is not homeless.140 In 2009, L.A. County’s 76 acute care hospitals treated 4,270 inpatients identified as homeless at an average cost of $37,150 over a year. About half of frequent ER users are homeless. General Relief recipients who are homeless have an average annual cost to L.A. County’s public systems of $34,764 per individual, 67% of which was incurred in the health and mental health sectors. For homeless individuals who are in permanent housing with needed supportive services, the amount spent on county-funded health and mental health drops by 85% to $288 per month.141 The Housing First philosophy has gained traction, which moves the chronically homeless immediately from the streets or shelters into permanent housing linked with intensive case management services. The Corporation for Supportive Housing is a national leader in Housing First approaches, targeting permanent supportive housing to populations that have a combination of physical health, mental health, and SUD issues, including but not limited to the chronically homeless, veterans, kids in foster care, and persons involved in the criminal justice system. The organization, which has national reach and impact, has a strong California presence with support from the L.A.-based Hilton Foundation and other philanthropic agencies. An evaluation of an initiative led by the Corporation for Supportive Housing that focused on frequent users of ERs and linking them with permanent supportive housing found a reduction in average ER visits by 34% and average inpatient days by 27%.142 Results of Housing First initiatives have demonstrated that effective health care for homeless individuals must include consistent access to comprehensive, coordinated medical and behavioral health care. This includes outreaching to and engaging patients, connecting patients to permanent housing, coordinating health care, educating and assisting patients to manage their own care, and facilitating communication among providers. Jail  Reentry   Jails offer opportunities for counties to improve the health of individuals in the community with complex, multiple needs by identifying conditions and providing treatment and prevention programs. Unlike prisons143, sheriffs or local governments run jails. Jails house individuals awaiting trial, conviction, or sentencing; with sentences of less than one year, 80% of which are for less than one month; and who violated probation and parole.144 Jail inmates encounter considerable challenges with physical health, mental health, and SUD issues, as well as housing and employment upon release.145 Four in 10 men and six in 10 women who were released prisoners reported a combination of physical health, mental health, and SUD issues, which they had upon entry to the facility and that required ongoing attention upon release.146 Between 50 to 75% of L.A. County probationers have mental health problems, while 58% of California prisoners show signs of drug dependency.147 Access to community-based care complements jail interventions, supports an individual's recovery and ability to comply with conditions of release, and provides continuity in treatment started while in jail. Releasing individuals with untreated illnesses creates an additional financial burden on a local public health system, particularly emergency services. Prior to incarceration, estimates indicate that only 10% of individuals with SUD receive treatment and 11.4% with co-occurring disorders receive care for both.148 Screening and assessment are critical, and the

                                                                                                               140 Todoroff C, Supportive Housing Initiative, Los Angeles County Department of Health Services, presentation to LA Health Collaborative, February 23, 2012. 141 Rapport S, LA Health Collaborative Meeting: Homeless Health Care Policy Opportunities, Corporation for Supportive Housing, presentation to the LA Health Collaborative, February 23, 2012. 142 Linkins KW, Brya JJ, and Chandler DW, Frequent Users of Health Services Initiative: Final Evaluation Report, The Lewin Group, August 2008. 143 Prisons are operated by state government and house individuals who are convicted of crimes. 144 Solomon AL, Osborne J, LoBuglio SJ, Mellow J, and Mukamal D, Life After Lockup: Improving Reentry from Jail to the Community, Urban Institute, May 1, 2008, accessed at http://www.urban.org/publications/411660.html. 145 Ibid. 146 Mallik-Kane K and Visher C, Health and Prisoner Reentry: How Physical, Mental, and Substance Abuse Conditions Shape the Process of Reintegration, Urban Institute, 2008, accessed at http://www.urban.org/url.cfm?ID=411617. 147 Anderson L, How Health Coverage Can Reduce Jail Overcrowding, California Healthline, September 24, 2012, accessed at http://www.californiahealthline.org/think-tank/2012/can-health-policy-contribute-to-drop-in-crime-rate.aspx. 148 Substance Abuse and Mental Health Services Administration, Results from the 2008 National Survey on Drug Use and Health: National Findings, SAMHSA Office of Applied Studies, 2009.

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information obtained should be used to guide care while incarcerated and upon release. Lack of health insurance and other benefits is a significant problem with nearly 68% of released prisoners without health coverage by eight to 10 months after community reentry.149 This critical period is associated with an increased risk of medical problems, recidivism, and mortality.150 The MHA Village (described on page 10) served as the model for AB 34 enacted in 1999, which provided $10 million for pilot programs focusing on comprehensive care for people with mental illness who are homeless, leaving jail, or at risk of homelessness or incarceration in L.A. Stanislaus, and Sacramento counties.151 The pilot programs were very successful in reducing the number of homeless days, jail days, and psychiatric hospital days. As a result, the Legislature passed AB 2034, which expanded the pilots and created additional programs statewide directed at serving homeless persons, parolees, and probationers with serious mental illness. AB 2034 funds served over 4,500 mentally ill homeless or incarcerated individuals through 53 programs operating in 34 counties. Due to the flexible nature of funding, counties were able to provide a comprehensive array of services including outreach, permanent supportive housing and other housing assistance, employment, SUD, mental health and physical health services. Areas for improvement included a greater emphasis on meeting the physical health care needs and strategies to increase retention of participants.152 With the passage of the Mental Health Services Act in 2004, Governor Schwarzenegger eliminated AB 2034 from the FY 2007-08 state budget.153 The local jail system is operated by the L.A. County Sherriff’s Department and has been referred to as the largest mental health hospital in the country. Around 900 persons enter and exit the jails daily, and the County receives and monitors the highest number of parolees of any county in the state at over 39,000.154 In 1972, the Sheriff’s Department collaborated with LADMH to establish on-site jail mental health services and specialized housing.155 Approximately 20% of LADMH’s services are provided within L.A. County’s jails.156 Approximately 2,000 inmates at any given time are diagnosed with a mental illness, 90% of whom report co-occurring SUD. Each inmate is screened and assessed upon intake. Mental health services for men are provided at the Twin Towers Correctional Facility in downtown Los Angeles, and services for women are provided at the Century Regional Detention Facility in Lynwood. Six Jail Mental Evaluation Teams provide outreach services to identify inmates with mental health symptoms manifesting while in jail or whose mental illness may have not been detected. These teams operate in North County Correctional Facility, Men’s Central Jail, and Twin Towers Correctional Facility, with each one staffed by a deputy sheriff and a LADMH clinician.157 Since jails are operated locally, county-level policy is crucial. Opportunities exist to leverage the realignment of state health care responsibilities to counties in order to encourage jail-community collaboration, allow successful reentry, and reduce recidivism. In April 2011, the California Legislature passed the Public Safety Realignment Act (AB 109/117), which transfers responsibility for supervising specific low-level inmates and parolees158 from the state parole department to counties. These laws are intended to cut state spending, reduce the prison population as required by a U.S. Supreme Court decision to address overcrowding, and improve the prison and parole systems.159 Prior to passage of these bills,

                                                                                                               149 Ibid. 150 Wakeman SE, McKinney ME, and Rich JD, "Filling the Gap: The Importance of Medicaid Continuity for Former Inmates," Journal of General Internal Medicine 24, no. 7 (July 2009): 860-62. 151 Burt MR and Anderson J, AB2034 Program Experiences in Housing Homeless People with Serious Mental Illness, Corporation for Supportive Housing, December 2005. 152 Homebase, State of California Highlight: AB 2034, June 21, 2006, accessed at http://www.homebaseccc.org/PDFs/CATenYearPlan/CAHighlightOutreach.pdf. 153 Mong S, Conley B, and Pilon D, Lessons Learned from California’s AB 2034 Programs, CHMDA and CiMH, March 2009, accessed at http://www.cimh.org/Portals/0/Documents/MHSA/mhsa-networks/fsp-advise/misc/ab2034-report/01-Descriptive-Research-(AB2034-Report).pdf. 154 Re-Entry L.A. A Self-Help Resource Guide, accessed at http://www.lasdhq.org/divisions/correctional/ebi/assets/re-entry-guide.pdf. 155 Los Angeles County Sheriff’s Department, Correctional Services Division, Jail Mental Health Services, accessed at http://www.lasdhq.org/divisions/correctional/mh/index.html. 156 Shaner R, Presentation to LA Health Collaborative meeting, July 26, 2012. 157 Los Angeles County Sheriff’s Department, Correctional Services Division, Jail Mental Health Services, accessed at http://www.lasdhq.org/divisions/correctional/mh/index.html. 158 AB 109 releasees are classified as non-violent, non-serious, non-sex offenders (N3s). In addition, AB 109/117 shifts the revocation process for parolees to the county court system. For more information, see County of Los Angeles, Community Corrections Partnership. AB 109/117 Implementation Plan, September 2011. 159 Krisberg B and Taylor-Nicholson E, Realignment: A Bold New Era in California Corrections, University of California, Berkeley Law School, September 2011, accessed at http://www.law.berkeley.edu/files/REALIGNMENT_FINAL9.28.11.pdf.

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individuals with mental illnesses received care from state parole department-operated clinics after release from prison, which has shifted to the county responsibility of jails and probation. The Community Corrections subaccount will support the management, supervision, and rehabilitation of this population, projected to amount to $842.9 million in FY 2012-13 statewide, or 14.3% of realigned revenues.160 In response to the legislative mandate, L.A. County’s Community Corrections Partnership developed a plan to implement community supervision of released inmates, which was approved by the Board of Supervisors and went into effect on October 1, 2011. Between 14,000 and 15,000 individuals are expected to be under community supervision by the end of FY 2013-14. In addition to the AB 109 population, L.A. County will be responsible for an estimated 7,000 newly sentenced felony offenders annually who will not meet the qualifications for state prison.161 The County projected receiving almost a third of the State’s realignment allocation in the Community Corrections subaccount in FY 2012-13 at $267.7 million.162 Since realignment began last year, the County’s jail population has increased by more than 25 percent to a total of 18,600 inmates, alongside an influx of released inmates with documented mental illness.163 , 164 Although counties received funding for community supervision, the state has not established standards, nor provided any funding, for evaluating county policies and practices in managing this new program.165 The implementation plan outlines several roles and responsibilities for county departments. In particular, LADMH oversees the review of the pre-release information, assessment for mental health needs, development of a treatment plan, and referrals to community-based services. LADMH staff will evaluate assessment information and county records for each inmate to screen for mental health issues.166 Individuals with a history of mental illness are required to report to a probation center hub to receive a behavioral health screening. LADPSS staff will enroll newly released inmates into public benefits for which they qualify. In particular, LADHS staff is available to enroll exiting individuals into Healthy Way LA Matched, the county’s Low Income Health Plan under the “Bridge to Reform” waiver, since they should qualify. However, because they are only required to meet with LADMH staff and not enrollment workers, establishment of benefits does not always happen.

Alcohol  and  Other  Drug  Use   The economic and social impact of untreated SUD is significant nationally and locally. The annual estimated economic cost in L.A. County for alcohol use alone is nearly $11 billion.167 Drug overdose is the fourth leading cause of premature death and the 17th leading cause of death overall, while drug offenses account for the highest percentage of overall felony arrests in L.A.168 SUD have significant impacts on health, health care costs, mental health, and behavior. Individuals with SUD incur between two and three times the total medical expenses of people who do not have SUD.169 Excessive alcohol consumption represents the second-leading cause of premature death and disability in L.A. County.170 Although rates of heavy drinking are highest among whites, the death rate from alcohol-related liver disease and cirrhosis is much higher among Hispanics. Nearly 61,000 L.A. County residents were admitted to publicly funded                                                                                                                160 Graves S and Sellers S, Finishing the Job: Moving Realignment Toward Completion in 2012, California Budget Project, June 2012. 161 Fujioka W, State Budget – Preliminary Analysis of the FY 2012-13 State Budget Act, Memorandum from the LACEO to the Board of Supervisors, June 29, 2012, accessed at http://lahealthaction.org/library/cms1_180684.pdf. 162 Ibid. 163 Shafer S, In Calif., Some Ex-inmates Get Help in New Ways, September 2012, KPCC, accessed at http://www.scpr.org/news/2012/09/21/34382/in-calif-some-ex-inmates-get-help-in-new-ways. 164 To address the surge, the L.A. County Sheriff’s Department is in discussions with Kern County cities to use their currently empty jails and considering several other strategies, such as releasing individuals with electronic monitoring systems and speeding up the resolution of lower-level criminal cases. See Blankenstein A and Song J, County Acts to Handle Inmate Flux, Los Angeles Times, July 10, 2012. 165 Lofstrom M, Petersilia J, and Raphael S, Evaluating the Effects of California’s Corrections Realignment on Public Safety, Public Policy Institute of California, August 2012. 166 The screening process determines whether an individual may be excluded from Post-Release Community Supervision due to being classified as a Mentally Disordered Offender. For more information, see California Department of Mental Health, Mentally Disordered Offenders Program, accessed at http://www.dmh.ca.gov/services_and_programs/Forensic_Services/MDO/default.asp. 167 Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Reducing Alcohol-Related Harms in Los Angeles County: A Cities and Communities Report. Revised Edition, December 2011. 168 LADPH SAPC, Strategic Plan 2011-2016, February 2011, accessed at http://publichealth.lacounty.gov/sapc/Plan/SAPCStrategicPlanFinal062011.pdf. 169 LADPH SAPC, Fact Sheet: Drug Use and Misuse in Los Angeles County, September 2010, accessed at http://publichealth.lacounty.gov/sapc/FactSheet/DrugUseFactSheet.pdf. 170 Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Reducing Alcohol-Related Harms in Los Angeles County: A Cities and Communities Report. Revised Edition, December 2011.

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drug treatment programs. The most frequently reported drugs for which clients received treatment were marijuana/hashish (27.2%), alcohol (25.6%), methamphetamine (18.1%), and cocaine/crack (13.0%). Individuals with SUD can suffer from permanent health and social consequences as a result of dependence or abuse. The field of SUD continues to change as funding shifts and the breadth of knowledge about prevention and treatment grows, coupled with the changing policy environment due to ACA, the 2008 Mental Health Parity and Addiction Equity Act, and realignment. The number of newly insured individuals seeking SUD treatment may dramatically increase at the same time the supply of qualified personnel available to provide treatment is reduced because they lack the necessary educational and professional training required in the new system.171 Reforming and expanding state Medicaid SUD benefits has been demonstrated to reduce costs and improve patient health outcomes. In Colorado’s Medicaid program, spending $2.4 million to expand SUD treatment benefits was associated with $3.5 million in reductions in dental, ER, hospital, outpatient, pharmacy, and mental health expenses. In the Ohio Medicaid program, individuals with SUD who received treatment had half the total medical costs of individuals with SUD who did not receive treatment, and in Washington State, expanding SUD services to Medicaid enrollees has resulted in estimated cost savings of $321 per enrollee per month.172 In California, an opportunity exists to upgrade the outdated Drug Medi-Cal benefit to meet ACA and federal parity requirements.

Integration  Examples   L.A. County has embarked on a number of efforts to integrate care over the last few decades. Often, the focus has been on piloting approaches in certain areas and particular populations given the geographic variation throughout the county, high levels of unmet need, and pronounced differences in regional delivery systems, rather than on building an integrated system of care. An overview of integrating care in order to improve outcomes and reduce costs in L.A. County is provided below. While this review is not meant to be an exhaustive one, it is intended to bring to light major initiatives that involve cross-sector collaboration, promising results, and potential for replication. Mental  Health  Services  Act   LADMH has used its Mental Health Services Act funding to promote integration of services through several of the Act’s components, with an overview provided in Table 3 on the following page.

                                                                                                               171 LADPH SAPC, Strategic Plan 2011-2016, February 2011, accessed at http://publichealth.lacounty.gov/sapc/Plan/SAPCStrategicPlanFinal062011.pdf. 172 Padwa H and Rawson R, A New Medi-Cal Benefit is Needed to Effectively Address the Patient and System Needs Associated with Substance Use Disorders, UCLA Integrated Substance Abuse Programs, September 2012.

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Table 3. Mental Health Services Act-Funded Integration Examples in L.A. County MHSA Component Integration Examples

Community Services and Supports

Older Adult Field Capable Clinical Services provided by 7 contracted and 10 directly-operated programs targeting adults 59 or older with a significant mental health diagnosis that creates some functional disability for those who are not able to receive services at a clinic. The teams spend some time co-located for a few hours a week in health care, senior centers, and housing.

Wellness Centers employed nurse practitioners to provide leadership on various wellness activities (i.e., smoking cessation)

Integration of Substance Use Disorder Programs in mental health Urgent Care Centers

System Navigators positions for each age group (Children, Transition Age Youth, Adults, Older Adults) within each of the county’s Service Planning Areas to enhance entry into the mental health system and reach ethnic and priority population targets for the Full Service Partnerships (FSPs), provide the linkage to the FSPs, accept referrals to FSPs, and seek out potential FSP clients through linkages to other systems

Housing Program allocates $115 million towards permanent supportive housing projects Prevention and Early Intervention

School-Based Services Project integrating mental health services with County-funded primary care services

Primary Care and Behavioral Health Services provides prevention and early treatment of depression in primary care through evidence-based practices (IMPACT and Mental Health Integration Program)

Innovation Integrated Mobile Health Team uses a client centered, Housing First model and comprehensive single-team approach that practices harm reduction strategies across all modalities to provide permanent housing, primary care, mental health and SUD services to homeless clients and families

Integrated Clinic Model uses the single team approach to provide integrated services in a community-based site by combining mental health, SUD and physical health in one common setting to fully meet the needs of individuals who are homeless, uninsured, and/or members of under-represented ethnic populations

Community-Designed Integrated Service Management Model (ISM) uses a holistic, non-traditional healing and culturally sensitive approach to care and focuses on individual integrated service approaches for UREP by employing specially trained “service integrators” to help clients access available resources

Integrated Peer-Run Model uses the Peer-Run Integrated Services (PRISM) model and Alternative Peer-Run Crisis Houses for people with co-occurring mental health and SUD needs with interventions provided by individuals with lived experience of mental health issues

Workforce Education and Training

Community Health Outreach Worker trains promotoras to work in an integrated patient centered medical home

Promotoras Program develops culturally sensitive mental health workers who can serve as coaches and navigators

Health Navigators trains individuals in recovery to work in integrated mental health-primary care settings Sources: Kay R, The Los Angeles County Department of Mental Health: Our Journey Toward Integrated Care, Presentation to the LA Health Collaborative, July 21, 2011 and MHSA Implementation Study: Community Services and Supports Successes and Challenges, June 29, 2009, NAMI California “MHSA County Programs 2012: Services Promoting Recovery and Reducing Homelessness, Hospitalization and Incarceration” National Alliance on Mental Illness, May 11, 2012, and LADMH, White Paper: The Los Angeles County Mental Health Network of Care: The Provider of Choice in the Era of Health Reform, Draft #2.

In particular, LADMH used the Innovations Plan to test four integrated care models targeting individuals with medical, mental illness, and SUD issues. This plan aims to identify new practices for learning, while increasing its array of creative and effective approaches to delivering needed services. Contracts were awarded in 2012 over a two-year period, with the four models summarized below:

• Integrated Mobile Health Team provides permanent supportive housing to homeless clients and families including primary care, mental health, and SUD services staffed by a multidisciplinary team

• Integrated Clinic Model provides services in a primary care setting or a mental health setting

• Community-Designed Integrated Service Management Model uses culturally sensitive approaches for underrepresented ethnic populations

• Integrated Peer-Run Model provides residential short-term respite care combined with linkages to health, primary care, and SUD services

In addition, LADMH initiated workforce development programs to meet anticipated increased demands under the Medicaid expansion, which includes a partnership with LADHS and the Worker Education and Resource Center to train mental health outreach workers in integrated patient-centered medical homes as part of the “Bridge to Reform” waiver, developing a system of peer bridgers and system navigators to support clients through transitions from higher to lower levels of care, often in inpatient settings, and a health navigator program to train individuals to work in integrated settings.173, 174 Other LADMH

                                                                                                               173 LADMH, White Paper: The Los Angeles County Mental Health Network of Care: The Provider of Choice in the Era of Health Reform, Draft #2. 174 Katz M, Development of a Pilot Curriculum for Mental Health Outreach Workers - Section 1115 Medicaid Waiver, Memorandum from LADHS to the Board of Supervisors, March 8, 2011.

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initiatives include defining elements of a behavioral health home, developing a countywide Enterprise Master Person Index and electronic medical record, and telemental health and consultation.175 LADMH’s leveraging of Mental Health Services Act funds for the Healthy Way LA Matched program, including the use of evidence-based practices, the Integrated School Health Centers initiative, and other programs are described in greater detail in the following sections. Integrated  Behavioral  Health  Project   Launched in 2006, the Integrated Behavioral Health Project was a four-year initiative to accelerate the integration of behavioral health services into primary care settings in California. Its goals are to enhance access to behavioral treatment services, improve treatment outcomes for underserved populations, and reduce the stigma associated with seeking such services. The project was funded by The California Endowment as a part of its strategic goal to promote the health of underserved individuals and families by expanding access to quality health and mental health services. The Project developed a grant program that included three separate phases to support and strengthen behavioral health integration efforts at clinics and consortia throughout California. The goal was to identify, elevate and accelerate promising practices. The project developed a Learning Community and Mentoring Program to support clinics at different stages of implementing integrated care. Table 4 summarizes the clinics funded in L.A. County in Phase II and III. Clinics outside of L.A. County were selected for Phase I.176 Table 4. Overview of Integrated Behavioral Health Project Grants in L.A. County, 2006-2010.

Overview

L.A. County Clinic Grantee(s)

Phase II

Expanded learning community activities to 27 grantees to include a mentoring component; advocating for policy and system changes to reduce barriers to integration efforts; and fostering innovative projects to: • Expand intra-clinic collaboration between primary care and behavioral service providers • Increase positive treatment outcomes • Maximize client engagement • Advance cross-system collaboration • Enhance the integration of primary care clinic SUD with primary care and behavioral

health • Broaden the provision of medical services for clients with serious mental health

problems • Develop a Prevention and Early Intervention prototype for replication, and define a

strategy consistent with the Mental Health Services Act guidelines and planning activities

• All for Health, Health For All • Asian Pacific Health Care Venture • Central City Community Health

Center • Eisner Pediatric and Medical Center • St. John’s Well Child and Family

Center • South Bay Family Healthcare • URDC/Bill Moore Community Health

Center

Phase III

Selected seven grantees to advance the base of knowledge concerning integrated care in primary care settings, rooted in each agency’s interests, internal structure, and current level of integration. Asked key questions including best practices for client engagement, defining a health home in a community clinic setting, models of collaborative care, developing a business case for integrated behavioral health for community clinics, and improving collaboration between community clinics and public mental health systems.

• St. John’s Well Child and Family Center

Source: Integrated Behavioral Health Project, Who We Are and What Are We Doing, Past Grant-Making, accessed at http://www.ibhp.org.

In addition, the Integrated Behavioral Health Project published Partners in Health: Primary Care/County Mental Health Tool Kit in 2009, which is designed to help primary care clinics and local public mental health agencies forge collaborative relationships. The report provides practical operational advice, forms, strategies and prototypes for integrating mental and physical health services.177

Low  Income  Health  Program:  Healthy  Way  LA  Matched   LADMH has leveraged the Mental Health Services Act Prevention and Early Intervention component to provide local matching funds for a mental health benefit under a new county program, Healthy Way LA

                                                                                                               175 Gupta N. 2011 LA Health Collaborative Executive Summary, LA Health Action, April 3, 2011, accessed at http://lahealthaction.org/library/LAHC_Executive_Summary_2011_final.pdf. 176 Integrated Behavioral Health Project, Who We Are and What Are We Doing, Past Grant-Making: Recipients, accessed at http://www.ibhp.org/index.php?section=pages&cid=217. 177 Integrated Behavioral Health Project, Who We Are and What Are We Doing, Past Grant-Making, accessed at http://www.ibhp.org.

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Matched. One component of California’s “Bridge to Reform” waiver is the Low Income Health Program (LIHP), which provides counties an opportunity to expand pre-reform coverage to uninsured adults, transition them to Medicaid coverage, and develop organized systems of care. LADHS implemented the LIHP through the Healthy Way LA Matched program. Healthy Way LA Matched has elected to implement one component of the LIHP, setting the income level at below 133% FPL178 , which mandates that counties must provide a minimum set of benefits and meet geographic and timeliness standards for accessing care.179 The LIHP is intended to move counties towards managed care readiness. However, counties are not required to provide dental, vision, and SUD coverage, which Healthy Way LA Matched does not offer.180 L.A. County did not include a LIHP SUD benefit because of a limited provider network, making meeting access standards problematic, and insufficient local matching funds.181 Individuals enrolled in Healthy Way LA Matched will become eligible for Medicaid once full ACA implementation occurs in 2014, when full federal reimbursement will occur for the next three years and decrease gradually to 90% in 2020 and thereafter.182 As of September 2012, HWLA Matched membership reached nearly 200,000 individuals.183 Table 5 provides the LADMH eligibility criteria and services provided for the new Healthy Way LA Matched benefit. Table 5. LADMH Matrix of Services for the Healthy Way LA Matched Program

Level of Need Client Criteria Services Provided Agency Providing Services

Tier 1 Current priority population: individuals with serious mental illness with a high need for mental health, rehabilitation, and/or long-term services and supports. These individuals may have low to high health care needs.

Medi-Cal-included DSM-IV-TR diagnosis and functional impairment. Other issues may include homelessness, multiple involvements in criminal justice system, and multiple ER visits.

Full range of rehabilitation option services

LADMH facilities and directly-operated network

Tier 2 Individuals seen in a primary care setting who may benefit from an early intervention via short-term, time-limited treatment, are moderate to low-risk, and have a need for mental health interventions, and/or

Individuals experiencing a recent crisis or trauma not been diagnosed with serious mental illness

Full range of included diagnoses generally less severe than Tier 1, difficulty functioning in one or more essential roles, and expectation that short-term early intervention will ameliorate symptoms or life problems

Services using evidence-based practice model, Mental Health Integration Program. Staff may use other evidence-based practices until training on the model is received.

Community Partner clinic

Tier 3 Individuals seen in a primary care setting who receive and desire only medication management and are not interested in participating in any psychotherapeutic interventions

Diagnoses less severe than Tier 1 or Tier 2 with minimal supports to maintain the client’s stability and functioning

Medication prescribed Primary care physician at LADHS or Community Partner clinic

Source: LADMH, Healthy Way LA Service Matrix, Revised May 1, 2012, accessed at http://file.lacounty.gov/dmh/cms1_177609.pdf, and Fernandez E, Mental Health at St. John’s Well Child and Family Center, Presentation to the LA Health Collaborative, July 21, 2011.

For patients who meet medical necessity criteria of having severe and persistent mental illness (Tier 1), LADHS’ contracted community clinic network (Community Partners) is matched with a mental health provider from the LADMH network that provides services. For patients who have a short-term moderate mental health condition (Tier 2), Community Partner clinics are reimbursed through the Mental Health Services Act’s Prevention and Early Intervention funds for providing services through an evidence-based practice, the Mental Health Integration Program. This model incorporates mental health screening and treatment into primary care settings serving safety net populations and supports stepped interventions. For patients whose mental health needs may be tended to in a primary care setting (Tier 3), care and medications continue to be provided by the primary care physician.

                                                                                                               178 More information about the eligibility requirements may be found at on the Healthy Way LA Matched program website at http://www.ladhs.org/wps/portal/HWLA. 179 A second component of LIHP is the Health Care Coverage Initiative (HCCI), which provides coverage to adults 133% to 200% FPL for a more limited scope of core benefits than the Medicaid Cob. Unlike the MCE, the HCCI has a maximum limit on federal matching funds available. For more information, refer to Artiga S and Schneider A, California’s “Bridge to Reform” Medicaid Demonstration Waiver, Kaiser Commission on Medicaid and the Uninsured, June 2011. 180 Katz M, Status Report on the Proposed Plan to Implement the 1115 Medicaid Waiver Initiative, Memorandum from LADHS to the Board of Supervisors, April 6, 2011. 181 Freedman J, Presentation from LADPH to LA Health Action Workgroup, March 28, 2011. 182 Cohen A, Driscoll K, Vane C, and Dougherty A, Health Reform Timeline – Key Dates for L.A. County, Insure the Uninsured Project, November 23, 2010, accessed at http://www.lahealthaction.org/library/LA_County_Implementation_Timeline.pdf. 183 Viste AL, LACEO, Presentation to LA Health Action Enrollment Workgroup, October 9, 2012.

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LADHS and LADMH staff has expressed strong commitment to the program’s vision and to building a strong interagency partnership in preparation for ACA implementation. In addition, a new electronic system has been adopted to facilitate data matching and referrals. 184 However, key administrative and programmatic challenges include a lack of regular, open communication, unclear collaborative roles and resources, the need for an accountability structure, the complex system design, a short implementation timeframe, meeting timeliness standards, cultural competency, patient engagement, and information sharing.185 The program has taken some time to be implemented by the Community Partner clinics due to required training in the Mental Health Integration Program (MHIP). Community Partners have been adjusting to the claiming and reimbursement process. In addition, since FQHCs may only receive reimbursement for Licensed Clinical Social Workers or psychologists per federal law, some clinics have encountered difficulty in hiring, particularly staff with Spanish-speaking capability. The MHIP model requires clinics to contract with a consulting psychiatrist, which has presented serious challenges to many Community Partners. The lessons learned from this large-scale integration effort, along with the Delivery System Reform Incentive Pool experience, should guide the development of future collaborative efforts. Delivery  System  Reform  Incentive  Pool:  Co-­‐location  of  Mental  Health  and  Physical  Health  Services   LADHS included the co-location of mental health services in the primary care setting through a component of California’s “Bridge to Health Reform” waiver, the Delivery System Reform Incentive Pool plan, under the Innovation and Redesign category. The purpose includes sharing clinical information about patients who would benefit from both physical health and mental health services, developing standardized procedures for coordinating care between the departments and referring patients from LADHS to LADMH, and addressing co-occurring mental health issues and chronic conditions. In particular, LADHS was interested in developing screening tools and protocols for patients with depression and diabetes in order to refer them to mental health services.186 Mental health services have been co-located in six LADHS facilities to date. Providers at each LADHS-operated facility screen patients for possible health service needs. Patients classified as Tier 1 (serious and persistent mental illness) by the initial screening are referred offsite to receive services through LADMH’s countywide network of providers and services. Patients classified as Tier 2 or Tier 3 (moderate or mild mental health needs) and with positive screenings are referred to the co-located LADMH staff, who are Licensed Clinical Social Workers, for a mental health assessment. LADHS providers complete a referral form that LADMH staff receives. This form includes information on patient demographics, medical diagnosis, and reasons for referring patients. LADHS completes a "warm hand off" by taking the patient to meet the co-located LADMH staff or by asking LADMH to come to the patient exam room. A mechanism to track referrals from primary care providers to onsite mental health professionals has been developed at the co-located sites. LADMH provides LADHS with the disposition of the referral including the services provided, general findings, mental health diagnosis, medications prescribed, and treatment plan overview.187 During the first year of the Healthy Way LA Matched program, LADMH received 4,347 referrals for mental health services from primary care providers located at LADHS and Community Partner facilities as well as from patient self-referrals via the LADMH toll-free numbers. These referrals were for Tier 1 and Tier 2 services provided to Healthy Way LA Matched patients, of which 93% were scheduled for an initial mental health appointment within 30 days and 56% accepted mental health services.188 LADMH used the Mental Health Services Act Prevention and Early Intervention component to provide funds in order to draw down federal reimbursement for this parallel effort. While LADMH providers at

                                                                                                               184 Chen S, Bridging the Gap Toward Integrated Care: A Policy Recommendation Report for HWLA, August 29, 2011. 185 Ibid. 186 LADHS Delivery System Reform Incentive Pool Plan, accessed at http://www.dhcs.ca.gov/Documents/5_LAC%20DSRIP%20Final.pdf. 187 California Department of Health Care Services, Delivery System Reform Incentive Payments (DSRIP): LADHS, DY 6 Year-End Report, Category 2: Integrate Physical and Behavioral Health Care, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/Delivery%20System%20Reform%20Incentive%20Payments%20(DSRIP)/LA%20County%20Department%20of%20Health%20Services/DY%206%20Year-End%20Report.xls. 188 Healthy Way LA, Referral Tracking Report, July 2011-June 2012, Office of Integrated Care, Los Angeles County Department of Mental Health, August 20, 2012.

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some of the co-located sites were not receiving the anticipated number of referrals from LADHS primary care physicians, others have been progressing well. Commitment from leadership from each department as well as from each health facility is crucial to the success of these collaborations. Lessons learned should be considered in planning future efforts.

Integrated  School  Health  Centers   In 2008, LA Health Action and the Integrated Behavioral Health Project determined that opportunities existed to advance school health center systems development and create a model for integrated services. Following the election of Mark Ridley-Thomas to the County Board of Supervisors, whose platform included improving the integrated health care delivery system, he and Supervisor Gloria Molina submitted a motion in April 2009 directing the LACEO, LADHS, and LADMH to produce a plan for developing Integrated School Health Centers pilot sites. The vote was unanimous to approve the motion. While the focus of integrated services is typically on clinical integration, LAUSD and the LA Trust for Children’s Health elevated school integration as a primary component to success. LA Health Action and the Integrated Behavioral Health Project began convening a stakeholder group that created of a set of recommendations and the L.A. Integrated School Health Center Model Standards in September 2009 to address student age-specific health needs, and internal and external service integration. In developing the model standards, the role of the school and the need for the SHC to integrate with the school community became the overarching paradigm. LAUSD articulated that integration must mean SHCs operate outside of their four clinic walls by building and sustaining relationships with school administrators, nurses and teachers; coordinate care with myriad agencies that provide a wide array of services on campus; and operate an active outreach program in the school community. The model standards drew from state clinic licensing as well as national and statewide school health center association standards. The stakeholder group evolved into a policy and planning council, which shaped its efforts in the context of health reform proposals as a major priority and transitioned to the leadership of the Los Angeles County Education Foundation. In addition, L.A. stakeholders conducted site visits with Alameda County, identified as the most evolved school health center system in the state, to identify best practices and lessons learned. An alignment of school health center expansion funding occurred. First, LADHS provided support to expand primary care services with a particular focus on South and East L.A., which amounted to $4 million in funding for school health center capital improvements and operations. Second, LAUSD allocated $29 million in joint-use funding to build 13 Wellness Centers in high priority communities based on a needs analysis revealing health hot spots in communities in South and Southeast L.A., East L.A., and the San Fernando Valley. The Wellness Centers are the next generation of school health centers that will offer preventive physical, mental, and oral health care, and leverage partnerships with parent centers, promotoras programs, student leadership councils, small learning communities, afterschool programs, and social services targeting the broader community.189 FQHCs have been identified to provide health services at each site to ensure sustainability due to their enhanced Medi-Cal reimbursement status. Third, LA Health Action provided funding for the LA Trust for Children’s Health to initiate a Learning Collaborative of schools and clinic operators to support the Wellness Centers and target operational and integration challenges. Eleven of the Wellness Centers are slated to open by the end of 2012. In March 2012, LADMH allocated $2.5 million in Mental Health Services Act Prevention and Early Intervention funds to support 16 Integrated School Health Center sites, which will draw down significant federal matching funds.190, 191 These sites, as summarized in Table 6, identify a clinic operator to provide health services, capitalize upon longstanding partnerships between particular schools and mental health providers to facilitate start up, and have experience in delivering evidence-based practices successfully that are appropriate to community need.                                                                                                                189 Ramirez, Mayra, “Clinics Set Out to Lower Illness Related Absenteeism at Schools” LAUSD Journal, April 19, 2012, Web. 190 Fujioka W, Status Report on the Implementation of Integrated School Health Center Projects, Memorandum from the LACEO to the Board of Supervisors, April 18, 2012. 191 The MHSA Prevention and Early Intervention funds are allocated for 3 months in FY 2011-12, with subsequent years to be financed by realignment (AB 100) and various MHSA sources. See Southard, Marvin, “Advance Notification of Intent to Enter into Sole Source Contracts with Seventeen (17) Existing Legal Entity Contractors” Memorandum from LADMH to the Board of Supervisors, March 15, 2012.

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 Table 6. L.A. County MHSA Prevention and Early Intervention Funding for Integrated School Health Centers, 2012

Supervisorial District School(s) / Unified School District Proposed Mental Health Provider(s) Health Provider(s)

First District $500,000 Roosevelt High School / LAUSD VIP, California Hispanic Commission on Alcohol

and Drug Abuse, Alma Family Services TBD

Second District $500,000

John C. Fremont High School / LAUSD* Special Service for Groups UMMA Clinic

Locke High School / LAUSD* LAUSD Mental Health, Shields Watts Healthcare Foundation

Hyde Park Elementary / LAUSD LAUSD Mental Health

St. John’s Well Child and Family Health Center Manual Arts High School / LAUSD* L.A. Child Guidance Center, LAUSD Mental Health

Washington Prep High School / LAUSD* Special Services for Groups, LAUSD Mental Health

Third District $500,000

Monroe High School / LAUSD* Child and Family Guidance Valley Community Clinic

Hollywood High School / LAUSD* Saban Free Clinic Saban Free Clinic

Fourth District $500,000

Fedde Middle School / ABC Unified School District

Helpline & Masada Homes Tri-City Medical Center + school nurses

East Whittier Middle School / East Whittier City School District Enki Health and Research Systems, Inc.

California Family Health Centers

Pioneer High School / Whittier Union High School District

Pacific Clinics Presbyterian Hospital Van (once per month) Whittier High School / Whittier Union High

School District The Whole Child

Fifth District $500,000

Child & Family Center of Santa Clarita / N/A Child & Family Center of Santa Clarita Most Likely Unavailable

Daisy Gibson School (K-6) / Keppel School District

Penny Lane

Antelope Valley Community Clinic (Care-a-Van)

Lake Los Angeles School (K-8) / Keppel School District The Children’s Center of Antelope Valley

Littlerock High School / Antelope Valley Joint Union High School District

Child & Family Guidance Center (SFV)

*Denotes LAUSD Wellness Centers Source: Southard, M. “Advance Notification of Intent to Enter into Sole Source Contracts with Seventeen (17) Existing Legal Entity Contractors, Memorandum from LADMH to the Board of Supervisors, March 15, 2012.

The districts of Supervisors Don Knabe and Michael Antonovich have selected a mix of middle and high schools, while the LAUSD Wellness Center located in the remaining districts are set up to serve not only the high school at which they are located but also feeder schools and the broader community. Given that four of the 16 pilot sites overlap with LAUSD’s Wellness Centers, the LACEO and LA Trust for Children’s Health have been collaborating to develop measures for a robust evaluation of each effort.192

Emergency  Services   To address patients with mental health and/or SUD who present in the ER but are more appropriately cared for in an alternative setting, several efforts have been undertaken in L.A. County. First, LADHS and LADMH released a Psychiatric Emergency Services (PES) decompression plan in June 2012 to address the excessive volume of patients entering PES or reducing the amount of time spent in PES. Since psychiatric patients present in outpatient mental health settings with significant problems, a need for PES will continue given the vast demand for care. Funding streams such as Mental Health Services Act will allow the County to reduce PES overuse by developing alternative services. In the last few years, LADMH received $9.3 million in Mental Health Services Act funds to add capacity in lower levels of care including Urgent Care Centers, Psychiatric Diversion Program, Institution for Mental Diseases programs193 and

                                                                                                               192 Fujioka W, Status Report on the Implementation of Integrated School Health Center Projects, Memorandum from the LACEO to the Board of Supervisors, April 18, 2012. 193 An “institution for mental diseases” is defined as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related

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services, and an array of crisis residential and emergency shelter beds. For example, Urgent Care Centers are crisis settings to put a patient on a 24-hour hold. This may significantly reduce hospital PES census, since two-thirds of patients were released within the required timeframe. The decompression plan proposes solutions that address existing processes and efficiencies, with some financed by Mental Health Service Act or County funds, and the remainder requiring dollars to be identified. The four strategies are summarized below: • Implement program and process improvements. These include developing a high utilizer program

for frequent users of PES and ERs, reformulating SUD referral protocols, facilitating referrals to sober living facilities and permanent supportive housing, expediting discharge of children, educating staff on available community-based facilities to discharge patients, and reducing variations in clinical practice patterns.

• Improve the County’s data infrastructure. Efforts include a PES Outcomes Study with LADHS, LADMH, the Coroner and L.A. County Sheriff’s Department; establishing a LADHS Unique Patient Identifier and creating a County Master Patient Index; and monitoring trends in PES utilization by AB 109 releasees. AB 109 has resulted in 8,223 individuals in Los Angeles County being released on Post-release Community Supervision, who are uninsured and may not be linked with health, mental health, and SUD services.194 A recent study on prolonged stays at the Olive View Medical Center’s PES determined that being uninsured, being homeless, arriving on a weekend, and having a criminal history or SUD correlated with an increased length of stay.195

• Expand non-PES hospital capacity. These initiatives encompass implementing the LADHS Supportive Housing program, investigating opening 24-hour holding units for LADCFS children, obtaining LPS designation for Olive View-UCLA Medical Center Urgent Community Services Program, pursuing development of a joint Skilled Nursing Facility contract to avoid Institutions of Mental Diseases restrictions196, opening a vacant unit at Augustus Hawkins Mental Health Center, expanding Psychiatric Diversion Program, investing in community-based residential facilities, and building mental health services capabilities and capacity at Juvenile Halls/Camps.

• Address the adequacy of existing PES facilities. Aimed at enhancing quality at the three LADHS PES sites, Olive View-UCLA Medical Center will receive $4 million in the FY 2012-13 budget to create holding areas for children, men, and women; LAC+USC Medical Center requires dedicated pediatric/adolescent space in an adjacent administrative area with funding to be identified; and Harbor-UCLA Medical Center is planning a project to build a dedicated pediatric space that will be incorporated into its ER renovation.

Second, SUD expertise has been infused into three projects at LADHS ERs. As an outgrowth from the three-year Frequent Users of Health Services Initiative, Olive View-UCLA Medical Center has continued to co-locate SUD staff from Tarzana Treatment Centers in its PES. Although the partnering organizations could not sustain the full project when funding ended in 2007, an evaluation found that ER utilization and inpatient admissions decreased by more than 60 percent.197 Through another effort, LADPH SUD counselors have been incorporated into multidisciplinary teams at LAC+USC Medical Center’s ER, which

                                                                                                                                                                                                                                                                                                                                                                     services.” See Rosenbaum S, Teitelbaum J, and Mauery DR, An Analysis of the Medicaid IMD Exclusion, GWU School of Public Health and Health Services, December 19, 2002, accessed at http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/behavioral_health/reports/IMD%20Report%201202.pdf. 194 Delgado M, Public Safety Realignment Implementation Update No. 6 – April 2012 to May 2012, Memorandum from the Countywide Criminal Justice Coordination Committee to the L.A. County Board of Supervisors, July 1, 2012, accessed at http://www.ccjcc.info/cms1_181008.pdf. 195 Ochoa, Kristen, MD, MPH “Factors associated with length of stay in Los Angeles County psychiatric emergency room” American Public Health Association, abstract, Web. 196 The Medicaid IMD exclusion bars federal contributions to the cost of medically necessary inpatient care incurred in treating Medicaid beneficiaries ages 21-64 who receive care in certain institutions that fall within the definition of an “institution for mental disease.” See Rosenbaum S, Teitelbaum J, and Mauery DR, An Analysis of the Medicaid IMD Exclusion, GWU School of Public Health and Health Services, December 19, 2002, accessed at http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/behavioral_health/reports/IMD%20Report%201202.pdf. 197 Linkins KW, Brya JJ, and Chandler DW, Frequent Users of Health Services Initiative: Final Evaluation Report, The Lewin Group, August 2008, accessed at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/F/PDF%20FUHSIEvaluationReport.pdf.

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conduct outreach with frequent users and link individuals requiring SUD treatment with the LADPH Antelope Valley Rehabilitation Centers.198 SAPC released a funding opportunity in May 2012, the Community Centered Emergency Project, in order to provide integrated services to frequent users of the LAC+USC Medical Center who are chronically homeless with co-occurring mental health and SUD. The project was initiated based on an environmental scan of the community around the medical center, which concluded that creating a safe environment for individuals seeking health care would be beneficial. The project’s purpose is to tackle the environmental factors that contribute to high-risk alcohol use, sales, consumption of illegal drugs, and other conditions affecting safety. The project will award $400,000 over two years to a lead agency to engage in activities including mobilizing community residents, businesses, law enforcement, alcoholic beverage control officers, and others to ameliorate the issue; raising awareness among local residents and involving them in neighborhood watch activities; and increasing use of public services to protect personal and family safety.199 In addition, LADHS and SAPC are considering expanding SUD counselors in the ERs at Harbor-UCLA Medical Center and LAC+USC Medical Center, and at other ambulatory care sites such as Martin Luther King, Jr. Multi-Service Ambulatory Care Center.200 Third, building on earlier initiatives, the Corporation for Supportive Housing developed the Frequent User Systems Engagement (FUSE) model that has been implemented in communities across the country to address the needs of homeless individuals with complex behavioral health challenges.201 L.A. County’s FUSE program targets the highest need, highest cost homeless adults by using permanent housing integrated with care management, primary care, and behavioral health services to improve health outcomes while reducing public costs, with funding provided by Hilton Foundation and UniHealth Foundation.202 The target population has a combination of mental illness, SUD, incarceration in a jail mental health facility in the past five years, multiple visits to hospital emergency rooms in the past two years, and/or inpatient stays in hospitals in the past two years. FUSE aims to identify and house 60 homeless frequent users through five regional partnerships among a homeless service provider, housing provider, hospital, and a FQHC using a triage tool developed by the Economic Roundtable.203 Table 7 summarizes each collaborative that has received funding and includes each agency’s role. Table 7. Description of Los Angeles FUSE Sites, 2010-2012

Downtown L.A. West L.A. East and Downtown L.A.

South L.A. San Fernando Valley

Team Builder Corporation for Supportive Housing

Corporation for Supportive Housing

Corporation for Supportive Housing

Corporation for Supportive Housing

Corporation for Supportive Housing

Initial Referrer California Hospital Medical Center

St. John’s Health Center, Venice Family Clinic, Ocean Park Community Center

LAC+USC Medical Center

St. Francis Medical Center

Mission Community Hospital, Kaiser Panorama City and Woodland Hills Medical Centers

Screening Economic Roundtable Economic Roundtable Economic Roundtable Economic Roundtable

Economic Roundtable

Case Management / Navigation

Housing Works California

Ocean Park Community Center

Homeless Health Health Care Los Angeles

Watts Healthcare Corporation

San Fernando Valley Community Mental Health Center

Initial Temporary Housing

SRO Housing Corporation

Ocean Park Community Center

Homeless Health Care Los Angeles

Watts Labor Community Action Committee

Los Angeles Family Housing

Health Care Provider

JWCH Institute Venice Family Clinic Clinica Romero TBD Northeast Valley Health Corporation

Permanent Supportive Housing

SRO Housing Corporation, TBD

City of Santa Monica SRO Housing Corporation, TBD

TBD TBD

Source: Economic Roundtable, FUSE Frequent User Housing Initiative, accessed at http://www.economicrt.org/housing/.

                                                                                                               198 Fielding JE, Integrating Alcohol and Drug-Related Services, Memorandum from LADPH to the Board of Supervisors, August 22, 2012. 199 Fielding JE, Notice of Intent to Release a Request for Proposals for Community Centered Emergency Room Project, Memorandum from LADPH to the Board of Supervisors, May 15, 2012. 200 Fielding JE, Integrating Alcohol and Drug-Related Services, Memorandum from LADPH to the Board of Supervisors, August 22, 2012. 201 Corporation for Supportive Housing, Los Angeles Frequent Users Systems Engagement (FUSE) Program, accessed at http://www.csh.org/csh-solutions/community-work/systems-change/local-systems-change-work/los-angeles-fuse. 202 Ibid. 203 Economic Roundtable, FUSE Frequent User Housing Initiative, accessed at http://www.economicrt.org/housing/.

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Additional support is planned to expand FUSE into Hollywood, West Hollywood, Pasadena, and Glendale. Outcomes achieved to date include a 30% decrease in ER utilization, 25% reduction in inpatient care, $3.3 million annual decrease in public costs, and improved health status attributed to high housing retention rates and effective case management.204 Finally, newer technologies to maximize efficiencies and limited resources should be explored. Hospitals have suggested that LADMH’s Psychiatric Mobile Response Team should use telehealth to perform an initial assessment and determine whether a patient may be released.205 LADMH has used telemental health and consultation206, which should be expanded to ameliorate the high demand for the Psychiatric Mobile Response Team’s services. Homeless  Initiatives   L.A. County has embraced a Housing First approach to address the health, SUD, and mental health needs of the chronically homeless. Following media attention around patient dumping by hospitals in the Skid Row area of downtown L.A., the L.A. County’s Board of Supervisors developed strategies designed to prevent homelessness. One initiative was Project 50, started in November 2007 as a two-year demonstration project offering permanent supportive housing linked with intensive case management targeting the most vulnerable, chronically homeless in Skid Row. The project used a nonprofit agency’s vulnerability index207, which was created by the innovative Street to Home Project that decreased the homelessness rate in New York City’s Times Square by 87% in two years.208 Using the index, a registry was created from which the 50 most vulnerable persons were identified who had a 40% probability of dying in the next seven years unless they could be housed and provided appropriate physical, mental health, SUD, and other support services.209 Over 24 partnering organizations were involved in the project including county and city leadership, public and private health and human services providers, law enforcement and criminal justice, housing and homeless service providers, and advocates.210 An outreach team maintained ongoing contact with homeless persons identified through the registry, attempting to engage them in services, assist with documentation, and place into transitional and permanent housing. Project 50 participants were housed in four single-room occupancy hotels owned and managed by Skid Row Housing Trust.211 An integrated, multidisciplinary team offered mental health care provided by a LADMH Medi-Cal certified outpatient clinic (Didi Hirsch), physical health services provided by a Federally Qualified Health Center (JWCH Institute), SUD services provided by LADPH, and wraparound services including case management, maintenance of housing, and benefit counseling.212, 213, 214 Spending $3.04 million from the County’s Homeless Prevention Initiative, Project 50 resulted in savings to public systems of $3.28 million over the pilot period.215 Preliminary results showed that two-thirds of project participants experienced an increase in benefits including Supplemental Security Income and Medi-Cal. While 100% of participants were diagnosed with a mental illness or a medical issue, 83%                                                                                                                204 Corporation for Supportive Housing, Los Angeles Frequent Users Systems Engagement (FUSE) Program, accessed at http://www.csh.org/csh-solutions/community-work/systems-change/local-systems-change-work/los-angeles-fuse. 205 Gorman, Anna. “ERs are becoming costly destinations for mentally disturbed patients” Los Angeles Times, September 5, 2011, Web. 206 Gupta N. 2011 LA Health Collaborative Executive Summary, LA Health Action, April 3, 2011, accessed at http://lahealthaction.org/library/LAHC_Executive_Summary_2011_final.pdf. 207 The vulnerability index developed by the nonprofit housing developer Common Ground featured a series of variables that would enable staff to quantify the degree of an individual’s physical and mental vulnerability, and determine who are most at risk of serious illness, injury and death. See Moreno M, Toros H and Stevens M, “Project 50: The Cost Effectiveness of the Permanent Supportive Housing Model in the Skid Row Section of Los Angeles County,” LACEO, June 2012. 208 Bergman, Ben. “L.A. to Offer Housing to 50 ‘Most Vulnerable’ People’” National Public Radio, December 19, 2007, Web. 209 Shaner, R, Project 50, LADMH, accessed at http://www.csam-asam.org/sites/default/files/pdf/misc/Shaner.pdf. 210 Partnering agencies included: County Board of Supervisors, LACEO, L.A. Mayor’s Office, LADHS, LADPH, LADMH, LADPSS, Veterans Administration of Greater L.A. Health Care System, Didi Hirsch, JWCH Institute, L.A. Police Department, L.A. County Public Defender, Sherriff’s Department, Probation, County Counsel, L.A. City Attorney, Courts, Housing Authority of County of L.A., L.A. County Community Development Commission, Skid Row Housing Trust, Common Ground, Public Counsel, and Volunteers of America. 211 Moreno M, Toros H and Stevens M, “Project 50: The Cost Effectiveness of the Permanent Supportive Housing Model in the Skid Row Section of Los Angeles County,” LACEO, June 2012. 212 Ibid. 213 Shaner, R, Project 50, LADMH, accessed at http://www.csam-asam.org/sites/default/files/pdf/misc/Shaner.pdf. 214 Fielding JE, Integrating Alcohol and Drug-Related Services, Memorandum from LADPH to the Board of Supervisors, August 22, 2012. 215 Moreno M, Toros H and Stevens M, “Project 50: The Cost Effectiveness of the Permanent Supportive Housing Model in the Skid Row Section of Los Angeles County,” LACEO, June 2012.

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reported a history of SUD, with almost all of them receiving treatment for their conditions.216 An evaluation of Project 50 showed decreased incarceration (-28%) and medical costs (-68%), offsetting a dramatic increase in mental health (367%) and SUD care expenses (60%) that most likely reflected previously untreated longstanding conditions. Overall, Project 50 generated a total surplus of $4,774 per housing unit.217 With a 25-year history of serving Skid Row, the Weingart Center opened the Center for Community Health through the Leavey Center in 2009 to provide integrated services to poor, housed, and homeless residents and workers in downtown Los Angeles. Building on the work of the Skid Row Homeless Healthcare Initiative, the center served as the new home of the JWCH Institute’s homeless health care operations. Services provided include mental health care from the Downtown Mental Health Center, SUD treatment, dental care by the USC School of Dentistry, optometry, and radiology.218 County departments provided services through Project 50 including LADHS, LADMH, SAPC, LADPSS, and LADCFS.219 JWCH Institute was able to use its FQHC enhanced reimbursement rate address the complex care needs of to bill for dental care and pharmacy services.220 Project 50’s results spurred policymakers to initiate Home for Good, a five-year plan to end chronic and veteran homelessness in L.A. County by 2016.221 The Business Leaders Task Force on Homelessness, a partnership of United Way of Greater L.A. and the L.A. Area Chamber of Commerce released the plan in December 2010. To date, 3,137 chronically homeless persons and veterans have been placed into permanent housing with supportive services.222 Home for Good established a Funders Collaborative consisting of 30 public and private philanthropic partners, which granted $105 million to 30 non-profit organizations in June 2012 to align funding for permanent supportive housing to the chronically homeless.223 A summary of funding priorities is provided in Table 8. Table 8. Overview of Home for Good Funders Collaborative Request for Proposals, Spring 2012

Funding Areas Description Funding Source(s) Grant Term

Permanent Supportive Housing

Support for permanent units available in 2012- 2013 (new development, scattered site, turnover)

Pool of private funding 1-2 years

Scattered Site Permanent Supportive Housing Program

Support for City/County scattered site PSH program for chronically homeless users of County services

Housing Authority of City of L.A. and County of L.A., LADMH, LADPH, and LADHS

2 years for the Program Coordination and Housing Retention Response Team, move-in assistance, and program administration

Corporation for Supportive Housing Frequent Users System Engagement

Support for housing placement of 10 chronically homeless frequent users of health services in collaboration with hospital/FQHC

Social Innovation Fund Grant, Corporation for National and Community Service

1 year

New Development Support for permanent supportive housing for chronically homeless families

City of Pasadena 15 years: Project-based vouchers

Scattered Site Program Support for scattered site program for chronically homeless households

Housing Authority of City of L.A. and private funders

15 years: Tenant-based vouchers 2 years: Supportive service housing location 2 years: Move-in assistance

Affordable Housing Trust Fund-Round II

Support for capital and operating subsidies for permanent supportive housing development

L.A. Housing Department and the Housing Authority of the City of L.A.

1 year: Capital development costs 15 years: Project-based vouchers

Stable Homes, Brighter Futures

Flexible funding to support the creation, access, and stability for transitional age youth in permanent supportive housing

Corporation for Supportive Housing, Stable Homes, Brighter Futures Grant

1-3 years

Request for Statements of Qualifications for Permanent Supportive Housing Services

Master Agreement to provide intensive case management services and/or property related tenant services for supportive housing projects

LADHS N/A

Source: Home for Good, Home for Good Funders Collaborative Spring 2012 Request for Proposals, Spring 2012.

                                                                                                               216 Shaner, R, Project 50, LADMH, accessed at http://www.csam-asam.org/sites/default/files/pdf/misc/Shaner.pdf. 217 Moreno M, Toros H and Stevens M, “Project 50: The Cost Effectiveness of the Permanent Supportive Housing Model in the Skid Row Section of Los Angeles County,” LACEO, June 2012. 218 Burt M, Widening Effects of the Corporation for Supportive Housing’s System-Change Efforts in Los Angeles, 2005–2008, Urban Institute, March 2009, accessed at http://www.urban.org/UploadedPDF/411864_supportive_housing.pdf. 219 Fielding JE, Integrating Alcohol and Drug-Related Services, Memorandum from LADPH to the Board of Supervisors, August 22, 2012. 220 Burt M, Widening Effects of the Corporation for Supportive Housing’s System-Change Efforts in Los Angeles, 2005–2008, Urban Institute, March 2009, accessed at http://www.urban.org/UploadedPDF/411864_supportive_housing.pdf. 221 United Way of Greater L.A. and L.A. Area Chamber of Commerce, Home For Good: 2012 Update, 2012, accessed at http://www.unitedwayla.org/wp-content/uploads/pdfs/HomeForGood_Action_Plan.pdf. 222 Home for Good, Home for Good Funders Collaborative Spring 2012 Request for Proposals, March 2012, accessed at http://www.unitedwayla.org/wp-content/uploads/2012/03/Spring-2012-RFP-3.14.126.pdf. 223 Ibid.

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While achieving numerous successes since its inception, Home for Good has encountered difficulty in reaching some goals, such as a slower pace in converting units of housing for the chronically homeless. The MHSA Housing Program was started in 2007 as a part of the Act’s Community Service and Supports component. The purpose was to provide funding for development, acquisition, construction, and/or rehabilitation of permanent supportive housing for individuals with serious mental illness who are homeless or at risk of homelessness and their families. L.A. County was allocated $115 million for the program that was administered by the California Housing Finance Agency, with $40 million to be used for operating subsidies. Nearly all of the program’s funds have been dispersed, resulting in awards to 21 housing developers working on 34 project sites that will provide 1,664 units of supportive housing across L.A. County. Nine projects have been completed. LADHS partnered with other governmental and community-based agencies to provide affordable housing linked to services for patients who are homeless and have a chronic illness/disability, or are high utilizers of services. One example is the Access to Housing for Health program, which began in March 2007 involving a partnership with City of Los Angeles, Los Angeles Housing Department, Housing Authority of the County of Los Angeles, and Homeless Health Care LA with funding the County’s Homeless Prevention Initiative. The program provided Section 8 housing vouchers to LADHS homeless patients with a chronic illness with 2 or more inpatient or ER visits in the last year. In addition to permanent housing, additional services included temporary housing, housing location services, case management, and linkage to health, mental health, SUD, and other supportive services. As of February 2012, 202 participants were enrolled in the project, of whom 62% had received permanent housing and are still housed, and 10% were waiting to be placed. Program participants experienced a 77% reduction in ER visits, 77% reduction in inpatient admissions, and 85% reduction in inpatient days in LADHS hospitals, and housed clients used an average of $32,000 less in LADHS services each year. Another example is the Neighborhood Stabilization Program, which was created by the federal Housing and Urban Development department to assist communities that have suffered from foreclosures and abandonment. Through this program, the Los Angeles Housing Department provided 15 newly renovated properties with 56 units of housing in South L.A, the Housing Authority of the County of Los Angeles offered Section 8 housing vouchers, LADHS identified clients and provided intensive case management services, and LADHS, LADMH, and LADPH provided health, mental health, and SUD services. In June 2012, through the Home for Good’s joint funding process, agreements were approved with 25 agencies to provide intensive case management services at the housing sites.224 Jail  Reentry   Several efforts have focused on assisting persons exiting jails in successfully reentering the community by integrating care. L.A. County departments are exploring ways to leverage newly available realignment dollars at the county level in the community corrections subaccount to address the higher rates of mental illness and SUD experienced by prisoners before or upon release. LADHS, LADMH, and LADPH are working closely with the Probation and L.A. County Sheriff’s Departments to develop and implement integrated assessment and treatment services for AB 109 offenders remaining in L.A. County or returned by state correctional institutions.225 The three departments in discussions with the Sheriff’s Department to initiate a Reentry Center at Men’s Central Jail226 that would provide assessment and linkage to services for persons released under AB 109, and are considering administering an initial dose of Vivitrol for individuals with alcohol and opiate dependence before their release. 227

                                                                                                               224 Todoroff C, Supportive Housing Initiative, Los Angeles County Department of Health Services, presentation to LA Health Collaborative, February 23, 2012. 225 Fielding JE, Integrating Alcohol and Drug Related Services, Los Angeles County Department of Public Health Services, August 22, 2012, accessed at http://lahealthaction.org/library/cms1_183037.pdf 226 As the largest jail in the world, Men’s Central Jail housing about 5,000 inmates from all around L.A. County. See L.A. Sherriff’s Department, Men’s Central Jail, accessed at http://la-sheriff.org/divisions/custody/mcj/. 227 Fielding JE, Integrating Alcohol and Drug Related Services, Los Angeles County Department of Public Health Services, August 22, 2012, accessed at http://lahealthaction.org/library/cms1_183037.pdf

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L.A. County participated in California’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) five-year demonstration project ending in 2010 funded by SAMHSA. SBIRT is an early intervention approach for persons with SUD as well as those who are at risk of developing these disorders. The purpose of the federal grant was to demonstrate the viability and efficacy of integrating routine SBIRT services in various health care settings, including trauma centers, emergency departments, and primary health clinics. L.A. County received support to provide SBIRT services to short-term detainees upon their release from the L.A. County jails through a partnership involving SAPC, the L.A. County Sheriff’s Department, and the L.A. City Police Department.228 LADHS may use AB 109 funds to draw down federal reimbursement for the Healthy Way LA Matched program, L.A. County’s Low Income Health Plan (LIHP) through the “Bridge to Reform” waiver. The LIHP Medi-Cal Inmate Eligibility Program provides coverage of LIHP-eligible inmates who receive inpatient services from a hospital located off the grounds of the correctional facility and the hospitalization lasts for 24 hours or more, allows counties to shift some of these expenses.229 In addition, L.A. County may be able to access additional state funds by aligning Healthy Way LA Matched enrollment efforts with other county initiatives under AB 109. While a number of community-based re-entry and jail diversion programs exist, Project 180 is a nonprofit agency serving offenders that has one program offering integrated care. Project 180 has partnered with a mental health services provider (Step Up On Second) and a FQHC (Saban Free Clinic) to establish the Health Outreach Street Treatment (HOST) project supported by the Mental Health Services Act Innovations component under the Integrated Mobile Health Clinic model.230 This model is intended to improve and coordinate the quality of care for individuals with severe mental illness/serious emotional disturbance are who are homeless or have recently moved into permanent supportive housing and have other issues, such as age, years homeless, SUD and/or other physical health conditions that require ongoing primary care.231 HOST employs a multidisciplinary team, including medical, mental health, substance abuse professionals and peer advocates, which will engage homeless individuals and offer street-based comprehensive services.232 Seniors  and  Persons  with  Disabilities  Transition  and  Duals  Demonstration   California has been moving high-cost, high-need patients into mandatory managed care by building on the state’s existing Medi-Cal managed care plan network, which in L.A. County comprise two plans: L.A. Care Health Plan and Health Net. First, Seniors and Persons with Disabilities (SPDs) with Medi-Cal coverage were required to move from fee-for-service into mandatory managed care in 16 counties including L.A. through the “Bridge to Reform” waiver. This shift occurred over a one-year period from June 1, 2011 to May 31, 2012. Approximately 15-20% of SPDs have the most complex care needs, including mental health, SUD, criminal justice, and housing, and would benefit from care coordination between a primary care provider and specialized agencies.233 While DHCS estimated that approximately 30% of SPDs were diagnosed with serious mental health issues, L.A. Care has found that the proportion has been closer to 25%.234 , 235 Almost 45% of the SPDs required to enroll were from L.A. County at 172,000 individuals.236 Nearly 70% of L.A. County’s SPD beneficiaries joined L.A. Care Health Plan, with

                                                                                                               228 California Department of Alcohol and Drug Programs, CASBIRT Finishes Wells, September 2010 newsletter, accessed at http://www.adp.ca.gov/pressroom/news/Focus.html#Feat1. 229 California DHCS, Low Income Health Program Inmate Eligibility Program, Letter to All Low Income Health Programs, August 29, 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/Publications/LIHP_PPL_12-001.pdf. 230 Project 180, Programs: Integrated Mobile Health Team (IMHT), accessed at http://www.project180la.com/Programs.html#anchor_60. 231 Southard M, Approval to Amend Nine Legal Agreements to Implement Innovation - Integrated Mobile Health Teams, Memorandum from LADMH to the Board of Supervisors, February 7, 2012, accessed at http://lahealthaction.org/library/cms1_173514.pdf. 232 Project 180, Programs: Integrated Mobile Health Team (IMHT), accessed at http://www.project180la.com/Programs.html#anchor_60. 233 Somers SA, Bella M, and Lind AR, Enhanced Medical Home For Medi-Cal’s SPD Population, Center for Health Care Strategies, September 2009, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/Enhanced%20Medical%20Home%20(CHCS-posted).pdf. 234 Kodmur L. Presentation from L.A. Care Health Plan to the LA Health Collaborative, July 21, 2011. 235 Personal communication with Phinney Ahn, Special Projects Coordinator, L.A. Care Health Plan, October 22, 2012. 236 Almost 380,000 SPDs enrolled statewide during the mandatory transition period. In addition, approximately 140,000 SPD beneficiaries chose a health plan voluntarily prior to June 2011. See Wunsch B and Linkins K, A First Look: Mandatory Enrollment of Medi-Cal’s Seniors and People with Disabilities into Managed Care, Pacific Health Consulting Group and Desert Vista Consulting, August 2012, accessed at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/F/PDF%20FirstLookMandatoryEnrollmentSPD.pdf.

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the remainder subscribing to Health Net.237 The auto-assignment rate averaged at 60% over the one-year transition period both locally and statewide.238 Second, L.A. County was one of eight counties awarded participation in the state’s Coordinated Care Initiative239, a three-year demonstration program for Medicare and Medi-Cal dual eligible beneficiaries (dual eligibles) that will coordinate financing and delivery of medical, behavioral health, long-term institutional, and home-and community-based services through a single health plan.240 Nearly 70% of California’s 1.12 million dual eligibles are 65 years or older, with the remainder being disabled adults ages 22-64.241 L.A. County has the largest concentration of dual eligibles in the country at 374,000 individuals who account for a little over one-third of state’s combined Medi-Cal and Medicare expenses for this population. 242 The SPD and dual eligible populations overlap, with an estimated 30% of SPDs with Medi-Cal coverage transitioning to dual eligibility within 24 months of enrollment in Medi-Cal.243 While all Medicare-covered behavioral health services will be the responsibility of the health plans, Medi-Cal specialty mental health services and Drug Medi-Cal will continue to be carved out of the capitated payment. Dual eligibles comprise about 28% adults served by the county Mental Health Plans and 13% of Drug Medi-Cal admissions statewide.244 Twenty-five percent of dual eligible beneficiaries using specialty mental health services reside in L.A. County, while a higher proportion of individuals using Drug Medi-Cal services (44%) were based locally.245 While all Medicare-covered behavioral health services will be the responsibility of the health plans, specialty mental health services and Drug Medi-Cal services will operate as a carve-out, as occurs with other Medi-Cal managed care product lines.246 LADMH and SAPC will be responsible for administering Medi-Cal-funded behavioral services governed by a Memorandum of Understanding (MOU) between each department and the health plan that will describe the coordination of services. The SPD transition laid groundwork for the duals demonstration by resolving issues between physical health and behavioral health providers.247 In particular, L.A. Care, LADMH, LADPH, and the County formed a subcommittee to develop a system for improving coordination of care and ensuring continuity of care. The subcommittee devised three strategies to overcome barriers. First, L.A. Care, LADMH, and LADPH created two forms for the purpose of exchanging provider and beneficiary information. Second, L.A. Care and LADMH created a process to identify shared clients and ensure care coordination by developing a MOU to exchange and match member data. Third, L.A. Care will be using a web-based application, eConsult, to allow primary care providers and specialists, including LADMH and its directly contracted network, to use electronic consultation to share clinical information securely and discuss patient cases. eConsult’s goals include offering improved collaboration, expanding the scope of the primary care physician, increasing efficiency, and accelerating resolution of patient cases.248 eConsult launched in August 2012, with plans to incorporate LADMH services by the end of February 2013.249

                                                                                                               237 SPD enrollment data, provided by Phinney Ahn, Special Projects Manager, L.A. Care Health Plan, September 7, 2012. 238 Wunsch B and Linkins K, A First Look: Mandatory Enrollment of Medi-Cal’s Seniors and People with Disabilities into Managed Care, Pacific Health Consulting Group and Desert Vista Consulting, August 2012, accessed at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/F/PDF%20FirstLookMandatoryEnrollmentSPD.pdf. 239 The Coordinated Care Initiative includes a second component, in addition to the duals demonstration: the mandatory enrollment of Medi-Cal beneficiaries including dual eligibles into managed care for all Medi-Cal benefits including Long-Term Supports and Services and Medicare wraparound benefits. See California Department of Health Care Services, Coordinated Care Initiative: Executive Summary, August 24, 2012, accessed at http://www.calduals.org/wp-content/uploads/2012/08/CCIOverview082312.pdf for more information. 240 California Department of Health Care Services, Coordinated Care Initiative: Executive Summary, August 24, 2012, accessed at http://www.calduals.org/wp-content/uploads/2012/08/CCIOverview082312.pdf. 241 Wallace J, Improving Care through Integrated Medicare and Medi-Cal Delivery Models, Presentation to the LA Health Collaborative, February 23, 2012. 242 Ibid. 243 L.A. Care Health Plan, California’s Dual Eligible Demonstration Request for Solutions Response, Submission to DHCS, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/Duals/RFS%20Applications/L.A.%20Care.pdf. 244 California Department of Health Care Services, The Coordinated Care Initiative and Behavioral Health Services: Frequently Asked Questions, September 2012, accessed at http://www.calduals.org/wp-content/uploads/2012/09/FAQBH090512.pdf. 245 Ibid. 246 California Department of Health Care Services, The Coordinated Care Initiative and Behavioral Health Services: Frequently Asked Questions, September 2012, accessed at http://www.calduals.org/wp-content/uploads/2012/09/FAQBH090512.pdf. 247 L.A. Care Health Plan, California’s Dual Eligible Demonstration Request for Solutions Response, Submission to DHCS, February 2012, accessed at http://www.dhcs.ca.gov/provgovpart/Documents/Duals/RFS%20Applications/L.A.%20Care.pdf. 248 Ibid. 249 Personal communication with Sajid Ahmed, L.A. Care Health Plan, October 21, 2012.

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Due to the complexities involved in merging the Medi-Cal and Medicare financing streams and delivery systems, discussions are continuing to plan for integrating behavioral health with the health plans. Issues to be resolved include care coordination to ensure clients may access services in a timely manner and redesigning the reimbursement system for Medicare services. LADMH is working on developing an interagency coordination team with the health plan that will be responsible for hospital discharges including tracking, and monitoring; using a consultation team for patients with complex needs; developing referral processes; and sharing of information.250 A concern regarding the limited scope of services available under the Drug Medi-Cal program is that patients may have difficulty in accessing treatment services for SUD at a higher level of clinical need.251 As a result, LADHS, LADMH, and LADPH have been working with other stakeholders on options for reforming Drug Medi-Cal that would provide increased funding flexibility and an expansion of services integrated into other care settings.252 Federal  Initiatives   SAMHSA’s Primary and Behavioral Health Care Integration initiative provided funding 64 agencies throughout the country, including a four-year grant to Tarzana Treatment Centers, an integrated behavioral health agency serving the Antelope Valley, San Fernando Valley, and Long Beach. These grants were focused on integrating primary care services for people with serious mental illnesses and co-occurring SUD. Services provided by grantees include facilitation of screening and referral for primary care prevention and treatment needs; providing and/or ensuring that primary care screening, assessment, treatment and referral be provided in a community-based behavioral health agency; developing and implementing a registry/tracking system to follow primary health care needs and outcomes; offering prevention and wellness support services, and establishing referral and follow-up processes for physical health care requiring specialized services beyond the primary care setting.253 In addition, the ACA provided states with a new Medicaid option to provide “health home” services for enrollees with chronic conditions that includes a temporary 90% federal match rate.254 L.A. County has been investigating the possibility of participating in this opportunity available beginning in January 2011.255 Health homes are designed to be person-centered systems of care that facilitate access to and coordination of the full array of primary and acute physical health services, behavioral health care, and long-term community-based services and supports. The health home model of service delivery expands on the traditional medical home by building additional linkages and enhancing coordination and integration of medical and behavioral health care to better meet the needs of people with multiple chronic illnesses. The model aims to improve health care quality and clinical outcomes as well as the patient care experience, while reducing per capita costs through more cost-effective care.256

Discussion   At the crossroads of systems transformation as full ACA implementation approaches in 2014, L.A. County has the opportunity to begin the safety net transformation process towards patient-centered, bidirectional, integrated care. L.A. County should be striving to meet the Triple Aim of improving the patient experience of care, improving population health, and reducing costs in order to optimize system performance. The goal should be clinical integration that increases patient satisfaction and promotes consumer self-determination. While significant progress made in the last few years under L.A. County’s

                                                                                                               250 Personal communication with Carlotta Childs-Seagle, LADMH, June 19, 2012. 251 Fielding JE, Integrating Alcohol and Drug-Related Services, Memorandum from LADPH to the Board of Supervisors, August 22, 2012. 252 Ibid. 253 SAMHSA-HRSA Center for Integrated Health Solutions, SAMHSA PBHCI Program, accessed at http://www.integration.samhsa.gov/about-us/pbhci. 254 Kaiser Family Foundation, Medicaid’s New “Health Home” Option, January 2011 accessed at http://www.kff.org/medicaid/upload/8136.pdf. 255 Katz M, Recommendation for Delegated Authority to Execute Amendment to Agreement with Health Management Associates for Consultant Services for Ambulatory Care Restructuring and Other Initiatives Required for the California 1115 Waiver, Memorandum from LADHS to the Board of Supervisors, December 6, 2011, accessed at http://lahealthaction.org/library/cms1_170496.pdf. 256 Kaiser Family Foundation, Medicaid’s New “Health Home” Option, January 2011 accessed at http://www.kff.org/medicaid/upload/8136.pdf.

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dynamic leadership supported by financing streams such as the Mental Health Services Act and the “Bridge to Reform” waiver, additional planning and collaboration will be required to ensure that the L.A. County safety net system will be a provider of choice post-reform. Based on the review of the policy environment, L.A. County’s physical health, mental health, and SUD systems, and integration efforts taking place, the following recommendations are offered. • Patients should be involved in integrating and transforming safety net systems into high quality,

responsive providers of choice in a post-reform world. This is especially given the stigma and discrimination associated with mental health and SUD. Particular attention should be focused on addressing disparities in access to improve the patient experience, given that Latinos and Asian Pacific Islanders are disproportionately represented in the Medicaid expansion population. In addition, approaches to serving vulnerable populations such as the chronically homeless and jail reentry populations should be fostered and expanded to improve health and life outcomes.

• L.A. County should design a system of integrated care to serve patients regardless of the door through which they enter. Significant progress has been made in integrating care for selected populations and providers because of cross-systems collaboration and commitment from leadership, as evidenced by the numerous examples provided above. However, L.A. County has piloted a number of programs rather than adopting an approach to building an integrated system. Time-limited grant funding supported many efforts, which have been difficult to sustain over time and have only addressed a small portion of need. While L.A. County faces challenges due to its siloed systems, level of unmet need especially with respect to the size of its high-cost populations with complex needs, and geographic variation, an opportunity exists to initiate a planning effort among the physical health, mental health, and SUD providers in preparation for full ACA implementation.

• The expansion of managed care in public health coverage provides an opportunity to provide high quality, integrated care that improves patient outcomes and reduce costs. With a growing emphasis on managed care, the health plans will be the accountable entity for coordinating beneficiaries’ care, assuring health outcomes, and improving the consumer experience and cost control as coverage expansion continues leading up to 2014.

• Detection and early intervention of mental health and SUD issues should be incorporated into the primary care setting, which may be particularly important in providing care to underrepresented racial/ethnic groups. With the majority of growth in newly eligible Medi-Cal individuals with mild to moderate mental health issues, the importance of integrating mental health and SUD into primary care setting is accentuated. This is especially true for Asian Pacific Islanders and Latinos, who may find accessing mental health and SUD services through medical care to be more culturally acceptable given the stigma surrounding behavioral health issues.

• Particular attention should be paid to integrating SUD services. Disparate, disconnected, and limited funding streams including Drug Medi-Cal and the SAMHSA block grants support SUD care presently. Parity provides an opportunity to upgrade and reform the limited Drug Medi-Cal benefit and to incorporate evidence-based practices.

• Training and practice should evolve towards integrated care. While providers will require assistance in adapting to the new coverage and delivery models, they may inform the systems transformations efforts. Evidence-based practices should be incorporated into training and continuing education curriculum. Channels for open, regular communication among administrative and clinical staff coming from different philosophical and systems orientations should be built into integrated care approaches.

• Care coordination and management, information exchange mechanisms, and new technologies should be maximized to facilitate and promote the delivery of patient-centered care. Building these tools and systems will be required in order to manage and improve care for patients. This will be required to address the underlying needs of individuals such as frequent users of ERs who may use multiple facilities repeatedly, instead of more appropriate, lower level care. Reimbursement issues may need to be addressed.

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• Financial and reimbursement incentives should be aligned to ensure the goal of achieving clinical integration and improving health and life outcomes. While carving behavioral health services into Medi-Cal managed care is one approach to aligning financial incentives among providers and systems, other options exist and should be explored. Developing consensus around how care will be integrated on the clinical level should be a top priority, followed by considering options on payment reform. A confluence of newer and shifting revenue streams such as the Mental Health Services Act, “Bridge to Reform” waiver, the 2011 realignment, and the ACA’s Medicaid expansion and the California Health Benefit Exchange, may converge to provide opportunities to promote integration or clash to allow the status quo to continue. Careful calibration will be required to balance the 2011 realignment of behavioral health funding and responsibility to the county level, while the public safety funding provides new opportunities to meet the complex of needs of this population, reduce recidivism, and achieve a drop in the crime rate.

While uncertainties remain with federal guidance on parity to be issued, the Medicaid benchmark benefit to be established, and the Special Session to commence at the end of the year, the patient should remain as the central focus in moving the county safety net system towards integrated care.

Conclusion   L.A. County has the opportunity to lead and shape behavioral health policy as the largest county in the state of California, while facing challenges due to its size, geographic and ethnic diversity, and the level of unmet need. Significant planning and collaboration efforts will be required to transform local safety net systems in order to become a provider of choice for patients post-reform. Experience from the increased reimbursement for prenatal care and deliveries in the mid-1990s, in which patients exited the LADHS system and opted to seek care from private providers, coupled with the recent survey results on the health care preferences of low-income consumers should be instructive on the work that lies ahead. Integration may offer a chance to learn from the strengths that each of the three systems of physical health, mental health, and SUD treatment has to offer and promote the move to a person-centered, recovery-oriented wellness model that promotes two-way communication to support the provider-patient relationship.

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Appendix  A.    Timeline  of  Mental  Health  Care  Development  in  L.A.  County      

Date   Major  Milestones  

Early  Delivery  of  Mental  Health  Services  –  Process  of  Deinstitutionalization  

1915   Metropolitan  State  Hospital  Opens  State-­‐operated  psychiatric  hospital  in  L.A.  County  

1924  

Mental  Hygiene  Committee  (Mental  Health  America  of  Los  Angeles)  Formed  One  of  the  county’s  oldest  nonprofit  mental  health  organizations  dedicated  to  promoting  mental  health  recovery  and  wellness  that  is  an  affiliate  of  the  national  Mental  Health  America  and  Mental  Health  America  of  California    Los  Angeles  Child  Guidance  Clinic  Established    The  first  child  guidance  clinic  west  of  the  Rockies  to  offer  pediatric  mental  health.    Founded  as  one  of  eight  demonstration  clinics  by  the  Commonwealth  Fund  of  New  York  and  the  Mental  Health  Association  in  L.A.  County.  

1926  Pasadena  Child  Guidance  Clinic  Established  Opened  by  Pacific  Clinics  to  serve  troubled  youth  referred  by  the  local  school  district,  the  program  was  initially  located  in  the  school  district’s  basement.  In  the  mid-­‐1940s  the  Clinic  began  serving  returning  fathers  and  family  members  coping  with  the  effects  of  WWII.    

1942  Los  Angeles  Psychiatric  Service  Established  Didi  Hirsch  Mental  Health  Services,  formerly  named  Los  Angeles  Psychiatric  Service,  was  established  as  the  first  freestanding,  nonprofit  community  outpatient  clinic  for  adults  for  adults  in  L.A.  County.  

1957  Short-­‐Doyle  Act  Seeks  to  encourage  the  treatment  of  a  patient  suffering  from  a  psychiatric  disorder  in  his  home  community,  with  assistance  of  local  medical  services.  State  pays  50%,  local  government  pays  50%.  

1959   First  Meeting  of  the  Los  Angeles  County  Mental  Health  Advisory  Board  on  January  14,  1959  

1960  LADMH  Founded  

Tri-­‐City  Mental  Health  Authority  Created  Serving  cities  of  Pomona,  Claremont,  and  La  Verne  

1963  

California  Increases  State  Funding  Share  for  Community  Mental  Health  Programs    Share  for  community  mental  health  programs  increased  by  75%  and  expands  scope  of  services  reimbursed  by  the  state  encouraging  additional  Short-­‐Doyle  programs  

Federal  Medical  Aid  to  the  Aged  Includes  Mental  Patients  in  California  

Long  Beach  Mental  Health  Service  Center  Opens  

1965  

Medicare  and  Medicaid  Created  Medicare  is  amended  to  include  mental  illness,  and  Medicaid  funds  are  made  available  for  outpatient  care  

LADMH  Begins  Oversight  of  Services  for  Developmentally  Disabled  Joint  Powers  Agreement  between  the  State,  County  and  Los  Angeles  City  schools  

Kedren  Community  Health  Center,  Inc.  Established  Launched  in  South  L.A.  after  the  Watts  riots  by  a  group  of  psychiatrists  who  came  together  to  understand  why  the  underlying  reasons  behind  the  problems  that  ignited  the  riots.  The  doctors  decided  to  target  the  youngest  children  who  had  been  least  affected  by  negative  influences  of  the  community  to  provide  with  mental  health  services.    

1966  Medi-­‐Cal  Program  Enacted  

Hillview  Mental  Health  Center  Opens  in  East  San  Fernando  Valley  

1967  

Lanterman-­‐Petris-­‐Short  Act  (LPS):  AB  1220,  Mental  Health  Act  of  1967  Established  to  regulate  civil  commitments  to  mental  health  institutions  requiring  a  judicial  hearing  procedure  prior  to  any  involuntary  hospitalization,;  implemented  July  1,  1969  

East  Los  Angeles  Mental  Health  Service  Opens  First  of  its  kind  in  the  nation  

1968   Olive  View  Psychiatric  Facility  Opens  

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Date   Major  Milestones  

Movement  to  Community  Based  Care  –  Distribution  of  Services  and  Funding  Allocation  Changes  

1969   Psychiatric  Emergency  Teams  (PET)  Launched  in  L.A.  County  

1970   San  Fernando  Valley  Community  Health,  Inc.  Opens  

1971   Sylmar  Earthquake  Destroys  Olive  View  Psychiatric  Facility  Programs  continued  in  a  mid-­‐San  Fernando  Valley  location    

1972  LADMH  Merges  with  LADHS  

Martin  Luther  King,  Jr.  (MLK,  Jr.)  Medical  Center  Opens  in  South  L.A.  

1973   First  County  Drug  Abuse  Plan  is  Developed  

1976   La  Puente  Community  Mental  Health  Center  Opens  with  an  NIMH  Grant  

1977   Coastal  Community  Mental  Health  Center  is  Established  

1978  LADMH  Re-­‐established  as  a  Separate  Department,  with  an  MOU  Created  Dividing  Responsibility  for  Mental  Health  Services  between  LADHS  and  LADMH  J.R.  Elpers  named  Director.    Outpatient  mental  health  services  assigned  to  LADMH;  hospital-­‐based  mental  health  services  assigned  to  LADHS.  

1979   LADMH  Takes  Over  Olive  View  Outpatient  Operations  in  Mid-­‐San  Fernando  Valley  

1981  Augustus  F.  Hawkins  Mental  Health  Center  opens  with  National  Institute  of  Mental  Health  (NIMH)  Grant  

Los  Angeles  Day  Treatment  Center  becomes  Hollywood  Mental  Health  Services  

1984   Roberto  Quiroz  is  Appointed  Mental  Health  Director  

1987  

River  Community  Opens  River  Community  opened  to  provide  integrated  services  for  co-­‐occurring  mental  illness  and  substance  abuse  

“Declaration  of  Conscience”  is  Written  Directors  of  emergency  and  inpatient  psychiatry  at  four  L.A.  County  public  teaching  hospitals,  a  representative  from  the  L.A.  County  Medical  Association  and  the  Southern  California  Psychiatric  Society  write  the  document  urging  action  to  prevent  collapse  of  emergency  and  acute  psychiatric  care  in  L.A.  County  

Homes  for  Life  Foundation  is  Established  

Office  of  the  Public  Guardian  Returns  to  LADMH  by  Board  Order  

1988  

AB  3777  (Wright-­‐McCorquodale-­‐Bronzan  Mental  Health  Act)  Funds  pilot  projects  in  three  counties  including  L.A.  that  combine  treatment  and  rehabilitation  and  provide  integrated,  flexible  24/7  services;  Village  Integrated  Services  Agency  in  Long  Beach  was  established  through  this  pilot  

A  Community  of  Friends  is  Established  Nonprofit  affordable  housing  developer  with  a  mission  to  end  homelessness  through  supportive  housing  for  people  with  mental  illness  

Realignment  Impact  

1991  Bronzan-­‐Wright-­‐McCorquodale  Realignment  Act  Gives  counties  more  control  of  resources  previously  used  for  State  Hospitals  by  funding  local  programs  from  sales  tax,  removing  “base”  budget  from  annual  legislative  budget  process  

1992   Areta  Crowell  is  Appointed  Director  of  LADMH  

1993  LADMH  Enters  into  a  Contract  with  Los  Angeles  Unified  School  District    Contract  would  provide  school-­‐based  mental  health  services.  It  is  considered  the  first  such  contract  in  the  country  to  be  executed  directly  between  a  county  public  mental  health  system  and  a  public  school  district  

  46

Date   Major  Milestones  

1993  LADMH  Launches  Children’s  System  of  Care  (CSOC)  CSOC  funded  by  SAMHSA  grants  is  an  intensive,  comprehensive  and  innovative  program  that  works  by  preventing  children  from  being  removed  from  their  families  when  faced  with  behavioral  and  emotional  challenges  

1995-­‐98  Medi-­‐Cal  Mental  Health  Managed  Care  and  State  Waivers  California  implements  Medi-­‐Cal  Mental  Health  Managed  Care  as  part  of  the  overall  thrust  toward  managed  care  in  the  Medi-­‐Cal  program.  As  part  of  this  delivery  system,  inpatient  and  various  specialty  psychiatric  services  became  the  responsibility  of  a  single  entity,  the  Mental  Health  Plan  (MHP),  in  each  county.  All  Medi-­‐Cal  recipients  are  required  to  obtain  these  services  through  the  MHP.      LADMH  implements  inpatient  and  outpatient  consolidation  phases.  

1996  

Mental  Health  Parity  Act  Eliminates  financial  caps  on  mental  health  benefits  in  health  plans  at  companies  

Early  and  Periodic  Screening,  Diagnosis,  and  Treatment  (EPDST)  Providing  increased  state  matching  funds  to  counties  to  comply  with  the  T.L.  v.  Belshe  lawsuit,  which  required  that  all  federally  mandated  Medi-­‐Cal  programs  be  funded  

1997   LADMH  Establishes  Office  of  Consumer  Affairs  

1998  Dr.  Marvin  Southard  is  Appointed  Director  of  LADMH  

LADMH  Launches  “Comprehensive  Community  Care”  Process  Comprehensive  Community  Care  Process  created  a  client-­‐centered,  family-­‐focused  integrated  mental  health  system  

1999   Assemblywoman  Helen  Thomson’s  Parity  Bill  is  Signed  Bill  would  eliminate  discrimination  practices  for  designated  diagnosis  indicating  severe  mental  illness  

2000  

LADMH  Publishes  Comprehensive  Community  Care    A  strategic  plan  focusing  on  developing  a  wellness,  remission,  and  recovery  focus  

LADMH  Establishes  the  Older  Adults  Bureau  for  Distinct  Planning  and  Services  

LADMH  Establishes  Emergency  Outreach  Bureau  

2001   LADMH  Publishes  Comprehensive  Community  Care  Progress  Report  

2002   LADMH  Establishes  Transitional  Age  Youth  Division  for  Distinct  Planning  and  Service  

2003   LADMH  Assumes  Operation  of  Augustus  F.  Hawkins  Mental  Health  Center  on  MLK,  Jr.  Medical  Center  Campus  

2004   Mental  Health  Services  Act  (Proposition  63)  Provides  funding  for  mental  health  based  on  a  1%  tax  on  those  who  earn  over  $1  million  annually,  emphasizing  recovery  and  wellness  

2006  MLK,  Jr.  Medical  Center’s  Psychiatric  Emergency  Services  Closes  Redistribution  of  visits  occurs  among  remaining  LADHS  facilities  (LAC+USC,  Harbor-­‐UCLA,  and  Olive  View-­‐UCLA  Medical  Centers)  

LADMH  Establishes  Alternative  Crisis  Services  

Health  Reform  –  Service  Integration  

2007  LADMH  Adopts  a  New  Vision:  “Partnering  with  Clients,  Families,  and  Communities  to  Create  Hope,  Wellness  and  Recovery”  

MLK,  Jr.  Medical  Center  is  Closed  MLK,  Jr.–Multi-­‐Service  Ambulatory  Care  Center  remains  open  

2008  Mental  Health  Parity  and  Addiction  Equity  Act  (MHPAEA)    Creates  health  insurance  equity  between  mental  health  and  substance  use  disorders  and  medical/surgical  benefits  for  group  health  plans  with  more  than  50  employees  

2010  Patient  Protection  and  Affordable  Care  Act  (ACA)  Makes  mental  health  services  a  part  of  essential  benefits  for  public  and  private  health  insurance  plans  

LADMH  Joins  CalMHSA      

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 Sources:  UCLA/LADMH,  Milestones  in  Mental  Health,  accessed  at  http://www.pendari.com/DMH/TimeLine/MILESTONES_IN_MENTAL_HEALTH.pdf  and  Watson  S  and  Klurfeld  A,  California’s  Mental  Health  System,  Insure  the  Uninsured  Project,  August  2011  (22-­‐23).  

Date   Major  Milestones  

2011  

Realignment  Transferred  responsibility  for  several  public  safety,  health,  and  human  services  programs  from  the  state  to  the  counties,  and  redirected  to  counties  a  portion  of  existing  sales  tax  and  vehicle  license  fee  (VLF)  revenues  that  are  intended  to  cover  the  cost  of  the  programs.    A  long-­‐term  framework  is  to  be  developed  and  has  been  proposed  in  Proposition  30,  which  will  appear  on  the  November  2012  ballot.  

Section  1115  Medicaid  Waiver  Delivery  System  Reform  Incentive  Pool  (DSRIP)  L.A.  County’s  plan  included  co-­‐location  of  LADMH  staff  at  eight  LADHS  directly  operated  or  contract  facilities,  which  would  result  in  improved  diagnosis  of  mental  health  conditions  in  primary  care  settings,  improvements  in  patient  health  outcomes,  reductions  in  medication  errors,  and  reduction  in  avoidable  emergency  department  and  hospital  services  

Section  1115  Medicaid  Waiver  Low  Income  Health  Program  (LIHP):  Healthy  Way  LA  Matched    Mental  health  benefit  provided  to  patients  based  on  medical  necessity  criteria  through  LADMH  directly  operated  clinics,  LADMH  contracted  providers,  and  Community  Partner  clinics  

LADPH  SAPC  Rate  Study  for  Substance  Use  Disorder  Services  Intended  to  determine  costs  associated  with  providing  adult  outpatient  and  residential  substance  use  program  services  and  develop  rates  in  fee-­‐for-­‐service,  in  preparation  for  a  capitated,  managed  care  environment  

2012  

Section  1115  Medicaid  Waiver  Behavioral  Health  Services  Needs  Assessment  Completed  by  TAC  and  HSRI,  the  assessment  was  released  in  March  2012.    A  draft  plan  outline  was  submitted  to  CMS  in  October  2012,  with  the  final  service  plan  to  be  completed  by  April  2013.  

Mental  Health  and  Substance  Use  Programs  Transition  to  California  Department  of  Health  Care  Services  (DHCS)  Effective  July  1,  2012,  DHCS  assumed  responsibility  for  administering  Medi-­‐Cal  mental  health  and  SUD  services  of  the  California  Departments  of  Mental  Health  and  Alcohol  and  Drug  Programs