Assembly Select Committee on Select Committee on California's Mental Health Crisis

We will bring the Select Committee on California's Mental Health Crisis to order. I want to welcome everyone to our third scheduled hearing on California's mental health crisis. For those who wish to participate in public comment via phone, you may do so by calling 877-692-8957 and the public access code is 131-5444 and it should also be on your television screen. Public comment will be conducted at the end of the hearing.

Today we are joined by people who will provide testimony from their various perspectives and fields on addressing the California's mental health crisis and understanding the problem in its full scope. Our first panel is a continuation of our second hearing about defining mental health and understanding the unique mental health challenges from various populations of California. After that, we will have our second panel, which will begin to talk about where do we go from here? What are we missing?

What do we need to continue to do past this legislative year and moving forward into the next? And what should we be focusing on? We will be hearing from the Administration and the Mental Health Services Oversight and Accountability Commission. And we have invited organizations who represent various groups. We have heard the public very clear. We must also focus on our API community, our veterans and our seniors. And today we will do just that.

California is home to almost 40 million people who are senior citizens, military veterans or Members of the API community. So today's hearing we will try to understand how these groups are impacted by mental health. Additionally, we will hear from the California and Human Services Agency and the Mental Health Services Oversight Accountability Commission to making sure that we wrap it up succinctly here.

This Select Committee, again, was created to address these issues and help formulate policies that will be effective in both near and long term to help Californians live a more joyous and meaningful life. I am grateful to my colleagues who have joined the Select Committee and we will now open it up for them to make their comments. Assemblymember. Pellerin.

Thank you. And thank you to our chair, Assembly Member Jackson, for pulling us all together and doing this important work in this space. So I had an experience today walking into the Capitol earlier this morning. A young girl was outside and just sobbing and was being comforted by another person. And I stopped and asked if I could help in any way. It just really impacted me. And she screamed out she did not want to live.

And I thought, wow, for a young person to have that kind of a feeling in her, to be able to shout that out. And it definitely impacted me and triggered me. My husband died by suicide November 2018 and I was so glad she had someone there to help her. And I didn't want to invade her personal space more.

But it made me think about our system of health or mental health care, and how hard it is to find counselors, how hard it is to get in for an appointment, how difficult it is to pay for those services and the stigma that is still there for people going through a mental health crisis.

And I'm just so grateful to my colleague here in the State Assembly, Dr. Jackson, for the work he's done in his personal life and the work he's carrying over now as a State Assembly Member and happy to see my colleague, Marie Waldron here today. Assembly Member because this is so critically important. We are in a public health crisis and people are suffering every single day, and people are making decisions that may be their last decision that they ever make in this Earth.

And we have to work together. We have to lead with love and compassion, and we need to find a path forward so people can get the care that they need. So thank you all for being here.

Assembly Member Waldron.

Thank you, Mr. Chair, and also for having this Select Committee that 's so critically important. The discussion about stigma, of course, is tantamount to how we address the mental health crisis. For 11 years I've served in the Legislature and we've been talking about mental health, especially stigma, and how do we reduce that?

Really, bringing mental health issues into the mainstream conversation is one of the best ways to kind of streamline that discussion and try to make it less embarrassing for people or restrictive for people to come forward. We need to have those conversations in our communities, in our schools, in our homes, that it's a commonplace issue. Everybody knows someone who's going through a mental health issue.

Everywhere I go in my district, whenever I speak, I always talk about what we're doing in the Mental Health Caucus, what's happening now with our mental health Select Committee and all of the work that we've been doing in the Legislature for as long as I've been here and earlier, as well as all the amazing work that our clinics and treatment providers are doing out in our regions. It should never happen that someone suffers in silence. And I think having that conversation is really the critical step.

So thank you for this meeting and I look forward to hearing the discussion.

Thank you. Assembly Member Bauer Khan.

Thank you, Mr. Chair. So I just want to start by thanking you, Dr. Jackson, for, your know, Assembly Member Walter and I have been around for a little while or longer than me, and when I got here, there wasn't much leadership in the mental health space, and that has really changed over the last four years.

But your work here and you're joining us, and also Assembly Member Pellerin, bringing this issue to the fore is really, really critical because for too long it wasn't something the Legislature spent much of its time or energy talking about or working on. And it is something that every one of our constituents lives every single day.

And so in my work in this space, it has been an absolute privilege to work in a bipartisan way every step of the way, knowing that this is not a partisan issue. It is not one that only affects some of us, but it actually affects all of us. And so I really want to thank you for convening this Committee, for all the work that you've already done. But I know the work you will continue to do.

And I just really appreciate everyone who's here today to have this conversation because the more we talk about it and the more we talk about mental health as a health concern and something that needs to be treated in the healthcare space and not in the criminal justice space and not in other places, but instead in the same way that we would treat other illnesses that we experience, the more people are willing to come forward and have conversations and get the care and support that they deserve.

And so it really continues to be an honor to work in this space and to do what Californians are asking for us to do, which is provide them with full service mental health care. And so I also want to thank our agencies who are going to be here today, who I know have a vision for California's mental health services that is so robust and complete and really provides a full spectrum of services to individuals who need it in a healthcare setting, as it should be. Thank you.

Thank you very much. We will now move on to our first two panelists that are here in person. We will start off with Sarah Sorokin from the National Union of Healthcare Workers. And then we will also invite up Janet Frank from the California Commission on Aging and Ms. Sorokin, you can lead us off. You can maybe begin when you're ready.

Thank you. So I have worked as a psychotherapist in various publicly funded settings throughout the state and in Kaiser's Napa Solano area clinics. The way our healthcare system is designed, most people get mental health care through commercial health plans and insurers. These plans and insurers have been failing to live up to federal and state patient access and mental health parity laws.

Patients who have means end up paying out of pocket for mental health treatment when they cannot find an available provider covered by their insurance, leaving those unable to afford private pay left without treatment. This is, in effect, a two tier system of health care and a social justice travesty. In my six years as a triage and crisis therapist at Kaiser, I observed chronic problems with access to care and systemic protocol used to hide these problems.

We were inundated on a daily basis with calls from patients and their families reporting worsening conditions and experiencing crises amidst weeks and months long waits between treatment appointments, while languishing for months on waitlists for treatment and when unable to get connected to treatment.

After calling through lengthy lists of providers, patients at Kaiser continue to be funneled into 30 minutes telehealth assessments, performed Assembly line style as an attempt to meet appointment timeliness standards, and the lengthy wait times they face for their first treatment appointments are not tracked or reported. Also, patients are routinely placed into inappropriate levels of care because of lack of availability of the medically necessary care needed.

For example, patients are often forced into group or brief treatments when this is not the standard of care for their conditions. Health plans and insurers can continue to delay and deny care because state regulators have not effectively held them accountable. We need to take stock of what regulatory activities work and what doesn't and get much more aggressive in enforcing parity and access laws.

While investigations by regulators move at a glacial pace and result in little to no change of the status quo, patients are experiencing severe emotional pain, worsened prognoses, negative impacts to the ability to function at work, school and home, increased disability, and worse. We have strong state laws that were passed to guarantee access to timely and appropriate mental health care. So it is inexcusable that many Californians aren't able to access that care.

Here are just two examples of the pervasive and widespread negative outcomes in our current behavioral health delivery system. During my short tenure so far at Solano County Behavioral Health, I became aware of a client who tragically died by suicide after being unable to get connected to an available therapist through Caroline Behavioral Health, formerly called Beacon Health Options, a managed care plan for partnership Medi Cal Members in the county.

When working at Kaiser, I spoke with a client experiencing a serious mental illness who had become homeless due to their undertreated and unmanaged symptoms. The public often thinks of homelessness and mental health crisis as two sides of the same coin. That is in many cases true, but they are symptoms of a bigger societal problem. We cannot focus mental health interventions only on the patients whose conditions have deteriorated that far. We need to invest in prevention by holding our health plans accountable.

A behavioral health workforce crisis isn't the problem here. The problem is Clinicians are abandoning providing care through the insurance system and health plans due to poor working conditions and reimbursement rates, and because of the barriers to getting on insurance panels, getting reimbursed and providing care that doesn't compromise their training, education and ethical codes. We are complicit in maintaining a health care system that harms people, families and our communities.

If we don't do everything in our power to ensure patients get the health care to which they are entitled, we need to take urgent action to improve the effectiveness of regulatory enforcement, or else mental health treatment will continue to be inaccessible. Psychotherapists will continue to be pushed out of providing care through health plans and insurance. Systemic inequities in our health care system will continue to be reinforced and ever increasing rates of homelessness, suicide, and other negative outcomes will persist.

Thank you very much. We will go next to our next panelist and then after that we'll have questions or comments from Committee Members.

Great. Good afternoon. My name is Janet Frank, and I am a Commissioner on aging and also a faculty associate at the UCLA Center for Health Policy Research. I reside in Monterey, so I'm actually one of your neighbors. It is my pleasure to join you today and talk about one of the Commission's priority areas behavioral health and older adults. State data clearly documents that older adults are systematically underserved across the state, with only 4% in need receiving services.

That's 96% gap and less than 2% of medical eligible older adults receiving even one specialty mental health service. Marginalized groups suffer triple jeopardy. They are old, they are poor, and they have even poorer access when it comes to getting services. And this includes racial and ethnic minorities in addition to special groups such as LGBTQ Plus and homeless older adults, which is the fastest growing subset of homeless population.

Prior to retiring, I led the Older Adult System of Care and Mental Health Study, the first study that assessed how well mental health services sponsored by the Mental Health Service Act were serving older Californians and that's defined as people 60 and over with serious mental illness. We found there are significant unmet needs and geographic disparities in services across the state, that few programs or outreach efforts are tailored for the complex care needs of older adults, that outcome measurement and data are limited and variable by county.

There are leadership gaps at the state for older adult behavioral health. There is, as the previous speaker noted, a lack of providers and lack of representative and well trained providers as relationship to older adults. But also there are evidence based effective programs and promising programs benefiting older Californians, and I think you may be hearing more about that from Toby Ewing when he presents and finally, older adults benefit most from an integrated service approach.

Our study included people with lived experience that participated in focus groups, and most participants had spent a lifetime as Low income residents in underserved areas of abject poverty and violence. A lifetime of exposure to and survival within these raw realities brought forth a depth of insight and truths that were shared with us in a most open and compelling manner.

The Homeless Group, which was primarily African Americans considered church and family as part of their service and support network, and they more frequently discussed individual level trauma in the context of collective and societal trauma framed in historical and social factors such as racism, the history of medical experimentation, generational poverty, lack of community resources, violence and a variety of drug epidemics. I'll just share with you several quotes from Members.

Quote I was just speaking as far as me being a black male, the older adults, you know, they came up and all them tests that they took and that stuff that was shot in them and the stories that was told. So me dealing with doctors, it's an issue. So actually, talking to a therapist, a lot of therapists just don't be looking like us, unquote. Here's another quote. Quote I got the royal runaround, so I don't find that the county is doing enough.

They say they offer services, but then to qualify for those services, you have to be well, you almost have to be on life support to get services, unquote. However, many of our group Members expressed appreciation and great benefits from the services provided, as evidenced from this quote from a woman in one of our Spanish speaking groups. Quote I also feel that they have helped me a lot, at least for a short time, two years, to get what the Americans call recovery. Recovery.

But it was very much because of their help, their presence. You feel motivated by the fact that they go to your house, that they ask you how you're feeling. They push me. They motivate me to know that and to be grateful for them, because they come see us in our homes, unquote. Based on our study data, and I do have some policy briefs here that go into much more detail. But let me just summarize. We have a number of recommendations.

Number one, create a Department of Healthcare Services leadership position to improve older adult service delivery and to facilitate working collaboratively across state and county departments. Number two, conduct dedicated outreach and document unmet needs among older adults. Number three, promote standardized geriatric training of providers to include the rich cultural and linguistic differences, including generational, cohort, race ethnicity, gender identification, and sexual orientation. Number four Institute mandatory and standardized data reporting requirements at the state and local levels for older age groups.

Many reports really lump older adults as adults. Anybody 27 and older after Tay. This isn't helpful. Number five, revise the current funding formuLA to ensure that rural counties are provided the necessary funding needed to address the critical geographic disparities, to provide services to all age groups that are in need, and finally, increase service integration efforts, especially the integration of medical, behavioral health, aging, social services, housing, and transportation services. In closing, older adults are survivors.

They are resilient, and they deserve their fair share of all types of behavioral health services, including prevention and early intervention. Thank you.

Thank you both very much. Questions or comments from Committee Members?

There was a lot there, so I don't know. I was trying to take notes, but we did pass the parity laws, and it struck me that you're saying that you're not really seeing that out there in the community and what can be done to basically improve the enforcement? Is it more data gathering, or is it more like, how can we help to do that?

Yeah. So state regulators like DMHC should shift away from complaint based enforcement. In my experience, a large majority of patients who have a hard time accessing appropriate and timely care don't go through the grievance process. And those processes can be quite challenging, especially if you have mental health symptoms. And instead, regulators need to track all the relevant data points.

They need to assess whether every patient is receiving timely and appropriate care, regularly scrutinize those patient records, and aggressively punish violations in a way that incentivizes quick and meaningful action. As of right now, therapists like myself, we're placed in jeopardy of losing our license if a patient doesn't get the care that they need. But these outpatient service providers are only regulated lightly, and that needs to change.

Any other Members? Yes, sir. Dr. Arambula.

I'll begin with Ms. Frank, if I can. I look forward to the conversation that Mr. Ewing will have later about evidence programs, evidence based programs as well as the promising programs, but I'm hoping you can speak to a few with specificity on how we can also address the geographical disparities that you had mentioned coming from one of those areas. I do like to remind our state that it is not one size fits all, but must meet the needs of all Californians, which requires us to meet.

You just came back, so I didn't know if you have your head, could.

Talk about some of those programs that have been showing promise yes. And figure out if those are some that we can talk about scaling.

Just a minute, there's someone who needs to mute themselves.

It's rush hour. Yeah, you too. Hopefully tomorrow everything will be better, because.

Moderator can you mute the lines?

Kathy, when she came.

She started making noise, but then she dropped.

Okay, sure. Well, one of the programs that has really had a lot of research around it is the Pearls programs, programs for enriched and rewarding lives, and that focuses on depression. And it is currently and I think that Toby will probably talk about this. Currently, the MHSA funding has just put in $20 million to the California Department of Aging to scale up those programs and to bring them to other communities. That's one of them.

There are some other promising programs that don't have that level of research. I mean, there's a number of evidence based programs that have been shown to really benefit older adults, and Pearls is the one that comes to mind right now. And there's other promising programs that are really more like drop in programs where they help people with job skills, know all kinds of different meaningful and provide purpose.

There's another great one in the Oakland area that is actually reaching out to previously homeless people, and probably still some are currently homeless. And they are creating ambassadors. And this is, again, an MHSA funded program. And they're creating ambassadors and helping them become advocates and speaking to city councils and other groups on behalf of homeless people and people with mental health illnesses.

And I actually have a policy brief that describes with a compendium of all the different promising programs and evidence based programs which I would be happy to provide to the Committee and give you.

That information forward to reading that through with more detail. We all know the effect that social isolation is having yes. Particularly in our elderly populations and thus absolutely believe it's important to listen to which programs are being.

And I think you're going to hear from friendship lines, I believe. Yeah, that's another really important program. But all of these anything that helps connect people I think providing programs and we were talking about access. I think older adult access issues really begin with the planning process. So counties have these planning meetings where they invite people to come in and research has shown that veterans and older people are the least likely to attend those meetings.

They then base their program planning for the county on the input at those planning meetings. So right from the very beginning, you've got kind of a deficit in input. And I think that one of the things that could be done would be to outreach through senior centers, community centers, food programs, different kinds of things like that, where they know older people will be and try to really gain some insight with older people about their needs, because this is the group, especially right now.

They came up by the bootstraps. Tremendous stigma. Don't want to ask for help. You've seen the numbers of suicide, especially in the northern rural counties, double digits. And so there's just a lot going on that could be beneficial. Yeah.

Thank you, Mr. Chair.

Go ahead. Assembly Member Pellerin.

So your statistic really shocked me that only 4% are getting services.

Yes.

And would you say the barrier is just that the stigma? Is it the access to providers, is it money, is it all the above?

Yes. So I believe that people that probably have the most access are the duly eligible and people tend to kind of dip in and out that eligibility. So having consistent benefits is an issue for people that have Medicare only. That is also an issue because even though they may have a benefit, they cannot find a provider that takes Medicare. And so that is a huge access issue.

Also the fact that there's a number of people that need pretty intense, in a way case finding to be able to get them into services, they're reluctant to say they have a mental health problem. There's a lot of stigma involved and so there needs to be relationships built. I think the promotoras and the different peer counseling programs are really beneficial when it comes to that kind of outreach and connection.

So there's just a lot of various issues and face it, a lot of programs don't relate to the needs of older adults. Many counties lump older adults in with all of their adult programming. Very few counties, maybe about a third across the state right now, have an older adult system of care where they have tailored services, really getting to the meat of what the needs are of older adults. And I think also integrated care would be very beneficial.

And there's a lot of great models of integrated care programs where they have behavioral health, where they have physical health, medical care, or they have medical care where they have behavioral health. So if you come into your Doctor, much more likely to go in to see your Doctor, and they can identify this because they've been trained to, they can link you up right there in the office with somebody and get you started on your treatment and recovery.

And when you say having separate care for older adults, what's that definition?

Separate programmatic. Separate kinds of programs.

So that 60, 65. What's that?

Well, in the mental health field, it's 60 and over. But for Medicare, obviously it's 65 and older. Yes. For that benefit. Yeah. Thank you. And thank you for your leadership, all of you.

Oh, absolutely. Ms. Sororkin, obviously, many of the thoughts in regards to having a life support system instead of a health system is something simply we've got to fix. And how can we transform our health system? Because in many cases, the only thing that communities have is a hospital. Yet the hospitals are not as really equipped with the Mental Health Services that are necessary to be able to adequately serve the various needs of our population.

I'm reminded of, you know, many of us are always trained in mental health first aid, but too many times people think that that's all there is, right? What is necessary? Obviously, there's a number of proposals. There's a number of things in the budget to begin to build out our behavioral health system. What are some things that you still see is lacking that we can begin to legislate on for next year?

Now, I am just a clinician, so a lot of that information would probably be something that NUHW could provide you. But in my experience, many psychotherapists choose to practice in a way where they take private pay, so they basically see the most privileged people who can afford private pay in order to make a living. In some cases, insurance rates, reimbursement rates for therapists haven't been raised in a decade or more.

And given the high demand for mental health services, it is confusing to me why these insurance companies and commercial health plans don't try to attract and retain psychotherapists by compensating a fair and living wage for them.

Thank you very much. We want to thank our two panelists for being here, and we will take our next two. Thank you all very much. Our next one, we will move to Swords to plow shares. That is Michael Becker, who is joining us via phone. Mr. Blecker are you with us? And we'll give them opportunity to be unmuted here. Mr. Blecker, are you with us? Okay, Mr. Blecker, they've requested for you to unmute so you can unmute yourself.

Do they know how to unmute themselves?

The phone will prompt them to pass.

Okay, then we will move on to Dr. Quatch from the Asian Health Services. Doctor, are you with us? It looks like this is one of those technology days.

I don't hear the phone at all. We not have the operator.

We'll wait just a few minutes until they can take care of the technology here.

Okay, we.

While we're trying to figure out our other panelists, for this panel, we can move on to the second panel, which is where we go on from here. And so let's bring up our two panelists here.

And with us for our second panel, we have the California Health and Human Services Agency with Melissa Stafford Jones and the California Health and Human Services Agency Stephanie Welch, Deputy Secretary of Behavioral Health and then of course, Toby Ewing, the Executive Director of the Mental Health Services Oversight and Accountability Commission. We want to welcome them with us. And we have had hours of testimony from particular groups, various racial, ethnic groups, aging, disability community to hear their specific experiences dealing with the mental health in their communities.

And it is our hope that, number one, of course, what are we already doing? The Executive summary is a lot. But then what do we have looking forward to for next year? What should we be gearing up for? Right? Because we know this work is going to take some time. So we're looking forward to hearing some of those as well. We will begin with probably Ms. Welch and then we will move on to Ms. Stafford Jones and then Mr. Ewing.

Great. Good afternoon, Honorable Chair Dr. Jackson. I got to meet Assemblymember Pellerin in the elevator on my way up this afternoon and I have had the opportunity to hear you speak last week, or I think that was last week, at the State of Reform. And I think you actually also came to our Care Court presentation. So it's really nice to see you as well. So my name is Stephanie Welch. I'm the Deputy Secretary of Behavioral Health for our Health and Human Services Agency.

And in that role, my job is to support our agency and all of our departments in building equitable, accessible and affordable behavioral health care for all Californians. Today, I'm going to start with really kind of an overview of kind of a variety of different things we're doing and then pass it over to my colleague, Melissa Stafford Jones, who is the Director of our Children and Youth Behavioral Health Initiative.

And that is a very future and forward thinking initiative which I'm really excited for her to share some details about. You have heard me say this in testimony before, and I'm sure you heard it from the individuals who have been coming to these Select Committee hearings, that at some point in our lives we are all going to be challenged with a mental health or a substance use issue ourselves.

There will be caring for a parent, a loved one, a neighbor, a coworker, a friend who will be on their own journey. And this journey ranges from everything from thoughts of suicide, which you heard about. And I appreciate you sharing your story of suicide loss and being a suicide loss survivor to individuals who just are deeply grieving, are isolated and are paralyzed by grief and anxiety. And the weight of this crisis as you have lifted up is most certainly not equally carried.

Black, Indigenous and communities of color, younger and older adults, people who identify as LGBTQ plus, veterans, people who are involved in the justice system, and people who are homeless carry the deepest burdens and the heaviest burdens. And this is just a clear theme that I appreciate you lifting up in these hearings. So we all have mental health. I'm also a social worker. Everybody has mental health. Some of us have mental illness. I fall into that category. Some people have serious mental illness.

And while many of us may misuse substances to cope with stress and pain, there are others who are living with chronic substance use disorder conditions, polysubstance use disorder, and may have had these conditions for such a long period of time that were untreated that they have long term cognitive and physical impairment. Behavioral health challenges are experienced on a complex continuum, from mild to chronic, just like any other illness. It's something that we just simply don't talk about enough.

And we oversimplify some of these concepts when we have these conversations. And I feel very strongly going forward that we can't do that. If we really want to improve outcomes, we have to be very specific to the response. And that response and what that response should be is based on need and based on who that individual is.

Today I'm going to talk very high level about our approach to comprehensively addressing this moment of crisis and which I also think is an opportunity as well as to look to really overall improve the mental health and well being of our state. How do we get to a system that really can prevent and intervene early and often so that mental health challenges do not manifest into serious mental illness?

And if it does, how do we ensure that the presence of that serious illness does not result in what we know are avoidable tragic outcomes? So, suicide, overdose, incarceration, homelessness, school failure. I have a long list that I don't nearly need to go through.

I did bring, and perfectly I have four copies, actual copies that I can leave behind of a policy brief that we put together earlier this spring to try to simply, thank you, simply organize some of our thoughts in our major, I would say not just investments, but truly initiatives.

We really try to lift up in a simple, easy-to-digest report, how we are trying to get at achieving these outcomes going forward as you've lifted up in this particular Committee, how incredibly debilitating stigma is, how misinformation can lead people to not getting help, and, frankly, how people experience discrimination in how they access behavioral health care. We have significant delays in getting access to timely treatment. Just want to be totally honest about that. It is a problem. It needs to be a priority.

We have significant disparities in utilizing services amongst BIPOC and LGBT communities. And we do not have enough services that help bring access to culturally responsive care. We have far too many individuals who have mental health and substance use disorders who are living in our prisons and our jails. I had to pull some data for something the other day and I saw that, and this is a two year data lag, but we had nearly 100,000 people incarcerated in local jails who were receiving mental health services.

That is an enormous amount of people. And we really have to increase quality community placements. We believe in this Administration that we need to do more to make sure that people can not only live in their communities, even if they have a very serious condition, they can thrive in their communities in a homelike environment. We obviously have a homelessness crisis, but we also have individuals who are part of our behavioral health system who are living with deep housing insecurity.

They are on the brink of homelessness because for whatever reason they haven't been able to work, they're experiencing poverty, et cetera. And this is probably my favorite goal that is outlined in this policy brief. We must increase the satisfaction and trust that people have that they are getting a high quality service. This is something I've said for much of my career, but people don't come back to get something that didn't work for them.

And in many cases we may not be offering people what they want and have to really look deeply into how that is working. Now I want to just move us to the next slide real quickly here. The report itself really uses this kind of simplified, I would say, visualization of the behavioral health continuum to talk about where our current investments fit in. And this is really important. I really want to lift up that as part of this visual.

You see at the bottom kind of the undergirding of all of our behavioral health issues, which are investments to build the pipeline of providers and physical infrastructure that we need in order to deliver care in each of these very important segments. For anybody who's experienced a mental health challenge to somebody who is diagnosed with a serious and persistent mental illness who may need ongoing long term care and support.

So if I were just to kind of walk through this real quickly, I can kind of highlight where we see some of these investments. First, I wanted to be specific in responding to the question on the agenda about our behavioral health workforce pipeline issues. Before I do that, first and foremost, there's really three strategies that we have both in CYBHI workforce investments and then last year we were able to get some additional resources for the overarching kind of health and human services workforce.

But first we have to support students seeking education and training and make sure that we have scholarship programs, not loan forgiveness, full scholarship programs from entry level to licensed clinical professionals. We need stipends for master's level social work to postgraduate fellowships and loan repayment programs for those professionals who choose to serve in underserved communities. I am getting close to 50 and still paying off my student loans from my time in social work school.

It is a tremendous commitment and personal and financial investment that is very taxing on our workforce. Second, we want to expand education and training programs and we have to have a new way of doing this. One of my, I'm most excited about are building up our capacity for our earn and learn apprenticeship programs, but we're also investing in things like psychiatric residential programs.

Something that we learned in our partnerships with our labor folks, and I certainly learned coming out of working with the reentry population, is how it was absolutely necessary to have that on the job experience. But also that paycheck. If you don't have a paycheck while you're having that on-the-job experience, you can't take that job. It's just not realistic. So I'm super excited about that program that we are building and have actually put out dollars for that program already.

And lastly, we have to create pipelines like the Health Professions Pathway Program that resource actual organizations that go out and encourage students from underrepresented regions of the state and diverse backgrounds to pursue healthcare careers and do this through mentoring, internships and fellowships. So I do also want to lift up that we do have resources that are going out the door for these programs right now.

For example, our Healthcare Access and Information Department--it still is hard to get that to roll off my tongue--has awarded nearly $100 million in training programs that will expand training by nearly 900 social workers, over 700 psychiatric mental health nurse practitioners, and 45 psychiatrists. I think that's important because it shows you where we're building our system. I also wanted to lift up that we are funding three new BSW and four new MSW programs, two new psychiatric residency programs and three new psychiatric nurse mental health practitioner programs.

And as I look at this continuum, I always wanted to lift up where I see some of the most exciting new elements of a workforce for tomorrow. We can see future wellness coaches providing prevention and early intervention services for our school age youth, while we can also see peer support specialists, right there in the crisis section, join our mobile crisis teams to provide behavioral health crisis response that is not based in a law enforcement response.

And we can see our new community health workers providing ongoing supportive services so that people who have intensive care needs, including medical care needs and other needs of that nature, to be able to live in the most least restrictive and most integrated residential setting in the community as possible. So the other thing I want to lift up is that we are tearing down some barriers to provide services that may have been happening in individual counties or communities, but we're not able to scale statewide.

We are in the process right now of implementing our contingency management program. It belongs on this continuum. So does medicated assisted treatment, dyadic services, our behavioral health integration in schools, but also services for people who have more complex problems like assertive community treatment. And very importantly, and I would imagine you'll probably hear about this too, specialty care for first-episode psychosis, we will be pursuing making that a Medi-Cal benefit.

We're doing jail inreach strategies and have a project as part of our future waiver to decrease lengths of stays in hospital emergency departments. We're adding supportive employment, recognizing it's not just about creating a livable wage, it's creating about meaning and supporting people to have their dreams no matter what health conditions they have. I'm so excited about the supportive employment piece and also adding enhanced care management, as I'm sure you've heard about in community supports.

In the continuum, when I started 20 plus years ago, these are not things that anybody could get. These were not services that were available. And so I think we're really hoping to scale these things so that every Californian, including potentially, regardless of payer, is going to have access to these particular services.

I just want to add before I turn it over to my colleague here, I have been quite a bit of a broken record about this, but since this particular Select Committee is about crisis, I just wanted to share that the very best way to prevent crisis is to increase access to equitable, affordable outpatient care. And that includes making sure that our high risk and vulnerable populations with high needs are safely housed and that they have access to ongoing supportive service.

That also means that we often stabilize someone in crisis, but there is no immediate follow up care. We have to resolve that, and that should be something that everybody gets, regardless if you have commercial insurance or Medi-Cal. To date, our Community Behavioral Health Infrastructure Program has awarded funds to create 88 new outpatient facilities that will increase capacity to serve over 200,000 people or 200,000 slots. We've added 65 residential facilities or awarded funds to build 65 residential facilities. Over $1.2 billion has already been awarded.

And we are, I think, a week or two away from the next round of awards, which will focus on crisis services. And we have $430,000,000 that we will be awarding this month to build those crisis service and systems of care. I want to acknowledge for you and for anyone who's watching and listening that Californians are rightfully frustrated with our current system. But I do believe we are making progress, and I do believe it is a long road ahead.

But I am very hopeful that the horizon is positive. And I think one of those shining positivity or pieces of positivity is really the Children and Youth Behavioral Health Initiative and so I'd like to turn it to Director Stafford Jones to provide an update on that particular program.

Thank you, Stephanie. Good afternoon, Chair Jackson and Members of the Committee. Thank you for the opportunity to be here to discuss this critical issue of where do we go from here? And for me to be able to share some of the work that is underway to reimagine the ecosystem of services and supports for the behavioral health of our children and youth through the Children Youth Behavioral Health Initiative, or CYBHI.

With the leadership and commitment to solutions from the Legislature and the Governor through his master plan for kids mental health, California is in the process of implementing a multipronged approach to create a system that is more coordinated, youth centered, equitable and well being and prevention oriented. The CYBHI is focused on the systemic changes needed to improve behavioral health access and outcomes for children and youth.

And we have heard loud and clear from our partners that simply doing more of how systems and services operate today is not good enough and will not be effective in building the systems and services youth and families need for mental health and well-being. Partners emphasize the need for fundamental transformational change and here's a few of the ways that we are working on that and that that has come up.

One is that systems are siloed and the lack of coordination gets in the way of children and families getting the services that they need. And that's why meeting kids where they are is a strong focus in the Children and Youth Behavioral Health Initiative. So building collaboration and integration across education and health systems is central to the work of CYBHI. When you ask the question "where do we go from here?"

I think where we're trying to head with this work is where schools are just a central access point for a range of supports and services for social, emotional, well being and behavioral health for children and youth. That it's easily accessible and easily navigable for our youth and families. And we know that schools utilize really a tiered system of support all the way from universal supports focused on prevention and well being for all students.

Up to a third tier of really thinking about children, youth that may need one-on-one clinical therapeutic services. And through the CYBHI schools, behavioral health providers, community-based providers and organizations and partners health plans, we're really working to support them in working together and coordinate their efforts so that we can create this ecosystem where youth can access greater services through school-based and school-linked settings.

We're also working at the overall state initiative level, for example, really thinking about how work that's happening in education and K through 12 education for community schools and the community schools framework can be implemented in a coordinated way with the Children and Youth Behavioral Health Initiative. So really trying to work on that integration between education and health.

Last year, the Children and Youth Behavioral Health Initiative met with 600 youth and families in nearly 50 convenings around the state to listen to what they want and need in terms of supporting their mental health and well being and what a reimagined ecosystem of behavioral health should look like. And I wanted to share with you some of the things that they really highlighted for us that are driving the where are we going with this work in the CYBHI.

One is that a system that recognizes and incorporates that culture is healing, that rethinks what treatment is, what it looks like, who provides it, including a focus on community safe spaces and expansion of nonclinical services and peer-to-peer services, a system that youth and families can navigate even when they are struggling. Youth told us they want places to be, to create and connect, including in the outdoors. They're looking for community centers, parks, mentors.

Youth recognized that we need systems that take care of adults so adults can care for children, that youth and communities have information and resources for self determination. And you heard this from Deputy Secretary Welch. And we heard, for example, in one group, with a group of youth who talked about the school wellness centers that they have on their school campus, and they know the first person when we walk in the door that we want to see is not necessarily a therapist. We might need a therapist.

We might want one. We might get to that point. But the first person we want to see is somebody who sort of looks like us, comes from our communities, maybe a little closer in age, sort of like a near peer. That's who they told us they wanted to see first. You have asked that we have a representative workforce and that historic and current harms from our systems are acknowledged and that hope and trust can be built.

You've also talked about--and this has come up in a number of forums--and I noted because of Deputy Secretary Welch's comments, they really want a system that is compassionate, that is full of love. I had one person say to me, we really should call this the Love Initiative, that every child in California knows they are loved and that they have at least one caring, consistent adult in their lives, because we know how critically important that is lifelong for mental health and well being.

I just every one of our kids should have that. And though all youth can experience mental health challenges, as was talked about and as we know the Committee has discussed and studied extensively, we do know that some groups of youth are disproportionately impacted and also face greater structural and systemic barriers both to access and to the kinds of things that support well being. I was talking with somebody earlier today, like things like activities, whether that be sports or other kinds of activities.

We know that our BIPOC youth, our LGBTQ plus youth, our youth from Low income families and underserved communities have faced greater inequities in terms of behavioral health. And so we are specifically working on in the planning, the design and the implementation of the Children and Youth Behavioral Health Initiative to address those things. So you can see in this chart of the different work streams that are in the initiative.

For example, in the scaling of evidence based and community defined evidence practices, we are looking specifically about how we advance racial equity. In the context of that scaling in the Targeted Youth Suicide Prevention and Outreach Campaign, it is looking specifically at what groups of youth are at highest risk for suicide and thinking about what messages, what messengers, what trusted partners.

Will specifically address their concerns, their community's needs, and thinking about all of the investments in the workforce through the Cybhi, about how do we really create a more diverse, representative workforce so that we can increase equity in the system. Also, while working across the entire continuum of care in the Cybhi, there's a very strong focus on building a more prevention and wellbeing oriented system.

We hear consistently from our partners, from practitioners, from youth and families themselves, that very often we could have intervened earlier, that we missed opportunities to reach children and youth before conditions were exacerbated and before suffering was even greater. And so wherever we have that opportunity, where is it that we can build systems and coordinated approaches that will allow for that earlier intervention?

Youth have told us they are tired of hearing that they're not sick enough to be able to access services and that they want us to stop waiting until they are in crisis to provide supports. So we are actively and concretely moving forward toward that vision through the work of the Children Youth Behavioral Health Initiative in four key focus areas workforce building ecosystem infrastructure, focusing on coverage, and focusing on public awareness and reducing stigma.

And I want to just share a few examples of some of the work that's happening to move us toward that future State of what we want and need for all of California's children in terms of supporting their behavioral health. Deputy Secretary Welch already noted some of the investments in workforce. I wanted to just lift up two additional ones. One is that as part of the Cybhi, in addition to the Health Professions Pathway Program Grants, she mentioned which are also partly funded by Cybhi.

The Department of Healthcare Access and Information also has a $25 million program to implement the Youth Mental Health Academy, which is to support early career development for 2500 culturally diverse California high school students with an interest in behavioral health careers. And also this summer, the Office of the California Surgeon General will launch a free online professional training that is designed to help early care as well as K through 12 education personnel to respond to trauma and stress in children. And the training has two main goals.

One is just increase awareness of the impact of stress and trauma on children's development and learning, but it's also to provide strategies to respond with traumainformed principles in order to help create the conditions that really support learning environments for our children.

In terms of the second category related to behavioral health system infrastructure, the Student Behavioral Health Incentive Program is supporting partnerships between medical managed care, health plans, schools and county behavioral health departments to work together in a coordinated way to increase access to school based behavioral health services with a strong focus on prevention, wellness and tier One Supports.

And we've heard from our partners that in addition to those interventions, the partnerships themselves are a critical outcome of this investment because those relationships and that collaboration is a critical foundation to building a more coordinated system and to addressing those silos that we know we have. As Deputy Secretary Welch mentioned, as part of building the bricks and mortar infrastructure, there were also specific investments of $480,000,000 related to children and youth services to address gaps we know we have there.

A new virtual services platform will provide information resources and self management tools will also provide access to online coaching and moderated peer supports, and linkages to community based services when ongoing services are needed for both youth and parents that's under development. And it will launch in January of 2024.

And also the Cybhi is working to support and strengthen social and emotional learning in schools, including through additional investments in the budget last year supporting well being, mindfulness and resilience in our children youth through partnerships between the health system and schools. In terms of coverage, in January of this year we added the new Dietic Services benefit in the Medi Cal program.

This is a really critical benefit when we think about sort of the future state because it recognizes the importance of treating and addressing the needs, both the development and the behavioral health needs of a child, but also their parent or caregiver and really thinking about how we support them, provide them services, coordinate efforts, provide holistic resources. As a Dyad. That Dyadic services model of really thinking holistically.

We are also putting in place a new system to provide ongoing resources to schools both Tk through 12 and higher education for funding for student behavioral health services. It is a fee schedule that will provide schools with reimbursement from both medical managed care plans and commercial health plans for school linked behavioral health services.

And I know this particular component can sound very sort of technical and maybe even a little bit dry and boring, but I think it is one of the most important pieces that is about building that infrastructure of the system to provide ongoing resources for schooling behavioral health services. Where we know kids are, we're meeting them where they are. If the service is there and the funding is there, ongoing to provide it, it's a way to really build this ongoing approach to increasing access and improving outcomes.

And then in the fourth category related to public awareness and reducing stigma, we have series of campaigns, outreach efforts and public information resources that are aiming to reduce stigma to increase understanding in culturally relevant and appropriate ways that it's okay to not be okay and to ask for help and support and to increase awareness of the ways that youth, themselves and the adults in their lives can support them with their mental health, well being and resilience.

I had the opportunity to visit a community school a couple of weeks ago, and we had a chance to meet with some parents. And there was a mom who talked about actually the views of mental health in her community and in her culture and the hesitation she had about thinking about what kind of services her child might need. And she talked about how the work the school has been doing with its partners as a number of behavioral health provider partners on the campus.

The way in which they are just continually raising mental health for students as just a regular part of the work of the school and the work of the community together, whether that's in newsletters, at parent meetings, in email blasts, they send in everything they do as if it's food, if it's healthy food, if it's water. Really, that that was starting to change her experience of stigma and how important it was in a trusted setting of the school to be doing that work.

So thank you for the opportunity to talk about where we are going together toward a reimagined system that supports our young people's behavioral health and well being so they can thrive.

Thank you, Mr. Ewing. Thank you very much, Mr. Chair and Members. I appreciate the chance to join you today and to join my colleagues. The Administration is really pursuing a historic initiative, and as Deputy Secretary Welch outlined, you don't have to have been here very long to remember a time when none of this was possible. Right. That we had dreamed about some of these opportunities. And to see it happen the way it's happening is really heartening.

I appreciate the chance to talk about the question put on the agenda. And thank you, dear staff, for the work in putting this together around MHSA and where do we go from here? I have a couple of handouts in order to respond to that question, I wanted to just do a short walkthrough of the origin story of the Mental Health Services Act.

And it's important to recognize that unlike in other areas of healthcare, in other areas of health more broadly, historically California has rationed access to care. The comments that you heard earlier are about a diagnosis should not be the determining factor of whether or not we get our foot in the door. And we don't have that conversation in much broader areas of healthcare. We really lead with a prevention lens in the mental health space.

Historically, we have not been investing in prevention and early intervention because we have had such resource limitations, but also limitations in how we think about what constitutes mental health, right? This narrow lens of a clinical response rather than this broad lens around well being. As Deputy Secretary talked about mental health versus mental illness, it really has been an illness driven model that we've had in the State of California for decades.

And I also want to put on the table, and this is key is really weak public commitment to mental health, the stigma comments when the Commission talks with young people as well, we hear much the same. These are all changing as we speak in California. COVID pandemic generational shifts and the Mental Health Services Act have really begun to reorient this framework around California's mental health system.

And the origin story of the Mental Health Services Act really focuses on that issue of rationing care, limited to no investment in prevention, early intervention, weak public commitment, that public support, that political capital, and really no strategy around continuous improvement. Again, that's not comments about the system we have right now, the work that is happening in the Administration. This is the origin of the Mental Health Services Act.

We look back 15, 20 years ago, the Mental Health Services Act was really envisioned as a counterweight to medical because those rules were in place for very good reason at the time, that it was about developing a community driven system, strong requirements for community engagement, which recognizes that what's happening in Trinity is going to be different than what's happening in Alameda. Right? Very much recovery focused very much with this mandate for right, with a mandate for early intervention, a mandate for innovation.

There are specific elements of the Mental Health Services Act that set aside dollars that can only be spent on prevention and early intervention. And I use that as this reference to a counterweight to Medi.

Cal very much appreciate the work that the Department of Healthcare Services is doing, the Administration more broadly is doing, to reorient some of the reimbursement strategies to recognize the opportunities around things like dietic care, which can support early intervention strategies, opportunities in Medi Cal to support prevention in terms of the reimbursement mechanisms that we have. And the Mental Health Services Act also calls out explicitly disparities. So comments about the Members of our communities who have the heaviest burden, the heaviest lift, the greatest needs.

There is supposed to be an equity perspective built into this strategy around community driven. We're not as far along as we'd like to be, but in terms of this origin story, the Mental Health Services Act really was designed to tee up and call out, to emphasize and elevate those key issues. And I want to point out that unlike some of our more traditional funding streams, it embraces this idea of a whatever it takes approach, right?

In fact, under state rules, counties are required to dedicate a majority of their MHSA service funds for whatever it takes approach, with a specific emphasis on addressing homelessness, incarceration and hospitalization. These negative outcomes that are the consequence of inadequate access to care that is aligned with my needs. So the comments of Deputy Secretary who talked about people may not return to services because they don't see the value or themselves in the services that they're receiving.

And so the MHSA was really trying, and I think it is being successful in many ways, to change that perception around what we can and should be doing with the resources we have. And that requires a high level of flexibility and it creates a definition embedded in the prevention or the intervention language of mental health that is much closer to a definition of well being.

So housing, employment, educational success, personal and community safety, avoiding the criminal justice system, for example, family connectedness, avoiding the child welfare system, avoiding premature death because of suicide or because of unmet needs, and avoiding suffering. It really puts out this assertive, expansive statement about what we're trying to accomplish rather than what we're trying to respond to. And so the Mental Health Services Act.

So the origin story there is to really reframe the conversation away from a system that looked at how much money we had and how do we divvy it up among competing needs and instead replace it with a strategy that says, how do we work upstream? How do we engage the community? How do we build trust and responsiveness? How do we get creative?

And how do we inspire public engagement and understanding to really tackle some of the most pressing challenges that cut across the most expensive, most devastating outcomes for individuals, families and communities? Homelessness, incarceration, child welfare involvement tasks that have not traditionally been the purview of our traditional behavioral health infrastructure. So conversations with county behavioral health directors who say, well, that's actually not my job, for example. And so I mention that because it is a disruptive act.

It was designed to say the system we had at that time, the system we have today, in terms of the financing and the workforce and our approach, the siloed nature of our approach, the Mental Health Services Act, its origin story is to be a disruptive act. We've been working and so the second handout that you have, I gave them all away. So I don't have.

Is highlight some of the efforts that we're doing and I'll just very quickly just point out we've been working to implement that vision in early psychosis and sequential intercepts around criminal justice. And this is not all in this handout. This handout is really just designed to focus on upstream opportunities, taking those three most expensive, often most negative outcomes from a system perspective of homelessness, hospitalization and incarceration, and talk about the upstream efforts that are necessary.

If we want to be effective, we need to make sure that the intervention that is just before someone is living on the streets or returning to the streets or jail or hospital is a full service partnership. How do we do that? The best we can. We really appreciate that. In the Governor's modernization proposal, he is highlighting the impact of full service partnerships before that in the Commission's work is early psychosis.

The research that we've been able to do with our partners at UC, Davis, UCSF and Stanford is that about 10% of Californians have access to most effective care in the early onset of psychosis. And just like other aspects of health care, if we can intervene early in some countries, they've established explicit goals that 100% of their residents will have access to effective care within two weeks of their first episode of psychosis. The average access to care, the delay in the United States is 18 months.

And the research shows, and it is surprising that we have to sort of reinforce this, is that if we intervene early, we can actually support an individual's ability to live independently, to manage psychosis, even schizophrenia, as a chronic condition. And so that early psychosis intervention is what we need to do in order to reduce reliance on a full service partnership as in itself, an effective but expensive intervention. And our youth drop in work actually is how do we create an environment where young people feel safe?

How do we design a service delivery system that young people who are very reluctant to access medical care in the first place, they actually feel welcoming and warm, that love, that sense of belongingness, so that if they develop symptoms, they have a trusted place to turn to for support before they need it. It may be that our youth drop in work may need to be what we can refer to as a loss leader, right? It may not pay for itself at the immediate care.

But if doing that helps us ensure that young people, as they age, as they progress, where the greatest likelihood of developing a mental illness happens in those late teens early transition age, early adult transition age, youth years. If we can make sure that we've built the trust and the capacity and the welcoming for someone who does develop those symptoms and can create that pathway to care in a highly effective manner, that's what it's going to take to get from 18 months to two weeks, right?

And before that, even as listed here, is the school mental health work that we appreciate. The Commission is part of the broader cybhi initiative and the mental health student services work, which is really about building out the partnerships. The Administration, the Department of Healthcare Services and others are doing the much heavier lift around the financing and the strategy and the workforce and the programming.

What we're leaning in on and supporting is building out the partnerships so that our schools and our county behavioral health departments really are working together in ways that they're recognizing the cross sectionality, that the opportunity to integrate educational outcomes improve when behavioral health needs are met. Behavioral health services improve when they're delivered where children are, which is in school. And so it's an access point. Our school mental health strategy is not adequate because not all youth feel that schools are safe, welcoming places.

And as we want, many young people actually graduate and so they move on. And so we need a strong school based and a strong community based strategy. And so I shared that with you just to highlight some of the work that we're doing to really operationalize the vision of the Mental Health Services Act in early psychosis. Our sequential intercept model around criminal justice is not on here. Strengthening full service partnerships is.

I want to appreciate Commissioner Frank calling out the investments that the Commission has recently made in partnership with the Department of Aging Around serving the needs of older adults. That is not in here either. What we're really doing there is using some limited mental health wellness act funds to incentivize an expansion of effective services as communities learn about what's working often through mental health services act innovation funds. We want to help scale, help disseminate those learnings in ways that other communities can benefit from the learnings.

And so Commissioner Frank highlighted that. And we appreciate that we're really working to improve understanding of prevention and early intervention we will have in the next 10 days. I'm told a hard copy of a prevention report that we recently did. It's designed to support this conversation around the expansive opportunities we have for prevention. When we have conversations with folks in the health field, there's no question that prevention is the right thing to do.

When we have conversations with folks in the behavioral health field, there is not that consistent public agreement, public understanding, and public support for prevention as a strategy. Right. I routinely get asked to speak to psychiatry fellows during typically the third or fourth year of their residency, and I'll ask them to talk about the training they receive around prevention folks at the top end.

And if we compare the conversations you can have with a cardiologist or an oncologist about prevention opportunities in their space, their worlds apart, we don't engage. There is not even agreement over whether or not we can prevent psychosis. Right 40 or 50 years ago. That may have been the case when it came to cancer, but that's not true today. And it doesn't mean we can prevent all cancers.

But we have very aggressive public awareness, public health education campaigns, and strategies to help people understand what prevention means and to live their lives and to make smart decisions. Put sunscreen on in the morning, right? Versus beginning our response to skin cancer through the lens of stage three. Stage four. Right. And so my earlier comment about rationing access to care and behavioral health, we have made tremendous progress.

And what you've heard today through the work of the Administration is incredibly heartwarming that we have made the progress, but at the same time, from a broad public understanding of what prevention means in the behavioral health space, we have a ways to go. The question was, what are the largest barriers to the success of the Mental Health Services Act?

It is that public understanding and shared vision that we find often gets in the way as we think about what we are trying to accomplish and how we get there. That in the prevention space. The work that we've done in prevention, it is very consistent with what you've heard. It is about parks and walkable communities and healthy behaviors, getting enough sleep. Sleep is a huge factor in understanding drivers of mental illness. Yet we don't prioritize that. We don't talk about that.

We put tremendous emphasis in our K 12 curriculum over the course of a young person's life around physical health, physical development, healthy eating, exercise. Right. We require children to take PE throughout from kindergarten through 12th grade. May not be a requirement in kindergarten, but we've just built into our schools an understanding of physical health.

We have not yet leveraged our full range of opportunities in our educational systems and in our workplaces to understand drivers of stress, drivers of trauma, the impacts of stress and trauma, and the opportunities for resiliency. So shared vision and public understanding about where we're trying to get to is a key barrier that is impeding our ability to have conversations with a much broader array of partners around how we can improve behavioral health public health outcomes.

Some of our best advocates in communities are in our libraries because libraries, like schools for young people, are often considered safe spaces for all residents. And libraries, as a trusted space, also can be a community center. But we don't historically think of our libraries as behavioral health partners when they very much can be. We've actually had some innovations led by counties who have really partnered with their libraries.

We're seeing really creative partnerships between behavioral health departments and the fire response system in some communities, because in rural communities, the folks who are often most trusted to knock on your door is the fire service.

And so in some areas of eastern San Diego, it is a partnership between CAL FIRE and some of the health districts that are actually bringing health care and talking about prevention and early intervention with residents who wouldn't trust any other government car to drive up their driveway and knock on the door. So, shared vision. Second, it would be our ability to recognize where we have fallen short and the opportunities in front of us.

If we look at the outcomes that we are achieving in California in just about any area, we are not top of the pack in terms of the outcomes that we would achieve. Suicide leading cause of death for yes, I think number two for young people, right? Shameful penetration rate for screening. An issue near and dear to you, Mr. Chair, even though the law envisions universal screening under EPSDT, we're not there. We've fallen far short.

Lots of areas where and I'll highlight the example of early psychosis, the vast majority will not get what is effective care and commercial insurance won't pay for it. But because we don't have that public understanding of the actual prevalence rates, that it's easy for us to sort of set aside these inadequacies or failures and not really move, bring the community together to drive the kind of change that we need to change.

And the last thing I would say is the strategy to get there and throughout all of these must be this recognition of disparities, right? We have to put that front and center in terms of our community engagement work, in terms of our understandings of the impacts, in terms of the cost effectiveness of services. We have to recognize that for years we have led our mental health system through a 911 law enforcement response. We're still seeing that today.

I think many of the proposals that the Legislature has authorized and approved and the Governor has led on and the team sitting next to me have really championed is in recognition that we need to do a better job. And we can and we are doing a better job. But the strategy to get there needs to recognize finance. Many of the funds that are being released are one time funds. It's very difficult to leverage one time funds for long term change.

So the work that's happening in Medi Cal, the work that's happening in the Governor's proposal under Cybhi and modernization to look past public finance and towards commercial insurance is necessary and incredibly welcomed programmatic approaches. Cybhi is making an incredible investment in scaling affected practices and we need to do that across the board, including for adults. Including for older adults. As Commissioner Frank pointed out, we're still struggling on the data and analytics. It is too hard for us to answer even the basic questions.

And again, if we compare that to healthcare overall, the discrepancy between where we are on the data and analytics and overall healthcare versus behavioral health is shameful. I mentioned the expansive partnerships workforce, very much a mismatch between the workforce we have and the immense needs that we have. And again, through Cybhi, through the modernization proposal and through others, the Administration, the Legislature have been making tremendous investments. We have a way to go and it's going to take us a little while to catch up.

And last, I would say, is the strategy to get there needs to include this continuous improvement. The Mental Health Services Act has that built in today under the innovation component. And so we welcome the opportunity to work with the Administration and the Legislature under the modernization proposal to preserve the ability to support counties to improve their systems as part of an expected, a mandatory element. It doesn't have to be mandatory in a statutory sense, but as an expectation that our system will improve over time.

There are other things that I just want to shift a little bit to the Governor's modernization proposal. The Commission has been working and we really appreciate and respect the call to do the actual integration of mental health and substance use disorder services so that we have a behavioral health model which is necessary because it's just so difficult to separate out these needs. And the reality is that SGD services are mental health services. And so I really appreciate the Governor's leadership on that.

Of course, I would be remiss if I didn't highlight that the Commission is very interested in this conversation about moving the Commission under the agency. The Commission appreciates its Independence and ability to really work in a dynamic way that is able to inform and shape and sort of look around the corner. And I think we've been able to do that in our workforce. Mental health, we have a current I'm sorry, workplace mental health. We have a current project on firearm violence.

And I'll share with you that one of our team yesterday had an experience of her daughter's school in a lockdown because of a credible school shooter situation. It was a social media, law enforcement was involved and our team Member shared that she did not fully understand why the Commission was pursuing a firearm violence project until yesterday when she got a phone call that there was a credible threat on her daughter's school.

This is an example of being a small entity that can be pretty nimble and dynamic, does not have the challenge that my colleagues have of running massive systems and programs and that nimbleness. That Independence allows us to tackle issues and bring them back to the Administration, to the Legislature, with guidance on how the state might benefit from the learnings that we can do. Thank you very much for the chance to be here.

The MHSA and the Commission are really designed to drive transformational change, to improve outcomes, to lower costs, to do that through a community driven approach that is recovery and prevention oriented and recognizes that we have to do a better job making sure that we improve outcomes, particularly for those communities that are least well served. Happy to answer any questions you might have, questions or comments from my colleagues, Assembly Member Pellerin and then Assembly Member Waldron.

Questions or comments from my colleagues, Assembly Member Pellerin and then Assembly Member Waldron.

Well, I'm super excited about the prevention report coming out, and I really think I love that focus of looking at the prevention of mental health. You talked about sleep, definitely, and being outside, and can you give me some other ideas on what you have, like, give us a little preview of what to expect in that report?

Well, the good news is it won't be shocking to you because it is a public health approach. Right. But what it really does is just reminds us that if we think expansively about prevention, we have tremendous resources out there. It is about connectedness. And so, as was mentioned earlier with older Californians, my mother lived isolated for 20 years following the death of my stepfather, and ultimately she developed alcoholism. And because of that, she fell, broke her leg, went into rehab center, got COVID, and passed away.

Her isolation led to her death. So we know this. We have known this for a long time. We haven't necessarily used that lens to think about behavioral health, though, right? When we talk with public officials about sort of their purview and we talk to public health officers, they speak very broadly about population health. Right. In the behavioral health space, we haven't quite crossed that. Public sector finance, commercial finance, things that aren't financed. Right. The report is online.

We'll bring you a hard copy because it's pretty and it's easy and you can carry it around. But what we're trying to do with that report is facilitate this exact conversation, move away from what should California be paying for with a limited public mental health dollar? Instead, how should we be thinking about prevention, and how can we leverage all of the resources we have, including our parks, walkable, cities? Again, just like we've done with physical health, how do we create? So it's education.

It's talking to each other about not being afraid to talk about our own diagnosis and the experiences that we've had.

One other thing that I've been advocating for is posting that nine, eight, eight number in every public restroom just to normalize the fact that it's okay, you're not okay, and that this is something that we're all experiencing. And there's a quick resource that you can call or text to get help, and hopefully we'll see that someday in our state capitol.

Good idea.

Assembly Member Waldron.

Oh, thank you for all the information. There's a lot, and we know as we work in this space that there's just so many different levels of issues and concerns. I've spent the last 10 years working basically in the incarcerational space. I'm very interested in trying to get more services into prisons and jails, dealing with generational traumas and how we address that. Every time I try to work on certain things, we always hear, zero, it's already being done. We're already doing it.

We have the services already, but yet we clearly see with the results just how many people we're incarcerating and the outcomes and the recidivism rates that were not succeeding. Last year, we were able to get $10 million for a grant program for counties to apply for services for mental health and substance use in the county jail systems. The 10 million for a state the size of California is not really enough, but it's a good start.

CMS just this February approved allowing people who are incarcerated in our prisons to be able to access medical services 90 days prior to release, which will help the continuity of treatment when they are released. And also a program four years ago that I worked on, actually, that would incentivize people when they are released to stay in a mental health or substance use program. And it deals with parole incentives. But there's just so many more things.

And every time we come to deal with it, we always hear about the workforce shortage and how do we get more treatment providers. So when we look at the behavioral health pipeline, how do we address that workforce shortage and dilemma that we have? Because we have great ideas and everything and we need funding for it. But if we don't have the people that can do the treatment, where can folks go? And that adds to the delays of people getting into treatment.

Lot there I actually want to start because one of my passion populations that I work with are also people who are justice impacted. And so I think it's actually a great example. And we talked about early psychosis. I hope we come away from today's hearing recognizing that there are so many systems that have a role to play, whether that is improving someone's mental health or treating their mental illness.

And I think what we were able to accomplish as the first state in the nation, we had an opportunity to meet with some CMS folks, the Director of CMS, take them down to the La. County Jail and talk about how is this going to work, turning on medical 90 days before somebody leaves, where it's going to be complicated, but it truly could be life changing for people who are who unfortunately, they are incarcerated, but for many they have been engaged.

As I mentioned, we've got 100,000 people in the State of California receiving mental health treatment in jails today. So how do we keep that going and making sure that we have the housing platements, the treatment slots, et cetera. But it's a great example of how I don't think our Medicaid system can do things like deliver parks. And it wasn't designed to do that, but it was designed to treat somebody who has a diagnosed disorder that is responsive to a course of treatment.

And it was designed to make sure that people get their just and right full benefit that they deserve so that they can get on the path to recovery. So we have to use each of our dollars, basically, and each of our systems. We have 12 departments, five offices within our Health and Human Services I love we talked about the population based approach. We need to have a strong partnership with public Health in doing prevention work.

We can't rely on the Medicaid system to do all of our prevention works. That's not what we're trying to do. But when there is an appropriate time, like with first break or early psychosis where we can push CMS and say, hey, we want this to be something you pay for in Medi Cal or we want you to pay for community health workers.

Those are our strategies that collectively we have to do together so that every funding source is able to address all across the continuum from health to severe illness. And I hope that this is an opportunity to do this work, whether it be through what we're learning with the Children Youth Behavior Health Initiative, what we're learning as we push Medicaid to its very, very furthest comfort level. So to speak, because it is essentially still a sick care system.

But let's do whatever we can with it because we get a federal dollar. And let's look at how we do other things as well. On the workforce piece, what I can say is partly because I already personally shared, we have to figure out how to support people before they go to school.

People, unfortunately, are not going to make the choice to not only go into behavioral health careers, but potentially take on a significant amount of burden of debt up front when they don't necessarily know if they're going to be able to pay that debt off. And so what I've heard from young people in particular, even when I mentor people, they ask me, should I go become a social worker? Okay, I'm always going to say, go become a social worker.

And I'm not just saying that, but do it with your eyes wide open. Make sure that you do your homework and that you look through all of the opportunities that are available to you.

Because I'm very hopeful in the course of the next two years that we as a state alone are going to have a variety of different options for young people to come and even people who want to get into this field, because I don't want to give up on the fact that this is an incredibly rewarding field. I love what I do. I feel blessed and honored that I get to have this rewarding job every day, no matter how challenging it is.

And I don't know if we tell that story enough to other people about the rewards of going into this career, but we do have to make sure that we're not making people incur a huge debt to then have us help pay them off in the future. I think we really have to support them through the entire process. And so I don't know if that answers your question.

It is probably our most that and the lack of actual facilities and frankly, facilities and I include in that ample and affordable and stable housing that is willing getting back to stigma to love and care for people in our communities.

And so anything that we can do to make sure that everybody, no matter what your mental health status is, that you belong in California and we have a home for you here and we're going to find a place for you to be, is a message that we can all get behind.

If I may, Senator Waldron, thank you for the emphasis on the criminal justice system. And part of the origin story of the Mental Health Services Act was recognizing that that is the only system that accepts everyone 24/7 right. I mean, our hospital, our emergency departments do as well.

But for short term kinds of interventions, I would say not only do we have to address the workforce issue that Deputy Secretary Welch is highlighting, but we also have to get better at understanding why so many people with mental health needs are in those situations in the first place. When we've looked at this historically through the lens of people who are in a hospital, we've actually designed systems and interventions to prevent hospitalization.

And the first thing that happens when someone is hospitalized is a conversation about discharge planning. Day one, people are starting to work around what's it going to take to get you out of here. We don't have that approach. There are activities, actions, circumstances, behaviors that result in people being involved with the criminal justice system.

We haven't necessarily rolled up our sleeves as aggressively as we can to ask ourselves if the folks who are in that system, if that is the best place for them to be, given what's happening in their lives and what's happening in their own behavior. So some of the data coming out of the Department of State hospitals is showing that before folks are charged with a felony, they were arrested 12 to 15 times for misdemeanor, but got no community based care.

So is the intervention improved access to care for folks who are at high risk? And can we actually allow criminal justice resources to be spent more effectively on people who really need to be there and make sure that they have effective services? And is there a percentage of that population who actually should be better served in the community and as a consequence of that, able to tap into that federal dollar more effectively, or even the commercial insurance dollar more effectively?

I think we've made a lot of strides in that space, but we have additional opportunities to better understand the problem, to take it apart and put in place interventions that actually allow us to make sure that we're getting best bang for the dollar in terms of the intervention that is there. It may, on the short term, feel like it's cheaper to call the police and have someone arrested and they get charged and they move through that system.

But in the long term, it may be far more expensive. So if the equivalent is institutional care on health care, we don't let that happen. Right. As you saw in the continuum diagram that was put on the board, we have not necessarily done the interventions, including what's known as the sequential intercept model, to make sure that we create lots of off ramps to justice involvement.

Deputy secretary Welch formerly was the Executive Director of the council on criminal justice and behavioral health and has really led for many years these efforts to make that happen. And we'd be happy to talk with you about some additional opportunities.

Last night, I was actually reading through some of our most challenged foster care children and how their delay of care is deplorable, to say the least, but also the fact that it's hard to find those clinicians who might be trained in a specific service that is necessary.

I remember going through when I was doing my MSW, even though I was on the community track, I still left with Mental Health First Aid certification. I still left with Motivational Interviewing certification, right? But for instance, you never really had an opportunity. It wasn't until I was in a MHSA-funded program that we had access to CBITS training to be able to help with young people in trauma in a school model.

What can we do to do a better job, that when people are leaving our programs, particularly those that are state funded, are leaving with the type of training and certification necessary to be able to immediately go into and provide some of these most critical-needed services as opposed to having them have to figure it out themselves and sign up for a training opportunity, pay for a certification?

Right? How can we better equip our upcoming clinicians to be able to handle some of these critical needs?

So I have a couple of thoughts on that. I spoke of the earn-and-learn model very specific to developing our substance use disorder counselors, but I do think--and I hear this from our community-based organizations, and obviously, I also had those placements myself--and I think we could do more to support those organizations, to have the capacity to train young people while they're doing their clinical hours or even just getting their hours while they're getting, say, like, their MSW or their BA or Master's Degree so that they're in an environment where their supervisor actually has an opportunity to provide them training.

Not just supervision, but training on what would be an evidence-based practice. So while I can't speak because I would have to go back to our department to see if there's any opportunities like that, I know that we've had some discussions, including with counties that administer their local MHSA dollars, but we are looking at ways in which we can make sure that our workforce education and training dollars that are a part of the Mental Health Services Act can also be used to really continue to train the existing staff.

Speaking about working with the criminal justice population, when I graduated from my MSW program, I don't even think I took a class on that, to be honest with you. I had an interest in SUD, so I had taken some of those courses, and so, we need to go back and really work with our schools to make sure that they're also supported to provide real-time training on what are the emerging best practices in the field and what are the target populations.

I know that there are specialties in gerontology and specialties in working with veterans, specialties in working with refugees and migrants, but we also need to specialize in what the actual service is. So I do think there's an incredible partnership we can have, and frankly, how do we also make sure that those students and young people who are still learning have strong supervision and that we don't have to pull somebody who needs to be delivering direct care away to do that supervision, that we actually support our community-based organizations that are sponsoring, so to speak, people getting their clinical hours to also have the capacity to really train them? I think it's an excellent suggestion and I'm going to take it back and talk to my folks about it.

Particularly, the state board that you have to go through to get your licensing number to be able to get your hours, right, do we need to strengthen some of those requirements to making sure that--whether it's not just hours but also specific trainings possibly? Is there opportunities? The organization that I left before coming here, luckily we were able to use PEI dollars to be able to hire a supervisor for clinical training, right, so we can build our own clinical department to be able to do that.

But I'm telling you, right, number one: helping community-based organizations and others be able to have the type of funding necessary to bring on someone with such high certifications, right, and of course, we know how demanding they are about--this is almost a specialty to be able to supervise someone. Lastly, I'm wondering about--man, there's so much.

There's so much, but I think, obviously, there's still some more work to do and you all have a strategic plan, a multi-year plan, and hopefully we can make some space in the future to actually go through that multi-year plan so people don't just think that this is what we're doing, but that this is a part of a coordinated, long-term plan of being able to implement one system to the next and those type of things, right?

Is there any additional work that we can do that we're thinking about doing with our health plans outside of just Medi-Cal as well, to making sure that we're more supportive of behavioral health services?

Yeah. So I certainly want to recognize the previous speaker who expressed frustrations with access to behavioral health services underneath commercial insurance. We're probably all here have employee-based insurance. We pay a premium for that, and we have a behavioral health benefit as part of that, and we are working really hard to ensure that Californians get access to it. I do want to share, a couple of years ago, we did receive some resources from the Legislature for our Department of Managed Care to do compliance reviews.

I think I have heard from some of our constituents, stakeholders. You may even hear some today that people feel like we're not being fast and furious enough. I do want to say, though, in that compliance review process of 25 plans, that there were 24 plans that were found to have some sort of compliance issue.

And so, like all things that are significant system change, we got to do things like pay attention, but also provide technical assistance and support and make sure that we're making sure that policies are getting updated, that people are understanding how to change and revise cost-sharing agreements, so I don't want to say, unfortunately, like I said before, we do have a road ahead of us, but we do have in place one of the strongest parity laws in the country.

And we are working hard to make sure that we're providing oversight of that and that we're working with our plans who are also, frankly, struggling with some of the same challenges that we have heard because of just the historic long-term stigma and discrimination associated with treating behavioral health conditions. They also have workforce challenges.

They also have challenges of not having the right kinds of interventions available, and frankly, the biggest hurdle that I see in looking at the care that they're delivering is how do we create more of what you all have been talking about, a system that's not just necessarily about you get in the door because you have an illness, but we're going to work with you to make sure that you're empowered to not only ask for help, but also have your tools at your own disposal to support your mental health and well-being?

And that's maybe more doable for someone who is not experiencing a more serious mental illness, but for many of us, I struggle with depression and anxiety, probably like many other people in this room--I'm just really open about it--and I've learned some tools. I have some tools from my provider to support me, but we have to educate all Californians to also ask for that.

I understand how frustrating it might be to take the extra step to file a complaint against your provider, feeling like you didn't get access to something that you deserve, but I really encourage people to go to our Help Center to file those complaints if they feel like they're not getting what they deserve, and the thing that I think in my interactions with some of the work that my colleagues do with younger people--I don't necessarily get to do it as much myself--is this new generation is demanding access to high-quality care and they deserve it, and that demand, I think, will catapult us to some change.

So I'm really excited about the energy and action that young people and their families are putting forward and saying, 'no, it says right here in my benefit package that I have access to psychotherapy and I'm not getting it,' and so, we want to hear from people if they're not getting the care that they need and deserve.

I think we're going to have an opportunity to learn along the way from a lot of the work that's happening, including, for example, the fee schedule for schooling to behavioral health services in the CYBHI. As we talked about it, it is both commercial plans and Medi-Cal-managed care plans. It does not allow for copays or prior authorization as part of the structure of the fee schedule, and so what can we learn from that experience?

What services do we see children accessing more because of the nature of that fee schedule? If something isn't being used as much as we anticipate, why is that? What are still the barriers that are there? And we're very committed in the CYBHI.

We have an evaluation plan that is very committed to learning along the way and not just thinking about at the end of the five years, what did we accomplish and learn, and so I think there will also be opportunities in this space to think about this more holistic approach across payers, and from the different initiatives that are underway, what can we learn from those and apply across the system?

Yeah, and I would add to that is: the regulatory model, the compliance model is a limited model. It's a cat-and-mouse kind of game. Can we find it? Can we catch them? Can we, right? And I'm not saying we move away from that, but I think we move beyond that, and there's so many aspects of our lives where quality is driven by something other than whether a government agency intervened after the fact and did an investigation and five years later imposed a fine.

We have to have that, but we haven't necessarily put in place the similar investments that we've seen are successful in other aspects of our lives, certification standards in terms of the quality when people are buying the service, right? And so the Commission has a recommendation--in front of the legislators and the governor through our mental health in the workplace--is the State of California is a major employer, among the largest in the state outside of the Federal Government, particularly if you include our public universities, right?

The public sector is the largest employer, and as the largest employer, we're the largest payer of health care benefits through the negotiations with plan providers, and so in addition to exercising your legislative authority to design a regulatory strategy, we also have the opportunity to just negotiate when we're paying for it of what the standards are for care as a buyer.

I strongly encourage this conversation to be more expansive about if the goal is to improve access to care, the quality of care, and the outcomes, let's think more expansively about the tools we have to drive that, recognizing that we also have to help the providers who themselves are sort of trapped in this workforce challenge in ways that we can actually incentivize progress, including compensation, right? We can't pretend that that's not a factor in people making decisions about whether or not they're willing to work in the public sector versus or willing to work with a forensic population, for example, right?

And in other areas of health care, we are often willing to pay more to do more complicated work. It's not clear that we've fully explored those pathways in the behavioral health space.

I want to thank everyone for participating. Obviously, we in the future want to definitely talk about more of the breaking down of silos that we continue to talk about, to make sure that our systems are designed to serve the unique needs of our populations and respond accordingly, but also, obviously, to continue to find ways to move the needle and push the boundaries when it comes to meeting this moment.

I particularly want to apologize to Executive Director Blecker, Senior Director Spencer, and Dr. Quach, who were the victims of technical difficulties, but we promise we will make sure that their voices are heard in the future because the populations that they represent are equally as important in this discussion. So thank you very much. I want to thank my colleagues for their participation, and we're looking forward to future discussions. Thank you. This hearing is adjourned.