SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 1443 (Maienschein) - Mental health: technical assistance centers

Bill Summary:

Assembly Bill 1443 would require the Mental Health Services Oversight and Accountability Commission (OAC) to, subject to available funding, establish one or more technical assistance centers to support counties in addressing mental health issues, as determined by the commission, that are of statewide concern. Would require the OAC to establish which mental health issues are of statewide concern with the input of relevant stakeholders. Would require the technical assistance (TA) centers be funded with state administrative funds

Fiscal Impact:

The OAC estimates a minimum low hundreds of thousands, ranging to the possible low millions, ongoing, depending on the number of technical assistance centers, type of technical assistance needed (i.e., how to maximize Medi-Cal draw-down, how to integrate home visitation programs), and whether the OAC will staff or contract for resources. Currently, the OAC does not have sufficient staff resources to respond to all TA requests. In addition, the bill’s broad language provides significant flexibility in program design, which affects the fiscal estimate. One example provided by the OAC to staff could locate the TA center in a university, which could be led by a non-profit or even a county mental health department.

Background:

In 2004, California voters enacted Proposition If the OAC was to act as a program facilitator or grants manager, at least 1.0 permanent staff person (staff assumes approximately up to $150,000 General Fund). For a similar bill, the OAC anticipated that funding for technical assistance could range from $5 - $10 million (MHSA Fund).The cost of each Center also can vary, based on the strategy pursued.  For example, a prior budget action authorized $15 million to UC to establish two Behavioral Health Centers of Excellence - one at UC Davis, the other at UCLA.  The OAC provided about $7 million (total funds) over four years for both centers.

Proposition 63, known as the Mental Health Services Act (MHSA), to provide funds to counties to expand services, develop innovative programs, and integrate service plans for children, adults, and seniors who were mentally ill, through a one-percent income tax on personal income above $1 million. The MHSA provides funding for programs within five components: (1) community services and supports; (2) prevention and early intervention; (3) innovation; (4) capital facilities and technological needs; and (5) workforce education and training.

The OAC was established to oversee the implementation of MHSA funds and works in collaboration with the Department of Health Care Services (DHCS), the California Behavioral Health Planning Council, and other stakeholders to design a joint plan for coordinated evaluation of client outcomes in community-based mental health. In these three-year plans, counties must include a list of all programs for which MHSA funding is being requested, identify expenditures and which populations will be served. Counties also must submit their plans for approval to the OAC before they can spend innovation program funds.

The 2013-14 Budget Act included MHSA funds to establish two Behavioral Health Centers of Excellence through the University of California (UC). According to the bill’s Senate Health Committee analysis, while those funds are largely exhausted, the MHSOAC has been working with a number of UC campuses, as well as UC San Francisco, UC San Diego, Stanford University, and others to tap the expertise available around the state to support transformational change in the state’s community mental health system. The MHSOAC also contracted with UC Davis to support counties interested in improving their early psychosis programs by providing approximately $100,000 for consultation and technical assistance.

Proposed Law:

Assembly Bill 1443 would require the Mental Health Services Oversight and Accountability Commission (OAC) to, subject to available funding, establish one or more technical assistance centers to support counties in addressing mental health issues, as specified, that are of statewide concern. The OAC must establish which mental health issues are of statewide concern with the input of relevant stakeholders and shall include reducing the seven negative outcomes of untreated mental illness, as identified in existing law. Costs must be paid using statewide administrative funds allocated to the OAC.

Related Legislation:

• SB 604 (Bates, 2019) is substantially similar to this bill and would require, on or before January 1, 2021, the Mental Health Oversight and Accountability Commission (OAC) to establish one or more centers of excellence to provide counties with technical assistance to implement best practices related to elements of the Mental Health Services Act (MHSA). The bill would require the centers of excellence be funded with state administrative funds, and OAC to consider specified data in determining the areas of focus for the centers of excellence. SB 604 was held on the Senate Appropriations Committee suspense file.
• SB 12 (Beall, 2019) would establish the Integrated Youth Mental Health Program (IYMHP), and would require, subject to the available funding, the OAC to administer the IYMHP through centers that provide integrated services, as specified, to youth ages 12-25 and their families by providing funding to specified entities. SB 12 is on the Assembly Appropriations Committee suspense file.

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SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 1443

SUBJECT: Mental health: technical assistance centers

SUMMARY:

Requires the Mental Health Services Oversight and Accountability Commission, subject to available funding, to establish one or more technical assistance centers to support counties in addressing mental health issues that are of statewide concern and reducing specified negative outcomes of untreated mental illness.

Existing law:

1. Establishes the Mental Health Services Oversight and Accountability Commission (MHSOAC) to oversee the implementation of the Mental Health Services Act (MHSA), enacted by voters in 2004 as Proposition 63, to provide funds to counties to expand services, develop innovative programs, and integrate service plans for mentally ill children, adults, and seniors through a one percent income tax on personal income above $1 million. [WIC §5845]
2. Permits the MHSOAC to perform various functions in carrying out its duties and responsibilities, such as assisting in providing technical assistance to accomplish the purposes of the MHSA. [WIC §5845]
3. Requires DHCS, pursuant to the MHSA and in coordination with counties, to establish a program designed to prevent mental illnesses from becoming severe and disabling, and requires the program to emphasize strategies to reduce the following negative outcomes that may result from untreated mental illness:
   1. Suicide;
   2. Incarcerations;
   3. School failure or dropout;
   4. Unemployment;
   5. Prolonged suffering;
   6. Homelessness; and,
   7. Removal of children from their homes. [WIC §5840]
4. Requires specified funds (referred to as “state administrative funds”) to be allocated to various entities, including the MHSOAC, to implement all duties pursuant to the programs set forth in the MHSA. Prohibits state administrative funds from exceeding 5% of the total of annual revenues received for the Mental Health Services Fund. (WIC §5892]

This bill:

1. Requires the MHSOAC, subject to available funding, to establish one or more technical assistance centers to support counties in addressing mental health issues that are of statewide concern, as determined by the MHSOAC with the input of relevant stakeholders. Requires the MHSOAC to include reducing the negative outcomes identified in 3) above of existing law within the issues of statewide concern.
2. Requires costs incurred by establishing technical assistance centers to be paid using state administrative funds allocated to the MHSOAC.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, costs could range from about $100,000 to in excess of $1 million for each center, for each year a center is operating. The total cost would vary based on the number of centers created (MHSA state administrative funds). This bill does not specify a number of centers nor specify the level of service provided.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, this bill would enable counties to use their funds innovatively and effectively to meet the mental health needs of their residents. Giving counties technical assistance centers will enable them to collaborate across county lines and provide effective mental health services where they each need it most.
2. MHSA. The MHSA requires each county mental health program to prepare and submit a three-year plan to DHCS that must be updated each year and approved by DHCS after review and comment by the MHSOAC. In the three-year plans, counties are required to include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. The MHSA provides funding for programs within five components:
   1. Community Services and Supports (CSS): Provides direct mental health services to the severely and seriously mentally ill, such as mental health treatment, cost of health care treatment, and housing supports. Regulations require counties to direct the majority of its CSS funds to Full-Service Partnerships (FSPs). FSPs are county coordinated plans, in collaboration with the client and the family, to provide the full spectrum of community services. These services consist of mental health services and supports, such as peer support and crisis intervention services; and non-mental health services and supports, such as food, clothing, housing, and the cost of medical treatment. Outside of FSPs, counties do not use CSS funds to assist with housing;
   2. Prevention and Early Intervention: Provides services to mental health clients in order to help prevent mental illness from becoming severe and disabling;
   3. Innovation: Provides services and approaches that are creative in an effort to address mental health clients’ persistent issues, such as improving services for underserved or unserved populations within the community;
   4. Capital Facilities and Technological Needs: Creates additional county infrastructure such as additional clinics and facilities and/or development of a technological infrastructure for the mental health system, such as electronic health records for mental health services; and,
   5. Workforce Education and Training: Provides training for existing county mental health employees, outreach and recruitment to increase employment in the mental health system, and financial incentives to recruit or retain employees within the public mental health system.
3. Framework for technical assistance centers. The MHSOAC states that the technical assistance model is well established and often used by the federal government as a way to engage expertise without the need for a state agency to hire staff for all potential areas of needed technical assistance. The model would allow the state to invest in specific needs for a set period of time, and, as technical assistance needs change, make new investments in other areas of concern. The MHSOAC spent about six months in 2018 engaging county and community mental health leaders on how the state could support their ability to improve MHSA-funded programs. Counties identified three key opportunities: clarifying what the MHSOAC is looking for when it approves a county innovation plan; launching an innovation incubator to support counties’ ability to develop effective innovation plans, particularly for multi-county innovations; and, developing a strategy to offer technical assistance to counties on innovation but also on other issues that fall outside of innovation, such as core operations, improving the effectiveness of FSPs, and other challenges. According to the MHSOAC, it does not have the expertise on its staff to provide technical assistance across the range of challenges facing the community mental health system, nor does it have the fiscal resources to secure that kind of technical assistance through a consulting contract. State and local policymakers have called for improved attention on areas such as suicide prevention, homelessness, streamlined Medi-Cal billing, school mental health, maternal mental health, criminal justice diversion, and early psychosis interventions. The MHSOAC states that it has approximately 35 staff with a range of responsibilities, most of whom are analysts focused on approving grants and innovation plans, conducting research, and other related analytical work. The MHSOAC has one consulting psychologist on staff who has a background in the delivery of mental health care. This bill, if funding is made available, would provide the resources to create technical assistance centers to assist counties with their various inquiries.
4. Related legislation. SB 604 (Bates) is substantially similar to this bill but requires the MHSOAC to establish an indeterminate number of centers of excellence (technical assistance centers). SB 604 was held on the Senate Appropriations Committee suspense file.
5. Prior legislation. SB 1113 (Monning, Chapter 354, Statutes of 2018) permits the MHSOAC to establish a framework and voluntary standard for mental health in the workplace, as specified, and to provide guidance to California’s employer community to support the mental health and wellness of employees.
6. Support. The MHSOAC states that its mission is to provide vision and leadership to ensure that Californians understand that mental health is essential to overall health. The MHSOAC states this bill will create technical assistance centers to support counties in their efforts to address mental health access and disparity concerns at the local level, further efforts to combat these issues and formulate collaborative and inventive solutions to the challenges counties are facing, and support counties in achieving the goals of the MHSA.

SUPPORT AND OPPOSITION:

Support: California Academy of Child and Adolescent Psychiatry

Mental Health Services Oversight and Accountability Commission

Oppose: None received

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ASSEMBLY THIRD READING

ATR Bill Id:AB 1443

Author:(Maienschein)

As Amended Ver:March 25, 2019

2/3 vote

SUMMARY:

Requires the Mental Health Services Oversight and Accountability Commission (the Commission), subject to available funding, to establish one or more technical assistance centers to support counties in addressing mental health issues as determined by the Commission, that are of statewide concern.

Major Provisions

COMMENTS:

A report from the California Health Care Foundation published in March of 2018 entitled "Mental Health in California: For Too Many, Care Not There," stated that California's mental health delivery system is a complex one. California counties are responsible for both Medi-Cal specialty mental health services for the seriously mentally ill and for safety-net (non Medi-Cal) community mental health services. While counties have historically provided most Medi-Cal mental health services in the state through county mental health plans, and some services on a fee-for-service basis, other services typically for people with less serious mental health conditions have become available through Medi-Cal managed care health plans since California expanded the scope of mental health benefits available to Medi-Cal beneficiaries in 2014.

While counties have the same mandate and same funding streams, each county approaches the delivery of care in its own way. Oftentimes a county may be unaware of programs or activities being conducted in other counties – programs that may work well in their own community. Many counties lack resources and may be unable to develop the level of expertise required to develop or implement new ideas or concepts. The Commission envisions the opportunity to work with the counties to identify key needs –including needs that are of priority interest to the State of California, such as enhancing opportunities for school mental health, improving response to maternal mental health, supporting opportunities to prevent child welfare involvement, unemployment of homelessness by engaging individuals and families earlier to support their mental health needs. Further, the Commission spent about six months last year engaging county and community mental health leaders on how the state could support their ability to improve programs. A key outcome of this engagement period was interest in developing a strategy to offer technical assistance to the counties on innovation but also on other issues that fall outside of innovation, such as core operations, improving the effectiveness of Full Service Partnership and other challenges.

According to the Author:

According to the author, counties offer their residents different mental health services. Local entities, such as school districts and law enforcement face many barriers in addressing the issues they face in their practice due to the lack of mental health services and resources that exist. Technical Assistance centers would help counties see what programs are being successfully run in other parts of the state and help them find opportunities to bridge the gaps in mental health services they each face individually. The author concludes that this bill would enable counties to use their funds in the most innovative and effective way to meet the mental health needs of their residents. Giving counties technical assistance centers will enable them to collaborate across county lines and provide effective mental health services where each county needs it most.

Arguments in Support:

The California Academy of Child & Adolescent Psychiatry states in support that in 2004

California voters passed Proposition 63, the Mental Health Services Act (MHSA), which called for the establishment of the Commission. The role of the Commission evolved under AB 100 (Committee on Budget), Chapter 5, Statutes of 2011, to providing training and technical assistance and review of county mental health planning, as needed. AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012, further expanded the Commission's role of training and technical assistance and reinstated the approval of county innovation plans. This bill will further those efforts by requiring the Commission to establish technical assistance centers to support counties in addressing mental health issues and determine, with stakeholder input, which mental health issues are of statewide concern.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee, costs could range from about $100,000 to in excess of $1 million for each center, for each year a center is operating. The total cost would vary based on the number of centers created (MHSA state administrative funds). The bill does not specify a number of centers nor specify the level of service provided.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: March 25, 2019

CONSULTANT: Judith Babcock / HEALTH / (916) 319-2097 FN: 0000602

Date of Hearing: April 10, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1443

Author:(Maienschein) – As Amended Ver:March 25, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the Mental Health Services Oversight and Accountability Commission (commission), subject to available funding, to establish one or more technical assistance centers to support counties in addressing mental health issues, as determined by the commission, that are of statewide concern.

It also specifies costs of establishing technical assistance centers shall be paid using administrative funds allocated to the commission and declares this is consistent with and furthers the intent of the Mental Health Services Act (MHSA).

FISCAL EFFECT:

Costs could range from about $100,000 to in excess of $1 million for each center, for each year a center is operating. The total cost would vary based on the number of centers created (MHSA state administrative funds). The bill does not specify a number of centers nor specify the level of service provided.

COMMENTS:

1. Purpose. This author-sponsored bill is intended to help counties learn about successful programs and approaches. The author asserts this bill would enable counties to use their funds in the most innovative and effective way to meet the mental health needs of their residents.
2. Background. In 2004, California voters approved Prop 63, the MHSA, which put into place a 1% tax on incomes above $1 million to fund mental health services. It allocates funds directly to counties to be used for a wide range of prevention, early intervention and treatment services. In recent years, the commission has noted a need for technical assistance to ensure counties are knowledgeable about best practices and available evidence-based programs.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 2, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1443

Author:(Maienschein) – As Amended Ver:March 25, 2019

SUBJECT: Mental health: technical assistance centers.

SUMMARY: Requires the Mental Health Services Oversight and Accountability Commission (the Commission), subject to available funding to establish one or more technical assistance centers to support counties in addressing mental health issues as determined by the Commission, that are of statewide concern. Specifically, this bill:

1. Requires the Commission, subject to funding, to establish one or more technical assistance centers to support counties in addressing mental health issues as determined by the commission, that are of statewide concern.
2. Requires the Commission, with input from relevant stakeholders, to establish which mental health issues are of statewide concern and to include the seven negative outcomes of untreated mental illness: suicide, incarcerations, school failure or dropout, unemployment, prolonged suffering, homelessness, and, removal of children from their homes.
3. Requires costs incurred as a result of complying with this bill to be paid using funds allocated to the Commission under the Mental Health Services Act (MHSA) Fund.

EXISTING LAW:

1. Establishes the MHSA, an initiative measure enacted under Proposition 63 to provide increased funding, personnel and other resources to support county mental health programs and monitor progress toward statewide goals for children, transition age youth, adults, older adults and families.
2. Establishes the Commission comprised of 16 voting members to oversee various mental health programs funded by the MHSA, including the Adult and Older Adult Mental Health System of Care Act; Human Resources, Education, and Training Programs; Innovative Programs; Prevention and Early Intervention Programs; and, the Children’s Mental Health Services Act.
3. Requires the Department of Health Care Services (DHCS), under the MHSA and in coordination with counties, to establish a program designed to prevent mental illnesses from becoming severe and disabling and requires the program to emphasize strategies to reduce the following negative outcomes that may result from untreated mental illness:
   1. Suicide;
   2. Incarcerations;
   3. School failure or dropout;
   4. Unemployment;
   5. Prolonged suffering;
   6. Homelessness; and,
   7. Removal of children from their homes.
4. Requires California counties to be responsible for both Medi-Cal specialty mental health services for the seriously mental illness and for safety-net (non-Medi-Cal) community mental health services.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, counties offer their residents different mental health services. Local entities, such as school districts and law enforcement face many barriers in addressing the issues they face in their practice due to the lack of mental health services and resources that exist. Technical Assistance centers would help counties see what programs are being successfully run in other parts of the state and help them find opportunities to bridge the gaps in mental health services they each face individually. The author concludes that this bill would enable counties to use their funds in the most innovative and effective way to meet the mental health needs of their residents. Giving counties technical assistance centers will enable them to collaborate across county lines and provide effective mental health services where each county needs it most.
2. BACKGROUND.
   1. Public Mental Health Delivery System. A report from the California Health Care Foundation published in March of 2018 entitled “Mental Health in California: For Too Many, Care Not There,” stated that California’s mental health delivery system is a complex one. California counties are responsible for both Medi-Cal specialty mental health services for the seriously mentally ill and for safety-net (non Medi-Cal) community mental health services. While counties have historically provided most Medi-Cal mental health services in the state through county mental health plans, and some available on a fee-for-service basis, other services typically for people with less serious mental health conditions have become available through Medi-Cal managed care health plans since California expanded the scope of mental health benefits available to Medi-Cal beneficiaries in 2014.

While counties have the same mandate and same funding streams, each county approaches the delivery of care in its own way. Oftentimes a county may be unaware of programs or activities being conducted in other counties – programs that may work well in their own community. Many counties lack resources and may be unable to develop the level of expertise required to develop or implement new ideas or concepts. The Commission envisions the opportunity to work with the counties to identify key needs –including needs that are of priority interest to the State of California, such as enhancing opportunities for school mental health, improving response to maternal mental health, supporting opportunities to prevent child welfare involvement, unemployment of homelessness by engaging individuals and families earlier to support their mental health needs. Further, the Commission spent about six months last year engaging county and community mental health leaders on how the state could support their ability to improve programs. A key outcome of this engagement period was interest in developing a strategy to offer technical assistance to the counties on innovation but also on other issues that fall outside of innovation, such as core operations, improving the effectiveness of Full Service Partnership or other challenges.

• 1. Technical Centers/Centers of Excellence. Technical Centers, also referred to as Centers of Excellence, is generally a team, a shared facility, or an entity that provides leadership, best practices, research, support and/or training for a focus area. Due to its broad usage, a Technical Center/Center of Excellence in one context may have completely different characteristics from another. The focus area might be a technology, a business concept, a skill or a broad area of study. A center may also be aimed at revitalizing stalled initiatives. The term may also refer to a network of institutions collaborating with each other to pursue excellence in a particular area. The Technical Center/Center of Excellence model is well established, and is often used by the federal government as a way to engage expertise without the need for an agency to hire staff for all potential areas of needed technical assistance. The model allows the entity to invest in specific needs for a set period of time, and over time, as technical assistance needs changes, make new investment in other areas of concern. The strategy allows the entity to make smart investment in dynamic ways. A visual representation of a technical assistance model follows. Each of the vertical branches of the technical assistance model may be replaced or expanded based on the entities’ needs.

1. RELATED LEGISLATION.
2. AB 563 (Quirk-Silva) appropriate $16 million from the General Fund to DHCS to distribute to the North Orange County Public Safety Task Force. Requires one-half of the moneys to be distributed on January 1, 2020, and one-half to be distributed on January 1, 2021. Requires the moneys to be used to provide a range of programs, services, and activities designed to assist individuals and families experiencing mental health crises. AB 536 is pending in the Assembly Health Committee.
3. SB 604 (Bates) is similar to this bill and requires the Commission, by January 1, 2021, to establish centers of excellence to provide the counties with technical assistance to implement best practices related to elements of the MHSA. Require the centers of excellence to be funded with state administrative funds provided under MHSA. SB 604 is pending in the Senate Health Committee.
4. PREVIOUS LEGISLATION.
   1. AB 1810 (Budget Committee), Chapter 34, Statutes of 2018, promotes the establishment of Community Centers of Excellence in perinatal health based on public health science concerning the causes of persistent inequality and current best practices to narrow the gap.
   2. AB 2643 (Quirk-Silva and Cervantes) of 2018, would have revised the definition of a federal small business technical center to include a state trade expansion program as an eligible grant applicant. AB 2463 died on the Senate inactive file.

REGISTERED SUPPORT / OPPOSITION:

Support

None on file.

Opposition

None on file.

Analysis Prepared by: Judith Babcock / HEALTH / (916) 319-2097