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

We are going to bring the Select Committee on California's Mental Health Crisis to order. I want to welcome everyone to the first of two scheduled hearings on the mental health crisis, and our second one will be held on Tuesday, May 16. For those who wish to participate in public comment via phone, you may do so by calling 877-692-8957. The Public Access Code will be 131-5127 and the information will be also on your TV screens. We will be handling public comment at the end of the hearing. Let me first begin the hearing by saying that California has come out of a pandemic crisis and right into a mental health crisis, and the US Surgeon General declared this nation is in a mental health crisis back in 2021. The White House said on March 2022 that our country faces an unprecedented mental health crisis among people of all ages. Two out of five adults report symptoms of anxiety or depression, and Black and brown communities are disproportionately untreated, even as their burden of mental illness has continued to rise. Even before the pandemic, rates of depression and anxiety were inching higher. But the grief, trauma and physical isolation of the last two years have driven Americans to a breaking point. The White House also says that our youth has been particularly impacted as losses from COVID and disruptions in routines and relationships have led to increased social isolation, anxiety, and learning loss. More than half of parents express concern over their children's mental health well being. In 2019, 1 in three high school students and half of female students reported persistent feelings of sadness or hopelessness, an overall increase of 40% from 2009. Emergency Department visits were attempted suicide have risen 51% among adolescent girls. Our own California Secretary of Health and Human Services stated in the State of Public Health in California that mental health conditions affect more than half of U. S. people over their lifetime and contribute to worse overall health and risk of death by suicide. In California, serious mental illness and substance use disorders have a significant impact on young adults, with mood disorders and schizophrenia as the first and third leading causes of hospitalization, respectively for Californians aged 15 to 24. Mental health conditions are the second leading cause of years lived, with disability for Californians and the leading cause for children between the ages of five and 14, emphasizing the need to strengthen prevention, early identification and compassionate care. Untreated mental health problems or substance use and addiction can result in injury and premature death. In 2021, over 4000 Californians died by suicide. The overall number of suicide deaths have increased have decreased since 2018. However, suicide and self harm are among the top five causes of death for 15 to 44 year olds, and rates have been rising in recent years among young Black and Latino Californians. Hospitalizations and emergency Department visits for mental health related conditions are higher among Black individuals than any other race or ethnic group. I and my own family have not been immune to this crisis, having lost an uncle to schizophrenia, addiction and homelessness, and a brother on the streets of California as we speak, as he suffers from bipolar disorder and addiction. And I myself have suffered from anxiety. That is why I have made it my mission to address this issue so California can find solutions to reducing the devastating effects of mental illness and to ensure that the state acts with the urgency and ingenuity as it has with COVID-19 and the homeless crisis. Mental illness not only affects the individual who is suffering, but it affects all those who are close to those individuals as well. This Select Committee was created to address these issues and help formulate policies that hopefully are effective in both the near term and long term, and help California's help Californians live their lives more prosperous and more joyful. To guide this Committee's work, we ask the following questions. How do we break down the barriers necessary to use the full force of our institutions, to stabilize the current population as we build out the long term infrastructure? Two, how do we respond with the same sense of urgency to mental health as we do with physical harm? And three, how do we reduce the stigma associated with mental health and improve the lives of those most affected and reduce this crisis to something that is treatable, manageable and curable? It is indeed an honor to serve with my colleagues on this Committee, and I'm looking forward to taking action in a bipartisan manner to meet this urgent moment. And it is my honor to now turn it over to my colleague, my partner in crime in this effort. Assemblymember Gail Pellerin, thank you very much.

I'm grateful to be here today with my colleague from Riverside County, who has his decades of leadership on mental health and training as a social worker are huge assets to this legislative body. I came to the mental health space as a result of personal experience. My family has been profoundly impacted by mental health for the past 15 years. Navigating finding the right mental health care for my family was daunting. Identifying the right counselors, treatment facilities and figuring out how to pay for it all was overwhelming. Plus, there was a stigma that made it difficult for me to talk to my family and friends. And then, in November of 2018, my husband of 25 years died by suicide. Suicide was not a topic I spent much time thinking or talking about before my husband Tom took his own life. Today, I'm motivated to speak openly and publicly about suicide and mental health conditions because suicide is preventable and mental health conditions can be treated successfully. I decided to put my grief to work after my husband's suicide, so I set out to learn about mental health in California, and then I joined the Santa Cruz County NAMI Board in 2020. My desire to work in this space was one of the motivating factors in my decision to run for the State Assembly. The State of our mental health is a public health crisis. There is a lack of parity with physical health care, shortage of trained counselors, deficiency of resources, insufficient number of bed facilities, and absence of mobile mental health care, to name just a few of our challenges. Mental health impacts all of us, and many are suffering, especially our most vulnerable. I was broken hearted to learn from teachers and childcare providers of the day that children as young as two years old are experiencing mental health conditions. Many of our grandparents, coworkers, neighbors and loved ones are experiencing mental health challenges, in some cases exasperated by the pandemic, the isolation, the economic toll the last few years have had on our families. Today's world of gun violence, bullying, social media impacts, climate change, racial disparities, LGBTQIA discrimination, and division have made many of us feel depressed and hopeless, and I count myself there as well. I believe we can do better. Together we can create a mental health care system where people get the care they need and the tools to live a thriving life. It is a great honor to be on this Committee and serve with our chairperson, Assembly Member Corey Jackson, and my colleagues. I'm here to listen, to learn, and to work on ways we can address the public health crisis. Thank you all for being here today. Now let's get to work. Thank you.

Thank you very much. Assembly Member we're going to just hop right into it and go to our first panel, which is the State of mental health in California. We ask our two panelists to come on up. Michelle Cabrera, the Executive Director of the County Behavioral Health Directors Association, and also Dr. Susan Hong, the Chief medical Executive of Providence Health. We welcome you, and we will begin with Ms. Cabrera, and then we will move on to our next panelist, and you may begin when you're ready. Thank you so much, chair and Member Peller. I'm Michelle Cabrera with the County Behavioral Health Directors Association of. California. And it's a real honor to be here today with both of you to kick off Mental Health Awareness Month. And I just want to start off by thanking you both for sharing your respective experiences with lived experience and uplifting a story and a message of hope and recovery. Because I think it is important for all of us to know that in spite of the crisis that we are confronting, that people every single day find, achieve, maintain recovery, and live purposeful lives. So thank you for that. I'm going to start off by providing a very high level, broad overview to help ground us all in the topic of the mental health crisis that California is facing currently. If we can start off with just the very first basic, and I know many of you know this, but when we talk about behavioral health, we really are talking about two distinct areas, which is mental health and substance use disorders. Next slide, and we can keep going. Thank you. One of the things that I think is so important, because I think when we talk about behavioral health, we're really talking about the biopsychosocial model, and this is really important in the policy sphere because we talk about biological factors, the body, the physical health, but we also have to keep in mind the emotional piece as well as the social and environmental piece, and all of that really combines to contribute to our mental health individually and as a society. Next slide. County behavioral health is really responsible for managing our public safety net for behavioral health. That includes Medi Cal entitlement responsibilities for what we call specialty mental health. So in physical health we have specialties, but we also do for mental health as well. And that includes responsibility for children and youth under the age of 21 for all specialty services, as well as specialty mental health for adults. We also manage substance use disorder treatment for all medical beneficiaries. And then there's a really broad range of community behavioral health services, which encompasses prevention and wellness, which are often not covered by insurance services that are also not fundable through medical, such as outreach and engagement, providing housing, doing jail based services, crisis and emergency care, and treatment in facilities larger than 16 beds. So all of those things fall outside of medical today. We also serve populations that can't be funded under medical, such as adults who may not have access to medical due to their income or because of their immigration status, moving forward. So in Medi Cal, we also have Medi Cal managed care plans which are responsible for providing what we call non specialty mental health, and that is sort know individual group therapy, those sorts of things that don't require a specialist. Next Slide. I wanted to uplift as well the California Bronze and McCorkadale Act, which is also a part of 1991 realignment, because I think that this piece of our state law is really interesting. Under the Bronze and McCorkdale Act, which establishes the community mental health services in California. It says that our mental health system needs to ensure that individuals with severe and disabling mental illness, as well as children with serious emotional disturbances, should have access to services and programs that assist them in a manner tailored to each individual to better control their illness and achieve their personal goals, to develop skills and supports leading to living the most constructive and satisfying lives possible in the least restrictive available settings. The caveat is that the law says that we should do this in California to the extent that resources are available. So we have this really wonderful, lofty, aspirational goal. Notice there's no sort of qualifier there about insurance status. And what I love about this is, to put it in layman's terms, we're really directed to assist people with behavioral health conditions to live their best lives, but only to the extent that we can afford to do so. Next slide, please. This is a comparison of, over the last several budget years, how much we Fund physical health and the non specialty mental health side of Medi Health versus how much we Fund the specialty portion of mental health and SUD services in California. So if you can see, the tall bar is our Medi Cal managed care plans system in California. The dark blue is the Medi Cal specialty behavioral health, and then the light blue, much, much smaller bar is that stuff which sits outside of Medi Cal in the county behavioral health safety net. So when we're talking about sort of resource allocations, particularly in Medi Cal and the safety net, I think it's important to really put things in scale. Next slide, please. There's also, and the chair mentioned this, as well as assemblymember Pellerin in your opening comments, there are a lot of other areas where we really have gaps and shortfalls. So Medicare, it turns out, is a terrible pair for behavioral health. There are lots of holes in what it'll cover. But in addition, behavioral health needs are often de facto treated like an elective for people with commercial insurance. And this is because the network access and quality and coverage is not there on par with what's available in our public specialty safety net. Federal and state funding has often been limited as well. And again, I think that we need to look at stigma as a possible reason for this. But our federal entities like SAMSA oftentimes issue grants, but they're limited. Right. So it's sort of, we're doing a little bit here and a little bit there, but we don't really have that broader systemic and sustained investment in behavioral health. The way we do with physical health. The net result of that is that we all pay the price for this collective lack of investment. When the specialty behavioral health safety net has the best coverage, the most robust networks, you know something's up. And there's a lot of variation that comes from that sprinkling grants approach, the one time money approach. And oftentimes over the last several years, I've heard a lot of frustration from providers, from community members, from policymakers about, why is there so much variation? Why is it that you can get this in this community, but not that community? And it really does derive from a lot of these issues. And then there's the issue that we talked about in last night's oversight hearing, which is this cost shift to the public system from people who are so inappropriately served and underserved with commercial insurance that they become disabled and end up qualifying for safety net services. Next slide, please. The chair really provided a very thorough overview at the top of the hearing about the impact that COVID has had on our behavioral health. I wanted to uplift a couple of things, because we knew very early on, actually, that there was a bi directional association between COVID and people with behavioral health conditions. We knew scientists had already pinpointed that individuals with schizophrenia were four times more likely to die due to COVID, and that COVID appeared to be triggering brand new mental health conditions in people who had never had them before, and so there was some sort of linkage there. We also know that individuals with SUDs and preexisting conditions faced worse outcomes and uses of substances just really shot up during the pandemic. We know that overdose related deaths have increased by 30% in the first year of the pandemic alone. Next slide. And, of course, with children and youth, again, as the chair very thoroughly laid out at the top, the rates of suicidality really shot up among Black and Latinx youth. And the statistics for LGBTQ youth are really something that, again, is also significant and worth calling out. More than half of transgender and non binary youth have seriously considered death by suicide, and these are national statistics. The CDC data from February has also really put an emphasis on what young girls are facing in terms of persistent feelings of hopelessness and depression. These are the highest rates that we've seen in a long time. And interestingly enough, I learned this from our membership, rates of youth crisis actually increase when school is in session, and a lot of that, we think, is due to some of the social pressures and the anxiety that comes with bullying, those sorts of situations, but also school pressure, performance, and achievement, those kinds of things. So there's a variety of things that happen when kids are in school that actually amps up crisis. And at the same time, we knew during the pandemic that many children are not safe at home. And so for those kids, not being in school put them at higher risk. Lots of trade offs there. Next slide. Behavioral health conditions globally are the leading cause of disability, and we by and large do have strong legal protections under the ADA, the Olmsted lawsuit in terms of emergency care, MTALA, as well as the Landerman Petra Short act, among other laws that protect individuals with behavioral health disabilities. Next Slide. So let's talk about some of the work that's been underway in California to address our mental health crisis. Next slide, please. This is not even a full summary of all of the things that we currently have underway in California to reform and transform our behavioral health system. Under Medi Cal alone, we have numerous brand new benefits that counties and managed care plans are bringing on board. Those that are noted with an asterisk here are the managed care plan benefits and the others are the county Behavioral health plan benefits. They include things like mobile crisis services, jail inreach, peer support specialists, contingency management, as well as more systemic reforms such as reforming how we pay our county behavioral health plans and their providers, changing eligibility criteria so that more people can be served by county behavioral health without requiring our clinicians to put a diagnosis on them right away. We are also reforming how we do quality, how we do documentation, and so much more. Next slide. And all of those things are happening at the same time. Looking ahead, DHCS has also proposed the Cal BHCBC, which is Jargon for a waiver of the IMD exclusion, which will allow us to get reimbursement for short term stays in inpatient and residential mental health facilities over 16 beds. The federal waiver which would allow us to do this comes with trade offs. We need to demonstrate to the Federal Government that we are amplifying community based treatment services for mental health in order to opt into the availability of federal reimbursement for those states. I do want to take a moment to call out that, in our opinion, the IMD exclusion, which again limits reimbursement under Medicaid nationally for these inpatient and residential stays, is something that we think the Federal Government really needs to take another look at. When Medicaid was begun in 1965, they were really trying to lean into the deinstitutionalization reforms that President Kennedy signed into law before he was killed. There was a real movement and a passion for not locking, warehousing and locking people up. And so at the birth of Medicaid, Medicaid said, We're not going to pay for those larger treatment facilities for mental health. We would argue that in 2023, however, we have much better tools at our disposal to manage quality and patient care outcomes through different drivers levers that are related to payment. The non payment of those inpatient and residential treatment settings really places them off book to both CMS and Medicaid in a way that we think is problematic for access for those people who may need higher levels of care. And while this waiver is a really important opportunity for us to get reimbursed for some of the short term stays, it doesn't address those people who may need longer term residential or inpatient care. California's waiver intends to support the buildout of community based services by requiring those counties that opt into this waiver to also implement a variety of new Medi Cal benefits that are intended to bring additional federal dollars into our behavioral health safety net, in some cases by covering things that we can't cover today under Medi Cal, and in some cases by supporting or uplifting certain services. So I'll give you a few examples. Rent and temporary housing would be a requirement for those opt in counties, as well as community health workers coverage of first episode psychosis, supported employment, but also assertive community treatment and forensic assertive community treatment. It would also require all counties to implement new evidence based practices for children and youth. So happy to discuss more that waiver still has not been submitted to CMS, but DHCS is working very closely with counties on putting together the concepts. Next, slide. Beyond county Behavioral health and Medi Cal managed care plans, there are a variety of other initiatives that this Administration and the Legislature have advanced over the course of the last two to three years. First, we must uplift that California has some of the strongest commercial plan parity laws in the nation, thanks to Senator Weiner's SB 855. Our commercial parity plan laws are really important, and they really dictate how insurance plans do underwriting and cost sharing, meaning they can't apply unfair rules to how they manage their health plan. It doesn't really speak to coverage and benefits, however, right? So colloquially, I like to say that parity law ensures that your mental health services coverage will be as bad as your physical health coverage. So if you have high cost sharing deductibles, those kinds of things with your physical health coverage, you'll have those with your mental health coverage as well, right? It's just as long as it's fair. For children and youth, we have the CYBHI, which I know both of you are very familiar with, $4.4 billion investment in virtual services platform core capital infrastructure as well as evidence based practices, one time funding. We have the community schools effort under the Department of Education, as well as the community health or behavioral health Continuum infrastructure program, which was $2.2 billion that I would argue are flying out the door. Demand for the B chip has far exceeded the 2.2 billion that was earmarked for that. We have many counties, most counties who applied did not get funding under the B-chip, and that was available to individual providers, not just counties as well. And then we have 1.5 billion in bridge housing funding again, one time funding for rental subsidies, shelter, interim housing, those sorts of things, the workforce investments under last year's budget, the passage of AB 988 last year to allow California to SSF fee for call centers and mobile crisis Care Court, which is underway currently, and numerous reforms related to the Department of State hospitals, which are driving community based restoration and diversion efforts. So all of that is happening as well, in addition to the other medical reforms. Next slide. I wanted to talk a little bit about our crisis system, if we can go to the next slide, as that is the topic of today's hearing, and talk about what is available. Next slide, please. And we can keep going. Sorry for all those header slides. Just a quick overview about the sort of history behind 988. We're really looking at efforts along the last 25 ish years, from when Congress first appropriated funding to establish a network of suicide prevention hotlines, to the establishment of the National Suicide Prevention Line, and through to the passage of legislation at the federal level in 2020 to establish an easy to remember three digit number for those suicide prevention hotlines, 988. Next slide. And that went live last year in July. In California. We have 13 national suicide prevention or 988 hotlines, including two that are run by counties in Santa Clara and Kern, the majority of which are provided through community based organizations, the ones that you see up here. Next slide. And the legislation which was passed last year, AB 988 would establish a technical advisory board under the Office of Emergency Services to work on 911 coordination and directs the Health and Human Services Agency to develop a five year plan for implementation. As you are aware, there is trailer Bill that it seeks to extend the timeline for that and make some other modifications. It also would impose or allow for the imposition of a new tax on phone users to help fund the call center and mobile crisis. But again, what it's going to fund is up in the air based on the outcome of the trailer Bill, as well as coverage for ensuring coverage for 988 services by commercial plans. Next slide.

Next slide, please. Okay, let's talk about mobile crisis in California. Today, we have a patchwork of mobile crisis services available in California. This is based on a survey that the County Behavioral Health Directors Association did with our Members to find out where mobile crisis services were already happening throughout the state. And the Federal Government has provided a new opportunity for Medi Cal to cover mobile crisis. But this really reflects, again, the lack of historical Medicaid or commercial insurance coverage of mobile crisis services. So sometimes, again, I like to say you get what you get model of services, which is folks doing what they can afford to do throughout the state. You'll note that the counties that have no mobile crisis services today are really largely rural counties that are either in the east or the northern parts of the state. Next slide. So, as I mentioned, the new Medi Cal mobile crisis benefit will launch by the end of this year. It will be fully covered by the state and Federal Government with federal matching dollars at 85% until 2027. So this was an incentive by the Federal Government to get states to lift this up. The federal criteria do apply a pretty high bar, however, we're going from, in some cases, zero to 24/7 coverage with two person teams. DHCS did provide $205,000,000 in grants under B-Chip to help counties purchase vehicles and Ipads and things like that to help support the buildup. And we've just received criteria this year in terms of how the benefit should function in California. We also applied for a CMS planning grant with DHCs and are supporting counties with technical assistance in terms of trying to lift this up. Next slide. There are some challenges, however, even with the generous federal Medicaid benefit. First of all, medical only covers one out of every three Californians. And so 70% of Californians either don't have coverage under medical because they're uninsured or they have commercial insurance. And again, depending on how they access those mobile crisis services, we may not have any reimbursement for them. There's really not a stable source of funding right now for dispatch, which is core. Many rural communities lack both workforce as well as broadband for these. And again, workforce is just the preeminent challenge for mobile crisis and many other services. Next slide, please.

Two more minutes.

Two more minutes. Okay, let's roll quickly then. I'm not going to go through all the data, but I will tell you that there are significant disparities based on geography when it comes to our workforce shortage, with the San Joaquin Valley being the most significantly impacted. As you can see here. Next slide. And we can skip this one as well. For both counties and our providers, the major barriers are competition from other employers. Again, as we're trying to beef up to address the crisis, there's a lot more demand in terms of enforcing parity laws, but also way more people experiencing distress and needing services. There's also recruitment from many telehealth providers, and we'll note that there's a lack of alignment between the workforce and the people we're serving. So just the people who are licensed today tend to be white women. In California, that does not align with the majority of people who we need to serve, especially in Medi Cal. Next slide. We did launch our peer support specialist benefit in California, which will help us with paraprofessionals who can provide extenders in our system. Next slide. And then we'll just move quickly. Next slide, please. I covered this a little bit earlier, which is that we are changing criteria to expand access under Medi Cal for specialty mental health services. I know you'll have a whole other panel touching on this. Next slide. And then with the school based initiatives, we have the all payer fee schedule, which is coming down under the CYBHI, but we also have investments through Mental Health Services act, for example, in building those partnerships, as well as under Medi Cal managed care plan incentIves. Next slide. County behavioral health, again, already had a fairly good presence in providing services to 85% of Californians, but we are looking to expand those partnerships. Next slide. And in terms of housing and homelessness, obviously there's a significant overlap there. And. I think you may have skipped a slide. I'm sorry. If you can go back one. I guess not. Next slide. We believe that it's important for our policymakers to focus on the workforce pipeline, particularly those funds that have been proposed to be delayed. We cannot wait on investing in the pipeline and the supply for our workforce. We also really urge the Legislature to consider the challenges of one time investments. To us, that is more of the same. That is what we've been doing, and it's what's led to care that shows up in pockets rather than a supported, robust safety net. We also feel like we've hit the turning point on the challenges with people with commercial insurance, and we really need to move beyond parity to improve both coverage as well as affordability. Plenty of low income Californians have coverage that they can't afford to use. And again, this stigma and unconscious bias that is really pervasive both among the public, but also at times with our providers and our institutions, and it's unconscious many times, but it really impacts how people can access and show up for care. So with that, I'll just say, thank you so much and happy to answer any questions.

Thank you very much, Dr. Hong.

Great. Thank you so much. Thank you for your time, and thank you for the invitation. It's an honor to be here today, and we appreciate this opportunity to share more about Providence's vantage point, given that we have facilities in a footprint that spans across California, and there's no time more appropriate than this month with it being mental Health Awareness Month. And earlier in your statements, you commented on the US Surgeon General Vivek Murthy's statements about the mental health crisis and really the urgency that we need to address these issues now. And he recently reported also that really, the next public health priority is loneliness and isolation. And as you mentioned, we need more attention on mental health similar to how we are addressing physical health needs. And what we know is similar to how we think about diabetes and hypertension as multipliers and risk factors for things like early morbidity, early mortality. We know the same is true for mental health issues as well. At any point, if you have comments, questions, please feel free to interject as well. So, my name is Dr. Susan Huang. I'm the CEO of the Providence Health Network, and I'm the Chief Medical Officer of the Providence South Division, which covers California. And by way of background, Providence has 17 acute care hospitals across the footprint of the state and over 10,000 physician medical staff. And we collectively served 1.5 million patients over the last year. Over half a million of those patients were among the poor and vulnerable. So that is part of our mission. In our footprint. We have three LPs designated facilities. They're all in Southern California. They're located in San Pedro, in Laguna Beach, and in Orange, so in OC and LA counties. In our vision at Providence is Health for a Better world. We're on a mission to achieve that through shedding light on the growing behavioral health needs of our California communities, and also a commitment to all the communities that we serve, all races, all ethnicities, and really all of the subpopulations of the communities of California. And as you stated, some of the statistics around mental health earlier today. So we know that over about 7.5 million people in California experience mental health disorders in any given year. And then from 2011 to 2020, there is a 68% increase in that statistic in the number of mental health patients in emergency departments that are seeking treatments. And as mentioned earlier, the data is still being compiled. We know that COVID-19 was a big driver of this. And we certainly, on an anecdotal basis, if you do rounds through our hospitals and you walk the floors, what you see is that there are different types of issues that are more and more frequent since COVID-19. What we're seeing is a population of younger patients, not just older patients, who we kind of deemed as complex patients in the past. There's increasing social complexity as well. So issues with homelessness, food insecurity, transportation, social isolation, along with mental health issues too. And what we're also seeing is that there's a combination of those types of issues, the social issues, with also increasing medical complexity as well. So now we've got this overall population that has increased social complexity, mental health illness, and then also multiple comorbidities, which are also increasing. So what it means is that the population we're serving is becoming more and more complex on many fronts. So we know that patient placement has also been impacted by COVID-19 and that's due to many of the facilities, behavioral health facilities, not having that infrastructure to isolate patients or to create the new spaces that are needed for these patients as well. And so because our 17 hospitals, we span kind of urban areas and suburban and rural areas, we have some of these unique insights in terms of what that variation looks like, in terms of how behavioral health services are administered. So what we are seeing is we are seeing that psychiatric patients are being brought to the emergency departments and these are being brought to our non LPS, designated ERs. And that results in what we call boarding, where patients stay there until a more appropriate facility is identified. And this occurs across both our kind of Northern California and Southern California footprint. Patients are being brought by law enforcement and by EMS as well. They're taking patients to the nearest facility, regardless of. And really they aren't really able to do that navigation to really properly match the patients to where they would be best served. And what we know is that a lot of these non LPS facilities, these emergency rooms, are really not the best places for patients with mental health episodes or needs to be. They're not properly staffed with the properly trained staff. If you just think about the environment of an emergency room as well, there's a lot of sometimes hustle and bustle. There might be patients boarded on stretchers in certain cases. And it's not the calming environment with the properly trained staff that we actually need patients to more quickly and more efficiently be transferred to. And the ability for a non LPS facility to hold a patient on an application to transfer to an LPS facility placed out into the field has become extremely challenging as well. What we also see is sometimes in our facilities, we do our best to meet the needs of the patients. So sometimes, because it's very hard to get the patients to the proper facility, we might do an admission into a medical or surgical floor in our hospital. And again, you're not really having that focused staffing. That would be the best place for that patient. Sometimes the patients come with both medical needs and also mental health needs as well. And so what we're seeing is sometimes if the patients meet admission criteria for a medical reason where the 51/50 application is no longer recognized, then the non LPS facility only has immunity provided under health and Safety Code 1799 for up to 24 hours. And they must continue to document attempts to place the patient at behavioral health facility, even if the patient is not medically stable. And what we also see is that patients might have needs that are also highly medical as well. They might need specialty beds, certain types of beds. Maybe they have certain wounds or ulcers. Right. And you can actually see the physical ailments with the mental health issues kind of going together. Right. So it's not uncommon that you're seeing multiple issues together. They might need intravenous pumps, IV pumps, they might need splints or crutches. And so we really have to kind of think about, how do we address this patient population, which has multiple needs. When we think about patients who are boarding, they're also taking up crucial spaces that right now, we know that a lot of our EDs, they're at capacity. So when they're boarding, A, it's not the best place for our patients, but B, we know that there's a crunch for patients who do have acute illnesses to be in those rooms as well. So when this happens, patients must wait. They remain boarded in the ED until an individual designated by the county Behavioral health Director can assess the patient and determine the next steps. And sometimes this can actually take a very, very long time. And the staffing challenges that were faced by county Behavioral health departments really kind of places that burden also on the acute care ministries, whose workflows and operations and systems were not necessarily set up to really account for this additional pressure, we're seeing even greater burden, greater difficulty in getting adolescents to the right place. So just anecdotally, just yesterday, we had one patient who boarded for over 90 hours in the emergency department. And so there are many, many anecdotal stories of individuals being held or boarded in places, really, which are just not ideal. The other need is also kind of long term care placements as well. We had a patient who stayed in one of our acute care facilities for a year and a half before we could find a safe long term care placement facility that really met their needs, and that is just far too long. And then for crisis stabilization units, there are also some intricacies in terms of whether they are on hospital license or they're kind of freestanding CSUs as well. We do have a CSU in San Pedro on hospital license, but when a EMS brings a patient who needs that CSU bed, they actually are required to bring them to our emergency Department first. So instead of a direct admission, which they could do if that CSU was freestanding, that patient is now having to go through our emergency Department. So again, just not ideal in terms of when you think about what is the efficient, what is really the right easy, direct path for these patients so we can navigate them to the right care at the right place at the right time as well. In Southern California, we take care of 3000 psychiatric patients, 70% of them boarded for a minimum of 4 hours in our acute care facilities. So though these seem to be more behavioral health resources in Southern California as compared to some of our rural communities and our footprint in Northern California, we're still seeing that really the need is throughout the footprint that we serve. And I share these stories and these examples and these anecdotes, knowing that we are not alone in dealing with these challenges of warding and of really navigating our mental health patients to the right place at the right time. And we've identified potential opportunities through the LPS act that, if clarified or implemented consistently, we believe would improve the current state. So what can be done to ensure that when a psychiatric patient is stabilized, they're taken to the appropriately designated facility? And it's in the best interest of our patients and of our systems as well, to really have the right resources to support them. And then what can we do to really think about moving care upstream as well? And maybe that's through kind of these mobile response units, and maybe thinking creatively about new ways, new care models that we can reach those patients sooner instead of being extremely reactive for once they get to our emergency departments, if they get to our emergency departments, right? So thinking about real new care models, meaning patients at home or where they are, because it is extremely hard for families and patients, right. Especially if they're in a crisis situation, to navigate themselves. And secondly, as alluded to earlier county behavioral health directors have the authority to designate individuals that can place and remove psychiatric holds, but these do not necessarily need to be county employees. So especially as we see that there are these huge workforce challenges, can we really be a little bit more flexible to think about what are all the employees and the caregivers in our healthcare ecosystem? How can we leverage those individuals by providing the right training and of course the right regulations and guardrails so that you don't have this additional kind of barrier when we need people placed on holds or taken off holds as well? There are opportunities, I believe, for private and public partnerships in Orange County. We have a partnership Be Well OC, which is a private public partnership. And can we really think about some of these models more broadly as well? Can we scale those models? Be Well is going to scale out to LA County as well. And is there opportunity to broaden the criteria as well to designate appropriate individuals at these non LPS facilities? Just kind of to that prior point. So there's no easy solution. And I think a lot of the different pieces are intertwined. We inherit the system that we are operating in today and I think our job really is to figure out what are those new models. How can we really think flexibly about workforce, knowing that there's a huge workforce shortage as well, so that we can really creatively co create what these solutions are to address our population of mental health patients. And I'm here to point out that there are these implementation opportunities. They have the potential to greatly impact the appropriately and timely placement of our patients. So in some, Providence is eager to partner and develop solutions in this space. We're actively pursuing opportunities in counties across our state to build out behavioral health capacity, and we welcome future collaborations to really ease the way of our patients. Thank you for your time and happy to entertain any questions.

Thank you. Questions or comments? Let me start off by thank you all very much for really articulating the whole issue when it comes to our behavioral health needs. And obviously this is very helpful to me because a lot of times we hear bits and pieces here and there, but we don't see how it's all connected. And obviously, as we begin to make our first round of attempts to address this crisis, we know that there's going to be many other rounds. And so what we're trying to do is get ahead of the next round of what needs to happen through our next round of legislation and policy proposals. What are we missing right now, though, in this first round that would make an impact and help, hoping to stabilize our population as soon as possible.

Well, I think your question is a really good one, chair, because you're asking about the community. Right. And what can we do better to meet them where they're at? I will uplift a couple of things that I think I really didn't highlight in my overview presentation. And again, I think that just speaks to the significant volume of sort of efforts that are concurrently underway today. Earlier in the pandemic, we worked on co designing CalHope with the state, which was built as the first of its kind community counseling program funded under FEMA, that allowed us to use Pierce to do text based and phone based, as well as in person counseling for people who were experiencing stress and crisis due to the pandemic. And there's so much that we can do today with our existing networks of peer support specialists in California. The state has really been a wonderful partner in trying to help us sort of loosen up certain restrictions and expand and sort of get the most out of the system that we have today while we're trying to build out for the future. But some of those connections through people with lived experience who are working in our specialty system are some of the most effective sort of immediate solutions that we can deploy in our communities. The outcomes are really there with peer models, and it's a lot shorter runway in terms of getting peers out in the workforce than it can be with people who require licensure certification. The other thing that we can do is really prioritize behavioral health and continue to prioritize behavioral health. The Governor and the Legislature have shown that since the beginning of the pandemic, a real sort of pedal to the metal approach. However, with the state of our budget, currently there are proposed delays, and we're talking about maybe we can wait. And I can assure you we cannot wait for things like the workforce dollars to hit the streets, because the result of delays on the workforce side is that we'll have all of these wonderful laws in place that are not actually going to be realized because the humans don't exist to implement those. So I think that there's a lot that the Legislature can do to help us. I will tell you, folks are unfortunately burning themselves out right now in the workforce, trying to meet all of the overwhelming needs and demands that are out there. And our clients deserve better. They get the best that we can offer today, but they definitely deserve better.

I think that's a wonderful question. And as I think about this whole issue, don't boil the ocean, start with a cup of tea approach. And if I just think about kind of this issue from a very practical lens, from at least our experiences that we have at Providence. I would say a lot of it is around the workforce, because right now we are just seeing that there's this traffic jam essentially in our facilities, and you're getting people caught in the traffic, which shouldn't be caught in the traffic, meaning they're boarding in the EDs or they're in med surge beds for an inordinately long period of time. So I think thinking what might be those easy little things? So can we broaden that designation of people in non LPS facilities who can do those assessments, even thinking about doctors as well? And because in California, sometimes these things are tied up in other policies and laws. So we're a corporate practice of medicine state where we don't directly employ doctors, but can we think of even using doctors as well to do some of those assessments? So I think those might be some of the lower hanging fruit as we think about, okay, immediately we do have some little fires that need to be addressed. And then certainly kind of a longer term strategic approach would be moving upstream, creating those bigger pools of workforce. But in the meantime, really thinking flexibly. I know in LA there were different pilots going on in terms of leveraging additional social workers and other parts of the workforce to do those evaluations. But if we can really think about scaling that out more effectively and quicker, I think that would be just something fast that we can do to address the current problem.

All right, go ahead.

Thank you. I know workforce is absolutely key to be able to move forward, and I'm particularly interested in the mobile mental health crisis support teams. I love what Oregon's done with the CAhoots program, and I know some counties only have mobile mental health care for set number of hours in a week and days. And sometimes it's only for people that are already in the county behavioral health system. And our backup really is having the mental health care provider as a ride along with the police teams that are going out and about. And again, those hours are limited. And as a result, we've had some horrible, tragic incidences where people who with mental health conditions have been shot and killed. So how do we move forward? And I'm super concerned about the current AB 988 that it looks like the funding for mobile mental health crisis teams has been no longer in the Bill. And so there's a lot of concern there. And what are your ideas on this? And do you see mobile mental health care as an essential piece to getting us to where we need to go?

I'll be happy to take this one, Assemblywoman Peller. So, as I mentioned, we have a patchwork today in California and across the nation. This is the first of its kind standard benefit. The Federal Government requires 24/7 coverage under Medicaid in order to opt into this. And so the challenge for county Behavioral Health, which will be implementing this under medical, is to get from those limited hours to would argue that we really need to be aware that building that mobile crisis system out to be on par with what we see with 911 and law enforcement today is going to take time, because the infrastructure needs to be built out, the workforce needs to be built out, all of it needs to be built out. And as I mentioned, we've got a third of the funding with medical. Right. So there's two thirds that we still need to close that gap. My understanding of the administration's proposal is not that it eliminates mobile crisis as a service that can be funded with 988, but rather it broadens 988 fees so that they can pay for a broader array of connected mental health crisis services pursuant to the federal law. So the federal law says that any of the mental health services that sort of flow through 988 that come through that 988 call or text can be funded by the fee. And I believe the administration's proposal is trying to sync that up with the federal law, which is much more open, which means mobile crisis services that are requested through 988 could be funded with the fee. I want to point out that there are plenty of mobile crisis services that might not come through that 988 door for people with private insurance, who then would be a gap for us in terms of coverage. And so we still have a lot more to do to kind of build out those networks. The sort of element with law enforcement is also tricky. The mobile crisis teams will not be reimbursed for any law enforcement folks who are part of the response. And it's pretty standard right now across the country, not just in California, that if there's a situation that is considered public safety risk, so if you think about someone who might be suicidal and have a weapon or something like that, law enforcement is likely to be deployed to ensure the public safety in those situations. And so the availability of an alternative to law enforcement response when the conditions are appropriate is absolutely something that will be, for the first time, really well supported through Medi Cal. But we've got a long way to go to get to a place where we can ensure that there's always going to be an alternative there because we have to build out that system, and it took years to get to 911, and it likely will take years for us to get to a robust, unique, sort of mobile crisis response system in California.

With that, we want to thank this panel very much for your time and looking forward to doing some follow up with you. We are going to get, right next to our next panel, the Children's Mental Health crisis. So we ask our next panelists to come on up from the California Academy of Child and Adolescent Psychiatry, the California Association of School Counselors, and First Five California. Of course, we are going, just like any other time, we are going to try to move a little bit faster here so that we can catch up with our time. And so we ask that our panelists be as brief but thorough as possible, if that makes sense. And looking forward to this conversation. First, we will start with Dr. Anne Mcbride, and then we will move on to Dr. Loretta Witson and then Sarah Bachez. Thank you. Okay. Dr. Mcbride.

Okay. Good morning. First, I want to start by thanking you both for sharing your own experiences. It's so important that we're talking about these issues. And so thank you for the invitation to speak with you today. My name is Dr. Anne McBride. I'm a physician who specializes in child and adolescent and forensic psychiatry. I'm currently the Division Chief for Child and Adolescent Psychiatry at UC Davis here in Sacramento. I am here today representing the California Academy of Child and Adolescent Psychiatry. As a child and adolescent and forensic psychiatrist, I work within multiple systems of care. In a typical week, I treat children and families in our Sacramento County Child and Adolescent Outpatient Clinic, where we serve youth aged zero to 21 with medical. At this clinic, many of the youth are or have been involved in the child welfare system, leading to higher rates of trauma related disorders as well as the common disorders we treat in children's mental health, like depression, anxiety, ADHD. I also work at our University Outpatient Child Psychiatry Clinic, where we treat youth and families with private insurance. And I work at the Mind Institute, where we treat children and adolescents with neurodevelopmental disorders such as autism, including many who, for their developmental disabilities, interface with or involved with our state's Regional Centers where staff burnout and turnover appear high. And at UC Davis, our cashmere area is geographically large. It extends across northern and Central California, and we includes about 33 counties. As a juvenile forensic psychiatrist, in a typical week, I evaluate minors who are involved in the juvenile justice system for issues such as whether they are competent to stand trial, what is their risk of reoffending what are their treatment needs and their capacity for rehabilitation within the juvenile justice system? These youth and their families are some of the most underserved that I see for their overall high mental health and other needs. For example, last week I evaluated an adolescent who was facing serious felony charges, and I found that he had almost no mental health treatment history, despite an extensive history of maltreatment, the tragic loss of a parent during childhood, and very clear subsequent post traumatic stress disorder, depression, and a severe substance use disorder. I believe I was the first person to diagnose these disorders and only in the circumstance of following a court ordered evaluation. While I hope this youth can now get the resources he needs, we cannot wait until juvenile justice entry when we know the associated outcomes with this population are much poorer for youth. We cannot wait to identify and treat the serious mental health needs that we already know exist in this population. When I think about the school systems that these youth interface with, while I know that schools are the ideal setting for frontline identification of youth with mental health needs, and I'm very excited that the school systems are such a big part of our state's children's mental health initiatives, I also see firsthand the systemic issues that perpetuate structural racism within the juvenile justice system by the school of the prison pipeline. Additionally, during the pandemic, I think we've all probably heard about the learning and social emotional developmental loss associated with social isolation and distance learning. But let's not forget about the absenteeism that occurred with students, especially within racial and ethnically minoritized communities. I can think of numerous examples of justice involved youth I saw who were simply lost to schools when they stopped attending, often spending more time in the streets where community violence exposure was high, and then entering the juvenile justice system. In every setting I work in, mental health, access and equity are the most important issues I see. Finally, in my typical week, I'm an educator and a program Director for our Child and Adolescent Psychiatry Fellowship. We're training the next generation of child and adolescent psychiatrists. However, we desperately need more providers. We've known for years that there's a national and state shortage of child psychiatrists, along with shortages in children's mental health providers overall. Every single setting I work within is understaffed, which means we simply cannot accommodate all the referrals we receive, let alone identify the youth who need mental health services during a time when we have remained in a children's mental health crisis. In October 2021, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Children's Hospital Association declared a National State of Emergency in Children's Mental Health. I'm so grateful that this Committee has been convened to examine California's mental health crisis. We know that most mental health and substance use disorders start within childhood, adolescence, or young adulthood, and we also know that many are preventable. And we also know that the earlier we intervene with evidence based practice and treatment, the less need we're going to run into down the road. I look forward to aiding this Committee in understanding the children's mental health crisis as we work together to generate solutions. Thank you.

Thank you. Okay, good morning. I am so happy to be here and thank you, Dr. Jackson, for hosting this. I think it's a very important topic and dear to my heart as Executive Director for the California Association of School Counselors. It's the largest state Association representing school counselors in the nation. Prior to that, I was an administrator overseeing mental health in a district in the Los Angeles County area. So that's where I draw a lot of my experiences, trying to make mental health work at the school setting. It is so important to look at how we structure the things that we do on school campuses to really be effective in not letting any kid fall through the cracks. We know that mental health conditions can affect a child's academic performance, their relationships with their peers and teachers, and their overall quality of life. On school campuses, students overall mental health has eroded, as been said earlier, especially in the last 10 years, even though it's been escalated since COVID schools are experiencing more behavior issues. There are more students experiencing disabling anxiety, bullying, stress, and suicide ideation. Always when I ask, when I talk to a school counselor, I say, tell me a story which is always so interesting to see how they handle their day. According to a 2020 report issued by the Center for Disease Control and Prevention, 54% of Schools report difficulty in providing mental health services because of inadequate funding. In addition, there is a correlation with a lack of mental health services in schools and high levels of poverty, which is where we need to have more services. Providing mental health services on school campuses can be effective and efficient in treating mental and behavioral health disorders. School based health systems meet students where they are. They eliminate transportation barriers and improve both health and education outcomes. California took a bold step in 2021, providing millions of dollars for the California Community School Partnership program. It's the nation's largest investment in student mental health and underscores the importance of a whole child approach to serving students, which is a new mindset. I've been in education for 40 years and just getting teachers and administrators to understand the importance of mental health has been so difficult. I think we've gotten past that. I would say that would be the upside, is that they know that it is important now. It's just how do we do it at this point? Another thing that we did is we passed a law that updated our Ed Code for school counselors, which includes mental health within our job description. We also have training standards now that have updated in 2019 that has more mental health services in our schools. And because of that, we now are able to Bill for medical services as school counselors. There's about 15,000 of us in the schools, and being able to Bill will offset the cost of it. And I believe we're the first in the nation to do that because I'm hearing from Executive directors from all over the nation asking how were we able to do that? But it's really that whole will to make sure that we have the people on our school campuses, because we do have a workforce shortage also. But to try to solve that, California last year passed a Bill, and they have a scholarship program now that addresses workforce shortages. So a professional, school based mental health professional, like a school psychologist, a school social worker, or a school counselor can apply while they're going through their program and they can get $20,000 provided that they give four years of their time to a high need school. We have had, since that was passed in September, we've had over 3000 people that have been able to get that scholarship in the school counseling profession. We're very excited about that and we think that'll help with some of the workforce issues we have in our schools. So one of the biggest factors in school based mental health services is structuring comprehensive programs that don't leave any kid out of the equation. Schools are fast paced, never knowing how the day is going to unfold. Environments sort of like the sounds that we've been experiencing today. It just was so remindful of being on a school campus. You get these things going on and you're trying to work with all the things at one given time. There are often thousands of students, faculty and parents associated with one school, and each student and their families bring with them their uniqueness. Quite a task to manage. School counselors, however, know that one of the first places start is in building comprehensive support on school campuses is building a trusting environment. Without that, you don't have anything. If a student is going to share their struggles, they must know that the person they are speaking with can be trusted and counted on trust takes consistency in staffing and purposefully building peer to peer and student to adult relationships. The framework most schools utilize is designed in a program called Multi Tiered Systems of Support. Some people have heard about that. We call it MTSS. This model was originally adopted as a framework for learning and instruction, but we have adopted that to expand to social and emotional learning, mental health. Within that framework, what is included is prevention services, school climate, universal screenings, early interventions and treatments. I will share briefly about a district because I think that'll kind of capsulate as some of my final remarks about how a district uses an MTSS program to deliver the services on a school campuses. So I'm going to focus in on Corona Norco, pretty close to where I live in Riverside County, and it's a very large school district, and in the last five to 10 years they have made some strategic moves and investments that have been very impressive to me and how they address the issues of mental health. One of the elements is they have ongoing training for teachers in topics such as mental health support, suicide prevention, stress management for teachers themselves, and early detectIon. Another thing they do, they have doubled the number of school counselors, including strengthening their elementary school counseling program, because that was just a desert in regards to the State of California until recently, where they were, legislators and others started figuring out that that's where a lot of times where the problems begin is at the elementary level. So they have strengthened that program. The school counselor started off at 600 students per school counselor. The recommendation is 250, we had 1000 to 1 at one point. I was, as someone who was an administrator over school counselors, I remember Gracious Shimoto, one of my high school counselors, said that we had 500. I thought I was doing pretty good to get our ratios down. She says, do you know 500 people's names? I said, I don't, but I recognize what she was trying to tell me. It is so difficult to manage that. So they have gotten. Corona Norco has gotten close to that. They're about 300 to one, which is plaudible for them. They created a unique system and something I haven't seen quite like this, but they have. At the high school, they have one counselor designated as an intervention counselor. So their counseling team is divided by alphabet, but then they have someone that just specializes in mental health, because as this noise is with an alpha counselor, you don't know what's going to happen and you're moving and you're trying to move students fast through your office. And so having someone designated and set aside just to deal with the mental health issues of students has been very helpful. And so they refer in and then she manages almost in a case management kind of situation, which I think is pretty good, but she also or he. It depends on the school. I'm talking about one school that I'm aware of. Groups are often organized around things like anger management, restorative practices, grief and loss, alcohol, other drugs, et cetera, whatever the need is, or individual interventions. They also contract with two agencies, and one is wellness together that provides licensed therapists on every campus. And so that is also a triaging type of structuring. They also have another organization that they contract with called Care Solace. It assists families in managing their managed care system to help them make sure that they get the services they need. The case managers are carefully matched with families to navigate the healthcare system because sometimes the wait time is like three months to have the services. Lastly, they have family centers and Arby School campuses, which I think is absolutely wonderful. So next week, just to conclude, is student mental Health Awareness Week that starts on May eigth. It culminates on May twelveth with a student summit that we are hosting in the Bayer area. And we also sponsor legislation, Assembly Concurrent Resolution 29, that recognizes this week, and this is the fourth time we've done that. So ACR 29 is authored by Assemblywoman Quirk-Silva, and the aim is for as many schools as possible to participate in demystifying the issues and stigma associated with student mental health. My Association is providing toolkits and other kinds of things for our school counselors so they're able to post on social media and really talk about mental health in a very robust way. So I urge you as a Subcommitee to prioritize mental health for California students. We must work together to create comprehensive programs under an MTSS model. Specifically, I think we would be very helpful to build a collaboration between stakeholders, including educators, school counselors, other mental health professionals, community organizations, and government agencies to determine and publicize districts like Corona Narco who can use it. Be an example for other districts to fall in line with some of these kinds of effective practices. There are school districts that are doing great jobs, there are others that aren't, and we need to help them in every way we can so we can reach kids early and effectively. Thank you so much.

And thank you, Ms. Bachez.

Good morning. Assembly Member Dr. Jackson and Members, My name is Sara Bachez, I'm the Deputy Director of External and Governmental affairs for First Five California. I wanted to begin by thanking you for acknowledging your personal story, the only way we removed stigma is by providing safe, open spaces. My husband's an elementary school teacher who had to pivot to online learning and I at the time worked 16 to 18 hours to help schools open up statewide during COVID and I did not have the opportunity, I missed it, where I didn't see him fading. Even though he was showing up to work every day on Zoom, he personally was fading because his trauma had caught up to him. And so it wasn't until August of 2020 when we finally came to head and had a crisis at home that we, by ourselves, had to figure out how do we move forward or else I'll lose you. And so that recognition, it's important because it's not visible, there is no badge you carry, but yet it's in your heart and it's in your daily practice and how you show up. So I'm very proud that he shows up every day as an elementary school teacher and he's there with his kids and he tells them it is okay to feel your feels. And so with that, I am proud to now work for First Five California. We serve as the state leader in creating meaningful impact in the lives of our youngest children and their families. Our commitment to strong collaboration with state policymakers and partners helps us to implement a vision centered around the construct of safe, stable, nurturing relationships and environments which is needed for a child's healthy brain development, physical and emotional development. 90% of a child's brain develops in the first five years of life, making it the most critical years, a time when a child's body is responding to stress and determining how best to cope with those feelings. As we emerge from COVID-19 we know families and children, as was stated, have been impacted by the loss of loved ones, the direct effect of the economy and environmental instabilities. We have yet to talk about wildfires, droughts, all of that. This generation of children have been through a lot, and so those traumatic events can potentially cause what is known as adverse childhood experiences, ACE's that occurs in childhood between zero and 17 years of age. Additional examples of these traumatic events, which we continue to face on a daily basis, is witnessing and experiencing violence, mass shootings, abuse and neglect, witnessing racism, bullying and inequities, having a family member attempt or die of suicide. Also included are aspects of a child's environment that can undermine their sense of safety, stability and bonding, such as growing up in a household with substance abuse problems, mental health problems, instability due to parental separation, or household members who are currently incarcerated. Adverse childhood experiences are more common than one might think. Nearly 2 million children in California are affected, and we have 9.7 million children in the state. So one out of five are affected. And 60% of adults in California have experienced at least one ACE. And there's possibly up to 10 ACEs. Our mental health crisis has required a collective recognition of the need to bring awareness to California parents and caregivers about toxic stress response in children, which is the body's response to lasting and serious stress caused by adverse childhood experiences. This means a child does not have enough support from their parents or caregivers to overcome these difficult experiences. Toxic stress is our body's response to prolonged exposure to trauma and can be harmful to children if nothing is done to stop it. Being in a constant state of stress can affect a child's brain development. And as I mentioned, first five years, 90% of your brain develops your immune system. At a time when we've had a pandemic, when we've had rise in flu, RSB, and different illnesses, their bodies are not able to sustain all of those prolonged experiences, which then turns and impacts their ability to learn, to develop and develop behavioral issues, such as difficulty regulating their emotions and feelings, and then it affects their ability to recover from illness and infection. Physical symptoms of prolonged toxic stress can persist into adulthood, which then can exhibit as stunted growth, obesity, asthma, health diseases, high blood pressure, and diabetes. Adverse childhood experiences are linked to chronic health problems, mental health, and substance abuse problems in adolescence and adulthood. ACEs can also negatively impact your educational attainment, your job opportunities, and earning potential. So if we're about breaking the cycle of poverty, lifting of families, if we don't prevent this early, it will have a lifelong effect. However, ACEs can be prevented. As traumainformed care continues to gain traction, more and more providers are beginning to screen children and adults for exposure to adverse childhood experiences and trauma. ACEs screening provides parents and caregivers the necessary information to understand ACEs and toxic stress and how to mitigate its effects. Screening instruments can validate a delicate situation. Sometimes it's difficult for parents to understand that their divorce, although the right decision for the couple, may have a long lasting effect on the child and be a useful tool for early detection of common childhood traumas. The ACE questionnaire is a simple scoring system that attributes 1 point for each category of adverse childhood experience. The questions cover a different domain of trauma and refer to experiences that occur prior to the age of 18. Higher scores indicate increased exposure to trauma, which has been associated with a greater risk of negative consequences. Screening tools can be administered in a variety of ways. We know that some providers have opted for open one face to face screenings such as social workers, school counselors, physicians, community health workers who ask their patients each question of this tool. Other providers have decided to allow patients to independently fill out the tool that may provide a little bit more comfort in disclosing information in private. The rise in toxic stress in young children has led our organization, First Five California, to evolve from our Talk Read sign campaign and has grounded us in the need to build a public awareness campaign called Stronger Starts, centered around educating parents and caregivers about the long term effects of toxic stress on their children. At First Five California, our focus is on prevention and support on building upstream solutions to help parents prevent ACEs and toxic stress by creating safe, stable, nurturing relationships, environments known as SSNREs for their children, which helps minimize the effects of ACEs and toxic stress. Parents and caregivers can take steps to help their children who are experiencing adversity by providing the appropriate support, bonding and safety. Examples of creating safe, stable nurturing environments and relationships include establishing daily routines A kiddo wants to know what do I expect? Where am I waking up today? What does today look like? Are you coming back? Am I going to see you? Creating consistent, positive relationships with adults, doing fun, positive activities to connect and bond, such as reading together and going on walks, and then helping guide your child through problems by helping them build their ability to cope with difficult situations. The good news is that by empowering parents and caregivers with resources, information that can buffer against the effects of toxic stress caused by ACEs, we can begin to address the rise in children's mental and behavioral health needs and ensure that every child can grow healthy and strong. We invite you to learn more by visiting our website firstfivecalifornia.com for additional tools and resources. And we thank you profusely for bringing light to this critical issue on behalf of our most valuable humans, our children.

Thank you very much. Questions from Committee Members at this time or comments?

Wow. I'm definitely learning a lot. Thank you so much. And it's just devastating to me. What's happening with our children today and what is the best? Is it resources? Is it money? Is it workforce? What else can we do to elevate this?

I would say structure and accountability is very important. There are some states that have a more accountable system for K 12 or grants that incentivize where there's an accountability measure showing that we're meeting the targets that the grant requires, and there's actually technical support on that. So you have school like Utah for an example. It has, I think there's 15 people on their staff at the Department of Education to oversee. School counselors. We don't have anyone in the Department of Education Overseas School counselors, school psychologists, school social workers in the Department of Education, we're sort of on our own. So having those kinds of structures, the technical assistance and the accountability to get the measures that we want as a state would be a good starting point for that.

Yes. I think I would answer yes to everything you brought up. We need resources, workforce access. Right now, access to children's mental health services are really not equitable. And so I can offer some services to people with Medi Cal and some services to people with private insurance. They're not always the same service. And we need to really improve equitable access to services, as well as the providers who can provide those services.

How do we return to building a village for our children? And that takes all of us at the state level to come together intentionally and make sure that as we're crafting policies that it's crafted with the mindset that we will all be responsible for coordinating, creating systems change, structures that uplift and move forward, policies that support, ultimately that child with that family. A child does not come alone. But how are we treating their support system? Are we making it difficult for mom to have access to childcare, workforce, transportation, housing, and food stability? Are we making it challenging for that mother who maybe is now in the donut effect of raising a child and caring for an elder parent? Do they have access to resources to ensure that those family members are being taken care of? And then how do we translate that locally where people feel connected to their communities, that they're seen and heard, that there's someone checking up using home visitation systems? I'm a new mom. I just had a baby during COVID last November, during the spike, which means my family was not able to come and visit the baby. But my husband and I made a decision that in the morning and at night, we would both check in on ourselves. As I'm going through Mommy Blues and he's making sure he's taking his little magical pill to self regulate his feelings and emotions, are we holding ourselves accountable? And do we do enough? As we built that school system that takes care directly of families and children, do they have the infrastructure? And then at the state level, do we have the right accountability systems to ensure that the policies that you pass get implemented?

Thank you very much to this panel. Really appreciate it. And we'll be having some follow up. Thank you. Our next panel is improving behavioral health, delivery I want to welcome up Kirsten Barlow and Sarah Gavin.

Then we'll start with Ms. Barlow, and you can just introduce yourself and who you're representing. And we're going to have to do five minutes each for your testimony.

Good morning. Or now, after afternoon. Chair and Members, I'm Kirsten Barlow. On behalf of the California Hospital Association, we represent the more than 400 hospitals, including emergency rooms and hospitals that provide inpatient psychiatric care in California. In the interest of time, I'm glad that you had Dr. Huang in your first panel from Providence Health. She covered quite a few of the issues and challenges that hospitals face.

So I'll be able to skip some of those comments today, only to say that we agree with many of the complex challenges she brought up, particularly in our hospital eRs. As you all know, and you've already heard about the growing influx of people in a crisis today. Obviously, we agree that lots of community based options in our state could keep people out of a crisis, but it is a chronic disorder.

Sometimes people do have an acute episode, and when that happens, we do rely on our hospital systems to help be part of that safety net. Wanted to just give you a few facts and figures about the role that hospitals play in delivering mental health care in California. In our emergency departments, about 5% of the patients we see in any given year are there, primarily with a mental health concern.

And I found this sort of interesting, that the principal mental health diagnosis or concern that comes to our emergency rooms is actually anxiety. In fact, the number of visits for anxiety are about three times higher than visits for depression in our emergency rooms. After anxiety, the other principal diagnosis we see in ER patients are suicide, schizophrenia, and depression. Most mental health visits to the ER are still among adults, but about 10% of those mental health visits to the ER are adolescents under 18.

About half of the people who seek care for mental health needs in an emergency room are covered by Medi-Cal. And less than 20% of the people who come to our ER in a mental health crisis have commercial insurance. So a big disparity in terms of where, socioeconomically we see people getting care in the ER.

While most ER patient visits, the kind of gold standard nationally, is about a four hour visit for you to get your care taken care of, people in a mental health crisis often spend many, many more hours waiting for the right level of treatment to open up. And you heard a lot about that from Dr. Wong. In terms of inpatient psychiatric care, our state has 31 psychiatric hospitals, just freestanding buildings. That's really the primary treatment they offer is inpatient psychiatric hospital care.

And then we have 86 hospitals throughout the state that offer inpatient psychiatric care in a unit of their broader community hospital. Again, there are more than half of our patients in our inpatient psychiatric hospital. Levels of care in California are either covered by Medicare or Medi-Cal. So, another sort of sign of economic disparity in terms of the level of acute need we have. Schizophrenia, bipolar disorder, and depression are the most common diagnoses of those who are cared for at psychiatric inpatient levels of care.

And the average length of stay for medical beneficiaries is about a week. So we're far from the old days of seeing hospital care as an institution where people go and stay for any indeterminable amount of time, often against their will. Really, right now, we're really just looking to stabilize the primary symptom of wanting to harm yourself or someone else and move you into the right level of care from there.

But there are some big outliers from this one week average stay because we don't have the subacute providers like we do in primary care when someone is ready to leave the hospital. We do have several thousand individuals in California that are kind of stuck in an inpatient psychiatric hospital bed because that next level of care isn't ready or available to them.

In fact, in 2020 alone, close to 2000 adult medical beneficiaries collectively amassed 35,000 days sitting in an inpatient psychiatric hospital bed when they were actually ready to be discharged. But that next level of care was simply not available. So, as you have heard and you all know from all of the oversight hearings you've been hearing about, the many, many investments that we're making in California's infrastructure, all of those needs can't come too soon.

Clearly, there's a crisis not only in the levels of care that we do have, but people really being stuck in the wrong level and not in the least restrictive setting. One of the areas just to highlight is that, as you might know, we do have disparities among what commercial coverage will pay and what Medi-Cal will pay or Medicare. But we also have a lot of disparities about what's based on where you live, frankly, just geographically, what access you have.

So even if there's a benefit that's on your list of things that's covered, it may or may not actually be available to you. That's similar in the case of Medi-Cal, where we do have a whole host of really rich benefits available, both outpatient crisis services and others. There is really no expectation for many of those services that we have an adequate amount of them in every County of our state.

So as a result, we do have parts of our state with absolutely no inpatient psychiatric beds available for anyone, including for people with commercial care. You'd have to travel out of your county if you needed that level of care. Mobile crisis. You saw a map earlier, which is a great model, especially to provide a non-law enforcement response to people in crisis and their families, again, not available everywhere.

So we really hope that as you do, oversight around how, for example, the infrastructure funds that we're letting out or workforce development, all of these great programs that you have in mind, an eye to really the geographic disparities that we have about in terms of where people live and what they really have access to, because we do believe that really shouldn't matter where you get off the bus.

The continuum that we want to make sure is available to everyone should be available truly to everyone, regardless of where they live, despite, of course, understanding differences in workforce availability and things like that. One of the other aspects that you heard a bit about earlier from the counties is. Just one more minute. Initiatives to try to reform how we pay for the services that we deliver.

By and large, the state's payment reform efforts have ignored the need to look at what we pay for in the role that hospitals play. So for many years now, we've really not made it clear how a hospital emergency room could be fully paid for the cost of caring for an individual in crisis, sometimes for days or weeks.

As a result, we're really left with no additional resources to do things like hire peer support specialists and navigators and psychiatrists and others who really could give patients and family Members a better experience when they do come to the hospital emergency rooms.

So we really want to make sure that we are looking not just at what we're making available, but how we're paying for it and making sure that all parts of our state delivery system not only have adequate levels of payment, but that it actually occurs in a streamlined way. And we're making it clear who's responsible and holding our health plans accountable for the part that they play. Thank you.

Thank you, Ms. Gavin.

I do have slides, slides.

And once again, five minutes.

Yes, I will move through these quickly. Thank you for inviting me here, for asking these important questions, and for sharing your stories. I'm Sarah Gavin. I'm the Chief Behavioral health officer at Communicare Health Centers. We are a nonprofit, federally qualified health center that provides care for 21,000 patients, over 100,000 visits last year in Yolo County, which includes major cities of West Sacramento, Davis and Woodland, and one third of our visits at Communicare health centers are attributed to behavioral health and substance use treatment.

I'm also a licensed marriage and family therapist and a licensed professional clinical counselor, and I have worked for Communicare for over 15 years, administering and providing many of the services that we've discussed today under the medical umbrelLA here representing California Primary Care Association.

Next Slide.

Like Communicare Health centers, there's 1300 licensed community health centers in the state, with the majority of being FQHCs with the umbrelLA term health centers. And these are, of course, models for this integrated care that people have come to appreciate, where we're connecting the brain with the body and looking at physical health and mental health and substance use treatment and dental services happening under one roof. And FQHGs can serve the uninsured and do not turn anyone away based on their inability to pay.

Next slide.

And as you can see, health centers provide care for over 7 million patients in the state and is part of the behavioral health system in California, serving one out of five Californians. And 11% of total visits happening at health centers in California are attributed to behavioral health.

Next Slide.

In addition to health centers being the safety net provider in the community for physical and Behavioral health service, I wanted to share and highlight that many of our health centers not only participate in hosting Medi-Cal managed care behavioral health services, but also variety of county level behavioral health services that have been discussed today. Specialty mental health, drug medical, substance use treatment, and for example, Communicare. Within Yolo County, we are the only outpatient drug medical provider for the entire county.

Next Slide.

Our behavioral health and substance use services and our system is complicated to navigate. I hope that that's appreciated today in hearing some of our speakers, and I wanted to share a real example of what a health center could provide and meet the needs of the community and create a stigmatized way to receive care. So this is an example of one of our clinic sites in Woodland.

And as you can see, this is all the services that happen under one roof, under one address in the community in a familiar setting for individuals to access. So when they're walking into our health center, they could be accessing dental, they could also be accessing substance use treatment. So it's a wonderful, destigmatized way to provide care and also help navigate some of these complicated systems that we're discussing.

However, there are challenges in Providing these servIces, and there's Limits to what health centers are able to do to expand. And I'll share some of those today.

Next Slide.

One example of the current challenge in providing integrated primary care and behavioral health services is that at a health center today, we cannot Bill for medical and behavioral health services on the same day. So, DHS allows us to Bill medical and dental services and dental and mental health services, but not physical health services and behavioral health services on the same day.

So I hope you can appreciate when we're talking about integrated behavioral health, this is a huge barrier for us to be able to really, truly provide the care that our patient deserves. And asking someone who is in crisis or struggling to come back on a different day and not having built in access to meet the needs for them right now just creates future delays and destigmatize and creates stigma for our patients.

We're asking them to come back or go somewhere else, and relationship is key to behavioral health care and engagement. And so Warm handoffs and having services on one day creates more relationship and trust. And this is a concept billing physical health and mental health on the same day is supported by the Federal Government. CMS as well as the majority of states allow medical and behavioral health visits on the same day and really is just one of the easiest ways to improve behavioral health delivery.

Next Slide for the sake of time, I won't go into this, but I hope you can appreciate when looking at this, how complicated and trifurcated our systems are and our patients who are facing multiple barriers are having to navigate this next slide. And as stated, some of our health centers participate in the provision of county mental health and substance use services and more would if changes were made.

CPCA attempted to break down some of these challenges and SB 323 was a process to clarify that FQHGs can participate in drug, medical and specialty mental health, which was helpful.

And I want to point out that we have to run these as two separate lines of business with a clear separation of what happens on the physical health side and what happens on the drug medical specialty mental health side, which comes with complications and challenges and also not all county partners with FQHCs in the provision of these services. And there are challenges when services are siloed.

Anytime we have to refer a patient out to another system, we risk losing them to the system and the complications to navigation. So anytime we can take care of them under one roof, it's a better model of care.

Next slide.

Additionally, while we are very excited by some of the changes that are coming out through Cal-AIM, we do want to express that there are some challenges when having to refer to county level services when there are waitlists because patients and clients end up in limbo and FQHDs are holding on to patients waiting for a county spot and health center patients who belong at a higher level of care are struggling to have referrals accepted because of staffing concerns and are siloed systems.

So we really need some guidance, some consistent guidance from counties as well as health plans. Everyone's sort of doing their own thing to have a system and a consistent interagency communication and standards to help our patients step up and step down.

Next slide.

More Challenges that we're seeing that's been expressed here is of course we have an increased need for behavioral health services coupled with a behavioral health workforce shortage. And nonprofits like FQHC providing care to the most vulnerable. Community Members are competing with salaries with behavioral health clinicians in a way that we have never seen before. Costs are increasing and reimbursement isn't, and it's very difficult to compete for those workforces.

Also, documentation and compliance standards for specialty mental health and drug Medi Cal far surpass our managed care system. I have built these systems. I can speak and attest that they are complicated and cumbersome. And for us at Communicare, this is the number one reason our behavioral health providers want to change their role and get out of the system is because of the paperwork, and to lose qualified providers because of paperwork to me feels tragic.

Next slide.

We also need everybody to do this work. We need diverse providers to meet the behavioral health needs of our community, which includes being able to Bill for all qualified providers and staff in our specialty mental health system and drug medic health systems. We have lots of flexibility in what licenses we can Bill for and registrations, and not on the FQHC side. For example, at an FQHC, we can't Bill for licensed professional clinical counselors, which is one of the licenses I hold.

But in the specialty mental health system we can. AB 1549 is an example of legislation that would make it a little bit easier to integrate diverse types of providers, such as community health workers. For example, although we're excited for them to be billable providers through Cal-AIM, FQHCs are not included in that. And so thinking about the rising operational costs, wanting to support integrated care, and that we're providing care to 7.2 million patients in California, we would really like the flexibility into doing this important work.

And then significant documentation would also help alleviate some of our challenges with workforce.

Next slide.

We need more flexibility in who we can hire and some of the requirements that prevent us from doing the good work and to be directly considered for more public health funding opportunities directly to integrate physical health and mental health. Thank you so much.

Thank you so much, Committee Members, any questions or comments? Thank you very much for your information. Of course, as we begin to think about continued silos to continue to break down. Right. Obviously, we're going to need another round of legislation to really look at some of those silos. We know that during COVID-19 also, we said, hey, we don't have enough people to provide this service. We might have to expand who can provide different services. Right. Until the workforce comes in our efforts.

So we probably need to be thinking about, we definitely need to be thinking about those ideas as well. So please be ready to provide us with some legislative solutions for that. All right. And with that, thank you very much for this panel.

Thank you.

Our last panel are perspectives from the field. We are looking forward to hearing from those who are on the ground providing various behavioral health services. We have some who are participating remotely, and then we also have someone participating here in person. And because you are here in person, of course, you get to go first.

Good.

So that we can make sure that we get your perspectives. Ms Karen Larson, Chief Executive Officer from the Steinberg Institute, you may begin.

Thank you. Good morning and good afternoon, I guess I should say, now. Thank you for having me and for having this important conversation. My name is Karen Larson. I'm the CEO of the Steinberg Institute. I'm also a woman in recovery, which I think is important to say out loud in this context. I'm proud to have worked in this field for over 30 years now, which is a little hard to say out loud, but it's true. All of that's been in California.

I started as an individual therapist, and over time, now I have this statewide perspective. The Steinberg Institute was created when our founder, Mayor Daryl Steinberg, left the Senate, and he kind of looked behind himself and said, well, folks aren't paying that much attention to mental health. And so I want to start this nonprofit advocacy organization.

Fast forward eight years, and we're here today with this remarkable attention being paid, with a budget being dedicated to behavioral health that's more than doubled over that course of that time, and with more than 200 bills this session that are focused on the behavioral health space. So definitely in a different spot, but still have our challenges. Before I came to the Steinberg Institute, I was the Health and Human Services Director in Yolo County, just across the river.

So I oversaw all of the public health, all of the behavioral health, and all the social services. I often refer to Yolo County as a Goldilocks size county. It wasn't too big, it wasn't too small. It was just right. Because I was over all of those systems, and because our community was relatively small in nature, I had this really unique perspective, right?

I got to see how all the systems, the importance of having all the systems work together to affect positive outcomes for the people we cared about. And I also had the gift, maybe it wasn't a gift, but this opportunity to watch multiple generations of folks go through our systems. So, the very first job I had in Yolo County, I worked in a perinatal day treatment program where women were involved with child welfare, would come into treatment with their littles.

The moms would be in their treatment, they'd do parent child interaction therapy. It was amazing. I was in Yolo County long enough to watch those same little people grow up and enter my juvenile justice system and then grow up a little more, enter the adult criminal justice system and grow up even more and have their children enter our child welfare system. And so that's a gift in some ways, because it definitely motivates you to do better every day.

But I think one of the questions I was asked is why having a statewide framework for outcomes and accountability is important and how that plays out on the ground level. And I think those multi generational patterns that are playing themselves out in all of our communities, throughout California, throughout the nation, are really what happens when we don't pay proper attention to outcomes and accountability and helping our systems do better by the people that we're intended to serve.

So my perspective today is that data is key to transforming the systems. You've heard lots of statistics. I crossed all those off my talking points because everyone did a great job. So we're really good about talking about the horrible outcomes associated with not doing what we should be doing, what we aren't as good at as a state, as a system, or a series of systems. Serving people living with these conditions is talking about the outcomes, the quality of life outcomes associated with achieving recovery.

And so we think that's the most important focus at this moment. When I became Director in Yellow County, we weren't focusing on the right things. There was great goodwill towards making these things better. There was financially, we had more money coming in on a regular basis for these types of services, but we weren't kind of all rowing in the same direction, focused on these life outcomes.

And so we were lucky enough that our electeds and the leadership in the county really encouraged us all to adopt an accountability framework that forced us all to kind of be rowing in the same direction and focusing on those quality of life outcomes. As a reSult, we reduced homelessness, incarceration, hospitalization, and several other quality of life kind of outcomes for people living with behavioral health conditions. And really, the less measurable kind of outcomes that we achieved were working across systems.

So we had all of our community corrections partnership working on this framework, rowing in the same direction. Law enforcement, hospitals, education, everybody was kind of using the same framework to tell the story about the outcomes. So another piece of the prompt that I was asked to talk about was access to care and why it's critical. And it is.

We believe that every Californian should have a right to accessing the care they need, when they need it, where they need it, and for as long as they need it. And what we also know is that over this past decade, our resources in behavioral health have more than doubled, but our penetration rates haven't changed at all.

And so, we can't continue to just talk about infusing more money into the system without also looking at these other outcomes above and beyond access to care, because the reality is access to care is not enough. If you access care that isn't high quality, then you're not going to get better. And so, what we really all care about is let's help our folks get better. Let's help them get jobs, enroll in school, have meaningful relationships with others, and be successful in life.

I think we've heard about all the challenges. There are lots of reasons why we aren't achieving the outcomes we all want. The pandemic didn't help. This workforce shortage is unbelievable. And we've been a part of a lot of the legislative work around those things. We sponsored 855, the parity law AB 988. We're working on all these things.

And what's really come to the forefront for us is that we need to focus on outcomes and really move toward a system where we're tracking those outcomes and telling the story about how to improve the lives of the people that we all love and care about. I don't want the message to come out of my statement that we don't need more money in this system. We definitely do. Only three cents of every Medicaid dollar in California goes towards behavioral health.

And at this moment in time, it's critical that we focus on these outcomes and really ensure that the resources that we are infusing into our system are being applied to effective treatment modalities that improve the lives of others. I will just quickly call out that we are sponsoring a Bill this year around outcomes and accountability. And we have other systems within California frameworks to go by.

The Calor statute and the Child Welfare Indicators Project, both are great examples of places where our state, when they've applied this concept of looking at outcomes and accountability, forced healthy competition among the private and public systems, help them kind of look at one another, learn best practices, receive technical assistance to have a quality improvement kind of framework within their systems, and improve those life outcomes for others. It's worth noting that the state is doing a lot in this space as well.

We think there's more that can be done. We look forward to seeing more from the administration's modernizing behavioral health framework. They've kind of talked about outcomes and accountability, but we'd like to see how that all pans out. So I think I'll finish just by saying there's a lot of hope. I mean, this in and of itself provides so much hope that there's an increased focus, that there's this path forward, that everyone's kind of interested in the subject matter and wanting to get to solutions.

And we're happy to be a part of that solution however we can. And so very grateful for your time today.

Thank you very much. Next up, we have a representative from the National Association of Social Workers, California chapter, Amanis Sneati. Wonderful. Yes, we can hear you. You have five minutes.

Okay, I'll speak fast. Good evening. Our greetings, Dr. Jackson and esteemed Committee Members. Thank you so much for having me. As we've been hearing, we are in a crisis right now. The mental health workforce especially is in crisis because burnout. And until we thoughtfully address the burnout with holistic and sustainable solutions that support the workforce, the status will continue to worsen and our communities will continue to suffer.

For over a decade, I worked in the biggest mental health facility in jail in the nation, Twin Towers Correctional Facility in LA. I started as an intern, an MSW program at UCLA.

And when I graduated, I returned with the County Department of Mental Health as a psychiatric social worker promoting to mental health clinical supervisor until I left almost a year ago, I worked in nearly every part of the jail, often for overnights and weekends, in an effort to do everything possible to learn and understand the system while juggling the demands of my family. Most of the time I worked with minimum supervision and support, but it was the only way to maintain employment and childcare needs.

I got to know so many outstanding colleagues who, despite the love of the work, also left, especially in recent times. Why are so many leaving, especially with years of industrial knowledge? I recently contributed to a story in the LA Times where this program was explored with a focus on social workers in the county sector. Since we comprise the majority of the mental health workforce, professionals representing various areas of profession contributed to the general consensus that this type of county work is simply too stressful to sustain.

Social workers are valuing quality of life, and they're either leaving the government sector to get their needs met or avoiding it entirely. Since people are leaving, we ought to consider why. Although financial incentives and flexible work schedules are necessary and may attract some as a meaningful start, especially in a sorely underpaid profession, they are not enough to retain I'm personally familiar because I left. I didn't want to leave, but I realized it was no longer sustainable and I wasn't alone.

As the mass exodus of staff continues, with my former workplace staffed at 56% to offset the shock of the situation, people often say new hires are on the way, but that only generates a false sense of hope and relief because more highly qualified staff continue to leave faster than new ones can be onboarded.

There's a distinct burnout that comes from this work that can only be understood when actually experienced after being on the front lines through the pandemic, in a place where there's no sunlight or ventilation, while seeing patients in squalid conditions, and what can only be described as a human rights disaster, it took me several months to begin to understand the weight this system had on me, which I believe is a metaphor for the weight this system has on our society.

We must fundamentally change how we operate if we want to improve our ability to provide services. If we care about the people we serve, we must care about the workforce to provide their service. Research supports what we're saying. My words and our actions, they all support what we're saying, that we need structural change, and I truly believe it's possible. The change that needs to come first. We don't need to look far for answers. There's ample research on burnout.

In fact, we're regularly trained on the topic and we have employee assistance with programs for help. I actually sought help, and when in one of my first of three allotted appointments, the therapist recommended meditation and encouraged me to continue advocating. Little did she know that I worked in a retaliatory workplace and that I was already told by my program leader that I would not be able to promote with this Administration because of my advocacy.

Incidentally, when I went to schedule my second appointment, there were none available, but I never wavered. The burnout got worse, and I learned that we often punish those who speak out, but we don't effectively support those who remain suffering in silence. All of this perpetuates more burnout and further contributes to the crisis. So, we need meaningful change, not a stress ball and occasional donuts for staff appreciation.

One incentive that could be a game changer are part time positions with full benefits in every sector of frontline work. This would allow people to have the option to work in a sustainable way for them. People have so many reasons to pursue this, including family, private practice, academia, or advocacy. People would have the power to create something that will help them be most effective versus being forced to a mold that is proven, dated, inefficient, and detrimental to everyone involved, including the clients we serve.

Another reason we should support part time options benefits is because we'd be directly supporting women in the workforce, especially mothers and caregivers. Social workers, who comprise the majority of the mental health workforce, are 90% women. So by this alone, we'd have a direct impact on a woman's employment considerations. And for those who are parents, women with children aged up to 18 years old comprise 71% of the general workforce. This doesn't even include women with nonparental caregiving responsibilities who are also 75% women.

The numbers indicate a majority of women doing this work also have caregiving responsibilities at home, I. E. Unpaid work demands and responsibilities. The workforce was not designed for women. However, we make up a majority of this workforce, and we are overdue for adjustments that allow us to do this work sustainably and effectively. By supporting women and anyone who pursues this profession, we are supporting the people we serve in the workplace and beyond. When I first took my maternity leave, my mother was also dying of cancer.

You have one more minute, okay?

I was juggling responsibility of caring for her while also becoming a mother myself. I knew six months wasn't enough, and luckily my Director understood, so I requested a year, but was mostly unpaid time off, a privilege no longer honored. When I returned, I hoped there was a part-time position available for me because they exist in the Department, although there are just very few.

Instead, I was offered a 30 hours work week with significant decrease in benefits, which I eventually did for a bit, knowing I was privileged and could do it, and then had to return full time. The strain caused on families to sustain what has become impossible for many is only causing further harm to our society. And I know because I now am struggling to keep up with the juggle myself and I work with families and students in our schools who feel the brunt of this weight.

Again, I work with social workers who have these same sentiments, but often are too stretched to do anything but to keep going. Part time positions are necessary, and so is telework, even if only a few hours a day for documentation. In fact, in our handbook at Correctional Health Services, telework is touted as a benefit, but only a few select staff are chosen to use it. It is not offered to the social workers doing the work.

Please conclude to wrap it up and.

Even a few hours a day wrap it up. Allowing those benefits will help mental health workers like you said. Dr. Corey Jackson at the NASW lobby a day rally, we can't go back to the new normal. We have to imagine a new normal, and in doing so, we need to take care of our workforce. I know it goes beyond mental health and we're in a perpetual State of trauma as a society, including us treating the trauma. And we need help, too. So thank you.

Thank you so very much. Really appreciate it. Next is Alexis Segan with the California State Association of Psychiatrists.

Hi, can you hear me okay?

Yes, we can.

Okay, perfect. So thank you, Members of Committee and the chair, Dr. Jackson, for having me here today. I'm Alexis Segan. I'm the Vice Chair for the California State Association of Psychiatrists, and I'm a psychiatrist at the UC Irvine Medical center in Orange County, where I primarily work as an inpatient adult. On the Inpatient Adult psychiatric units, I also perform ECT and C adult outpatients. Our UC Irvine Medical center is a safety net hospital, and the majority of the individuals we serve have Medi Cal.

I wanted to acknowledge first the efforts that have been made by the State of California to prioritize mental health. 98 has been an amazing accomplishment, and it has the potential to help people in crisis and direct them to the services we need or they need. However, there are still a lot of gaps in our crisis response. We frequently have people brought to our ER from jail, and it's unclear why they were taken to jail in the first place. If they really needed mental health care.

We need more education for first responders. The wait time for crisis assessment teams is high. Often they may not be able to come until the next day. So it's still police that are coming. I know of an individual who has a schizophrenia spectrum disorder. He is on a conservatorship, and his family, he asked them to call 911 because he wasn't feeling well. He said something was wrong. He was assessed by the police.

They didn't really know what a conservatorship meant, and so they didn't take him in. And he actually, then later on went to assault a neighbor, thinking that they were trying to abuse somebody. And so now he's in the jail system. And this all could have been avoided if he had just been taken to the hospital, if the people who assessed him had better education. And the crisis assessment teams, they're also very disjointed between cities.

Again, in general, psychiatry there are definitely limitations to our current treatments, but we're pretty good at getting people well. In an acute crisis, what we struggle with is keeping people well and out of crisis. And a number of people have talked about the different factors that come into this today. And so I want to just highlight a couple that we see when we're in the field that are some of the major barriers. So we know that outpatient care is essential. Keeping people well.

However, our current model for getting access to these great assertive community treatment programs is that you have to fail upward. You need to be hospitalized a certain number of times to meet criteria to get access to those programs. And the goal, we need to have the capability to expand these programs to people who are at high risk of rehospitalization to reduce the chance that they actually need to be hospitalized again. As many people have said, programs have high staff turnovers.

We also need to have highly trained physicians working with these complex individuals who are often on very complicated medication regimens and have tried and failed multiple. Also, the transition out of the hospital, as many people have discussed, is a key opportunity to establish outpatient connections. But oftentimes our hands are tied by the lack of availability to access these community resource programs.

In Orange County, anybody who with Medi Cal wants substance abuse treatment has to be seen in person, outside of the hospital and placed on a waiting list. We cannot refer them from inside the hospital. As numerous people have said, we need these residential supportive, crisis subacute step downs to help reduce inpatient stays, especially while people are waiting for placements for different programs.

And then something that's just, I want to mention, because to me, it's so egregious, and in Orange County, there's no way I can obtain a shelter bed for somebody who's in the hospital, whether it's medical or psychiatric, until they're actually out and on the street, because that's the way the Access program has been designed, is that people have to be on the street in order to get services. And so when they're in a hospital, they're technically not on the street.

Now, in the last couple of seconds, I just want to focus on housing. People cannot stay well without safe and affordable housing that provides the appropriate level of care and support for their illness. We want people to be independent at the least restrictive level of care, but that can require various levels of support. SendinG people with severe mental illness and trauma to the streets is just setting them up to fail.

I have, multiple women have told me that they use meth in order to prevent themselves from being attacked on the streets at night. And so we have things like full service partnerships that have some housing stipends, but really they're only rooming boards and overlivings, which may not provide the support that some people need.

I wanted to highlight one example of a program in Orange County, which is the John Henry Foundation, which is a residential facility, that it's not locked, but it's for people with a schizophrenia spectrum disorder, where medications are administered. There are psychiatrists that come on site, and it's a supportive living situation. People are in semi-independent places, but it's only one facility, and it's a wonderful one. It has waiting lists for up to a year, and it also isn't covered by insurance or Medi-Cal.

We need these variety of options in order to help the individuals that are struggling with different levels of care to help keep them independent. I think I made it in almost a little over five minutes.

Did a phenomenal job. When I see you, I have a sticker, a certificate waiting for you. That is fantastic. Thank you so much. And for our last person. Absolutely. And for our last person, we have Joy Alafia with the California Association of Marriage and Family Therapists. Welcome.

Thank you. And thank you so much for having me. Can you hear me okay?

Yes, we can.

Okay, well, the bar has been set, so I will do my best here. Five minutes or less. Thank you, Dr. Jackson, for allowing us the opportunity to be here today, along with the esteemed colleagues and Members of the public. The California Association of Marriage and Family Therapist, or CaMP, represents 35,000 Members, and we are dedicated to maintaining high standards and professional ethics and upholding qualifications for the profession.

In addition, expanding the recognition and awareness of the important work that MFTs do, marriage and family therapists beyond couples therapy. So I'd like to share that MFTs are trained to assess, diagnose and treat individuals, partners, families and groups from a variety of mental health for a variety of mental health issues. So they treat areas including personality disorders, bipolar disease, depression, PTSD, in addition to anxiety and interpersonal relationships.

And so because of this, you'll find MFTs in a variety of populations, schools, hospitals, different mental health facilities, agencies, and of course private practice. I'll just kind of give some highlights here, some of which has already been set, so I won't emphasize those items. But when we look at areas that can help improve access, I want to echo Alexis Segan's comment that looking at the rates and being able to have compensation, that really keeps people in the field.

So I'm looking specifically at Medi Cal and looking at the insurance rates, and we really have a desire for those rates to be higher, to attract more providers to participate in Medicare. Many of our pre licensed providers gain their 3000 hours of work for working low wage or even for free, and so they're needing to pay off huge loans and often they then go into private practice versus staying in these types of settings because of the compensation.

I echo the part time with benefits, similarly grants and scholarships. So really looking at the pipeline at the outset and how do we increase that opportunity? Telehealth has been very significant in terms of broadening our reach and is still important. So we hope that that stays at the forefront. A few other things here is just looking at making sure that we also are able to attract diversity amongst the NFT so that we could be culturally responsive to our community.

So looking at ways to support different organizations such as the ones you have here in their pipeline, outreach to diversify the representation as appropriate. We're looking for freedom of choice in the treatment and provider options to serve individuals unique mental, emotional and therapeutic needs. Providing team based and collaborative care models is also very important to provide a range of services to ensure positive outcomes and also looking at removing existing jurisdictional barriers that prevent qualified people from being able to render continuity of care.

So we have seen instances where because someone runs up against a barrier, they no longer can see a provider that they've seen for many years. Similarly, other types of barriers, removing provider parity barriers to increase access. So really looking at opportunities to support qualified providers versus defining based on licensure type preferences. So that's really big and I think a great way to increase opportunities there and just reducing administrative burdens, that's a big challenge for our professionals, MFTs as well.

This is prevalent in the health insurance systems and programs that detract from the patient care and disincentivize provider participation. So I think more broadly, I love this forum and what we're doing is exactly what we need to be doing.

Having these discussions looking at statewide and also local campaigns to increase the level of health and literacy and psycho education amongst consumers and to continue to destigmatize mental health illness amongst consumers and providing policies that support health equity and reduce workforce disparities between rural and urban areas and also between organizations and facilities. And then lastly, funding for investments that develop and support healthcare technology, so resources and services to improve the quality of care, lower cost of care, and improved access to care.

So I cut out a lot that I had. Thank you again for this opportunity, and I'll hang around if there's time afterwards for questions.

Thank you very much. We want to thank this panel for giving us a glimpse on things that are happening on the ground. We hear you loud and clearly in terms of workforce and understanding that we cannot afford to delay workforce investments, and we're going to do everything that we can to make sure that that pipeline continues to grow and the funding that comes with it. So, thank you very much to this panel. Really appreciate it.

Now, we will go to any public comment, or if there's anyone in the room that would like to do public comment, please come on up and then we will open it up to the phone lines before we adjourn.

Chair Jackson and Committee Members, thank you so much for really putting shining the light on this crisis, and it is a crisis. I'm Chris Stoner Mertz. I'm the CEO of the California Alliance of Child and Family Services. We have 160 nonprofit, community-based organizations doing behavioral health, as well as other family support services to children, youth, and their families throughout the state. As I said, we really appreciate the attention you're bringing to this crisis.

Our Members have seen the impact of this crisis on our children and youth, resulting in increased rates of suicide and hospitalizations, particularly for youth of color and those in the LGBTQ plus community.

The intensity of need for mental health and substance use interventions, a workforce crisis, burdensome documentation requirements in Medi Cal, the loss of short term residential therapeutic programs, and significant changes to the financing structures in Medi Cal, all happening simultaneously, are further exacerbating the issues that providers have around providing these services quickly, timely and ensuring that the full array of services are available. So we deeply appreciate your leadership and look forward to working with you and the Administration on solving these issues as quickly as possible.

Thanks and thank you. Next we will go to our phone lines. Is there anyone on the phone lines who wish to provide public comment?

To provide public comment, please press one, then zero on your telephone keypad. At this time, an AT and T specialist will provide you with your line number by which you'll be identified. We will first go to line 15. Go ahead please. Line 15. Your line is open. Go ahead please. Line 15. Please check your mute feature or pick up your handset. We will move on. One moment, please move on to line 17.

Good afternoon.

Mary Creasy on behalf of the Children's Partnership, commenting on the children's mental health crisis, the Children's Partnership applauds the investment in the Children and Youth Behavioral Initiative, in particular the prioritization of infants and toddlers in existing investments thus far. The reality remains, however, that the vast majority of the historic CYBHI investments are going to school aged children and the systems that serve them.

PCP believes that in order to meet the state's goal of reducing acEs and toxic stress by half within one generation, and to advance the governor's commitment to improving the mental health of our state's children and youth, an additional one time, 100 million dollar General Fund appropriation to support infant and early childhood mental health services and provider training would significantly move our state to greater mental health equity for California's infants and toddlers, especially those from communities of color that have been historically marginalized and hit hardest in the last three years.

Funding dedicated exclusively to infants and toddlers is necessary to ensure our mental health system of care is prepared to meet the needs of all children and youth in California. We look forward to working with you, the Administration, partners and families across the state to ensure children from birth to 26 are prioritized. Thank you for your consideration.

Thank you.

Line 16.

Good afternoon. My name is Lisa Coleman. I'm the Legislative Director for the California Commission on Aging, and I just want to start by saying I did sign on a little late, so if I missed it, I apologize in advance. When I was reviewing the announcement of this hearing, I was very excited to see that it referenced children, adults with disabilities, families and older adults. But then I didn't hear anything about older adults. So again, if I missed it, my apologies.

But I am calling to remind this Committee and to thank them for this focus on behavioral health and to remind. Us that older adults is the fastest.

Growing segment of our population. Even before COVID 30% of older adults were diagnosed with cognitive impairment, anxiety, or depression, and that was before COVID But of the 30% that had a diagnosis, less than 4% of older adults utilize long term services for behavioral health because many of them don't have access to it. I want to remind this Committee of the growing impact that behavioral health has on our homeless older adults in California.

From 2017 to 2021, the number of people 55 and over who sought homelessness services, with the majority of them experienced homelessness for the very first time, increased by 84%. Now, certainly not every older adult who is facing homelessness has behavioral health issues, but certainly all of those who are now homeless have behavioral health issues. And so we look for are. What's that expression? The cure is? I'm getting myself all confused. I think you know what I'm trying to say. Prevention is cheaper than a cure.

And so we ask that you focus some of these intentions on older adults. Thank you.

Thank you very much.

As a reminder, if you do would like to comment, press one, then zero at this time. We'll go next to line 19. Go ahead.

Good afternoon, this is Rebecca Gonzalez of the National Association of Social Workers, California chapter. I just wanted to comment very briefly about the pipeline for people entering the profession of social work. Recently, the Association of Social Work Boards has released long sought data on who is passing the national exam that we take in California for people to become licensed clinical social workers. And the exam disparities that we had suspected for many years were confirmed.

Black test takers, in particular, were not passing the exam at the same rate. And there has been a lot of discussion about the construction of the exam and the bias built into the exam. So I do think we need to look at how we are licensing our professions, making sure that there are enough diverse professionals to serve our diverse communities.

Thank you.

Thank you.

We have no further lines in queue at this time.

Okay, thank you very much. We want to thank everyone who participated today. Once again, this is just the first round of hearings, and our next one will be on Tuesday, May 16. And we're looking forward to continue the discussion, to making sure that we get this right and we meet this moment again. I would like to thank my colleague, Assemblymember Pellerin, for her partnership in this effort.

We want to thank the sergeants for all the behind the scenes work and want to thank my staff as well, who I have stressed out immensely in making sure that this goes right. So, thank you very much and hearing is adjourned.