Committee Agenda Date :April 5, 2006

County of Santa Clara
Santa Clara Valley Health & Hospital
System

OOUA/;.

Mental Health Services

HHC08 040506

Prepared by: Nancy Pena, Ph.D
Director, Mental Health
Department
DATE:

April 5, 2006

TO:

Supervisor Liz Kniss, Chairperson
Supervisor Blanca Alvarado, Vice-Chairperson
Health & Hospital Committee

FROM:
Kim Roberts

Acting Executive Director, Santa Clara Valley Health & Hospital System

SUBJECT: Report on Mental Health Services Act (Proposition 63) Community Services and
Supports(CSS)Implementation Plan Including Status of Collaborative Efforts to
Provide Housing for Individuals Eligible for MHSA Funding

RFCOIVfMENDKD ACTION

Accept report on status of Mental Health Services Act(MHSA)Community Services and
Supports(CSS)Plan implementation, including planning regarding development of housing
options for mental health clients.

Board of Supervisors; Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

FISCAL IMPLICATIONS

There will be no impact on the General Fund as a result of these actions. Planning and

Implementation expenses incurred during Fiscal Year 05/06 will be reimbursed through an
allocation to the County from the State Department of Mental Health(SDMH),pursuant to the
MHSA.

REASONS FOR RECOMMENDATIQgj

On November 2, 2004, California voters passed Proposition 63, establishing new tax revenues

to be used to expand county mental health services to children, adults and seniors with severe
mental illnesses. The new Mental Health Services Act(MHSA)will also fund prevention and

early intervention services, innovative programs, human resource development, and capital
facilities and technology improvements. The Statewide amount of revenue for calendar year
2005 is expected to be in the range of $700 million.

The Health and Hospital Committee and the County Executive have requested that the Mental
Health Director provide regular status reports on state MHSA requirements and the county
planning process. In addition, during the January 10, 2006 meeting of the Board of

Supervisors, Supervisor Beall requested that the Mental Health Department(MHD)and the
Office of Affordable Housing seek the advice of experts on financing housing for homeless
mentally ill and to prepare guidelines and notice of funding availability(NOFA)to assist in
the development and/or securing of new housing for the homeless mentally ill.
This is the fourth formal status report on the MHSA planning and implementation process.
BACKGROUND

The initial MHSA report provided an overview of the legislation, the various funding

components, including estimates of annual statewide funding, in addition to a proposed local
planning process that was approved by the Board of Supervisors on January 25, 2005. The
second MHSA report was presented at the April 20, 2005 Health and Hospital Committee
meeting. It provided a status report on the local planning process and included a copy of the
"Plan to Plan" document submitted to the State Department of Mental Health(DMH)on

March 15, 2005. The "Plan to Plan" was subsequently approved by SDMH resulting in an
initial planning allocation of $302,171 for FY05.

Board of Supervisors; Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
Count/ Executive; Peter Kutras Jr.
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Committee Agenda Date :April 5, 2006

The third MHSA report was presented at the October 5, 2005 Health and Hospital Committee
meeting. It provided a summary of the nine-month planning process facilitated by MHD to
produce the draft CSS Plan. The final draft plan was subsequently approved by the
Stakeholder Leadership Committee and was posted for a 30-day public review during the
month of October 2005. In November 2005, three public hearings sponsored by the Mental
Health Board were held in the north, central and southern regions of the County. The final
plan was presented at the December 7th Health and Hospital Committee meeting, reviewed
and approved by the Board of Supervisors at the December 13th meeting, and subsequently
submitted to SDMH on December 31, 2005.

On January 10, 2006, the MHD and the Office of Affordable Housing responded to a referral
from Supervisor Beall made at the September 27, 2005 Board of Supervisors meeting,
regarding collaborative efforts to plan for housing for individuals eligible for MHSA funding.
That report recommended that $2 million in one-time housing funds proposed in the CSS
Plan be matched with an equal amount from the County's Affordable Housing Fund; the
recommendation was approved by the Board. The MHD and the Office of Affordable Housing
staff were directed to seek the advice of experts on financing housing for homeless mentally
ill and to prepare guidelines and notice of funding availability(NOFA)to assist in the
development and/or securing of new housing for the homeless mentally ill.
On March 14, 2006, the MHD submitted a report back in response to another referral from

Supervisor Beal regarding local planning for implementation of future components of the
Mental Health Services Act(MHSA).

This report provides an overview of the CSS implementation process that officially began
with a large stakeholder forum held on January 27, 2006, and includes an update on specific
planning being done in the area of housing.
MHSA Overview

The State DMH has identified six components of MHSA that will be implemented in phases.
They are:

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

1. Community Program Planning - This component provides funding for local planning.
FY05 allocation has been received and the FY06 allocation is pending.

2. Community Services and Supports(CSS)- This eomponent provides funding for system
expansion to new and current clients. The County plan was submitted to SDMH on December
31, 2005. Close to $37 million in funding over a three-year period is anticipated to begin in
April 2006. This eomponent is the subject of this report.

3. Capital and Information Technology - This component provides funding for housing,
facilities, and technology. The requirements for this component are under development at the
state level and the method of alloeation of funds to counties is unknown at this time.

4. Education and Training - This component provides funding for consumer, family and staff
training. The requirements for this component are also under development at the state level
and allocation method is unknown at this time.

5. Prevention and Early Intervention - This component expands services to early intervention
and prevention services. It is also pending state requirements and county allocation
methodology is unknown at this time.

6. Innovative Programs - This eomponent sets aside 5% of MHSA funding for new
demonstrated innovative programs. It is also pending state requirements and eounty allocation
methodology is unknown at this time.

The Community Program Planning component was the first MHSA component to receive
funding. Santa Clara County received $302,171 for planning in FY05 and is expected to
reeeive $670,000 in FY06 for continued planning. The CSS Plan is the second and largest
component to be funded(50% of overall MHSA funding). These funds must be used to
expand current services to the most severely mentally ill across California. The Santa Clara
County planning estimate is $13.4 million per year for FY06, FY07 and FY08.
Each County is required to utilize a publie planning process to determine specific sub-groups
of un-served and underserved individuals of all ages, with a particular focus on ethnic

disparities in mental health service access. From the critieal concerns identified, counties are

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jim Beall, Liz Kniss
County Executive; Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

required to consider evidenced-based strategies that will address the unmet mental health
needs of the community.
Santa Clara County CSS Plan

The CSS Plan submitted to SDMH contains seventeen distinct work plans, many with

multiple components, designed to transform the current system into a resiliency and
recovery-oriented system that is consumer and family-driven. The plan is also intended to
address current disparities in specific ethnic population access to services.
Work plans are organized into five categories:
1. Children zero to 15 years old
2. Transition Age Youth(TAY)16 to 25-years
3. Adults 26 to 59 years

4. Older Adults 60 plus years
5. Cross-cutting (all ages)

Attachment A provides a summary of the various work plans, including which components
are to be contracted out through an RFP process, and which will be county-operated. The
summary also indicates which type of program is included. There are three types of services
included in the CSS plan: 1) Full Service Partnerships are wraparound-like,
"whatever-it-takes" programs that provide comprehensive, integrated services that include
housing, employment support, health care, mental health treatment and intensive case
management. Average annual costs are estimated to be $15,000-$20,000 per year per client
for adults and $41,000 for children and transitional age youth. The majority(51% or more) of
CSS funding must be dedicated to these new partnerships; 2) System Development strategies
are designed to improve the current service delivery system through implementation of
evidenced-based practices and consumer/family-run services; and 3) Outreach and
Engagement strategies which are designed to access un-served and underserved populations
to needed services.

The Plan also included proposals to utilize all but $45,882 of the funds allocated to Santa

Board of Supemsors: Donald F, Gage, Blanca Alvarado, Pete McHugh, Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

Clara County for the new services as well as planning and one-time "pre-implementation"
activities. SDMH has indicated however that they will be setting aside approximately 25% of

unexpended FY06 funding for each county's reserve, a requirement of MHSA,in order to
provide assurance of "maintenance of effort" funding for CSS Plans in the event of lower tax
revenues in subsequent calendar years. The MHD will therefore need to make adjustments to
the Plan to reflect the unavailability of these funds.

The expected implementation date of the Santa Clara County CSS Plan is April 2006. A
formal review of the CSS Plan was conducted by SDMH in Sacramento on February 22,

2006, and on March 13th the MHD received a follow-up letter outlining 23 items to be
addressed before formal approval is given. While the feedback was overwhelmingly positive,
there are some changes that are required. They involve shifting budgets in some plans from
system development into full service partnerships, providing more detail on the Housing
Option plan, modifying several of the remaining Cross-cutting plans, and providing more
budget detail on some of the plans. A formal letter is being prepared to submit to SDMH

responding to all the items with corrections or modifications. SDMH must be satisfied with all
corrections, upon which the MHD will receive formal notification of the plan and notice of
funding. The FY06 payment will follow notification of approval, which is expected sometime
in mid-April.
Implementation Process

The MHD has outlined an implementation timeline for the specific CSS work plans. In
general, work plans are being considered to fall in three categories:

• System-wide changes in process - The CSS Plan includes several strategies that will
redesign service screening, assessment, and level of care determinations across the four age
groups of Children, Transition Age Youth, Adults, and Older Adults, incorporating a
recovery-oriented, consumer-driven philosophy of service delivery. In addition, one plan
proposes the development of an interagency System of Care for Children under the age of five
years. These strategies will be implemented through a process that will be facilitated by the
MHD and will include involvement of consumers, family members, service providers, and

system partners. The MHD will initiate the planning for implementing these initiatives in
April 2006. The planning process is currently being outlined and will be presented at the next
Stakeholder Leadership Committee scheduled for April 21, 2006.

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
Count/ Executive: Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

• System-wide implementation of new practiee models - A second set of strategies fall in the
category of introducing new evidenced-based practice models of service delivery throughout
the mental health system. A wide variety of practices known to be effective with various
populations will be implemented, requiring extensive training, program modifications to
accommodate new practices, ongoing supervision, and evaluation data collection. An
implementation plan will be designed with county and contract provider involvement, in
addition to the involvement of consumers and family members. This initiative began in March
2006 with the offering of several trainings- the first being a half-day orientation to the MHD
open to current and potential new providers. The second event provided four full days of

training from experts in Full Service integrated models of care. Over 100 individuals attended
each day of training. A calendar of training events is being designed for the duration of the
initial three-year CSS Plan. The training plan is posted and regularly updated on the MHD
website.

• Implementation of new services - The large majority of CSS funding is dedicated to the
implementation of three types of new service - Full Service Partnerships (over 50% of CSS
funds); System Development; and Outreach and Engagement. These services will be
implemented through both county-operated and contract providers. The new services have
been organized into groups based on type of service. The MHD has planned for three phases
of RFP releases to implement those new services that will be contracted out. In addition,
planning is underway for the new services to be implemented by county programs.
The planned RFP release dates are outlined below:
March 24, 2006

* Full Service Partnerships - Children, TAY, Adults, Seniors
* Full Service Partnerships - Jail Aftercare
April 24, 2006

* Dual Diagnosis Mental Health/Substance Abuse Service Expansion-Substance Abuse
Detox Services

* Expanded Services to Seriously, Emotionally Disturbed, Under-Served Youth
* Integrated Mental Health/Developmental Disability Service Expansion

Board of Supervisors; Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
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Committee Agenda Date April 5, 2006

* Mental Health Support to Outpatient Medical Services
* Expanded Day Services to Support Existing Community Providers
* Mobile Assessment and Outreach Team Response: Mobile Assessment Team and Outreach
Team (to identify and assist Older Adults in accessing services)
* Enhanced Peer Support Services

* Family/Primary Network Support and Education

* Specialized Lesbian, Gay, Bisexual, Transgender, and Questioning(LGBTQ)
* Outreach, Engage, and Direct Services to Unserved and Underserved Transitional Aged
Youth

* Drop-in, Peer Support Center
May 24, 2006

* Urgent/Crisis and Mobile Response and Crisis Services - South County Locations
* Urgent/Crisis and Mobile Response and Crisis Services - North County Locations
* Self-Help Development and Peer Support Services
* Family/Primary Network Support and Education
Housing Options Development

The CSS Plan includes housing resources in all Full Service Partnerships (FSP), estimating

that up to one-third of annual budgets may be utilized to address the individual housing and
related support needs of enrolled clients. In addition, the plan includes a $2 million one-time
fund for the development of permanent housing resources. Finally, the Board of Supervisors
has approved an additional $2 million from the County's Affordable Housing Fund. These
three funding sources will offer a variety of housing options for mental health.
The MHD and the Office of Affordable Housing are collaborating on an expenditure plan for
the use of the $4 million combined MHSA and Affordable Housing Fund. An initial meeting

of experts was held on March 14, 2006. Attendees included experts from the City San
Francisco, Alameda County, the Corporation for Supportive Housing, non-profit housing
development, housing consultants, and county MHD and Office of Affordable Housing staff

Board of Supervisors; Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive; Peter Kutras Jr.
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Committee Agenda Date :April 5, 2006

Several short- and long-term housing options were identified. It was agreed that a variety of
options will be required to meet the unique socio-cultural needs of mentally ill clients of all
ages, and that short-term efforts will be to insure flexible options and to gather information
regarding the permanent housing needs of the 300+ individuals expected to be enrolled in
FSP's through the initial three-year plan.

The group reviewed the Mental Health Services Act Housing Toolkit prepared by the
Corporation for Supportive Housing (available at www.csh.org). It was agreed that initial
attention will be given to addressing individual client needs through use of FSP funds. This
will involve working with new FSP providers to establish housing specialists, either through
individual providers, or through collective pooling of FSP resources. These efforts will focus
on securing rental resources and supports for clients.

The second phase of work will be to identify mid- and long-term housing solutions to be
secured through the $4 million one-time funding and implemented through RFP processes.
These solutions must be informed by the needs of identified consumers and availability of
housing units, either currently available or to be developed.
Next steps are to:

1. Formalize Housing Expert Advisory Committee - May 2006
2. Provide local housing training for all stakeholders - June 2006

3. Select FSP providers and establish housing resource development function - July 2006
4. Establish FSP provider housing resource team and attend regional 2 day training - August
2006

5. Complete strategic implementation plan for use of$4 Mental Health housing fund September 2006
Conclusion

The MHD will continue to sponsor open stakeholder forums to insure mental health
consumers, families, providers, system partners, and advocates are included in the major

implementation process that will be underway for the next several years. In addition, the

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive; Peter Kutras Jr.
9

Committee Agenda Date April 5, 2006

MHSA Stakeholder Leadership Committee will be convened quarterly to provide leadership
and oversight of the CSS Plan implementation, and to offer input to planning for the
remaining MHSA components to be implemented by SDMH. Consumer Advisory, Family
Advisory, and Ethnic Community Advisory, and Special Needs Advisory Committees will
continue to be developed and will provide critical input to system transformation. Regular
reports will continue to be provided through the Health and Hospital Committee.
CONSEQUENCES OF NEGATIVE ACTION

The Board will not receive the information it requested.
ATTACHMENTS
• Attachment A

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
10