Assembly Budget Subcommittee No. 1 on Health and Human Services

Good afternoon. This is the Assembly Budget Subcommittee Number One on Health and Human Services. Today's hearing will be focused on behavioral health. Given the length of today's agenda, I would like to request that all of our speakers be as brief as possible. While we will be wanting to hear what you have to say, we also want to hear from the public, who have to wait until the end of the hearing.

We will have panel presentations on the first 29 issues in today's agenda, while the remaining 19 are non-presentation items. Members are welcome to ask questions on all issues of the agenda, including on nonpresentation items, and we welcome public comment on them at the end of the hearing, should there be any. I want to remind everyone that public comment on all issues of the agenda will be taken at the end of the hearing.

After the last issue has been presented, we will first take public comment from those who are here in the room, and then we will be going to our phone lines. With that, let us begin with issue one. Our first issue is an overview of the Mental Health Services Oversight and Accountability Commission and its proposed budget. We will have Dr. Toby Ewing, the Commission's Executive Director, to present this issue. Welcome and please begin.

Thank you very much, Mr. Chair and Members appreciate the chance to join you today. We did provide some materials in the form of a handout. I will reference that in my brief comments. Do my best to be brief. In the write-up, the staff identified a couple of questions here. What are the the highlight the Commission's most significant work and achievements?

And it asked this question around kind of the Commission's portfolio and whether or not it exceeds the original intent of the MHSA statute as it was drafted. In terms of our most significant and what we tried to do in this handout was to give you that portfolio.

Maybe move the mic a little bit closer.

You bet. Apologies. So in the handout we provided, we provide 20 or so key initiatives, and we try to give you statements about what each of those initiatives are covering, the accomplishments that we have achieved to date, and what the opportunity represents. And I want to highlight a couple of the graphics in there. The first is this lifespan graphic, and what we're really trying to do with this lifespan graphic is to put that portfolio in the context of the public that we serve.

It's really an effort to identify the work that we're doing, but more importantly, the work that isn't being done in terms of the Commission's own portfolio. And when we first did this, we recognized that we had some significant deficits in early child education and in older adults. And subsequent to that, we've been working to develop a partnership with the Department of Aging to really strengthen our work on older adults.

And we've been able to make some investments in that area and we're working to make some similar investments in early childhood education. In terms of, I'm going to get to the graphic at the end of this document.

I won't go through all the initiatives in reference to your comment about being brief, but in terms of our most significant work and achievements, I want to highlight that the Commission was really formed to elevate mental health in terms of public policy and practice, going back to the origins of the Mental Health Services Act, the early work 20 plus years ago done by the state's Little Hoover Commission, really recognized that it was important to have an entity whose job it was to really drive transformational change, to ask tough questions and to provide advice and guidance to the Legislature and the Governor.

And that is one of our most significant accomplishments to date. We have not done this alone. It has been done in partnership with the Department of Healthcare Services, Community Organizations, Community Partners, CBHDA counties, others.

We really see ourselves as shaping and informing opportunities, serving as a catalyst, and some of the work that's mentioned here, some of the work that you're well aware of in school mental health, our recent work in workplace mental health, our work around digital strategies and delivering care, as exemplified by the work that the Department of Healthcare Services has done most recently with CalHope, are areas where the Commission has elevated an opportunity that otherwise was not being pursued at a point in time.

On our programmatic work, as mentioned, is mentioned in the agenda, suicide prevention, the early psychosis work, our alcove youth drop in, fortifying fsps, enhancing understanding of the mental health system and enhancing transparency around funding, services and outcomes. These are all among what I would call the most significant accomplishments and achievements of Commission. We've been elevating innovation. We have been really working to identify leadership opportunities at the community level. We elevate the voice of community Members of youth, in particular around youth and school mental health.

And so I would say the Commission stands apart because we do not have the significant portfolio that other departments much larger than we have. That allows us to actually be dynamic, that allows us to identify opportunities that are not being pursued, which is part of what this analysis is. Last, I would draw your attention to the second, to the last page in this document that we have provided to you, focusing on upstream efforts.

And what we've really tried to do here is we start with this understanding that We, the State of California cannot afford to pay its way out of the challenges we have in mental health care today, we must invest in upstream opportunities around prevention and early intervention that is built into the Mental Health Services Act. Prevention as a mandate, one of the only areas where it actually is a mandate.

And the act really defines prevention in very broad ways, looking at the factors that actually contribute to mental health needs, such as unstable housing, unemployment, lack of hope. Right. It's creating work is about hope and opportunity. And so the Commission's work, the Mental Health Services Act work, is really about elevating upstream opportunities to support people before needs develop and to design systems that are responsive and then intervene early to prevent the escalation of needs over time.

And so in this graphic, we've tried to represent the school mental health work, which is really about a broad population-based strategy to engage young people. We have not put our workplace mental health effort on this document yet because it's just emerging, but comparable to school-based mental health. Workplace mental health is about engaging adults. Our risks, our resiliency, the opportunities that we have don't come from work alone, but can be influenced and impacted by work.

And for those of us who receive health coverage through our employers, work is a place where we receive access to high quality, effective mental health care, or not, depending on the quality of that coverage and the types of services that are available.

But our school mental health work, our alcove youth drop in work, is really about creating trust and creating very accessible, easy pathways to care for young people who often struggle because of issues of trust or the responsiveness of the system to their needs, into our early psychosis work, which you'll hear a little bit more about later today, which is that early psychosis work is so important in terms of engaging early in the evolution of someone's disorder that is likely to lead to the most devastating impacts that we see in our communities, homelessness, incarceration, hospitalization, and death.

And so our early psychosis work is really that most important, early intervention and then our full service partnership work and this array of upstream strategies are really designed to address some of the most pressing, some of the most expensive, some of the most devastating impacts on individual families and communities, namely in the three maroon circles at the bottom, homelessness, incarceration and hospitalization.

So I think, I mention this because it's this framework that we are very proud of and we think is very significant in terms of the opportunity and the accomplishment of the commissions. I don't want to say that that's something we've accomplished.

But what we're promoting is an upstream strategy that ties together a broad array of programs and opportunities designed to reduce public sector costs, reduce the kinds of suffering, the trauma, the impacts that we see on individuals and families, and do it in a way that ideally never requires the engagement with the mental health system because we have designed interventions so early in this system that we're supporting people so they don't end up needing mental health care. Thank you for the chance. I know that was quick.

We try to give it to you in writing so that we could get to any questions you might have. Appreciate the chance to be here. Thank you.

Thank you. Department of Finance.

Good afternoon, Chair Members. My name is Elena Ramos, Department of Finance. We were asked to comment on why there is a negative fund balance in the Mental Health Services Fund. Just note that as of the 2023 Governor's Budget, there is no negative Fund balance. However, the state receives 5% of the annual Mental Health Services Fund's revenues for state-directed purposes. And in recent years, the state-directed expenditures have been higher than the revenues. And that's achievable given that there are carryover fundings from prior years.

We were also asked to comment on whether the term expenditures refers to the funding being distributed to counties or actual expenditures by counties. So with regards to the 95% of annual mental health Services Fund revenues, the Fund Condition Statement reflects the amount allocated to counties as opposed to actual spending by the counties. And lastly, we were also asked to comment on the fact that the state reported 5.8 billion mental health services Fund for past year and the state controller's office reported a different number.

So in the spirit of being brief, the primary difference between the $2 is that the administration's amount includes accrual amounts. So money that is due in the future attributable to the past year.

LAO

Yes, LAO, as this is kind of an overview item, we don't have anything to comment, but are available for questions.

Bring it up to the dais for any questions. Dr. Jackson.

Can you describe anything that's in the works into making sure that we are following the best practice of universal screenings for mental health?

That's a good question. So we have not looked at that issue specifically, but there's not consensus on what that means. Best practice in terms of universal screening for mental health. The Commission has a position that everybody who needs care should get care, and through our prevention or intervention work are working to sort of promote that strategy. But when we engage subject matter experts, there are disagreements on what it would mean to adopt that goal and what it would mean to operationalize that.

And so I think there's a handful of issues here. One is establishing that as an agreed upon goal, being clear about what we're screening for, the kinds of instruments that we would use, where that screening would get done, and what the response would be when screens reveal something that is needed. We're making progress on suicide screening. We're making progress on screening in schools. But I think we're not yet to the point where the statement you made is something that's being operationalized statewide.

Definitely no, it's not being operationalized. I mean, you look at the US surgeon general's recommendations in regards to youth mental health crisis. One of his recommendations, actually is universal school mental health screenings. Our first surgeon General of California also said that we need to be doing universal screenings. Can you think of anything else we can do that's better than universal screenings? Because at this point, what we're looking at is we're waiting for things to manifest itself. By that time, it could be a suicide.

By that time, it could be some type of manic issue. But if we talk about prevention and early intervention, I can't see any type of tool or anything we can do that's better than universal screenings. So I'm not sure who is in disagreement with that. Now, operationalizing it, is an issue, not because we can't do it, but because people are trying to hold on to their own systems of power. This is an adult issue that we are looking at.

And so I would just say that if we can look more into that and provide a better way forward so that we can do what we know works. PHQ, right? Even you look at the PHQ for, by the way, PHQ is an assessment tool for depression. When you even look at those key questions, you can tell that something's going on, whether someone has lost their appetite, whether someone can no longer sleep very well, whether someone is losing hope. Right?

These are key questions in PHQ that even if we did that, think about how many young people we could have on our radar screen to be able to interact with them more so that we can prevent greater mental health things going on. I must admit I'm very frustrated about this, if you can't tell, because we talk about youth being in a national mental health crisis,. Suicides being the second most cause of death, and adults can't get their act together to do something that could literally save lives.

You have nothing in your purview that is responsible for that. You're just here, and I'm sorry, you're now divine focus. Anyone else want to take the seat? Right.

But the idea is this, we're still not acting as if this is a crisis. We are doing a great job of beginning to look at the whole mental health infrastructure pipeline, directing more money towards facilities. We need more inpatient and outpatient facilities. We need more beds for people to housing for those with mental health issues. We're dealing with it on the homelessness front, we're dealing with workforce dollars, but we're trying to save workforce dollars for these things. Right.

But we're not doing anything right now of significance to stabilize the current population. Right.

And we're seeing some good practices from time to time, but we're not doing it statewide. And if I hear someone tell me about local control one more time before we have to, instead of focusing on saving lives. Right.

I might need an evaluation. So I think the idea is we've got to be more aggressive. I can't think of a time that we're right now that we should not be more aggressive. And so I would urge you to even be more aggressive with your recommendations. Let's really dig in there, because we are in a crisis. And I'm just dumbfounded by system leaders being more concerned with the system than the people that the system is supposed to serve. So I would just urge that we do more. Thank you.

Thank you, Dr. Ewing. I'm going to focus, if I can, on the Commission's work, which are highlighted predominantly on pages 30, 31, and 32. I'd like if I can, for you to speak about the Mental Health Student Services Act implementation and see if you can paint a picture for us on how we're bringing mental health services to our schools.

Thank you, Dr. Arambula, for that question. And I will sort of weave in some responses to Member Jackson along the way, if I may, so you know just recall that the Commission's work on the Mental Health Student Services Act really was designed to incentivize partnerships between school districts, local education agencies, and behavioral health departments, where we had examples of strong partnerships happening across the state. But to Dr. Jackson's point, one-offs or examples, we were not seeing scale.

We were not actually seeing strategies that were learning from one particular program and extending that into these other programs. That capacity to learn and to scale transformational change was missing. The MHSSA, the design that the Commission brought to this was not to try to fight every battle around local control. It was to say, we will incentivize a partnership. And what that partnership looks like needs to be tailored to what's happening in Los Angeles or Del Norte or Imperial or Trinity.

Recognizing that there's lots of differences and in terms of needs, the politics, the relationships, but also their capacity to deliver. And so the Mental Health Student Services Act really wasn't designed to be a unified statewide program. It was designed to be a statewide incentive to create strong partnerships that could be tailored to local needs and that ideally would flourish through the capacity because it's short one-time money, a limited dollars was not a lot of money. 6 million was the largest grant to LA County.

Two and a half million was a grant to smaller counties. And so we never thought that what we could get with that was to pay for care for every student. What we knew we could get was county behavioral health departments and leas that were already working together, to work together better, those that had not yet met each other, to connect in ways that would be supported at our fiscal risk, let us put the money on the table to get them to engage and take risk.

We saw this as an incentive and an opportunity for innovation locally. We went down to Imperial County a few weeks ago and heard from local directors there that it has been phenomenal in that their education leadership and their behavioral health leadership are partnering in ways that they had never spoken to each other. And they're engaging and they're engaging their juvenile justice partners, they're engaging their food banks, they're engaging broad community partners to create a partnership.

They've put more local dollars in, well beyond what the state put in to create that partnership. And we're working to actually bring some young people from imperial up to Sacramento for your May hearing a couple of examples, a young woman shared that she was getting all f's because school was not a safe, comfortable place for her, and because her school provided her with a therapist at school who connected with her teachers, she's passing all her classes.

A young man said, he talked about struggles, and this is a largely impoverished community, right? Farm workers, I think they said 67% non-English speaking in the household, something like 76% free introduced price lunch eligibility across their entire student population. And this young man says, school was not positive for me, and I was out of school more than I was in school until this program came along. And I realized that if I was struggling, going to school got me access to a therapist.

And so now I'm actually participating in school as a strategy to actually address the issues that he's dealing with, driven from his community, his family, his life experiences. So Imperial county has really tailored a strategy that meets their needs very different in Ventura, where they're working to build out wellness centers in all of their high schools and all of their middle schools. Some partners are really focusing on screenings and assessments, suicide screenings in particular.

Some are working on trainings for their teachers so they can understand and recognize the needs of mental health needs of the students that are in the classrooms. So we're working to put together sort of a portfolio of what these practices look like. Our role has been to incentivize these partnerships and then to facilitate cross partnership learning. And so we host learning collaborative meetings. We don't have the expertise in school mental health. That's not who our staff are.

We have some, but what we're really trying to do is to connect local partners with each other so that they can learn from each other and get to the point where that scaling and that continuous improvement and that collaborative learning is happening on their dime as part of their normal course of business. That's the best that we could do with one time funding, limited amount of money. And so we'd be happy to give you more examples if you'd like to see those.

In terms of what's happening in your districts or in any districts. Our goal is to really elevate those successful practices so that they scale in ways that still can be tailored to the challenges that are unique to rural, urban, high schools, middle schools, elementary schools and all the above.

I'll use that then, earlier you stated in your testimony that it's your job to elevate innovation. And you also stated that early psychosis is the most important early intervention that I'd like to try and understand if I can. Your thoughts on early psychosis only being only being in 14 counties out of 58? Since this is the most important strategy, how do we make sure that all counties are aware and are learning from your Commission so that we can Institute this at scale?

So you have in the audience here today and who I think will present one of the foremost national experts on this issue. And I'm hesitant to try to sound smart in front of her or her team. What we did was this project started with hiring researchers to go out and ask tough questions about what's available today and are we delivering highest quality of care. And the answer was, it really depends on where you live.

It depends on what insurance coverage you have, how assertive you are, how aggressive you are, how hard you are willing to fight to get what you need. And in response to that, and consistent with Member Jackson's comments, that's absolutely inappropriate right we use limited funding, one time money to try to incentivize opportunities to strengthen early psychosis care.

The funding that we've made available is from the state, but in partnership working with counties, we've been able to leverage county innovation funding and some federal money and some philanthropic dollars to actually build out a learning collaborative that is designed to be data driven, designed to provide technical assistance and support. And it works with people who want to work with us. And so because we don't have the funding to scale this overnight, what the Commission does is create opportunities and then asks who's interested?

We tend to focus on those folks who want to engage because they're easiest to work with, particularly when this work is hard. And this work is very hard for lots of reasons. I'd say three in particular, workforce, as you all know, as has been discussed in many of these hearings. Second would be technical assistance. People coming out of training programs are not on first day skilled in delivering this kind of care.

And so there's a lot of technical assistance to move from typical care, what we might call standard care, to effective evidence based practices. We don't have this problem in other areas of health care. We have this problem in mental health care. And then the last piece is funding. Our financing systems don't actually pay for the care that the research shows is necessary and most effective.

And so we have been promoting a range of strategies, including doing research with managed care organizations to see if we can document that it's cost effective for them to pay for evidence based care as a way. Although the mental health costs go up, we anticipate that the overall health care costs would go down because someone can manage their diabetes care better, right? Or they'll avoid ER utilization.

For those reasons, the work we're doing there is probably not going to pay off because there isn't enough time and the subject base isn't big enough to really make the case for insurance companies to voluntarily jump in. But the Commission is promoting a strategy through some of our workplace efforts to encourage the state to leverage the public sector purchasing power of health care benefits through our pension plans, to actually create a marketplace where access to care mental health funding matches expectations for care.

We don't have this problem in other areas of healthcare. We have this problem that there's a mismatch between what we need to do and what we're willing to pay for.

Can you say a little bit more about the innovation summit that's at the top of page 32? When and where was it? Who was there? And what was discussed?

So in 2018, in partnership with county Behavioral Health Directors, with some Philanthropy with Verily Health, which is a healthcare division of Google at the time, hosted an innovation summit. At this point in time, although the Mental Health Services Act requires a 5% set aside for innovation, and the law says use the money or return it, the Commission found that counties were not investing in innovation. And so ultimately, the Auditor and LAO, I've forgotten who actually did the work, found about, or DHCS, found about $350,000,000 in unspent funds. And a significant portion of that was innovation. There was hesitation and frustration on the part of counties about, what does this look like? What does this mean? We did not have streamlined systems for Commission approval or for county approval. And so the innovation summit was designed to sort of kickstart.

What we wanted to do was to create a partnership between the mental health community in California and the innovation community in California, which is why we turned to verily health. Right. And at that time, there was a lot of frustration and pushback in communities, in counties. We had counties that invested in a community garden. In Fresno, your county invested in a community garden as a strategy to engage among immigrant community. And there were editorials saying that this was a complete waste of money.

We wanted to create this partnership so that when counties were trying new things, and even if those new things didn't work out and someone wrote an aggressive, negative response, that the business community would step up and say, I'd rather live in a state that's trying to do better than in a state that's given up.

And so we turned to the best innovators in the world to try to bring that culture, that perspective and attitude, and to create stronger freedom and willingness on the part of our county partners to take risks. And subsequent to that summit, it was incredibly successful, and it was really difficult and challenging all at the same time. But in subsequent years, we've seen an explosion of county's interest in innovation, and we've seen a much greater willingness to try creative things.

Much of the innovation that the Commission reviews and approves is more about continuous improvement kinds of things. It's not colonize Mars kinds of innovation. It's how do we get better. The Commission is exploring the idea of hosting a subsequent mental health summit, possibly next year, to really achieve three things. The first is to just celebrate the fact that counties are innovating and how important that is. It's 5% of the MHSA, but it's less than 1% of overall public mental health spending.

And so it's a tiny investment that has outsized potential for impact. And so we want to celebrate that because counties are taking risks, they are doing things that are hard. They're doing things that may be bucking traditions or cultures, and so we want to recognize and reward them. Second, we want to identify core priorities that should be on the table for innovation, right? So what are the big challenges, as Member Jackson points out around screen, like, what should we be innovating in? Right?

Where might we identify, how might we identify core issues that should be the focus of this investment from a statewide perspective, but still respecting local decision making? And the third issue would be, as we identify those core challenges, might we identify partners who have expertise, who could lean in, co-invest, and support success, particularly where we're asking the behavioral health system to tackle challenges that are outside of its comfort zone or level of expertise?

California has the academic research potential and capacity that is unrivaled in the world. We have an innovation sector that is unrivaled in tech, in communications. We think that there is no problem that we cannot solve if we can marshal the political capital, the ideas, the resources, the expertise, and point that all of those resources and energies towards those challenges.

And so that third issue is about how do we bring together the support that is necessary for this less than 1% investment to actually trigger the kind of transformational change that is necessary that we don't have to have a conversations about. Is screening appropriate? Because we don't have to have that conversation in other areas of healthcare.

Thank you, Dr. Ewing. I will thank very much this entire panel. And we will move on to issue two. The focus of the next three issues is on the children and youth. And the first of these is an oversight issue. We will begin with Fiona Lu, a youth advocate with GENup. Will you please begin when you are ready?

Good afternoon, Chair and Members. My name is Fiona Lu, and I'm currently a high school senior at Northwood High School in Orange County, California. I'm also a youth advocate with GENup, a youth-led organization that champions educational equity through state policy and grassroots organizing. It's an honor for me to be here today to talk about youth behavioral health, and I deeply appreciate the State of California for prioritizing youth voices in these spaces.

It's known that every generational cohort witnesses an event so critical in their lifetime that it defines a bonded experience for most people in that age group. Among other things, the pandemic was undoubtedly a major life alteration for Gen Z. I've even heard people make jokes that we can pinpoint the exact moment. All of us were thrilled to be off school for two weeks, thinking that it would just be a small interruption in our lives. This was obviously not the case.

The reality is that the effects of the pandemic are still ongoing and insidious for youth mental health. If you had asked anyone who knew me both before and after the pandemic, they would describe "before me" as outgoing, extroverted, and frankly, annoying, and "after me" as more cold, reserved, and introverted. And there's nothing wrong with being introverted. But the truth is that my change in character was due to my skyrocketing social anxiety from the isolation of the pandemic.

This was coupled with depression and loneliness I already felt in my freshman year because I had been separated at my new school from my friend and my support system because of rezoning in my district. Being trapped in my room and on Zoom for days on end caused my increased anxiety, feelings of sadness, chronic exhaustion, and learning loss, a lot of which I still suffer from today.

This testimony wouldn't be a full and accurate attestment to my mental health journey if I didn't speak about the overarching problem that prevents youth like me from seeking help: the stigma. Like many other youth in California from diverse families, I grew up in a household where I not only felt like mental health was not discussed, but where I also felt like my family hadn't had the opportunity in life to even address their own mental health.

Take my single mother, for example, who juggles work on top of taking care of me, my brother, and my grandma, and running errands to keep our family functioning, leaving her with no time for self healing and seeking help. This is why, at every doctor's visit, with her peering over my shoulder at the teens-only survey they gave me, I would reluctantly choose "never" for all the questions that asked me whether I had experienced any mental health struggles.

I hope that more resources are catered towards parents who are like my mom, who is an immigrant and a Chinese native speaker, and who is also foreign to what mental health awareness looks like in the US with a culture that is vastly different from her homeland. This will help them better understand what their children are going through and how they can help support them in navigating their process. Another critical access points are schools.

As students in the K-12 public education system, we spent a vast amount of our time in the school setting and even after school being integrated in that same setting. The interactions we have daily with our peers, teachers, and school administrators all contribute to what type of environment we foster for ourselves in our schools, and whether that environment is safe or discouraging.

As a student who attends a school that is academically rigorous and puts an emphasis on grades and maximizing our time efficiency, my mental health is also one that is grounded on burnout. Even though my school says they prioritize student mental health, that is not the way that is vastly received by many of my peers. Our teachers still emphasize grades over learning and our counselors and Administration are complacent.

Recently, my school implemented a punitive tardy policy that locks students out of class even if they are a minute late, which causes them to get to class even later, sometimes 10 or 15 minutes. This is a disruption to their learning, other peers, and for the teacher. During this tardy sweep, they had also even played music that sounded like purge music on the school speaker, which made students feel mocked and ashamed.

Educators need to receive adequate and meaningful trainings that are student-centered to learn how excessive schools, disciplines such as these, which keep students away from class rather than incentivizes them to have a good relationship with schools, are dangerous and affect the most vulnerable groups. As someone who had trouble waking up for school in my freshman year because of chronic tiredness, I had no doubt that this policy would have driven me away from feeling safe at school even more.

California is a leading state with the mental health resources that we provide for our youth, families, and schools in many other communities. And even though this is the case, we still recognize that we have a long way to go in supporting our most impacted communities. And with that, thank you for allowing me to share my experience today.

Thank you. Our next speaker is Kassy Poles, who is a youth mental health advocate and a member of the Children and Youth Behavioral Health Initiative Advisory Board. Begin when you are ready.

Hi, how are you guys doing today? Hi, my name is Cassie and I'm a youth advocate. We are at a record high for the amount of people seeking mental health services. Mental illness is the most common health condition faced by Californians. Nearly one in seven California adults experience a mental illness. One in 26 experience a serious mental illness, and one in 14 children have emotional disturbances. Currently 5.7, which is about three and a half million people, have unmet mental health needs.

36% of those people could not afford to get the help they needed, but 67% could. I have been a receiver of mental health services for more than half of my life, and I can personally vouch for this, and the difficulty in finding services that are timely and aligned with who I am and what I need.

Before the pandemic, our mental health care system was already in a crisis situation with the second opiate wave, continued stigma around mentioning mental health, a continued lack of resources and education all over the state, and the mentality of punishment over rehabilitation was already wearing down the system. When Covid came, the system came tumbling down with it. After having my therapist of 10 years quit, I went two years without active mental health treatment, despite given outside referrals, but yet no providers returning my calls.

This led me to a crisis point in which I am still recovering from. I was told by four Kaiser hospitals that I was not sick enough for their intensive outpatient program, despite having severe depression, nearly having a manic episode, and self medicating, the best they could do was three crisis counseling sessions in which I had to wait two weeks before my first appointment. I never want anyone to go through the experience of feeling like they need to harm themselves to get help.

In these unprecedented times, we are being handed the golden ticket to collaborate and create a functional system that would be able to hold its own for decades. In an article written by CalMatters, Christine Stoner-Mertz was quoted saying, "the question in our minds is, what is the approach and process to solving some of these problems? We would welcome greater partnership around that," and this is where I come in.

I'm here today as both a receiver of mental health care services and as an advocate to tell you what the solutions can be. And it's pretty simple. Youth involvement, engagement and continuous education, and more access to substance abuse resources, but above all else, love and compassion. Earlier this year, California Health and Human Services, as part of the CYBHI initiative, published a report called Youth at the Center. It gives us 12 call-to-actions to reimagine the system.

But as evident today, we are missing one very huge and important aspect of this: youth. We must have youth be involved and they must have a seat at the table. We want to be involved and we want to be actively participating. I don't think youth get enough credit for what they're capable of bringing to the table. And if the adults in the room cannot work in partnership with each other and offer youth the support they need, nothing will change.

Senate Bill 224, which was signed into law in 2021, requires that schools with health classes now have to expand the curriculum by the curriculum set by the Department of Education to include mental health. However, the scope of this Bill was limited to only those schools that offer health service, that offer health classes, and gives no extra funding to do so.

If we can barely give an equal educational opportunity to all walks of life in the state, how can we expect there to be culturally sensitive, diverse and effective education about mental health? When I was in elementary school, we had a thing called Ocean Week, which was a week dedicated to learning about different aspects of the ocean. So I think there should probably be a thing called mental health week, where every year from K-12, students learn and discuss mental health through evidence-based practices.

This can be done by partnering with outside nonprofits and educational programs. Studies have shown that this leads to an increase in suicide prevention awareness, a decrease in depression and suicide attempts, as well as creating solidarity and better peer support among the school community. It also provides access for all. I'm hopeful about a Bill moving through legislation this year, SB 509, that aims to mandate mental health instruction at all schools.

24 counties in California have no detox or MAT treatment options or harm reduction programs like needle exchanges, safe injection centers, and lack of naloxone, which as a result, these counties have much higher rates of overdose. Every county should have to sustain a set number of recovery resources per capita, and those resources need to be placed within marginalized communities and receive adequate funding by the state. We also need to change the perception of these words. Needle exchanges do not create more drug addicts.

It simply allows for those who already use the ability to get clean supplies, which lessens the burden on the system from overdoses, HIV, hepatitis and other illnesses. It can also lead a person to getting help in a way that's nonjudgmental and in a safe environment. As a former heroin and meth addict, substance use felt very limited. When I entered treatment at 20, it felt very isolating.

I have always had the viewpoint that we need more harm reduction and that it needs to be more acceptable in addiction medicine, especially as young people are being more and more involved in choosing their treatment plans. You shouldn't have to be ready to entirely quit using before you're able to get help. It allows you to go at your own pace and do what sets you up for success.

We need to stop having the one-size-fits-all approach. For some, abstinence work, but it creates a wall of shame and embarrassment. You also shouldn't have to live in fear of being punished for having mental health issues. The formula is pretty simple: youth involvement, engagement and continuous education, as well as more access to substance abuse resources and loving one another. What are you guys going to do to make this happen? Any questions?

I got a ton and we'll ask them at the end, but I'm just going to take a moment and appreciate both Kassy and Fiona for grounding us in the perspective of our youth. It's very important for us and it was intentional as well to make sure that we both created the space, but look forward to being able to engage in conversations as soon as we finish this panel.

Thank you.

Next we will hear from Director Melissa Stafford Jones, who's the Director of the Children's and Youth Behavioral Health Initiative.

Good afternoon, Dr. Arambula and Members of the Committee. Again, Melissa Stafford Jones, Director of the Children Youth Behavioral Health Initiative at the California Health and Human Services Agency. Thank you for inviting CalHHS today and for the opportunity to provide an overview and a status update of the work underway on the CYBHI. Behavioral health continues to be a top priority for this Administration.

We are fully committed to accomplishing our transformational goals to improve the mental health, well being, services and ongoing supports for all Californians, including our children and youth who we know are struggling. And this is a commitment we know we share with all of you and appreciate the leadership of the Legislature on the critical issue of children's mental well being.

As you know, the CYBHI is a five year, $4.7 billion initiative working to reimagine and transform the system supporting behavioral health and well being for children and youth into a more coordinated, youth-centered, equitable and prevention-oriented ecosystem of services and supports. It's a core element of the Governor's master plan for kids mental health, which takes an all-of-the-above, cross-sector, systems-change approach to improve kids well being and access to services.

And we know the need continues to be significant and urgent, with children and youth continuing to struggle as they have over the last decade with increasing mental health challenges.

And we also know that although these challenges for youth have grown overall and can affect all youth, some groups of youth are disproportionately impacted, including our BIPOC youth and families, LGBTQ+ youth, youth from low-income and underserved communities. And these groups face more systemic barriers to accessing services and supports and building a more equitable ecosystem is core to the work of the CYBHI, and the Legislature's and Governor's recent budget investments and actions underscore the commitment to solutions to addressing these issues.

We have heard loud and clear from our partners working on the CYBHI over the first 18 months of implementing the initiative that simply doing more of how systems and services work today is not good enough and will not be effective in building the systems and services youth and families need for mental health and well being. And I think we just heard that from our two youth as well. Partners emphasize the need for fundamental transformational change, and we recognize that the systemic change is needed.

Breaking down silos, coordinating across systems as Assemblymember Jackson talked about, in ways that actually center kids and help them access the supports and services they need as early as possible. Reducing stigma and discrimination cannot be addressed overnight, but the need for this work is acknowledged universally at the Legislature and among our partners.

We have particularly heard this from youth, as you heard already today, who have challenged us to redefine treatment to include not only clinical services, but also things like arts, activities, mindfulness, access to safe parks and green space, access to peer services, and as you heard so powerfully from Miss Poles about love and compassion relationships with caring adults, that culture and culturally relevant practices must be part of healing, youth have emphasized.

Youth have told us they need systems to stop waiting until they are in crisis to support them, that they want and need a behavioral health workforce that looks like them, speaks their language, comes from their communities, and understands their experience. Youth have also told us, as we heard from the youth who presented, about the importance of ensuring that their parents and their families have the care and supports they need because our young people know that affects their well being.

And youth have also told us that the harm systems have caused to the mental health and well being of some youth families and communities in the past must be recognized for them to trust that the improved systems we are all working on will truly support them. What youth and families want and need to improve behavioral health is summarized in the recent report that was mentioned, Youth at the Center, and its findings are really grounding and guiding the work of the Children and Youth Behavioral Health Initiative.

All of the work streams in the Children and the Youth Behavioral Health Initiative are continuing to engage youth and families. The initiative overall is also in the process of forming a children, youth and family engagement network that will continue to strengthen and build our capacity for ongoing youth engagement in the CYBHI, including the formation of an evaluation advisory group to the CYBHI that will include youth and families, and I'm pleased that Ms. Poles has actually agreed to be a member of that group.

We are also in the process of working to hire a youth fellow to be part of our CYBHI team at CalHHS. CYBHI has been progressing with research, planning and design and we are now actively moving into the implementation phase with many of the CYBHI's 20 component work streams.

Through the end of 2022, we had engaged over 1000 organizations in our efforts across multiple sectors of health, education, community, families and youth, conducted almost 400 listening sessions and expert and stakeholder interviews, and held over 75 roundtables and focus group discussions. We've held almost 50 events directly engaging youth and families, and cross sector collaboration and centering what youth and families want and need is central in the work.

The input, the insights, the expertise from both lived and professional experience from our engagement with our partners is shaping the plans and work underway through the CYBHI. And meeting kids where they are at is critical to increasing access to behavioral health services and supports, and we know that schools are where many kids are.

Health school partnership is core to the work of the CYBHI and includes multiple efforts to support increased access to school linked behavioral health supports and services for students, which you will be hearing more about from my colleague Autumn Boylan, as well as other presenters today. CYBHI also released a working paper earlier this year on this issue about how do we put into practice more coordinated efforts across education and the health systems.

For example, CalHHS and the California Department of Education are in discussions around how we can support coordinated implementation of community schools and the CYBHI at both the state and local level. The overall work of the CYBHI has four main focus areas, building the behavioral health workforce, building infrastructure we need across the ecosystem for that more coordinated, integrated approach. Coverage and all payer financing and increasing public awareness and reducing stigma as we heard from our youth is so incredibly important.

The work in each of these focus areas is led by and coordinated across multiple departments within CalHHS, and you will be hearing from those departments about their specific work streams next from the Department of Healthcare Services, and later in the agenda, from the California Department of Health, Public Health and the Healthcare Access and Information Department about the concrete activities and progress underway in each of the work streams that their departments are leading.

In January of this year, we also published a CYBHI progress report, which is available on our website to provide updates on the activities and accomplishments of each component. Spending plans of over $2.3 billion for work underway across the CYBHI are in place for years '21/'22 and '22/'23, combined with an additional estimated $750,000,000 planned spending in '23/'24 additional funds will be spent as they become available in the out years of the initiative.

And lastly, for the initiative overall, CalHHS has selected Mathematica as our evaluation partner for the CYBHI, and groundwork is underway for the evaluation, including, as I mentioned, formation of an evaluation advisory group, finalization of our outcomes, goals, and ongoing work to make the evaluation a learning process along the way, and not only a report that comes out at the very end, but hopefully an opportunity to be learning along the way.

Before turning it over to my colleague, Autumn Boylan from DHCS, to report on the specific work that DHCS is leading, I was asked to provide a brief report on the two CYBHI components underway through the Office of the Surgeon General. The first of those is that the Office of the Surgeon General was funded $1 million under the CYBHI to develop a trauma-informed training for early care and education personnel to help build an overall more trauma-informed system of services and supports, since we know that stress and trauma can have a significant impact on a child's health, development and their ability to learn. The training is designed to provide foundational knowledge and the Office of the Surgeon General has worked with an expert working group as well as many stakeholders over the last year to inform its development. Beta testing by 200+ practitioners in the field was recently completed and the training will be publicly online for free to educators and other child serving staff this summer.

It includes specific modules for three age groups: 0 to 5, 5 to 11, and 12 to 18, and is computer, smartphone and tablet compatible. The training is designed to engage the learner with examples, strategies and practices that vary according to developmental stage served, and includes topics such as identifying activated stress responses, self regulation for children and adults, and looking at practices and conditions that really support safe and supportive relationships and environments in schools.

And I think we heard from Miss Poles about the importance of that work. The OSG will be working in the coming months to deploy the training and help make sure it reaches its target audiences and to hear ongoing feedback on the training.

The second work stream under the Office of the Surgeon General is part of CYBHI's fourth bucket of work to increase public awareness and help kids get connected to needed services and supports. And as part of that, OSG is implementing an ACEs and toxic stress public awareness campaign that was created in the CYBHI.

The campaign aims to provide awareness, support and healing strategies for individuals and communities by increasing awareness of the impact of trauma on a child's health and development, providing support to parents and caregivers in raising resilient children and creating positive experiences for them, while also supporting older youth with the tools to enhance self care and reduce stress. The campaign will highlight and engage communities in practical strategies that parents, caregivers and young people can build upon.

The campaign will primarily focus on engaging economically disadvantaged LGBTQ + and rural communities, communities of color, immigrants, refugees, justice and welfare-involved youth and young people ages 18 to 24. A campaign vendor contract was recently awarded and the campaign is anticipated to launch in the fall of this year. Thank you for the opportunity to present today and I look forward to answering your questions.

Thank you. Our next speaker is Autumn Boylan, Deputy Director of Office of Strategic Partnerships with the Department of Healthcare Services.

Good afternoon and thank you for having us here today, Chair Arambula and Members, and thank you to Ms. Poles and Ms. Lu for their testimony this afternoon. We have had the pleasure of working with Ms. Poles in the work that we've done at the Department of Healthcare Services and some of her colleagues, and really appreciate having their voice and their bravery coming here before this audience today.

The Department has made significant progress and taken important steps to implement the key provisions of the Children and Youth Behavioral Health Initiative that we oversee, including improving access to critical behavioral health services and supports for children, youth and families across the state. Over the past 18 months, our Department has engaged extensively with over 1000 unique and diverse stakeholders from across the state, as well as key implementation partners for the work that we are leading.

Most importantly, we've worked to include voices from youth and families as well as caregivers in this work. We've also engaged with our local education agency partners, educators, healthcare providers and payers, behavioral health experts, and community-based organizations, among others. We have done this through key informant interviews, town hall sessions, roundtables, surveys, work groups, two expert panel think tanks, and monthly webinars where we've shared information publicly on all of the status of our work streams.

We have, in all of this work, prioritized hearing from children, youth and families, and not just hearing from, but actively engaging as partners, youth in the work that we've been doing. We have convened with a youth advisory panel who has explicitly informed the work that we've done around the virtual services platform and school-based services, and have partnered with Ms. Poles and others to help co-facilitate focus groups with other youth throughout the state.

We've engaged in total with over 300 children and youth, and really we do not have a "if we build it, they will come" approach to this work. We know that it needs to be designed by and for youth and with their voices in mind.

Throughout this engagement, we've also sought to engage diverse populations, regions and age groups, making sure that we're inclusive of individuals from Black, Latinx, Asian American, LGBTQ+ communities, as well as other historically underserved populations such as rural communities, families experiencing homelessness, justice-involved and foster youth. We've also convened over 200 leading experts in think tanks and various work groups and will continue to partner throughout our work. At the Department, we oversee 12 different work streams.

I'm going to give a brief update on some of those work streams today. In January of 2023, so just this year, the Department implemented the Medi‐Cal dyadic services and dyadic caregiver services benefits. Dyadic services integrate physical and behavioral health screening and services for the whole family during a child's well visit, and not just the child who is the identified patient.

Adding dyadic services as a Medi‐Cal benefit offers sustainable funding to create and maintain this infrastructure for integrated care for children, creating seamless access to behavioral health assessments and connection to other locally available services as needed. We are also leading efforts around the Behavioral Health Virtual Services Platform, which will launch in January of 2024.

The Behavioral Health Virtual Services Platform is a technology-driven solution for all children, youth and families in California that will improve access by offering youth, parents and caregivers a new way to access behavioral health services and supports. The platform will provide support and resources such as interactive digital education tools, self monitoring tools, app-based games, mindfulness exercises, and access to free on-demand, one-to-one coaching and counseling supports. It'll also include the opportunity for young people and parents and caregivers to engage in screening and assessment.

To better understand the behavioral health needs of our youth, we conducted an extensive market scan to review digital behavioral health platforms that exist in the world today--so not just in California, but across the globe--conducted a request for information and numerous vendor demonstrations to get to the right answer for California's digital behavioral health solution.

We recently announced that we have selected a primary vendor partner, Kooth, and Kooth is a pioneer in youth-focused digital behavioral health, with a platform that is today accessible to over 8 million teens and young adults. In partnership with Kooth and other selected vendors, we will continue to conduct extensive user testing to obtain input from youth and families as key partners in the design, content creation and functionality of the platform to make sure that it meets the needs of our youth.

These activities will continue both prior to and after the go live in January. We are also working with leading vendors to provide a statewide eConsult solution for pediatric and primary care providers to be able to connect and get consultation from licensed behavioral health providers in the state.

To date, we have engaged extensively with leading experts on the econsult services and recently launched a work group representing primary care providers, pediatricians, behavioral health experts and others to help inform the design of the statewide solution, which will launch in January of 2024.

We have also worked with stakeholders closely to identify and scale evidence-based and community-defined evidence practices through a granting initiative that is scaling these practices throughout the state based on robust evidence for effectiveness and the impact that the practices have in terms of racial equity and sustainability.

We publish a grant strategy document outlining our approach to scaling these evidence-based and community-defined evidence practices across six distinct rounds of funding, with each having a distinct priority focus for the funding. And to date, we have released the funding applications for two out of six of the rounds of funding and are getting prepared to release the other rounds of funding.

The six rounds of funding focus on parent and caregiver support and training programs, particularly focused on supports for young children ages zero to 12, including practices such as Triple P, Incredible Years and Healthy Steps, which is the foundation of the medical dyadic services benefit.

We are also scaling trauma-informed practices and programs such as trauma-focused CBT, cognitive behavioral intervention for trauma in schools, multisystemic therapy and others. Early childhood wraparound programs including home visiting models and infant and early childhood mental health consultation, youth driven programs in partnership with the Mental Health Services Oversight and Accountability Commission, including the ALCOVE model, early intervention programs particularly focused on early psychosis, which we know is of particular interest to this panel today. And partnering with the California Department of Public Health to identify strategy to scale community defined evidence practices in a managed care environment.

As I mentioned, we are working closely with the Mental Health Services Oversight and Accountability Commission, who will lead, in consultation with DHCS, the Grant Administration activities and provide technical assistance to grantees for the ALCOVE Program and coordinated specialty care. We also are leading, as part of the master plan and the CYBHI, a number of initiatives to expand access to mental health and substance use disorder services and supports for children and youth through schools.

This is building off of and leveraging the work that has already been done around the Mental Health Student Services Act, which you heard Director Ewing talk about earlier today, as well as the Community Schools Initiative, as Melissa Stafford Jones mentioned in her opening comments. In collaboration with the California Department of Managed Healthcare, we are working to develop and maintain a school-linked, statewide all-peer fee schedule that will reimburse school-based and school-linked providers for delivery of outpatient mental health and substance use disorder services.

This includes psychoeducation services, screenings for school-age children for both mental health and substance use disorder services, treatment case consultation, and many services within those categories. The fee schedule will launch beginning in January of 2024 and will be implemented across the state in a phased approach to ensure successful participation by all publicly funded K-12 schools and districts, as well as the California Community Colleges, California State Universities, and University of California systems for all students under the age of 26.

The goal of the fee schedule is to simplify reimbursement processes and administrative burdens for schools, school districts and their partner organizations, including community-based organizations, county behavioral health departments and behavioral health providers to obtain reimbursement from all payers. So that's what makes the CYBHI so unique. It's not just the medic health program or commercial health plans, but really thinking about that universal approach to making sure that children in our schools have access to the necessary behavioral services and supports.

This includes services provided at school or near school through partnerships between schools and communities. DHCS and the Department of Managed Healthcare collaborated to launch a statewide cross-sector work group, consisting of over 60 members representing local education agencies, education sector associations and union representatives, county offices of education, county behavioral health departments, health plans, both commercial and Medi-Cal, among others, and we acknowledge that this is a complicated and complex initiative.

There are still many outstanding policy and operational questions about the fee schedule implementation that we are working with our colleagues and implementation partners to address. We are carefully considering input from our implementation partners around policy decisions in collaboration with our schools and health plan partners, as well as the counties. And the intent of the workgroup is to help inform these complex policy and operational decisions, and the workgroup will continue to meet throughout 2023 and beyond as necessary to inform this work.

We also meet separately and regularly with county behavioral health plans and associations, the health plans and associations, and local education agencies and a large coalition of education leaders.

We are working closely with the LEA and institutions of higher education partners to also, in conjunction with this fee schedule effort, to design the granting initiative for the School-Linked Partnership and Capacity Grants, which will be used to support operational readiness and help schools be positioned to be able to deliver a wider array of services to students on school campuses. We are finalizing the grant design administration strategy and anticipate issuing the grants beginning in June of this year.

And we also, as part of the Student Behavioral Health Incentive Program, have launched in 2022 the incentive program to encourage managed care plans to partner and build sustainable relationships and infrastructure between the Medi-Cal managed care plans and local education agencies, which will also lay a foundation for the work we are doing with the fee schedule as well.

The Student Behavioral Health Incentive Program improves coordination of student behavioral health services, increased access to preventative and early intervention behavioral health services for transitional kindergarten through twelveth grade, increases mental health services on or near school campuses and increases access to behavioral health services through school-affiliated behavioral health providers.

Furthermore, through the CalHOPE Student Support Initiative, DHCS and its partners have established a statewide social and emotional learning community of practice, which aims to provide resources, training, and support to local education agencies for implementing social and emotional learning programming in schools, including some of those that were mentioned by our youth speakers, such as partnering with nonprofits to be able to provide SEL programming in schools. DHCS also launched with partners, the calhopeschools.org website that ensures that these resources are available statewide through our CalHOPE program.

As we roll out all of these school based initiatives, DHCs and DMHC are also developing oversight strategies to ensure successful implementation and coordination of these programs at the local level, working with our colleagues at the Department of Education and State Board of Education to coordinate and align implementation strategies for the CYBHI community schools and other programs.

We are also engaging regularly with the local education agencies, health plan partners, and counties as we address operational considerations such as quality oversight and monitoring, which we know is at the forefront of their minds as well.

And furthermore, all Medi-Cal managed care plans will be required to enter into memorandum of understanding with the local education agencies in their service area is beginning in 2025, and this MOU requirement will include the provisions related to coordinating various school-based services and programs and efforts between the managed care plans and the local education agencies. Thank you.

Our next speaker is Dr. Toby Ewing.

Thank you very much, Mr. Chair and Members. Toby Ewing, on behalf of the Mental Health Commission, the agenda really highlights. A couple of questions here for the Commission. Do we see gaps in the state's efforts to meet the behavioral health needs of children and youth and our counties making good use of the funds that are available under the MHSA?

And we don't have to look farther than the Administration's handout that identifies some of the statistics around suicide risk, just profound sense of hopelessness among young people who should be at their most sort of joyous and hopeful times in their lives. And so the data really suggests profound impacts. I want to highlight that we're seeing tremendous work happening across the state, as evidenced by the testimony that you just heard on school mental health, on prevention, improved access to care, youth empowerment.

The young people presenting before you today is phenomenal, something that we're seeing more and more in the Legislature, exceedingly rare two years ago. And so the state is making profound progress in terms of tackling the issues. We're asking the questions about universal screening that we weren't asking before, but we're not at the point where we don't need to ask those questions right. We're not at the point where we can say that we should pat ourselves on the back and that we're done.

It is still too hard to access care services and supports are often unavailable in ways that are tailored to who these individuals are, where they live, work, play, love, and spend their time. We have tremendous barriers to care. Item one on this agenda references some reauthorization funding that we're seeking, in part because we've given funds out to counties and they've given it back. I'll use the youth, the alcove funding in particular. Alcove on paper is a very elegant, simple, tailored strategy.

Open the door, let young people walk in and meet their needs. Physical health, primary health care, mental health supports, no questions asked all payer strategy consistent with CYBHI, we've had county partners turn down the money because it's harder to implement than it should be. Few providers do the level of integrated primary health care and mental health care that young people are seeking.

And we know if they come in for the primary health care and we need to send them down the street, around the corner in the next town or wait a month to get access to the mental health care, they won't follow up. International research shows if you integrate the services, if you open the door, if you design the service with youth in Santa Clara County, where we helped support the first alcove. They asked young people to interview the staff who were being considered for hiring.

They were going to hire a very qualified nurse practitioner. And the young people said the vibe isn't there. They didn't hire that person because they put young people first in front, in the design, in the delivery, even in the staffing of services. Who is going to be most appropriate working with the young people who are going to walk in the door? It's very difficult.

On paper it looks easy, but in practice, because of funding and licensing and the hiring and training, we've designed this system to look very different. I was thinking about this and if we want to serve whoever walks in the door, we really need to rethink the design of the system consistent with what CYBHI is doing, right? All payers, all comers, not separating out based on who the insurer is, what the diagnosis is, but really streamlining care. So we're making tremendous progress.

But there's a lot of work to be done. Are counties using MHD funds to serve children and youth effectively? Absolutely. Pick a county. We can show you a phenomenal program in every county, but we still have the issue that Dr. Jackson has pointed out, that because it exists in a county doesn't mean it's statewide. What we're trying to do with youth Alcove is to create a consistent, youth driven, branded model that is available statewide.

That if a young person participates in an alcove program in Santa Clara and they happen to be in San Diego, they know what they're going to get when they knock on that door. We're trying to actually recognize the local control and achieve statewideness at the same time. And that gets very difficult to do. This is a really tough question to answer because it's written in the spirit of do we have access to effective services everywhere? We don't have a unified mental health system.

We have this mosaic of thousands of programs that are all different and they're different for different individuals in different communities. And that is both a strength and it's an incredible limitation in terms of asking the kind of statewide overarching questions that you're trying to get at is, are we serving Californians to the best of our ability? One of the things I was thinking about this question, and too many children and youth and families first, we don't recognize the mental health needs that we have.

When we do recognize mental health needs, it's very difficult to know how to get what you need right. And then if you have a strong sense of what you're looking for or what you need. It's then difficult to get access using the early psychosis example, as an area where we're hoping to create improvements, right? So we don't necessarily have that high level awareness of what mental health is and what it means to be healthy.

When illness requires some sort of response, how to seek care, and then whether or not the care we're getting is the care we need, we don't do this in healthcare. Right? Imagine if the majority of Californians started their health care journey only when they got sick or felt pain. And the first stop was, I'm going to Google stomach ache, and then I'm going to start looking around and saying, well, who could actually pay for? Who do I turn to when my stomach hurts?

And who's going to pay for that? And what services and what's the weight? Am I going to go to the podiatrist for this stomach ache because of that mismatch between the services that I need and what may be available? We have to rethink this system through this much more upstream strategy. Consistent with the comments earlier about screening, about awareness, today my kids are hosting a convening at McClatchy High School for 150 young people to talk teens to teens talking about mental health.

This really is about empowering young people to be vocal about what their needs are, what's working and what's not working. And it really is about our ability to listen to them and to put in place strategy that will be helpful. So the short answer is counties are doing some phenomenal things.

The real answer is we're falling way short of where we need to be, and we have to do a better job of making it easier for our local partners to be successful and harder for them to make it less likely for them to struggle in doing what they want to do, what they know is right, and what they have the potential to do in terms of meeting those needs. Happy to answer any questions you might have.

Thank you. Next we will hear from Michelle Cabrera, Executive Director of the County Behavioral Health Directors Association.

Good afternoon, chair and Members Michelle Cabrera with the County Behavioral Health Directors Association. I was asked to speak today to the challenges that county behavioral health agencies are experiencing in implementing services for children and youth in this moment post pandemic. And first, I want to reiterate and affirm what Dr. Ewing just said, which is that counties are doing some amazing work in serving children and youth.

And one of the main challenges that they face does go to some of these structural issues around funding, which goes back to insurance coverage, right.

We are able to do so much of the amazing work that we do that is prevention oriented, that is upstream of illness, that is engaging children and youth in connection in culturally and linguistically meaningful ways, in large part because of the MHSA and specifically prevention and early intervention funds within the MHSA, there are significant gaps in coverage, there are significant shortages in the workforce, and those things, I think are connected. Right.

If you don't have enough insurance payers out in the world to provide reimbursement to the workforce that you need, you're going to have a very inadequate and lopsided workforce. And that's part of what we see today. We see specialists and these really vibrant programs in pockets and patchwork throughout the state that are funded with these unique sources of funding under county behavioral health. But we don't see the safety net supported and bolstered through long term, sustainable and varied payers in this system. Right.

So I think it's important to sort of highlight and lift up some of those structural and systemic challenges, because when we talk about funding and systems, it's not because we care about our own needs, it's because we see what's possible. But we're only out on that little isthmus. Right. We need to build a whole landscape that is supported in those ways. I want to say a little bit, too, about what counties have done.

We surveyed our Members and we found that 85% of county behavioral health agencies already had some form of school based services. Obviously not entirely to scale, but our perspective is really unique because most counties already are in schools, and that's been growing with investments like the MHSSA. I asked counties why they had invested so significantly in school based services, and they said, we're looking for our kids. We need to go where they are at, right.

And most kids, after a certain age, they're not hanging out in primary care. Luckily, historically, the challenges that we've had in building out those school based services have come down to, you have to build partnerships across systems. Right. So you have to engage with your education partners who are busy with their own business of trying to run a school and educate kids. Right? So you're trying to get in the door to say, hey, partner with me. We want to help.

And then the other piece is space. Like, literally space, right. We've had clinicians who are delivering school based services out of janitor's closets, quite literally because there's no other place for them to do confidential services. So really practical things like that. The last thing I want to highlight is that gap in coverage issue.

And for a long time, MediCal was actually a very inadequate payer of school based services because we had to establish that a kid met the very high bar of needing specialty services, meaning they had some sort of functional impairment in order for them to get into county behavioral health medical services. So we were just paying with MHSSA to cover both MediCal kids who weren't at that level of severity, and kids with private insurance.

And so we've been kind of holding up a whole lot and schools don't get to turn kids away based on their insurance status, right? Schools serve everybody and so they very rightfully said, if you come onto our campus, we want to know that everybody gets served. Right? That's an appropriate request. I think under the CYBHI, this is going to totally take the chessboard and sort of flip it on its head and rearrange all of the different pieces.

And so I think it's important for us to understand what the impacts of that will be and how it's going to work out. We think it will be most effective if we are looking at having all the Clinicians working at the top of their license and for those services to be sustainably funded and supported. There is a difference in terms of the way that the fee schedule is being conceptualized today. It's thought of as budget neutral.

So you don't have a line item in the budget to Fund the fee schedule. Why is that? Because it is assumed that existing insurance payers already have responsibility to serve children and youth. However, the reality is most likely private plans are going to increase premiums to cover the cost of the fee schedule. Most likely Medi Cal managed care plans will get their capitated rates adjusted. County behavioral health plans, we get what we get, right?

It's not tied to population, it's not tied to those sorts of things. What we do argue is that the state does owe us reimbursement for new services over what we already provide to cover the cost of the fee schedule. Otherwise we will be robbing Peter to pay Paul. We're going to be taking out of one area of our services to cover the fee schedule services. Right now, the fee schedule is contemplated to be substance use disorder services for us.

And to the comments of the earlier speaker, we absolutely agree that we need to do so much more with youth SUD treatment and access to those services. Schools can be a little tricky in terms of Sud services because they're not all friendly places to kids coming out and saying I'm using alcohol or I'm using drugs, right. That can get a child suspended from school or even expelled or worse. They could face criminal charges because it's all illegal.

And so there are a lot of different serious considerations that come into play when you're talking about citing SUD services at school. And we as county behavioral health have experience in this and we have a really big stake in making sure that we're ultimately protecting kids and doing it in a way that is quality and that, again, keeps them safe. But yes, to all the comments about harm reduction, broadly speaking, we definitely see that and support it.

In order to bring this to scale, we also need to understand, again, the underlying workforce considerations. And I will say nothing about bringing school based services to scale looks free from where we sit. Our workforce is too scarce, demand for their services is too high, and frankly, at this moment in time, they are burned out. Our workers deserve a living wage and the system funding to support that does need to go along with it.

Otherwise, where consumers will be left, whether they're Medi Cal, whether they're privately insured, whomever is in the same frustrating position that people are in today, getting ghost lists from health plans to call providers who don't return their phone calls. And one thing we don't want to see with the implementation of them CYBHI is more of the same as we heard before. I'm happy to answer any questions, but thank you so much for the opportunity to speak with you today.

Department of Finance.

Nate Williams with Department of Finance. Nothing further add but available for questions.

Ryan Miller. LAO, nothing to add but available for questions. Thanks.

LAO.

Bring it up to the Dias for any Members questions. Dr. Jackson.

And if I can invite the youth to come forward as well. I just want to make sure you have a seat at the table.

Not for Department of Finance, Ms. Jones and Boylan.

And for our young people. I'm so sorry I missed your presentation, but good job anyway. All right. If I walk on a school campus in the 2024, 2025 school year and I'm a young person, what should I see different then than I see today?

Sure. Thank you for your question. In 24, 25 when we start to phase in the fee schedule, schools will have the option to participate and we would expect there to be some ramp up in terms of the implementation of the fee schedule. We're working with our LA partners closely to make sure that they are ready to implement the fee schedule across the state, but I would expect that you would see more programming in schools across the state.

I think the needs of various school sizes and districts will vary. Different schools have different models for how they deliver healthcare services, including behavioral health services. Some have wellness centers and programs that they are operating on their school campus. Some partner with county behavioral health departments, as you just heard from Michelle Cabrera. Others have partnerships with community based organizations and behavioral health providers in the community.

So it varies across the state, but there will be a more sustainable access to resources provided and reimbursed through the commercial health plans and the medical managed care plans so that schools have a sustainable source of funding to support students'behavioral health needs on campus and through off campus partnerships with community based organizations.

What measurements are we using to ensure that if they access those funds, that it's based upon a best practice or based upon what the actual needs is, instead of just checking a box?

So there's a variety of services that will be included on the fee schedule, including evidence based interventions and services that will be available in schools across the state. We are also looking to, as part of the CYBHI evaluation, identify specific measures that we will be reviewing as part of the evaluation to determine the effectiveness of these programs across the state, looking at things like reduced utilization of emergency Department services, reduced hospitalizations, reduced absenteeism, and other markers of student success and youth success in our state.

So many things that we're looking at, and I think Stafford Jones could speak to the evaluation.

Thanks, autumn. Yes, we are certainly looking in terms of our outcomes, goals at both for the fee schedule itself, sort of how it's being utilized, the takeup rate, what that means in terms of accessible services, but also overall, are we decreasing barriers and increasing access to supports and services?

And is that the perception of youth and families that they know how to get to the point that was made earlier, that they feel like they have more routes and they know how to get to the supports and services that they need and they actually feel like their well being is improved or certainly part of outcomes goals.

I'd also note that in the 2425 school year, we would hope that there are more education professionals who have had the opportunity to engage in the trauma informed training that I described earlier. We know that many schools already do that kind of training, but we've also heard from our partners that not all do, they don't all have that, and this will be free, publicly available training, including in early care and learning settings, as well as 4k through 12.

So we would hope to see that there are more education professionals and other school serving staff, whether that's the bus driver or the school custodian who's had an opportunity to have that training.

We will also start to see in the 24,25 school year the addition of wellness coaches, which you'll be hearing an update about earlier, but really building out that team of supports and wellness coaches in many ways will be able to function like a near peer services, providing non clinical supports and coaching to our young people.

We've certainly heard from youth that we have engaged with in this work that the first person they want to see when they walk in the door of a wellness center on a school site, to be honest, is not somebody who looks like me, middle aged white woman. That's not who they want to see. They want to see somebody who comes from their community, who understands their experience.

And a wellness coach is a really important way for us to both add to and diversify and create a more representative workforce. And then you also heard earlier from my colleague Ms. Boylan about some of the other work that DHCs is doing in terms of strengthening social emotional learning programs across the state.

So I would hope to see that we would have more effective and more learning from each other social emotional learning programs across the state, and that the new virtual services platform is also another tool for both educators and youth to be connected to, obviously outside of their school hours, but that it's a chance for them to increase their awareness of the tools that are available to them across the system.

Is it possible that a school district or a school just may choose not to do anything?

Yes, it is possible that the districts and the school sites, on an individual, case by case basis, opt not to participate. There's not a statutory requirement for the schools to participate in the CYBHI schedule.

However, we are working very closely with all 58 county offices of education district partners to make sure that the schools and the districts are supported in doing this work, that they're appropriately resourced to do this work and that they have the partnerships with the medical managed care plans, commercial health plans, and county behavioral health departments in order to be able to sustain and implement this structure.

So it's not a mandate, but it is something that our local education agency partners, as well as our college and University partners are keen to make sure that they have resources available to be able to support the service needs of their students. So we're all kind of in it together in terms of why we're showing up and the work that we're doing.

And so I think it's really just about making sure that the schools are appropriately resourced and supported, that we're thinking about the implementation strategy, that we're partnering with them to do it in the right way. And that's why we are taking our time to phase in the approach work with our local education agencies, make sure that we are implementing it in the right way so that they have the tools and resources that they need in order to be able to opt in for this program.

And I would add to that that, as you heard Ms. Boylan describe earlier, it's not a fixed, inflexible model. I think something we've really heard from our LEA partners is the way in which they want to perhaps increase or expand behavioral health services and supports varies. And some of them, they might want to hire more staff directly through the schools. Some want to do more of that because they have a really robust set of community based organization partners to help deliver the services.

So it doesn't have to be sort of only one way in which they can do that. Ramp up the way the fee schedule will be structured. It will really support schools developing that suite of services that really makes sense for their entity, for their students, for their community, and for their partnership, sort of the ecosystem of their community.

And then the other thing I would mention is that a lot of our discussion with thinking about how do we create a more coordinated approach, say, across education initiatives and CYBHI is that we've certainly heard from partners at the local level in the field that it's very challenging to simultaneously implement islands of initiatives. There's CYBHI, there's Calaimm, there's community schools, there's expanded learning, there's universal pre kindergarten.

And so part of the work that we are trying to do right now with the State Board of Education and California Department of Education and our partners in the field in both education and health is how do we support a more coordinated approach. So rather than feeling like you're implementing completely separate initiatives. Where do they actually come together?

Because they do have a unifying vision and approach of a whole child approach, a very strong focus on equity and making sure that we are really addressing the needs of the most underserved kids and that our goal is for our kids to thrive, for them to be well from a health perspective and be able to learn. So how do we bring that together more?

And I think we're really trying to think about what does the kind of implementation supports look like that will do that, which will hopefully help schools tap into the work of the CYBHI because it will feel connected to the work they are trying to do as a school and an LEA in the first place.

Young people, do you have any wellness centers on your campus?

I don't feel as qualified to talk about this just because I went to private school, but there was not a wellness center. But we had the counseling center that we could go to if we were in a crisis situation or whatnot. Like, I know when I had my eating disorder, my therapist was very, my counselor was very supportive on signing off and making sure that I ate my lunch and things like that.

So we did have something along the lines of that, but not necessarily a wellness center like we're trying to define today.

Yeah, I'm still a high school senior, so I go to public school in Irvine Unified, and we do luckily have the privilege of having wellness centers. But I think a big issue in my school is the culture between educators, especially Administration and students. A lot of times there's a lot of mistrust between just the adults in school and students because of, like I mentioned before, some school discipline policies that have come up lately.

And since my school is very high performing, very merited kids, obviously they expect us to abide to a lot of those things without realizing that we also have mental health concerns, just ones that we don't voice as much. But I think because of that, a lot of students don't turn to our school to address our mental health needs, and we more so just suppress it ourselves.

What do you need to do to gain access to the wellness center?

Most of the time we can just walk in, but I know for our counselors, they have a lot more on their plate if we actually want to talk to someone. But our wellness center just has a lot of destressing activities, stress balls and sand and things like that. But if we want some kind of session with our counselors, that would have to be prescheduled.

I've gone to some campuses where you have to earn points to get to a wellness center. Right. We're still using. There are some places where in order to have access to wellness center if it is even staffed full time, which in most cases is just not the case. Right. But you're either sent there because you have some type of behavior issue and they're going to send you there to get some support, or there are certain times where you just can't have access to it.

You want to say something before I go on my tirade?

I know my community college. The only way you can get access to the wellness center is by another person, whether it's a friend or a teacher or someone else having to refer you over.

So this is my thing. I'm not a total fan of wellness centers. Why? Because if you go there, you most likely will not get a professional to help you at this current state time right now. Or like I said, it is more merit based for lack of a better term. My whole point is this, is that we are not treating the mental health crisis like we treated Covid-19 and that's just a fact. There was no such thing as silos anymore.

There was no such things as this is the way we do things anymore. We tore absolutely everything down to meet the current need to get people vaccinated. We shut down schools. We had all kinds of things, but we're still trying to fit mental health into current systems instead of transforming the systems itself. And if we know this is a crisis but yet it is still voluntary to provide it, how are we calling this a crisis?

We're not really calling it a crisis. We're ignoring the need. And at the end of the day, it's adding more burden on the public health care system, on taxpayer dollars. In one Kaiser system, I've seen 40 people leave in the last really year and a half because of the burden onto the system.

You better stop preaching, girl. My whole point is that if the question is, are we serving youth the best that we can, the answer is no, because we are still preserving or still trying to step over landmines instead of save lives. And this is just the way we're trying to accomplish this. Right? And so I would continue to challenge anyone and everyone who will listen because as you know, I'm prone to repeat myself over and over again. That we still got to do better.

We have got to put our foot down and say, this is a crisis. This is what our young people need. Therefore, everyone get out the way so that we can serve them the way we know we should be serving them. And even if it's from a local perspective and making sure that there's flexibility, because you're right. Different cultures, different things like that, they need a level of flexibility so it fits their areas, rural areas, mountainous areas, there's some level of flexibility that needs to occur.

But the way we're doing it, we're still saying, we'll give you some money, please do this, as opposed to saying we need to do it. Submit your plan, right. So that we can help you to accomplish that. We're still not at the full level yet. And when we have another hearing next year, next budget year, I can almost guarantee you that I'll have to say the exact same thing. If we keep going down the road, we're going right now.

And it hurts me to have to say that. But before I got here to Sacramento, I ran a nonprofit that did restorative practices. And I myself conducted circles. And the worst thing you want is to have conducted circles. And then a year or so later you are told that someone that was in your circle committed suicide, a young person. I wouldn't wish that on anybody.

But I guarantee you we might have caught it, if I had the knowledge at the time to do some type of universal screenings or something. So the idea is, and I'm imploring everybody, push the envelope like we did Covid-19 because all of a sudden we found money. All of a sudden there were no sacred cows and all we did was people complained. But hey, we all took it because it was about saving lives. But we continue to.

But we continue to, not because that was a physical ailment, but because this is a behavioral health ailment. We don't take it as seriously or we don't act as aggressively. So again, I ask everyone, please, we've got to do more. We've got to do more. Go ahead.

You kind of missed a pretty powerful speech earlier, but I meant the formula. You know what? Watch the recording later.

I'm going to watch the recording. Okay.

There's one word in every statement that you have said that you have missed, and it's youth. Youth need to be involved. And at the table, they're willing, ready and able to. It's weak. If you, as the adults, cannot help us and listen to us, then, yes, you're right. We're going to be here next year and it's going to be the same BS like it is today. So if we don't get more youth involved because it's going to affect us, it's going to affect our kids.

The old archaic system didn't work. And if we're going to do the same thing, then it's going to continue to not work. So we really need to put youth at the forefront in every decision that's made involving this.

Amen.

I can't wait to see you in one of these seats one day. My first question is going to be for you, Ms. Polls, if I can just off of what you were stating, we heard that you were co facilitating focus groups regarding the virtual services platforms that I'd love to hear from you what responses you were hearing.

So since I'm a little bit older in this space, I'm 24, I was co facilitating for both the adults and the youth, kind of providing a middle ground. And so from youth, a big problem with COVID has been the lack of connection, but also feeling like if their parents aren't informed about mental health and the parents are really willing and want to be involved and even if their kid doesn't have mental health issues, just learning about stuff.

And so I think a lot of it has to do with privacy because kids are worried, like how is their data going to get used and what not? But also parents, it's like, well, can I be alerted when my kid says that they want to harm themselves so then I can help get involved in the process.

So it was a very interesting thing because at the end of the day, kids want to be more face to face and have relationships like that and not just talking to a chat bot online.

Along those lines, there are no silver bullets. And it is in all of the above approach that I'd like to come back to the wellness centers and any suggestions that the youth are making on how we could strengthen them or increase access to them.

I think increased access, like I come from Vallejo and so there, I meant any access is abysmal in the education system. In the know, there is no such thing. But I think having professionals, and I think what is really needed is the peer to peer support because kids feel more comfortable talking to kids and that's how a lot of them are going to get help. And so I do think having the peer to peer education is really what's going to be helpful.

And we never know where that's going to end up leading in terms of like, maybe it makes youth want to get more involved and then maybe then become mental health facilitators themselves. But I think having professionals there and having the resources to at least guide them to continued services, I think is what's needed.

Can we get an update from the Administration? We had heard about the strength of peer to peer from our youth last year that I'd like to understand how we're incorporating that and moving forward.

Sure, I'm happy to provide an update. So one of the initiatives that was funded as part of the 2022 Budget act is the high school peer to peer demonstration pilot project. We are contracting with the children's partnership to roll out the grants for that initiative. They are planning to convene an advisory group of youth to help inform the request for proposals from all of the high schools.

They will select up to eight high schools over the course of the next two to three years to pilot the peer to peer programs, evaluate the outcomes, and to develop statewide standards for high school peer to peer programming. We are also building in peer programming as part of the virtual services platform based on what we heard from youth over the course of this last year around the virtual services environment.

And so there will be moderated, safe peer to peer forums where young people can share their stories, encourage each other without replicating the bad things about social media, like likes and dislikes, but giving youth an opportunity to learn from each other and share from each other. And that'll be a part of what we deliver through the digital Behavioral health platform, which will know, and I think to Member Jackson's point earlier about how are we pushing the envelope to do things a little bit differently.

Creating this opportunity for a state funded digital behavioral health platform where youth can get access to one to one coaching sports with the real person on their phones at any time of the day is something that really does, I think, push that envelope forward.

And through that, we're also going to be making peer to peer programming available and as well as through evidence based practice grants and school based fee schedule that we really are trying to think about, the opportunities for young people to lead and guide this work through the peer to peer programming in all of these various components of the CYBHI.

Would just add, I know when you hear a little later from the Department of Healthcare and Access and information about the workforce pieces, that one of the components, as you know, in the Medi Cal program is the new peer support specialist benefit and work. And for example, in some of the funding from HKI to increase the training for peer support specialists, they really prioritized young adults.

They even allow 16 and 17 year olds into the program so that when they turn 18 and can actually be eligible to provide the service that they're ready. So there was a strong focus on young adults. So even though it's more of a near peer model but that it has that aspect to it.

And as I mentioned earlier, the wellness coach really has many aspects of that near peer model, trying to increase that kind of support and availability of a workforce that is more representative of our youth as an important part. And I do think the wellness coach is part of our transformational effort. It really is meant to sort of help shift the workforce to address what we are hearing from youth are their needs in terms of better addressing those.

And I think we all working on the CYBHI, and I don't just mean in state government. I mean all of our partners share this sense of urgency and the need for transformation and wrestle with the very questions that Assembly Member Jackson is raising every day about is there any stone we've left unturned? Could we move things faster?

And candidly at the same time, our partners are also saying, don't just take the well worn paths, though, because the well worn paths are the stuff we already know how to do. And if you just do more of that, it's not good enough. So how do we move quickly but do it differently and not just do the same and actually do something that's transformational? And yet, I can tell you, we ask ourselves every day, could we do it faster? Could we do it better?

Could we do it deeper? And so I appreciate sort of the comments around that because I think we are all wrestling and working toward that. So thank you.

For Director Stafford Jones, you said that Mathematica was going to be convening an outcomes group. How can we ensure that we have youth who are included into those groups and spaces?

Yeah, thanks very much. We've actually been working even before we selected Mathematica through a competitive RFP, we had been conducting a series of focus groups, specifically with youth around the state, as well as communities, families, and our partners with professional experience to inform what should be the five year outcomes goals for the CYBHI. So we've actually gathered quite a bit of input directly from youth already and families in terms of what those outcome schools should be.

So before we even hired Mathematica, we had a draft set of outcome schools, and then we're working with them to refine those. And they have been both meeting with. We have an equity working group for the CybHI. There's a data Committee they've been meeting with to help inform that, particularly from an equity perspective. And then, as I mentioned, we're forming a CYBHI evaluation advisory group that will be made up of youth, parents and families, researchers, frontline clinicians and local systems leaders.

So that group will also be helping to inform the finalization of those outcomes goals.

I'm going to stick with this theme if I can. You had mentioned a work group associated with coordinating mental Health Student Services act, as well as community schools, and that there were 60 people in the work group. I heard LEAs, CBHDAs medical managed care plans, but again, I didn't hear youth, and I want to be intentional to ask to make sure out of those 60 people that we're having space for the youth as well.

So the 60 person workgroup is the implementation Partners group for the CYBHI fee schedule specifically. However, we did and continue to engage with youth in a variety of settings to get input on the design of the fee schedule in terms of what services kids want to have accessible on school campuses. We did some listening sessions and focus groups last year.

We also engaged with a youth advisory board through some of the statewide youth serving organizations such as the California Coalition for Youth and the California Youth Action Network to be able to inform this work that we're doing. And we have Members from those organizations that participate in that work group as well.

So we're trying to engage youth on all fronts across the board and really have spent some time thinking about how we make sure that we build youth engagement not only into our work groups but also into our contracts in terms of the requirements of our partners and vendors as well. For example, there's a requirement in our virtual services platform contract that there's a youth advisory component to that as well. So really trying to build that in structurally into the work that we're doing.

Final comment, if I can, I'll elevate. I believe both youth spoke about how hard it was for us to access care, and as we're increasing access across the state, we're going to have more and more workforce challenges. And so as the agenda later will discuss workforce proposals, I want us to ground ourselves in the comments that we heard from the youth about making investments into that space as well. With that, I will again appreciate Ms. Lou and Ms. Polls and this entire panel, and we will now move on to issue three.

Thank you.

Thank you.

Issue three on the CYBHI reappropriation included in the spring Finance Letter. Department of Finance will present this proposal. Please begin.

Department of Finance Nina Hong within the larger CYBHI initiative, Cal HH's agency was allocated 50 million General Fund over five years in 21,22 to support cross departmental coordination, procure subject matter expertise and acquire technical tools, engage stakeholders and local implementers, and support initiative wide, comprehensive, multiyear evaluation to identify best practices and inform future policy and program work. CalHHS is requesting to reappropriate 8.8 million General Fund from 2122 allocated amounts to be available to expend until June 30, 2025.

LAO.

Ryan Miller. LAO, we have not raised concerns with this proposal.

Bring it up to the dais to see if there's any Members questions. Seeing none, I will thank this panel and we will move on to issue four.

Thank you.

Issue four is on the Children's psychiatric residential treatment facilities AB 20317 trailer Bill we have DHCS Director Michelle Boss to present this issue. Welcome and please begin.

Good afternoon, Mr. Chair Members. Michelle Boss, Director of the Department of Healthcare Services AB 20317 was passed in 2022 and establishes the psychiatric residential treatment facilities as a new category of health facilities licensed by the Department. Psychiatric residential treatment Facility is defined as a licensed health facility operated by a public agency or private organization with a provider agreement with a state Medicaid agency.

AB 20317 also requires the Department, in collaboration with stakeholders, to establish regulations and certifications consistent with Medicare and Medicaid regulations to maximize federal participation. The proposed trailer Bill Language is meant to clean up statute governing the psychiatric residential treatment facilities to align with federal law and make other technical changes. The current language is in conflict with federal requirements and puts the Department at risk of losing federal Medicaid dollars due to non compliance.

Additionally, the trailer Bill Language proposes to align the composition and credentials of the interdisciplinary team Members with federal regulations and CMS requirements. Specifically, the current language allows for a registered nurse or a licensed vocational nurse to serve on the interdisciplinary team. However, a licensed vocational nurse does not meet the same educational requirements as an RN. Including an LVN in lieu of a registered nurse would not meet the federal requirements.

Additionally, federal requirements require minimum staffing that includes a master level psychologist that is distinct from California's definition of the mental health professional. The Department provided a walkthrough of this language with legislative leadership, Assembly Member Ramos's office, and other legislative staff.

Our next speaker is Christine Stoner Mertz, Chief Executive Officer of the California Alliance, California alliance of Child and Family Services thank you.

Good Afternoon Chair Arambula Members of the Budget Subcommitee Christine Stoner Mertz, CEO of the California Alliance Child and Family Services representing 116 nationally accredited community based organizations providing services to children, youth and families in California. The California alliance was a proud sponsor of Assembly Bill 20317 authored by Assembly Member Ramos. We were seeing the impacts of not having this level of care all around us and continue to see that Medi Cal youth being unnecessarily hospitalized and not receiving life saving ongoing mental health services.

Our partners at the California Children's hospitals have alarming data about youth in their emergency rooms and psychiatric crisis, and these are not the right places for many of these youth who could be better served in their communities and in an environment staffed with mental health professionals. AB 20317 fills a life saving gap for youth in crisis and we are grateful, excuse me, to the Administration for all of the support to get this far.

We do feel that in order to fulfill the promise of AB 20317 and ensure that there is an interdisciplinary team that reflects the reality of California's medical program, we must look at the changes that are being suggested in TBL. In trailer Bill Language. We must consider who's working within our current specialty mental health system now, which includes master's level clinicians. We have severe workforce shortages and are at a crisis point.

By deleting some of the proposed team Members from the original language, including master's level therapists, we believe that our providers will have a very difficult, if not impossible, time standing up any of these programs in California. We believe that with some modest amendments, we will maintain the integrity of these programs, provide high quality services, and be able to staff the programs and stand them up in California.

Our recommendations include inclusion of the option for a mental health professional who has a master's or doctorate degree in psychology, marriage and family therapy, social work, or counseling, and who has been licensed, registered, or waived by the state. Inclusion of licensed vocational nurses, in addition to registered nurses include the option for a nurse practitioner as one of the staff and ensure that we're aligning these regulations and Cal aim documentation reform, for example, around the requirement of an individual plan of care.

We very much appreciate the Subcommittee's oversight of this issue. We thank Assemblymember Ramos for his authorship of this Bill and continued commitment to children's mental health. We look forward to a positive outcome so that we can stand up children's crisis residential programs

Department of Finance.

Nate Williams of Department of Finance just want to agree with the department's assessment that this trailer Bill should be going through the trailer Bill process. It's an appropriate avenue in that it is tied to a budget change proposal as well as it's changing language that could affect federal funding.

LAO.

No concerns.

Bring it up to the dais for any Members questions. Assembly Member Ramos.

Thank you, Mr. Chair. And getting to some of the discussion and recommendations, is there an option or is there willingness to look at some of the amendments that have been discussed here to try to maybe add in there the health professional and the different components that are there without jeopardizing federal funding? This whole Bill was set to make sure that definitions were in sync here at the State of California and the Federal Government so we could use that funding for psychiatric residential treatment centers.

And so it was a long process to get to that point. We worked with the Administration on several amendments to try to adapt and to make sure that it did meet all those criteria that was in front of us. We did get it through the Legislature. It wasn't easy, but we got it through, was signed into law.

And now understanding that there could be some components that could jeopardize some of the funding, but is there willingness to look at some of these different classifications of the workforce because of the workforces that are actually available in the State of California versus other states in the nation?

And we would be willing to work with you on some of that language to ensure, as close as we can get to that, to ensure without jeopardizing funding for it, because we do know that this needs to move forward. We did work hard on it. It's attested to the Administration, to the Legislature and the body, both houses. We got it through.

But I think now coming forward within the trailer Bill and setting out the parameters, but now, I guess, is there a willingness to work with my office and some of the recommendations to see if there's a way we could even fine tune it a little bit better?

Yes, of course we're willing to continue to work on this. Our guidepost really is meeting the federal requirements because we do not want to jeopardize the federal dollars. And so also doing an assessment of maybe with some of the other states how they've implemented this, we're willing to kind of engage and continue those discussions.

We did flag this issue back in August for legislative staff that there was some conflict here, but we agreed that we would move the Bill so that we can continue to work on this because there was a lot of effort over the summer months in terms of negotiating on this Bill. So continue to remain committed to engaging on the definition, but do want to flag that. Our guidepost is to ensure that we.

Get FFP and we know that we do need this in the State of California. If I remember right off of memory, there was only two counties that even were able to have any type of services out of 58 counties here in the State of California. So I guess how broad and how narrow is that definition? I think just taking off one of the recommendations here, inclusion of the option for a mental health professional who has a master's or doctorate degree in psychology, just that.

Is there an opportunity within the federal guidelines to be able to add some of that? Or.

I'd be happy to read the federal regulation for you. The team must also include one of the following, a psychiatric social worker, a registered nurse with specialized training or one year's experience in treating mentally ill individuals, an occupational therapist who is licensed, if required by the state and who has specialized training or one year of experience in treating mentally ill individuals, a psychologist who has a master's degree in clinical psychology or who has been certified by the state or by the State Psychological Association.

So that's the federal definition of what must be included in the interdisciplinary team.

And it's a federal definition that blankets all the states in the nation, which some of those in the workforce don't go by some of those categories here in California, that was the whole purpose of the Bill. But we do know that things have to move forward.

So we would try to open as much as we can to some of these different components to ensure that there's a workforce that's part of the infrastructure that could meet the challenge coming forward without having to go back and reestablish different degrees, different areas to move forward with a new workforce that then would delay the whole implementation of it. I think we're all on the same page.

We worked with the Administration, we worked with our sponsors to ensure that there is something moving forward within the psychiatric residential treatment center. And we did do a lot of amendments to try to curb some of these things.

But if we can try to see if there is some of the recommendations that are here without jeopardizing the federal funding, because the only way that I understand it, if we go outside of the federal funding definition, then it would be the State of California that would have to Fund those programs. Is that correct?

Yes, that's correct. It would be General Fund.

At this point, we're moving forward on the federal funding, the federal flow through on the money coming forward. All right, well, let's see if we can't get creative and see if there is a way without jeopardizing that. We would definitely be engaged and want to be part of that discussion.

Great, Thank you,.

Thank very much, panel four, and move on to issue five. The focus of these next two issues is on suicide prevention, beginning with issue five, which is an oversight issue. Our first speaker is Leshon Francis, senior Director of behavioral health with children now. I know. Please begin when you are ready.

Thank you, I think. I'm Lishaun Francis, last time I checked. Thank you, Chair, Members, for having me today. My name is Lishaun Francis. I'm with Children Now. I'm going to spend some time talking to you today about suicidality and its relationship with social media. That's going to be the crux of my comments. But first, let's just level set. Overall, the number of suicides in California have decreased in 2020 in particular.

But rates of suicides for certain subgroups increased, and I think we can safely correlate that in 2020 because of everything that was happening in the world. That is a large reason why we saw that increase. Specifically, those who were ages with 10 to 18, that subgroup increased. Black and Latinx youth, specifically black youth. Suicide rate has doubled since 2014. So not really since 2020, but since 2014. And then female youth, that group also increased in 2020.

Traditionally, we've actually seen more suicide attempts among female subgroup, but more deaths by suicide among the male youth. And while that trend is generally true, there's been an increase in death by suicide among female youth. As an aside, the use of firearms as a mechanism for suicide increased in 2020. One thing that's not talked about often is the rate of suicidality among our rural youth. Nationally, the rate of suicide among rural youth ages 15 and 19 is 54% higher than that of youth in urban areas.

Given the increase of isolation within the pandemic, we really do need to look more closely at our rural youth and how they're doing since 2020. Suicide related behavior is complicated and rarely the result of a single source of trauma or stress. Youth who are at risk for increased youth who are at increased risk for suicide related behavior are dealing with a complex interaction of multiple relationship, peer, family, or romantic, mental health, and school stressors.

I want to be clear that while several surveys have examined the relationship between young people in social media as it pertains to their mental health, there isn't enough evidence to state that social media is the cause of suicidality. However, what is clear is that young people are reporting that social media is the main reason their mental health is getting worse, like increasing anxiety and depression.

Research suggests that young people who are heavy users of social media, spending more than 2 hours per day on social networking sites like Facebook, Twitter, or Instagram, are more likely to report poor mental health, including psychological distress like anxiety and depression. Essentially, you've got the FOMO right here. You constantly seeing friends on holiday or enjoying nights out. They are feeling like they're missing out and they're not enjoying life right?

So that is promoting this compare and despair attitude in young people, and they might be viewing images that are heavily photoshopped and as young folks who are going through changes with their body and with their self esteem, that can really impact them in ways that don't impact adults. Specifically, we're seeing that girls who use social media heavily are two to three times more likely to be depressed.

One survey that was done in the UK revealed that Instagram is actually the worst social media network for mental health and well being for young adults. While the photo based platform got points for self expression and self identity, it was associated with high levels of anxiety, depression, and bullying.

What's interesting to me is out of the five social networks that were included in that survey, YouTube actually received the highest marks for health and well being, and it was the only site that received a net positive score by respondents. Twitter came in second, which is my personal favorite, followed by Facebook and then Snapchat and then Instagram dead last. Another indicator related to social media is sleep.

We know that studies have shown that increased social media use has a significant Association with poor sleep quality in young people. Using social media on phones, laptops and tablets at night before bed has been linked with poor quality of sleep, even more so than regular daytime use of social media. As you know, sleep and mental health are tightly linked. Poor mental health can lead to poor sleep and poor sleep can lead to states of poor mental health.

And this is particularly important for teens who are going through key stages of brain development at that time. One in five young people in that survey said that they woke up during the night to check messages on social media. I also want to spend a few minutes talking about cyberbullying. This comes up a lot when I talk, people ask me, what's the difference? We got bullied when we were kids and we were fine. Why are we making such a big deal out of cyberbullying?

Don't kids just need to toughen up? That is my favorite question. The reality is, cyberbullying is actually an easier way to bully because unlike traditional bullying, it doesn't involve face to face interaction. Teens can become desensitized to a computer screen and say or do things they wouldn't do in a person's face. The computer desensitizes teens and decreases the level of empathy they feel toward the victim.

Plus, when they can't see the person's reaction to what they post or text, they may not even know that they've gone too far. Youth who report both bullying others and being bullied bully victims have the highest risk for suicide related behavior of any group that reports involvement in bullying. Negative outcomes of bullying for youth who bully others, youth who are bullied, and youth who are both bullied and bullied.

Others include depression, anxiety, involvement in interpersonal violence, sexual violence, substance abuse, poor social functioning, poor school performance, Low gpas, standardized test scores, and poor attendance in schools. In short, very bad outcomes all around for those participating in bullying. Any involvement with bullying behavior is one stressor that may significantly contribute to the feelings of helplessness and hopelessness that raise the risk of suicide. So then what can we do? There have been a number of policy solutions floated around that we should all really explore.

So to be clear, a lot of these solutions aren't live, meaning we haven't tried them. But things that have been discussed was introducing things like a pop up, heavy usage warning on social media. Like, we're warning you that you've been using social media today for more than 3 hours. Maybe it's time to give yourself a break.

Another thing could be when the social media platforms can highlight when photos have been photoshopped or digitally manipulated so people know, zero, she does not have the perfect body and you're just fine. And then, honestly, safe use of social media should be taught in schools. That's something that's largely been missing in our public school education program. And then my personal favorite, really doing more research to understand the effects of social media on young people's mental health. Thank you.

Next, we have Shari Sinweski, Vice President of Crisis Care at Didihirsch Mental Health Services.

Good afternoon, chair, Rambula and Members of the Committee. I'm Shari Sinweski, VP of Crisis care at Didihirsch. Didihirsch Mental Health Services is a pioneer in suicide prevention and crisis care for all ages and home to the nation's first and largest suicide prevention center. We were proud to be selected by the Department of Healthcare Services to be the statewide leader for the 12988 crisis centers across California.

As it was said, suicide is a complex public health issue that is not usually the result of one factor. Stressors such as relationships, jobs, school or financial issues, as well as factors such as mental illness, substance use, social isolation, historical trauma, inequities in health care, and easy access to lethal means of suicide can all contribute to increased risk. The bottom line is that suicide impacts everyone.

In fact, almost inevitably, when someone speaks to me about the work that I do, they tell me a personal story about how suicide has impacted them. Last week, the CDC released data highlighting that the overall suicide rate in the United States increased by 4.7% in 2021 from 2020. It also showed increased rates of suicide among various populations, specifically youth, communities of color, and Native Americans.

And while the overall suicide rate in California only rose slightly, trends among youth, communities of color, and Native Americans are similar in California to those seen nationally. What is more important to remember when talking about trends is that each one of these numbers is a human being, a loved one that mattered. We must continue to work together to help people create lives that are worth living. We must work together to reduce the loss of life and those left behind to grieve.

Suicide prevention is a mental health concern. Suicide prevention is a public health concern. Suicide prevention is an educational concern. Suicide prevention is everyone's concern because anyone can be impacted by suicide. Don't we all want a California where people live thriving, fulfilling lives? Suicide prevention is everyone's business and should be a concern for every californian. Didihirsch recommends the following things that can be done to help involve all Californians in suicide prevention. Educate the media on best practices when reporting on suicide.

This includes not glamorizing stories of suicide, sharing resources, and sharing stories of hope and healing. The papagino effect shows that exposure to positive examples of people who have overcome suicidal thoughts or crises can prevent or reduced suicide. Attempts in vulnerable individuals. Continue to dedicate funding for prevention and early intervention. The Office of the California Surgeon General has focused our attention on adverse childhood experiences and their impact over the lifespan. According to the CDC, having any adverse childhood experience is associated with an increased risk for suicide.

The odds of ever attempting suicide are 30 times higher for adults with four or more adverse childhood experiences compared to adults with none. Continue to Fund mental health curriculums in schools for both students and staff. Young people need to be just as comfortable communicating when they are in emotional distress as when they are experiencing a physical ailment. Adults need to know how to respond to these concerns as easily as they would to symptoms of a common cold.

Everyone needs to be better able to listen when someone is in distress. We talked about screening earlier, which of course, I'm a proponent of. But we have to be careful with screening as well. As we heard earlier, sometimes people just say no because they're afraid of the impact of answering screening questions. So we really need to allow people to feel comfortable to talk about how they're feeling.

Parity with physical health care and mental health care, not just in reimbursement rates, which are important, but in timely access to care when needed, including the expansion of the 988 crisis care continuum and ensuring that all suicide prevention resources are created with a focus on diversity, equity, and inclusion so that everyone has access to support in a way in which they need it.

We are excited about the creation and existence of a statewide office of suicide Prevention housed within the California Department of Public Health. We would encourage our state leaders to make sure it becomes a focal hub for coordinating suicide prevention efforts in our state.

While still in its infancy, we hope to see the Office of Suicide Prevention take a leadership role to help coordinate similar networks across the state, bringing us together to discuss best practices, gather resources, and ensure that California continues to be a leader in this space. And we thank Assembly Member Ramos for authoring AB 2112 creating the Office of Suicide Prevention. We very much appreciate the Subcommittee's oversight of this issue and are grateful for your commitment to suicide prevention.

Thank you for the opportunity to speak for you today, and I'm happy to answer questions.

Thank you. Next we will hear from Dr. Tara Niendam, Professor of psychiatry, Executive Director at UC Davis Early Psychosis Program.

Okay, thank you all so much for your time today. So, as you may have heard, I represent one of the many early psychosis programs that exist in California that are funded through a variety of funding streams, including the MHSA, mostly PI Dollars, the Sampson mental health block grant dollars, as well as Medi Cal dollars. My Sac county program serves youth and young adults in the earliest stages of psychotic illness.

As we've heard so eloquently put today, individuals with mental health challenges are at high risk for suicidal ideation and behavior. But for individuals with early psychosis, the risk is even higher, particularly in the first one to two years after onset of illness. So in that space, in that brief time period, about one in four will endorse ideation and one in 10 will make an attempt. And so they either pass away or have significant injuries as a consequence.

We've been collecting data from early psychosis programs across the state as part of our collaborative outcomes, and 42% of individuals at intake report some form of ideation. So I want to highlight this as a particularly high risk group, and California's early psychosis programs are playing a really critical role in reducing suicidal ideation and behavior. We train our programs to use evidence based practices to provide a very thorough assessment.

We do suicide screening, and then we implement evidence based practices to manage risk so that we can support our clients and loved ones to stay in the community and reduce costly and traumatizing hospitalizations. So I really just wanted to take the time today to highlight the role that evidence based practices can play in reducing suicide in our communities and how our growing availability of early psychosis programs help to reduce this in a particularly high risk and vulnerable group. Thank you.

Thank you. Next we will hear from Sarah Mann, violent injury policy and program secretary chief with the Center for Healthy Communities.

Good afternoon. Thanks for having me. Hi, my name is Sarah Mann and I serve as chief of the Office of Suicide Prevention, or OSP. The OSP is housed within CDPH's Center for Healthy Communities and is integrated into the organizational structure of the Injury and Violence Prevention Branch to maximize resources and leverage program and research expertise in the prevention of all forms of violence, including suicide, from a public health perspective. Oversight of the OSP is provided by the center's Deputy Director and assistant Deputy Director.

The OSP conducts activities that are guided by California's strategic plan for suicide Prevention, striving for zero, and other recommended actions from the Centers for Disease control and prevention. So a few key highlights the OSP has produced and released several suicide and self harm data, resources and reports, which can be found on CDPH's website under the Suicide Prevention program.

Recently published resources include social media shareables that raise awareness around suicide and suicide prevention, suicide trends in 2020 data brief with an accompanying PowerPoint slide deck with additional charts and graphs veteran suicide in 2020 data brief, older adult suicide in 2019 fact sheet and the California Violent Death Reporting system, also referred to as Calvary DRS fact sheet and infographic on suicide in California.

Additionally, the OSP has distributed approximately 4500 lockboxes to reduce access to lethal means from things like firearms and medications to 10 local health and behavioral health departments in counties with higher rates of suicide and self harm. OSP has also distributed 38,000 mental health thrival kits to schools throughout the state, as well as local health and behavioral health departments in counties with higher rates of suicide and self harm.

These kits can be used to celebrate wellness and promote positive coping skills for youth with easy to follow activities to enhance basic skills for social emotional wellness. Additionally, the OSP has sponsored 4 zero suicide Institute informational webinars for local health departments, behavioral health departments, school based health centers, providers, clinical supervisors, staff with quality improvement assurance roles, peer support staff, and others who work in the healthcare field and are interested in learning about how to prevent suicide within that context.

Additionally, the OSP is also administering two new youth suicide prevention projects as part of Cal HHS's sponsored Children and Youth Behavioral Health Initiative. I can give a brief update on those two projects as well our youth Suicide prevention media and outreach campaign. The OSP is implementing a targeted and community based youth suicide media campaign for youth at increased risk. In addition to the media campaign, grants will be provided to youth serving community based organizations to promote campaign messages and conduct outreach.

The media campaign will be launched in the fall of 2023. The process for community based organizations to apply for funds has already begun. Approximately 30 to 50 youth serving CBO's will receive two year grants ranging from 150,000 to 250,000 per year. Additionally, the University of California at Los Angeles will serve as an independent evaluator for the project. The second project, the Youth Suicide Reporting and Crisis Response pilot program.

The OSP is also administering or implementing this pilot to develop and test models for rapidly reporting youth suicides and suicide attempts that will trigger local level crisis response and resource connections involving schools, community based organizations, and other partners. The OSP has selected 10 local public health and or behavioral health departments to participate in the pilot program. Pilot counties will begin implementing the program in July of 2023.

Counties will receive in depth training and technical assistance and similarly to the media and outreach campaign, UCLA has been identified to serve as an independent evaluator for the program. Thank you for allowing me the time to share these updates and I look forward to your questions.

Next we will hear from Martha Dominguez, who is the health program manager at. The CDPH Office of Health Equity

Good afternoon, [Spanish] .

I'm here the Office of Health Equity our campaign is actually under the Children and Youth Behavior Health Initiative and the goal of the campaign is really to develop, implement and evaluate public education and change campaign that is co designed for and by youth to advance equity and race behavioral health literacy for children, youth caregivers and their communities in California and provide public health education campaigns to five priority populations such as Black and African American, Latinos, Native Americans, Asian Pacific Islander, and the LGBTQ plus community, while also considering unique needs of the transitional age youth, persons with disability, justice involved youth, foster care youth, and those living in rural areas.

We have three objectives under this campaign. The first one is really to create awareness without stigma around mental, emotional and behavioral health, including substance abuse disorder and wellness. Our second objective is really to partner with CBO's across California to develop culturally linguistic and age appropriate campaigns aimed to reduce stigma and discrimination. Our third objective is to partner with the communities such as the children, the youth, the caregivers, families, communities to codesign reflect on culturally linguistic and age appropriate products, tactics and approaches.

In this process, we're also developing a multifaceted approach that really includes macro and micro campaigns throughout California. Everything from state to local will be multicultural and multilingual regarding the key languages to reach our key communities that I've already listed. We've also have highlighted that our development will happen in three phases, the development, implementation and evaluation.

The development actually started last year with us talking to communities across California where then talking and giving us feedback on how the process should be improved, not just the business practice, but also the development and implementation. We were very eager to hear from the community, but also take some learnings from our previous experiences to make the improvements now in this process. So we have applied that and we'll continue to do that.

We also develop a braintrust, which is a group of subject matter experts that are across California, the nation and even international. The braintrust will be our Advisory Committee that will keep us intact in making sure that we are best applying all best practices, as our colleague has shared, but also community based approaches, but ensuring that we continue to have the voices of the community, both families and youth. We will also have a formative research we've developed a multicultural formative research model.

We have already entered a contract with the contractor that will help us collect the data to talk to children, youth, and families across California. And then we'll be also entering into a media consulting contract as well to do the macro level campaign and also contracting with CBOs across California to do the micro media campaigns. And that will all be considered part of our implementation.

The implementation also will detail the evaluation kickoff because we will have a baseline data that will help us measure and track all the components and tactics that we do across for the campaign and multiple languages as well. And we'll also use that data to do any quality improvement. And then obviously the evaluation will assess the tracking of the waves of our efforts throughout the campaign and the duration.

But we'll also have an interrupted time series analysis of the resources and services that Californians need. And that will allow us to ensure that we're providing the press approaches, but also related to cultural, health and community best practices. We'll have a process and outcome evaluation and then we'll have a thorough report that will outline all of our efforts throughout. I also wanted to give you an update in terms of our budget and how we're spending our dollars.

So through 2024, we have already planning to allocate $33 million for our macro campaign and then $15 million will be for the micromedia campaigns. $5 million is going to our formative evaluation research budget and then 2 million for our administrative personnel budget. Through 2026, we'll have an additional $5 million spending for Administration and personnel budget and then we'll add another 20 million for our macro campaign and another 20 million for our micromedia campaigns.

Overall, what we wanted to underscore is that we're making sure that culture is part of health, but also community is part of health. And we want to make sure that.

And we are very confident that with our best practices and our subject matter expertise, we'll be able to increase mental, emotional, and behavioral health, and substance disorder education and awareness, but also partner with caregivers and families to ensure that they have the proper resources and services and co design all of our elements, culturally and linguistically to ensure all messages are saturated across Californians.

Thank you. I may ask to clear the chairs for now, and we'll bring you back for questions if we can. Next, we have Director Boss, followed by JC Cooper, followed by Toby Ewing.

It will just be me for DHCS. She'll be up here in a minute. As outlined in the Committee agenda, California has significantly invested in initiatives to respond to suicide and suicide prevention efforts. I'll briefly highlight a few. A few of them have already been discussed in prior items, so I'll just quickly highlight as part of the 2022 Budget act, the Legislature authorized additional funding to address urgent and emergent issues for children and youth and families. Ms. Boylan just discussed that.

I just want to highlight as part of that it will include social media, healthy use of social media technology just in response to some of the previous conversations on this item. So that will be part of that piece there. Additionally would note that we are taking advantage of enhanced federal funding opportunity for mobile crisis. We implemented that benefit and that's an integral part to response with regarding community based care and needs.

We've submitted the state plan amendment to CMS and issued guidance describing the minimum requirements for this new service, including the federal requirement that mobile crisis services be available for 24 hours a day, seven days a week, and 365 days a year.

The earliest possible date for counties to implement this benefit was this past January, and all counties must implement by December 312023 except for 11 small rural counties where we are still working on some of the key rate pieces and finalizing rates for our rural counties because there are unique considerations for them. Counties will undergo a readiness process to ensure they meet state and federal requirements, and the Department is providing extensive technical assistance to support implementation.

I will also note as part of our behavioral Health Continuum Infrastructure program, the first round of grant funding, we awarded 163,000,000 to 49 cities and counties and tribal entities to Fund 245 new enhanced mobile crisis response teams. And then finally, just a brief update on Cal Hope, which Ms. Boylan referenced as well. Today, as of January 23, we provided approximately 1.3 million individuals in California who have actively addressed received services through Cal Hope.

So that's kind of in response to crisis or wanting to have an opportunity to chat with somebody. So I would note that as well. And then lastly, as part of our California Behavioral health community based Continuum Waiver proposal, which we are kind of one of the proposals in the budget, we have added coordinated specialty care first episode psychosis as an optional benefit for counties to opt into. So that is also part of that proposal. Happy to answer any questions.

Toby Ewing thank you, Mr. Chair. And Members, in terms of some of the suicide prevention work as outlined in the materials for the hearing today, the Commission played a key role in partnership with this Subcommitee in really drafting a suicide prevention plan. And thank you Senator Ramos for your leadership in helping to really push for the Office of Suicide Prevention to be reestablished within the Department of Public Health.

Along the way, and particularly in the context of COVID resources and some of the funding that we were able to free up in response to the pandemic, we not only working with the Department of Public Health to really launch that office and support them and transition some of our work to them, but we were able to provide some resources for trainings within school districts, within county behavioral health departments.

Some of those trainings are around strengthening local suicide prevention strategies, really bringing internationally recognized experts to make them available to local agencies so that they could understand best practices, but also recognizing what we've referred to as postvention, how communities respond when there is an attempt or a loss of life associated with suicide. We've been trying to play a supportive role with the Department and agency around the rollout of 988.

We did a convening with OES and agency to really talk about what's working, where there are challenges, the work that has to get done on 988, particularly recognizing that it's going to take not just California but the nation some time, some years to really design a 988 system. Took us a long time to learn how to get 911 working. It's going to take us a while to learn, and so we're trying to create space and resources for that.

What we're really trying to do is transition a lot of the very specific work that the Commission has done in the past around suicide prevention over to the Administration in ways that make sense given their improved capacity, greater capacity to do that work effectively, but also recognize where we think we can have a key role in an ongoing way, particularly around data reporting and analysis. Part of that oversight is to really understand what's working and what's not working.

Continuing to focus on youth and community empowerment, veterans, in addition to youth, native populations specifically, and really understand how we can support their ability to elevate their voices so that those voices are part of the conversations that are happening not just at the State of California, at the state level, but more locally where so much on the ground work is happening, a lot of stigma reduction.

And so part of our effort with Ken Burns, the world famous documentary, is to elevate stories of survival and trauma and grief so that we can reduce the know. My own family, Lishaun says. Someone mentioned every time there's the Didihirsch speaker said, every time someone tells a story and my own family we talk openly about people who die in our family due to cancer or pneumonia, but we've had two suicide losses and nobody will talk about it.

So stigma reduction will continue to be something that we hope the Commission will focus on in terms of making it easier for people to put this out there and to share our stories so that we can engage as freely about what's happening in our mental health space as we do about healthcare. Right. We've got this tremendous willingness to share our stories around cancer. And being a cancer survivor, there's still a tremendous shame and stigma around mental health in suicide in particular.

And lastly, I would say innovation is the space that the Commission hopes to preserve and continue to push because that is a funding stream that has this mandate for recognizing that we can do better and we must try to do better. On a continuous know our, in the slide deck that we passed out, I listed some accomplishments that we've had over the last few years around suicide prevention.

Department of Finance. LAO?

Most of that work will begin to end as the funds that were one time and were available are fully exhausted. But we hope to continue to work with the Department of Health Care Services, with the Office of Suicide Prevention at CDPH. But in those areas that I mentioned, data stigma, information, innovation, continue to push on this as a key area of concern for the State of California and the Commission.

Nothing to add, but we're available for questions.

I'll bring it up to the dais. We'll begin with Assembly Member Ramos.

Thank you, Mr. Chair, and thank you for the work that's being put in to the office of Suicide Prevention and all the different material that was discussed. Part of the Bill also talked about ensuring that we were getting resources to the demographics that drastically need it. At that time, it was our youth, and Native Americans, LGBTQ and veterans.

So are we assuring that the resources that now we're moving forward in these different programs are reaching those that are most vulnerable, that drastically need the resources in a timely manner?

Yes. So for our two youth suicide prevention projects, we are focusing on youth disproportionately impacted. So we are looking at youth who are black, youth who identifies Latinx, Latino, youth who are American Indian, Alaska native, and also how that youth who identifies those priority populations also may identify as LGBTQ, plus involvement in the foster care system, a history of mental health conditions, et cetera. So, yes, that is the priority for those projects so that we can reach those youth disproportionately impacted.

Thank you. Thank you for that. And that was a big component of making sure we're getting resources to the areas that are needed. And so it's great to see that that's happening. But also around the stigma, the stigma of mental health. I know there was talking about some type of outreach that would start to deal with the stigma that's out there also.

So are we moving forward in that, on a campaign that way also to break down that stigma so that people could come and get support services that then could tell their survivor stories?

I mean, in the community, we talk about how mental health services growing up on the Indian reservation, those that would go in to get dental, those that would go in to get medical, and then those that would go to the office to get counseling, those that went to those areas ended up having some type of chatter about them moving on that then broke them down not to go out and seek any more support services.

We have to get to a point to where here in the State of California, if not the nation, if not the world, that we break down that stigma, that those that are seeking mental health resources, that it's something that's acceptable by our community. So are we also tackling that issue.

On the forefront in regards to the public education campaign? That is the intention of the micromedia campaigns, for lack of a better word, you may recognize guerrilla marketing.

So it's similar approach where we can go down to the communities and they can develop really creative innovation or tactics or approaches that allows them to reach the community, go to a grocery store or go to, maybe it's a trusted messenger within their community that can talk to them and make those proper referrals or even just have the conversation.

We do know that with stigma, just communities, especially within the black, Latino, and Native American communities, and even Asian Pacific Islanders, the five priorities that I mentioned earlier, they need to discuss it, they need to talk about it. So we want to make sure that we can empower, build that self efficacy so communities can do that and then get really creative in ways that they can do it.

Whether we build that self efficacy with a mom's and pop store or a laundry mat, there's different ways for us to get really creative. And the micro media approach really would allow us to do that. And then the macro campaigns that will be sort of at the higher level will continue to support that. It really is a multifaceted approach because we can't just do one remedy or one formula to reach the community. So we do want to be creative.

Is the campaign partnering with the areas that are most vulnerable in getting the different resources too? So then the resource that's going into this population demographics. We have an also stigma, anti stigma campaign also tackling the same demographics.

Yes, that's the intention. And that's part of the call to action that we'll have to bundle and we'll need to prioritize all those different resources, whether if it's a hotline or different key communities, wellness centers or a Doctor, a [Spanish], whatever that may look like. That's why I can't give you sort of a blanket answer, because it's going to look very different for a Latino community as opposed to a native community, Native Americans. And you know this better than I do.

You guys do a lot of community media or different powwows where they come together. The Latinos, they rely on the [Spanish] and the peer to peer conversation. So we want to make sure that we can build a structure that allows for that and continues to allows us to be creative throughout the duration of the campaign. Therefore, the monies will go to those most vulnerable areas and those partners that can really allow us to be that community broker or that trusted messenger within those areas.

Well, thank you for that. And as always, our office is here to assist you in outreach in any way that we can. Looking forward to seeing these resources get into the community of the most vulnerable that are out there. Thank you.

I'll bring it up to the chair if I can. I'm going to begin in part because of what Didihirsch said and also because of what Toby Ewing called out and the courage that was shown by Ms. Polls earlier, as well as by a young student, Alyssa, when we announced the children's and Youth Behavioral Health Initiative. But we must start with stigma reduction and acknowledging what's happened in our own families.

I say this to share that my maternal grandmother committed suicide when my mom was seven. And that effect on our family and trauma is one of the major reasons why I am so focused on making sure that we provide supportive services to community Members as well. And it's important for us to make sure that it's not anyone else, but it's all of us. And it will take all of us to be able to solve this level of problem.

So I want to appreciate the testimony from so many of the panelists, but it will take us as well to make sure that we're reducing stigma. We'll take a moment to call up Miss Francis, if I can. Now you touched on a nerve and you didn't even know it.

Oh boy.

I'll start by. I got three young girls.

Yeah.

And 7,10, and 11. And I'm really focused on the impact that social media has on their developing brains. And so when you're telling me that girls are two or three times more depressed when they use social media, are there any recommendations on if they should be using social media? Are there ages that we should be discouraging use of social media? I would love you to comment on it.

Yeah. So I'm not a physician, so I'll say that first and foremost, there hasn't been a lot of research about how young is too young to be frank. I think people have made assumptions and, you know, social media, their own platforms say that you have to be, I think, 14 before you even go on Instagram or Facebook. I think that is probably more of a suggestion as opposed to an academic stance or a medical stance on how young is too young.

But I do know that what you're seeing, particularly with girls, is a compounding of what's happening in society about body image issues. Right. That's not unique to social media. Girls are feeling that because socially, on their television screens, even as well as on their phones, they are getting these messages that might not also align with how they're feeling. What was interesting to me, though, were the young people who were reporting that they were feeling social connectedness through the use of social media.

So people who might have trouble getting friends face to face or making friends face to face, they were finding community online. So I think that's a hard question to really answer. I think what's been happening is families are trying to figure out what works best for their individual circumstances. If they have a child who hasn't been making friends at school and have been making friends online, they've been letting the use continue.

I'm going to be careful because you mentioned in your testimony there's not causality. And yet what we're hearing from the young people is that it is social media that I'd like to understand. What type of research would we need to do to understand causality?

Yeah. So this one's a hard, because the causality is really in reference to suicidality, not depression. Right. So we know that they are depressed with the use of social media. Right. They're already reporting that. The suicidality piece is probably much more of a long term longitudinal study to see what we're looking at as young people have been using social media over time, how many hours, et cetera.

I also don't want to say that the absence of evidence means that we can suddenly prove that this exists, but the speculation has been the high use of social media means it leads to depression, which means it leads to suicide. But the reality is suicide is a little bit more complex than that. It's not a one to one relationship. So what you're seeing is that young people have a bunch of other things going on in addition to feeling sad about social media.

So it's not just social media. It's also their peer relationships, their parent relationships, their romantic relationships, what's happening academically. So these are compounding issues. And social media is the one thing that we can point to that is new and different in the last 20 years than how I was raised or how you were raised.

I don't even want to start to think about it, but I'm sure most children might consider placing a different age in if that increased the likelihood that they could participate in an app that they wanted to participate in.

Oh they do.

Are there states that have creative ways to ensure that we are able to create those limits?

We haven't seen that nationally as yet, but they do. I have nieces and nephews. That is exactly what they're doing. They're lying about their age to get on Instagram and to get on Facebook. That is a fact. And we don't really know. I mean, oftentimes I know parents don't know that their kids are on social media because they have spoof accounts and they have accounts that aren't in their name that they're using. So this is a very hard thing to monitor.

They're not signing up as their own name because their mom and dad are also using Instagram. So that's a difficult thing to track.

I'll follow up, and I may do this offline with the office of Suicide Prevention, but I'd like to understand what other states are doing that's innovative in this space. We'll just elevate. We don't try out medications on people and then see their effect. And yet it seems that we're trying out many of the apps or social media and finding the effect within our children that keeps many of us parents up late at night. I don't believe my kids have been on social media because they don't have phones yet.

Right.

I hear about that every day. Right. And I think it's important for us to make sure we're doing all we can to be as cautious and protective as they appropriately develop and start to have confidence in themselves. So I'll hit pause on that, but just really appreciate this entire panel, and we will now move on to issue. Six.

Provisional language we have Kimberly Chan, assistant secretary with program and fiscal affairs with California Health and Human Services Agency to present this issue. Welcome and please begin.

Mr. Chair. Good evening. Kimberly Chan, assistant secretary for program and fiscal affairs at CalHHS. As folks know, federal law has designated 988 as the new three digit number for the National Suicide Prevention and Mental Health crisis hotline. To adequately and sustainably Fund the 988 system, federal law authorizes states to impose a fee on access lines for providing 988 related services.

Assembly Member Bauer-Kahan's Bill AB 988 of last year was signed by the Governor does just that to support the broader implementation of the 988 suicide and crisis prevention line. The Governor signed the Bill with a signing message instructing the Administration to propose additional cleanup language in the governor's '23, '24 Governor's Budget. So today you have that BCP and trailer Bill in front of you, which combines the trailer Bill and the BCP for CalHHS, DHCs and DMHC.

At this time, I can go through the BCP and trailer Bill in detail, or I can jump to the stakeholder concerns. Yes, I'm seeing head nods to stakeholder concerns. Wonderful. Okay, great.

So I will just say that we did have a chance to meet with stakeholders last Tuesday to discuss the trailer Bill in detail. We discussed just about every single item on the concerns list, and I feel, and folks can speak for themselves here, that we are on the right path to helping to get to a resolution on most, if not all of these pieces. And we did receive from the stakeholders in coordination with Assembly Member Bauer-Kahan revised language. And so we just got that this morning.

We haven't had a chance to review all of it yet, but we are pleased to have a dialogue going on that. And then finally to the other point I think I noted earlier, we are proposing this as trailer Bill Language because it was in the Governor signing message asking us to please propose trailer Bill Language for cleanup. Just broadly speaking, on the stakeholder concerns.

First off, our trailer Bill Language is meant to promote more efficient use of staff time and resources, and in no way is trying to remove legislative oversight. We have quarterly implementation meetings both from the CalHHS side and Cal OES, along with a five year implementation plan. So we're happy to continue to provide updates. Just really wanting to prioritize our staff resources and time.

In reference to the second point on mobile crisis teams, we wanted to make sure that we're providing as much flexibility in this Bill as possible. Not every single call to 988 is going to require a mobile crisis response. Perhaps it's just as it is today, a person on the line providing additional counseling. Perhaps down the line we're able to do really innovative things like connecting to a provider and network. Right. It may not require mobile crisis in person. And so that's the key point.

We're not trying to remove mobile crisis teams. We're really trying to broaden it so that it compasses a range of behavioral health services a particular individual might need. To the next point, I think the key point to note here is that we believe that it is premature to be so prescriptive to the language on what recipients of funds will have to report. We may not have all this information right now.

In fact, we have proposals in other spaces to try to get to that level of detail. That is a point that we are talking through with the stakeholders to see if we can land on a sweet spot on that. But the key piece is that we just don't have that level of data and detail at this point to be so prescriptive in statute. And lastly, on the last point, regarding insurance protections broadly, we believe our proposed language is actually much stronger than existing law

and in federal law, there are, of course, nuances to the federal no surprises act, and we are happy to work with stakeholders to work through how to balance that federal law and our state law. We do have staff here from Department of Healthcare Services and Department of Managed Healthcare to answer any of your questions you might have on the BCP or trailer Bill. So I'll just end it there and pass it on to the other speakers on this panel.

Next we will hear from Tara Gamboa Eastman, senior advocate with the Steinberg Institute.

Hello Chair, Tara Gamboa Eastman with the Steinberg Institute. We were the proud co sponsors of AB 988 last year with the Kennedy Forum, as well as others, and just want to take a moment to acknowledge the Committee for all of your tremendous work to implement this as well as the Administration. You guys have so much on your plate, and we're just incredibly grateful for the hard work that you're doing and for the ongoing conversations around the trailer.

bill language we also feel very positive about the direction of the conversation and think that we can find mutually agreeable language. I think on both the issues of legislative oversight and the planning around mobile crisis teams, it's just an issue of specificity. I think we have faith in the work that the Administration is doing and just want to make sure that the goals are clear while allowing them the needed flexibility. On the issues related to the fee, we are concerned about removing critical guardrails here.

First, the language as proposed removes language that would prevent the 988 fee revenue from being used for any other purpose or moved into another Fund. This is an incredibly serious concern given the history of 911 fee diversion across the nation. California has been a leader at preventing that on the 911 side, and we want to ensure we continue to be leaders on that front.

Additionally, while we understand that there may be existing data concerns that we need to address, we're worried that if we're not requiring Fund recipients to report, if they've billed insurance companies, and if they've received reimbursement, we may have a misuse of taxpayer money and also may not be using our resources most effectively or have the information to fix that.

The language also deletes reporting requirements around system performance metrics, and we want to make sure that we're consistently improving the system for the callers. On the issues around insurance, yes, the issues with the No Surprises act are quite nuanced from our perspective. The language as written in the Health and Safety Code would both narrow existing law and conflict with federal law. The federal No Surprises act requires coverage of certain post stabilization services without prior authorization or regard for network provider status.

We believe that California should ensure the protections in place under state law are not less than those under federal law. The definition of behavioral health crisis services should also align with the broader federal definition in order to ensure the state is not unnecessarily limiting the scope of services and benefits protected under federal law. We're also concerned about narrowing existing state law, namely SB 855, which requires that all medically necessary behavioral health treatment be covered.

The trailer Bill Language sets Medical services as a ceiling, reducing the commercial coverage requirements in place under SB 855. We propose maintaining existing requirements while clarifying that these requirements include, at minimum, the services covered by medical. We do enjoy or are excited about many of the protections included in the health and safety Code, namely mandating payments for services rendered. But we are concerned about the limitations as currently written. We do feel incredibly optimistic about where we're headed and look forward to working with the Committee. Thank you.

Next we will hear from Shari Sinwelski with Didihirsch.

Thank you, Chair. First, before I start my prepared remarks, I just wanted to first offer my condolences for the loss of your grandmother. I'm sorry you never got to meet her, and I thank you for sharing that personal story. I also want to just recognize anybody here in the room who's lost someone to suicide, because my guess is probably most people have.

And also to the people in the room who have had their own thoughts of suicide or their own suicide attempt, I hope that the work that we're doing today is creating a community where they're more willing and able to reach out for help. We know that one in 20 people have had thoughts of suicide, and I know that 988 is an opportunity for people who have not been comfortable in asking for help are doing that now.

And so I just wanted to acknowledge that I'm still Shari Sinwelski, I'm still with Didihirsch, and we are still the lead in the state for our 988 implementation, and we're honored to work collaboratively with the 11 other California 988 crisis centers. California centers have long influenced best practices and led innovations in hotline operations.

SAMHSA's leadership consistently commends the performance of California with its rollout of 988, and points to the work in the state as a shining example of 988 implementation in the nation. On average, California's 988 crisis centers respond to more contacts than any other state per month, responding to over 260,000 calls, chats, and text annually 24/7.

The 988 suicide and crisis lifeline is not a new service, but it's an easy to remember number to reach the network of crisis centers that have been providing services as the national suicide prevention lifeline for years. Previous SAMHSA evaluations have found that seriously suicidal individuals call the lifeline and that there have been significant decreases in callers reports of intent to die, hopelessness, and psychological pain after speaking to a lifeline counselor.

All 988 crisis centers are aligned with lifeline evaluated best practices, including the suicide safety policy that requires that all centers practice active engagement with the goal to establish rapport and collaborate with individuals to secure their own safety, utilizing the least invasive intervention, and only using emergency interventions as a last resort. California 988 crisis centers do an outstanding job at achieving this goal. Approximately 96% of contacts are resolved by crisis counselors on the contact and do not require further intervention.

Since launching 988 in July 2022, total instate contacts answered have increased by 22%. Young people under 24 have accounted for nearly 40% of total contacts. Individuals reaching out about someone they were concerned about have increased by over 150%. Help seekers were 54% female, 43% male, and 3% transgender, nonbinary or other gender. 58% of contacts came from black, indigenous, and people of color, as well as those identifying with multiple races or other races.

The 12 California crisis centers are working to make 988 a trusted resource for all Californians. There's currently a press one option for veterans, a press two option for Spanish speaking individuals, as well as translation services for other languages, a press three option for LGBTQ plus help seekers. Additionally, Didihirsch has recently convened two statewide 988 tribal summits in collaboration with Assembly Member Ramos to address specific cultural considerations to make 988 a trusted resource for California's native communities.

Without question, 988 is already saving lives. A recent 14 year old chat user who identified as nonbinary wrote in, "I'm feeling better, thank you so much for talking to me, understanding me, and helping me through this night. You are a beautiful human being and I appreciate the stuff you do for everyone. You are doing miracle work. You save people's lives. You calmed my mind down tonight and I thank you so much for that. You forever have a special place in my heart'.

Another caller called in to say,"Thank you. On this day years ago, she had called the lifeline while in a dark place, and the counselor was able to give her the foundation of emotional support she needed to seek help and to heal. Today, she's in a really good place and she's currently looking to buy her first home, and she felt compelled to call into the lifeline and express her thanks".

The vision for 988 is a crisis care continuum consisting of three components like a three legged stool, someone to contact, someone to respond, and somewhere to go. The 988 crisis centers and the Administration have focused this first year on the first leg of the stool to ensure that there is sufficient capacity for 988 contacts from everywhere in California.

We know that the volume to 988 will only increase with diversions from 911, with people seeking mobile crisis, and with increased advertising. Therefore, it is critical we ensure that there is sustainable, predictable funding in place as this life saving resource becomes even more recognized in the coming years.

I want to thank all of our incredible 988 California crisis centers for their tireless work saving lives and their commitment to making the 988 network in California the very best that it can be.

On behalf of all of the 988 crisis centers, we also wish to express our gratitude to our state partners at the Department of Healthcare Services, the California Health and Human Services, and the California Office of Emergency Services for their ongoing support and collaboration, as well as Assembly Member Rebecca Bauer- Kahan, the principal author of AB 988. Thank you Chairman and Committee Members, and I'm happy to answer any questions thank you.

Next we will hear from Michelle Cabrera with CBHDA.

Hi. Good evening, chair and Members, Michelle Cabrera with CBHDA. We want to first thank the Administration and the Legislature for the significant investments that have helped to lay some of the groundwork and the foundation for both our 988 call center infrastructure, as well as our mobile crisis infrastructure counties have in California for the last couple of decades, really seeded the investments that have made the network of suicide prevention call centers and warm lines throughout the state possible.

And in particular, they were able to leverage MHSA funding to help build out California's 988 call center capacity for Spanish language services, which then was the National Suicide Prevention Line, and are today and continue to be funders of those call centers to varying degrees, with two of those call centers being operated by county behavioral health. Specifically, I'm going to speak a little bit to both our efforts around mobile crisis services implementation as well as to the 988 rollout and the trailer Bill.

So on the mobile crisis side, again, much like the school based services, we've got a bit of a patchwork right now in California. And a big part of the reason why is because before the Medicaid benefit which CMS just brought online, there really was sort of not a consistent benefit or sustained funding. And with the Medical benefit, we will have funding for one out of every three Californians to receive a mobile crisis service.

With the AB 988 legislation last year, the intention, I know was to put language in that would strengthen the requirement for private insurance plans to reimburse. We actually think that the administration's proposed trailer Bill revisions of that language does strengthen the opportunity for us to receive reimbursement for those out of network private insurance plan services. And it is nuanced, and it does get into your interpretation of federal law.

I would say we lean closer to the state's interpretation and think that it's really important for us to remove the requirement that exists in 988 today for us to establish medical necessity to reimburse for call center services and for a field based mobile crisis. We actually preferred the administration's original language, which aligned reimbursement requirements with the prudent layperson standard for ambulance services.

So generally, if you think you have an emergency and it seems reasonable that you thought that, that the provider will get reimbursed for coming out and serving you. So we prefer plan a in terms of what has been offered, but think that this language is a step in the right direction and reimbursement on the private side is essential because again, 70% of Californians won't be captured under the medical benefit. And yet when people call 988 again, they're not going to be.

When someone's having suicidal ideation, it's not a great time to say, hey, what kind of insurance do you have, by the way? Right? Or when they're in the field having a crisis. And so we want to remove as many barriers as we can to all get to that uniform, unified vision. It is going to take time to build out our capacity and infrastructure. The fact that the state put infrastructure money on the table, we've gotten a CMS planning grant.

All of those things are really wonderful and really help to sort of move us in the right direction. But rural California is going to be tough, right? Finding the humans to work a night shift, a swing shift. I'm sure, you know, Dr. Arambula is really tough. And so we've been really appreciative to the state for allowing us to craft the benefit for a mobile crisis in a way where we can really maximize our use of paraprofessionals and phase in implementation, including with those 11 frontier counties.

But we do think that it's still going to take a lot to get there. And so we need to take a sort of steady, focused approach, again, working in partnership with communities and along with the state. I'll just say one other quick thing, which is that in terms of the 988 call center structures and infrastructure, it'll also take time to knit together our 988 call centers with the mobile crisis services on the ground. Right.

Right now we have largely volunteer operated 988 call centers. And doing mobile crisis dispatch is really a professional job. Right. You need a clinician to do that triage and to determine whether or not you need to send a mobile crisis team out. That is a skill set in and of itself. We've got 12, 988 call centers in California today, compared with the almost 450, 911 call centers.

And so that just puts into perspective a little bit the road that we're going to have to walk to get to that three stool vision that Shari laid out. And happy to take any questions?

Department of Finance.

Department of Finance. We would like to echo services agency's comments that trailer real language is an appropriate vehicle for this, given the governor's second message, and that it's related to a proposed ECP and DHCF.

LAO.

Ryan Miller. LAO, no concerns with the proposal.

We'll try again. Department of Finance.

Elena Ramos, Department of Finance this time on the record. We would like to echo the Health and Human Services Agency's comments that trailer bill language is an appropriate vehicle for this issue given, given the governor's signing message and that it's related to multiple budget change proposals.

LAO?

Ryan Miller, LAO. We have no concerns with this proposal.

Bring it up to the dais. I'll begin. I want to focus on the mobile crisis teams. I think that's a really important part, and I'm hearing something different than I saw within the agenda, and it really sounds like you're trying to create flexibilities and broaden the service and acknowledge that it's not a one-size-fits-all, but many of our rural counties may need certain flexibilities. But I really want to get an understanding.

Are we expecting to be able to operationalize this by the end of the year, come next year? Are we expecting us to be able to realistically say we're treating the brain like we do medical emergencies? We'll get nuanced, too. But if we have a medical emergency and it's the prudent layperson standard, why do we have a different standard when it's a psychiatric emergency in terms of calling and not using that same one?

So I'm just trying to get a sense, how can we make sure we're operationalizing by next year?

Sure. I'll take, those are two different questions. And I will also welcome my DHCS and DMHC colleagues to speak to the mobile crisis pieces. And of course, to add on to the commercial coverage pieces. I'll speak first to the commercial coverage pieces. I think what you will see is that we actually mirrored the statutory language that is under 911 as the basis for the process for reimbursement for 988.

So we didn't want to put it in the 911 statute for a number of reasons, and so we decided to mirror that language. So I don't know if Mr. Southard or others want to add on to that. And Mr. Sadwith, if you want to add on to the mobile crisis piece.

Good evening. Dan Southard from the DMHC. As Ms. Chen was noting, our trailer bll language was trying to mirror our current statutory requirements for emergency services. And so it's a high-level overview of that. If an enrollee presents with a 988 crisis, no prior authorization is required by the health plan before those services are rendered until the point of stabilization.

What we've noted in the trailer bill language is at the point of stabilization that the provider would need to contact the health plan to request either authorization for the services post-stabilization or transfer the enrollee to an in-network provider. Payment is at reasonable and customary for an out-of-network provider, and an in-network provider would be the contracted rate, and the cost-sharing for the consumer would be the in-network cost sharing, no matter which provider is providing the services.

So that was our trying to mirror that. And I know we're working with the Steinberg Institute and Kennedy Forum to finalize that language because there's some concerns with the No Surprises Act going a little bit further on the post-stabilization, I think it's more specific to the requirement that the enrollee could be transferred through a non-emergency transportation service, which is a little bit of extension of our current 911 requirements. But again, more than happy to work with the Steinberg Institute and Kennedy Forum of Language.

I'm going to uplift their comments about feeling positive. I too am encouraged by the conversation that we're having here, and it does appear the goals are clear, but I'm going to end like Ms. Cabrera did. It will take a lot for us to get there and I think when we hear about these patchworks, for us to make sure we have a stable safety net, it really takes collaboration and so look forward to those continued conversations and the direction that we're moving.

Did you want Mr. Sadwith to speak to the mobile crisis?

Please.

Hi, good evening, Chair. Tyler Sadwith, Deputy Director, Department of Health Care Services. Deputy Director for Behavioral Health I wanted to provide clarification on the timeline for the implementation of the Medi-Cal mobile crisis benefit. One panelist noted that there's flexibility for 11 counties, so we have submitted a state plan amendment to our federal partners at CMS seeking coverage for the new Medi-Cal mobile crisis benefit effective January 1 of this year.

We are working with our counties to ensure they have, over the course of this calendar year, to implement it so that counties would go live with Medi-Cal mobile crisis by the end of this calendar year. There are 11 counties representing less than 1% of the Medi-Cal population, whose population is so small that the rate development process based on projected service utilization for the 24/7 365 capacity means we still haven't finalized rates for those small counties.

So we have proposed a six-month extension so that those counties would go live July 1, 2024.

With that, I will thank very much this panel and we will move on to issue seven. Issue seven is an overview of the Department of State Hospitals and the proposed DSH budget. Our first speaker is Stephanie Clendenin, Director of the Department of State Hospitals. Welcome and please begin.

Good evening. Chair Stephanie Clendenin, Director for the Department of State Hospitals the Department of State Hospitals manages the California State Hospital System. DSH's mission is to provide evaluation and treatment in a safe and responsible manner by leading innovation and excellence across a continuum of care and settings. We operate the five state hospitals located throughout California with over 6,000 in-patient beds that include acute, intermediate, skilled nursing facility, and residential recovery level of beds.

We also operate the Conditional Release Program, which is a system of community-based services operated in partnership with county Behavioral health and private providers that is designed to transition patients back into the community following a forensic commitment to DSH. We also have partnerships with county behavioral health programs, private providers, and county sheriffs to provide community-based restoration diversion opportunities and jail-based treatment programs for individuals committed to the Department as incompetent to stand trial.

The individuals served by our system of care are mandated for mental health treatment by either a criminal or civil court judge or the board of parole hearings. The majority of the individuals we serve are forensic commitments. They have either committed or have been accused of committing crimes linked to their mental illness and come to us directly through the criminal courts or after they have completed a sentence at the California Department of Corrections and Rehabilitation. We serve six different type of patient commitments.

These include incompetent to stand trial, the not guilty by reason of insanity, individuals who have completed a sentence at CVCR for their crimes but then are committed to the Department as offenders with mental health disorders, or sexually violent predators after they've completed their sentence, and then current inmates from CDCR who require inpatient mental health treatment. And finally, we serve individuals conserved by a civil court under the Lanternman-Petris-Short Act who require state hospital-level treatment.

The 23-24 Governor's Budget includes a total budget of 3.2 billion for DSH operations, an increase of 35.5 million, or 1%, from the 2022 Budget Act, with 49.7 proposed new positions in 23-24. The proposed budget augmentations generally include investments to continue the department's efforts towards improving the department's operations and delivery of services, and state hospital facility improvements.

The caseload estimate is projected to exceed 9,000 by the end of fiscal year 23-24 with a total of 5,468 patients across the state hospitals, 2,772 in contracted programs, and 1049 in the conditional release programs. Before I proceed, I did wanted to check in with the Chair too. We are prepared to present an overview of each of the estimates that recognize in time whether you would like us to do that or not.

High-level overviews are okay due to the lateness of the hour, and so 22 issues for us to address tonight. Let's keep it high-level, if we may.

Okay, so I'll go ahead and turn it over to Chief Deputy Director Houser to cover the first half of them.

Good evening Chair. My name is Brent Houser, Chief Deputy Director of Operations.

I'll speak at a very high-level to specific program and caseload updates given the hour. Starting with the County Bed Billing Reimbursement Authority, this item is comprised of two main components that the county reimburses the Department for patient treatment, the first being Lanternman-Petris-Short population and the second being non-restorable incompetent to stand trial defendants who are not timely transported and returned to the committee county within statutory timelines. At the 2023 Governor's Budget, the Department proposes to maintain the current reimbursement authority of 191.6 million.

Moving on to a different item. Under our estimate, the DSH-Metropolitan Increased Secure Bed Capacity Project, the Department reflects a one-time savings of $11.2 million General Fund in the current year. The project, which originated with the capital outlay project in 2016, added security, fencing, and infrastructure to an existing patient building at this hospital so the bed capacity could be used to serve additional forensic patients.

The construction project was completed and two of the five patient units were activated prior to the pandemic for treatment of individuals found incompetent to stand trial. At the Governor's Budget, one unit is being used for COVID isolation space and the other two units are housing DSH-Metropolitan SNF patients. The savings identified are related to personal services associated with the delay in activation of the remaining units. Providing a quick update on enhanced treatment program.

DSH is reporting a one-time savings of 4.8 million in the current year. In the prior year Budget Act, DSH was appropriated capital outlay funding to convert existing patient units into an enhanced treatment program. Units and resources were authorized to activate those units when they were completed. DSH previously completed the construction of a 13-bed unit at DSH Atascadero and that has been activated since September 2021.

The second 10-bed unit at DSH Patton is underway and as of the Governor's Budget, DSH is experiencing a nine-month program activation delay for this unit due to construction and that's what the savings are reflecting.

Moving on to DSH's mission-based review initiatives in the 2023-24 Governor's Budget, DSH reflects the savings of 44.9 million in current year, savings of 24 million and 46 and a half positions in 23-24, and 10 million and 46 positions in 24-25. And lastly, a savings of 10.9 million and 46 and a half positions at 25-26. Several years ago, DSH initiated an effort to evaluate staffing practices across the state hospitals and reviewed four components, hospital forensic departments, 24-hour care, nursing services, protective services, and treatment planning and delivery.

As a result of these processes, proposed staffing methodologies and positions, requests and adjustments were requested and authorized to be phased in over a multi-year period for these four components, and the savings are reported are due to delays and challenges experienced with hiring positions that were authorized. Recognizing the challenges with recruiting and hiring, DSH has been implementing a multifaceted approach to expand its recruitment and retention efforts through marketing and outreach, pipeline development via educational partnerships, and streamlining the hiring process.

Two more issues for me just summarizing high-level for the patient-driven operating experience, expenses, and equipment update DSH requests 20 and a half million ongoing to support the increase in patient-driven support costs within the DSH system, which include, but is not limited to, clothing, personal supplies, food, laundry, medication, and outside medical expenses. And DSH is utilizing the methodology established in prior budget acts to include a funding request in the budget year and ongoing based on 2021-22 actual expenditures and 2023-24 projected census. In relation to the COVID-19 response in the budget year, DSH is requesting 51.3 million one-time to continue to support infection control measures to protect the health and safety of our patients and our employees beyond the state of an emergency end date.

With the onset of the COVID-19 pandemic, the Department has executed a COVID-19 response plan in alignment with CDC, CDPH, and local public health departments, and we adjust this plan on an ongoing basis based on the nature of the pandemic. Resources are needed to continue to support testing surge capacity resources for public health-related personnel and PPE. With that, we'll go ahead and turn it over to the Chief Deputy Director of Program Services to conclude this item.

Hi, Chris Edens, Chief Deputy Director, Program Services. I'll be commenting on the Conditional Release Program Non-SVP caseload. The Department is requesting 2.6 million and 2 positions in 23-24 and ongoing in response to increased workload and costs for the Department and our contracted providers and evaluators, which is driven by the activation of new placement options established under CONREP's expanding continuum of care.

The CONREP Program is DSH's system of community-based services designed to transition individuals who are treated in the state hospitals and back into the community. During the past several budget acts, the Department has been authorized to expand the continuum of care in its CONREP Program to provide additional treatment settings to increase the number of individuals who are able to transition from the state hospitals.

This has included establishing a new CONREP Forensic Assertive Community Treatment Regional Program, expanding the statewide Transitional Residential Program, and increasing the number of IMD beds in the CONREP program to help individuals transition. The projected CONREP Caseload is 1,020 CONREP clients in 22-23 as well as in 23-24.

Lastly, we do have an item within our IST solutions estimate item with respect to this the budget adjustment reflected in this item is specific to the Jail-Based Competency Treatment Programs and the one-time infrastructure funding authorized in 22-23 to develop residential housing settings to support felony IST individuals participating in either community-based restoration or diversion programs.

The Department is requesting one position in 23-24 ongoing to support the shift in administrative workload from clinicians to an office technician, which is going to free the clinical staff to focus on patient care issues and provider oversight. Additionally, the Department is reflecting a net savings of 27.4 million in the current year and 3.1 million in the budget year and ongoing.

Primary driver of the savings is a reduction in the San Bernardino Jail-Based Competency Treatment Program's capacity from 146 beds to 64, which was effective in September of last year. In addition, there are a number of offsets to the level of budget year savings due to a number of programs that are pending activation. Three additional programs were able to increase their bed capacity by 40 beds and bed rate increases anticipated for 20 of the participating counties.

As of December 2022, there were 413 beds across 23 county programs and with that, I will conclude my presentation and ask if there's any questions.

Department of Finance?

Department of Finance, Nina Hoang. No further comments.

LAO?

Will Owens, LAO. We have no concerns with any of the proposals.

With that, I will thank very much this panel and we will move on to issue eight. Issue eight is an oversight issue on behavioral health and justice involvement. Our first speaker will be DSH Director Stephanie Clendenin.

Thank you, Mr. Chair. Stephanie Clendenin, Director for the Department of State Hospitals.

The 2022 Budget act authorized 535 million, increasing to 638 million in fiscal year 25-26 for the Department of State hospitals to implement incompetent to stand trial solutions to help address the growing number of individuals being referred from the courts to the Department as incompetent to stand trial. Individuals who are incompetent to stand trial, have been arrested for a crime and as a result of their mental illness, are unable to understand the nature of the charges against them or assist their counsel in their defense.

The courts make the determination whether an individual is incompetent to stand trial based on the evaluation by a court-appointed evaluator. Individuals who are found incompetent to stand trial on felony charges are typically referred to the Department for restoration of competency treatment. Over the last decade, despite DSH's efforts to expand treatment capacity, among other efforts, the increasing number of individuals being found IST and referred to the Department outpaced the Department's efforts and resulted in an ongoing waitlist for individuals needing restoration of competency services.

Additionally, due to the COVID-19 pandemic and necessary infection control measures that we had to implement at the state hospitals during the first two years of the pandemic, the waitlist increased significantly.

As a result of a 2015 lawsuit by the ACLU regarding the time that IST defendants were waiting in jail to be transferred to DSH's treatment programs. The court ordered the Department to initiate substantive treatment services within 28 days for IST defendants by February 2024 and also set interim benchmarks for the Department to achieve between August 22 and February of 2024.

The additional solutions funded in the 2022 Budget Act, along with other recent investments in prior budget acts, included short-term and long-term strategies centered around two primary goals. The first being initiating treatment services for our IST individuals within the 28 days as required by the court, and secondly really changing the arc of the lives of those that DSH serves by reducing criminalization of individuals with serious mental illness. The IST solutions are focused on three strategies.

They include expanding the treatment continuum, maximizing efficiencies, and reducing demand. Now I would like to turn it over to Chief Deputy Director Chris Edens, who will walk through and provide a brief outline of the implementation efforts associated with each of these strategies.

But before I do, I did want to acknowledge, as she presents all of these, that we have been able to accomplish all this through the tremendous partnerships with County Behavioral Health, sheriff's departments, and private providers, and just really want to thank them all for their participation in all of these efforts as well, because the Department cannot do it alone.

Hi Chris Edens, Chief Deputy Director, Program Services. So for the first strategy, we focused on significantly expanding the treatment continuum for IST individuals, with an emphasis on community-based treatment options such as community-based restoration and diversion that connect individuals to treatment in their communities rather than institutionalization in a state hospital.

However, building out the infrastructure needed to significantly expand community treatment options will take multiple years and we have individuals on the waitlist who need treatment now, so we have had to include more short-term strategies such as jail-based treatment options. To highlight some of the key investments under this strategy, in the short term, we augmented current diversion pilot contracts with counties to provide one-time housing augmentation to provide greater opportunities for individuals on the waitlist to be served in the existing diversion pilot programs.

Additionally, we implemented early access and stabilization services, which is designed to provide early access to treatment for IST individuals on the waitlist. Currently, we've implemented this program in 32 counties as of July of last year, and over 1,000 IST individuals have received treatment in this program.

In the longer term, the current and prior budget act supported a significant expansion of community treatment options, which included funding to develop up to 5,000 beds over a four-year period, and that includes both the infrastructure funding and ongoing operational funding to provide the dedicated housing and treatment needed to support the IST population served in community-based restoration or diversion programs.

We've contracted with Advocates for Human Potential to help us administer the infrastructure program, and the request for proposal for funding was released to counties in February of this year. In addition, the 21-22 Budget Act provided funding for the Department to contract for community inpatient facilities. These facilities primarily are envisioned to provide treatment and stabilization for IST individuals to increase opportunities for placement in community-based treatment and diversion.

In the past year, we've contracted with the Sacramento Behavioral Health Hospital for 78 beds and continue negotiations for additional facilities with service providers over the next 18 to 24 months. The second strategy is focused on improving processes to help maximize efficiencies in the placement process. I will highlight a couple of efforts in this strategy that were funded in the 22 Budget Act, and they include implementing new care coordination teams.

These teams will help the Department to screen all felony IST patients to determine appropriate placement within DSH's broad and expanding continuum of care, provide enhanced monitoring of the waitlist, and provide commitment to admission case management to maximize bed usage for the IST population. Since July, we've worked to rapidly hire new staff and have implemented care coordination across 34 counties.

In addition, we are piloting a new independent placement panel for CONREP transitional patients to increase the number of state hospital patients served in the community within the Conditional Release Program. We are currently planning to begin implementation of this new program by July 2023. The third strategy focused on reducing demand for IST treatment services includes the IST Re-Evaluation Pilot Program that was implemented in 21-22.

This program reevaluates individuals in jail and on the waitlist pending placement to a DSH treatment program to see if they have already restored to competency and no longer need treatment in a DSH bed. To date, this team has performed over 2,500 reevaluations, and nearly 30% of those of the individuals that have been reevaluated were found competent by the evaluators, and the other 70% were identified as not competent and remained on the pathway to admission into a treatment program.

Additionally, funding was provided in 2022 Budget Act for DSH to partner with the Judicial Council to develop and implement training and workforce development programs for court-appointed evaluators with the goal of improving the quality of IST evaluations utilized by the courts to determine if someone is incompetent to stand trial. We have now entered into an interagency agreement with the Judicial Council for the development of the IST court-appointed evaluator training.

Lastly, the IST solutions also included implementation of a felony IST growth cap to help ensure that the expansion of DSH-funded community-based care does not create unintended incentives that may drive additional IST determinations. In December, the Department issued to county administrators, the courts, sheriffs, district attorneys, and public defenders information about the growth cap program, how penalty calculations will be made, each county's 2021-22 baseline determinations, and the county's first quarter 22-23 determinations and how that compared to their baseline.

Last month, the Department provided an update to the same recipients on each county's second-quarter referrals and trends compared to their baseline. The data showed overall statewide referrals in total across the first two quarters have increased by about 20% over last year, which is their baseline year. But in comparing the first quarter to the second quarter, there was a 4% decrease in the total referral statewide between quarter one and quarter two, with 30 counties experiencing a decline between these two quarters.

To assist counties in identifying strategies to reduce the number of IST determinations, the Department is partnering with the Council on State Government's Justice Center to develop training and technical assistance opportunities for counties, and in December, the Department released to counties a request for application funding process for $100,000 annually for each county to establish collaborative stakeholder workgroups that target strategies and seek solutions to end the criminalization of individuals with serious mental illness in their communities.

To date, 32 counties have applied for this funding to convene these work groups in their counties, and the Department will be hosting another round of funding applications for the new fiscal year. The agenda did include a couple of questions for the Department. I can provide a response to number two, then hand it back to the Director to provide a response to number one and close that up.

Question number two is when is it reasonable to expect that the Department will have outcomes data needed to evaluate the Mental Health Diversion Program? I will say that the initial IST Pilot Diversion Program is still currently underway. This program was extended effective with the 21-22 Budget Act due to the impacts of the pandemic and the delay in implementing some of these programs in the counties. To that end, the pilot program is not expected to end until June of 2025.

However, while this program is underway, each year the Department collects and reports on data and outcomes of the individuals that are being served within our diversion programs, and we publish this as part of our budget estimate in the Governor's Budget and May Revision. Information that's included in this report includes number of individuals participating in the program, demographics, diagnoses, the charges that were associated with their arrest, the current status of participants, including the number of individuals that are in the diversion program who've completed the program those who may not have successfully completed the program.

We also include success rates for individuals with certain factors such as homelessness, substance abuse disorders, treatment with long-acting injectable medication. Further, outcomes are dependent upon the Department's access to DOJ criminal offender record data, and there is a proposal that's currently being heard later to be able to access this information to look more at long-term outcomes for this population. Additionally, funding in the IST solutions budget was included to perform a more comprehensive evaluation of IST solutions, including our diversion program.

And to that end, we've entered into a contract with policy research associates to design and implement a phased evaluation of the diversion programs, and we expect this initial report to be completed next year in 2024.

And then just to close up with the final question, which was to provide the most recent assessment of progress being made with regards to the waitlist. And Chief Deputy Director Eden's provided an overview of all the implementation efforts that we have implemented across this last year.

And as a result of that rapid implementation of these solutions, as well as easing of the pandemic-related infection control measures that were required on healthcare facilities during the past year, we have significantly reduced both the IST waitlist and the time to treatment since this time last year. In March of 2022, we had over 1m],900 individuals on the waitlist. In April this year, we are currently at 1008, which is a 48% reduction in the waitlist.

And of those 1008 on the waitlist, actually 174 are already receiving treatment through the Early Access and Stabilization Services Program that we implemented this year with counties, sheriffs. And then with respect to the wait time, the average wait time to treatment has reduced from an average of 134 days in March of last year to 60 days in March of this year, which is a 55% reduction.

So we are seeing tremendous progress as a result of all the efforts that we are working on with everybody and our partners.

Thank you. Next, we will hear from Dr. Ewing with the Commission.

Thank you very much, Mr. Chair Members. So the Commission has done a number of things in terms of trying to focus on upstream opportunities to prevent. The Department of State hospitals are sort of the end of the line, so to speak, in terms of some of our most negative outcomes. It's a combination of hospitalization tied to criminal justice involvement, and we know there's a significant factor of homelessness associated with the population who's at exceptional risk.

So in many ways, the Department and its work is catching all of the missed opportunities, so to speak, that have happened along the way. The Commission's work is in the context of the challenge that's laid out in the hearing materials. We would say there's a couple of opportunities here just in interest of time. We need to do the data work to understand what's happening upstream. Right?

The Department has done some phenomenal work to show a high level of criminal justice involvement at the county level well before someone has a felony charge. We've been working with local officials to encourage them to ask some fundamental questions. Who's in their jail? Who's receiving mental health services? And are those folks known to their behavioral health system? If they're known to their behavioral health system, then it's clear that we may have a quality of care problem.

If they're not known to their behavioral health system, then they may have an access problem. They're accessing mental health services for the first time through law enforcement involvement, and that's inappropriate. I want to distinguish between people who are committing criminal justice infractions or very serious criminal behavior versus criminal behavior that may be simply tied to unaddressed mental health needs. My comments earlier about the importance of early intervention in psychosis because the presumption is that we don't know as much as we could know.

Looking at the data that the state has between the Department of Justice, the Department of Health Care Services, and the Department of State hospitals really understand the patterns in terms of whether it is psychosis that is leading to involvement with the Department of State Hospitals and how an expansion, to your point, of highly effective early psychosis care available on a statewide basis could actually fundamentally reduce those costs.

So that's part of the reason why I made my comments about early psychosis earlier, but the state's investment in full-service partnerships. Those programs were designed originally to bring people out of state hospitals more of an LPS population, a civil commitment population at the time, 20 years ago plus than a forensic population.

But again, we need to ask that question of why are people becoming into contact with the criminal justice system at the rate that leads to them landing at the Department of State Hospitals in the first place. So based on the graphic that I shared with you earlier, the Commission's approach is really to say before someone gets to a state hospital, before they have that justice involvement, that pattern, there needs to be a robust full-service partnership strategy.

But that's also expensive and we have limited capacity. To reduce demand on that component of our system of care, we need to have an aggressive early psychosis strategy. And an upstream strategy from there is our youth drop-in work. Because psychosis is likely to occur in the late teens or early 20s and that's where this youth drop-in program is designed. It's how do we create trust? How do we create understanding? So when someone begins to develop symptoms associated with psychosis, they're not masking that.

They've already developed the trusting relationships with the provider community to enable them to stop by and say, hey, I need help. And through that youth drop-in, be able to get a referral to a high-quality, effective program even farther upstream. Gets at the comments that Dr. Jackson made around school mental health is how do we create awareness?

How do we do the anti-stigma work so that for that percentage of the population that is likely to face those risks as they move down that Continuum with an illness, that they have the resources, the tools, the supports, the trust that is necessary to get in front of this problem very early on? For us, it starts with doing the data analysis and building out a prevention strategy that's responsive to that analytic framework.

I will now call up and apologies for jumping over her before, but next is Jacey Cooper, State Medicaid Director with Department of Healthcare Services.

That's okay. No apologies. Jacey Cooper, State Medicaid Director. There's two main intersections with what the Department has been working on, both that will be presented later in this hearing. So I'll be very short with my comments. Mainly the main intersection is around our justice-involved waiver. Would just want to say coverage of individuals incompetence to stand trial would only be covered if someone is pending so in a jail facility for those 90 days.

So we think it would be a very small touch in regards to any interaction there, but there is an opportunity, if they are in a jail setting for at any time before or after their time at a state hospital, that they would be able to receive services there. The only other piece I would flag is within our CalBHCBC waiver, our demonstration waiver for behavioral health, the addition of fact would allow for us to provide some additional services for individuals in the community, and counties could opt into that as an option, and we'll provide more information in the hearing later regarding both of those options.

Thank you. Next, we will hear from Phebe Bell with the Nevada County Behavioral Health, who is their Director. Welcome.

Hi, good evening. Thanks for having me, and in the interest of brevity, I'll try to keep this short. First and foremost, county behavioral health departments very much are aligned with the Department of State hospitals and I'm sure everyone in this room and our desire to keep people with mental illness out of jail and in treatment. To that end, we've really appreciated the partnership and the great programs that DSH has put forward, and most counties have been taking full advantage of those, including my own Nevada County.

And in addition, we've always done work with this population and continue to do so. In Nevada County, we have staff embedded in the jails, staff in the Probation Department, staff in the Public Defender's Office. We staff specialty courts, and we have staff working in the courts every day. So we deeply understand the need to find ways to pull people out of that system and into treatment.

My comments today, though, are really on our concerns with the new growth cap policy that's on track to be implemented this year. The growth cap is designed to compel counties to reduce the number of individuals who ultimately end up on the state hospital waitlist by financially penalizing those who send greater numbers of felony ISTs to the state year over year. County behavioral health agencies opposed this policy last year, in large part because we have very little influence on the key drivers of IST.

We know that housing status is one of the most critical indicators or risk factors for being found IST. Similarly, the decision to arrest somebody or not arrest somebody, take them into a crisis system or arrest them, the decision to file felony charges or not, there are multiple systems that impact that outcome, and it's a complex driver of the outcome of an IST finding.

We're concerned that counties have not been involved in the development of the growth cap methodology, and we think that some of the approaches being used now is pretty fundamentally flawed. First and foremost, the state's own guidance says that all determinations by the courts will be counted toward the cap.

Even when individuals never go to the Department of State hospital because they're diverted, because they've been found competent before they actually get to the state hospital, or even because they're deceased, they still count towards our cap, which is problematic. It's particularly problematic to count all determinations because we know the quality of IST determinations is not great. DSH's own review found that there's many issues with the determination process and including that fact that at least 30% of individuals turn out to be found competent on reevaluation.

So given the considerable lack of consistency and quality monitoring of evaluations, findings of incompetency by the court should not be the numbers used by DSH, but rather they should count the people who actually make it into DSH beds. In addition, the structure of the growth cap actually disincentivizes counties like mine from participating in diversion and community-based restoration, as we're still penalized for this population even while we're working to solve for keeping people out of DSH.

And then also lastly, the methodology, as it currently stands, disproportionately impacts smaller counties who traditionally have not sent many individuals to the state hospitals as felony ISTs.

So CBHDA would like to see changes to the statute that ensure that the proposed growth cap does not inadvertently find counties who build out diversion and community-based restoration options, assurance that counties will be consulted in the development of the growth cap methodology, and assurance that due process and an appeals process will be developed so that counties can verify and validate any individuals who may count toward their penalty.

As it currently stands, counties like my own are on track to pay collectively millions of dollars in fines this year, with no guarantee that the state-directed investments will ultimately be successful in turning the tide. This is, for me personally, particularly ironic because my county currently has the lowest rate of referrals to DSH in the state, and yet we're on track to pay fines this year. We need a system that incentivizes systemic solutions to the IST challenge and doesn't indiscriminately penalize counties.

We urge the Legislature and the Administration to continue to work with us on solutions that will get us to that end. Thank you.

Department of Finance.

Nina Hong, Department of Finance. Nothing further to add.

LAO

Will Owens. LAO. Nothing further but available for questions.

I'll bring it up to the dais. I'm going to begin, if I can, the court determinations. The court makes the determinations. And you said there were 2500 evaluations and 31% of those were restored. Is that an appropriate number for us to restore? Is there an appropriate amount of concern that this number is so high? It sounded earlier that you're working with the judicial counsel on court appointed evaluations. Will that help us to make sure that those determinations are more accurate?

Thank you for the question. So with respect to the reevaluations, the 2500 individuals that have been reevaluated and 30% were found competent. It's important to note that the finding of competency, many of these individuals had been treated within the jail programs, and so they may have restored just by the nature of the amount of time.

We've got to remember in the last couple of years, people have been waiting an inordinate amount of time on the waitlist to get into treatment, and we're receiving some level of services. So that's going to be one factor that probably drove that number higher in recent years than what we would anticipate.

Our work with the UC Davis, in looking at the incompetent to stand trial population, historically looked at more, I think it was about a 20% rate of individuals coming into our system in the historical years. In looking at the numbers that were coming incompetent, again, it's difficult to tell how much of that is due to treatment received versus really looking until you get in and do a study of the reports.

We did do a review of the reports, and I'm going to fail to remember the, I think it was AB 1394 which required us to establish requirements for the courts on kind of the evaluator training or expertise that they should have in order to be court appointed evaluators. And when we did do a review of those reports, we did find that a good portion, that's probably not the appropriate way to say it, because we only sampled the reports.

But we did find a portion of those reports that we sampled did have. They were reports that did not meet all the criteria of either the statute or really didn't highlight clear criteria for the court as to the reason that the individual should or shouldn't be found competent. And so we do know that, as we see and are performing evaluations and reevaluations, we do question some of the court appointed evaluator findings I elevated as.

There's an acceptable amount of appendixes you can take to the or without having all of them be infected, that we need to be cautious and if the court appointed is determining that too many are being labeled IST, that has complications as well. And so I look forward to the continued work that you're doing. I want to bring up what the Director had just talked about, though, about the determinations all counting against the cap. I was really struck by that dead people are counting against the cap.

Why aren't we looking towards those who end up in Department of State hospital beds total, rather than all that come up for determinations?

Thank you. That's a really good question. Just kind of looking at a historical perspective of all of the department's efforts. The Department and the Administration and the Legislature have all invested a tremendous amount of money and time, resources and effort into building out capacity for individuals who are found incompetent to stand trial. And what we've seen is as we build more continue to be referred to the Department.

And when we say the Department, the Administration, the budget, the General Fund is funding all programs, not just the ones of individuals coming to the Department of State hospitals. But this includes the community based restoration programs, this includes individuals that are coming and being participating in diversion and our jail based treatment program. So it's all of those services, all of that capacity that we're building out in order to address this increasing number of individuals who are being arrested and committed to the department's total programs.

And so that's why as we look at the determinations, we're looking across all the programs, because the state's investing in all of these programs in order to address this continuing growth of individuals that are being referred.

Are dead people included in all of those programs. I'm really struck by that example.

That's a good question, and we'll have to go back and take a look at whether we adjusted for those individuals, but that doesn't necessarily mean they didn't receive any of the Department services while they were waiting on the waitlist. Particularly, we do have the early access services program, so we would have to take a look at and look to see what.

I just would love to stress what counties want is to partner. As we are in many ways with DSH to again serve these people in a community setting. We know the outcomes are better if we use this opportunity to get people connected into long term resources and care. And so continuing to incentivize that work feels more important than penalizing a decision that has multiple factors weighing into the decision that was made to identify somebody as IST to begin with.

I wanted to point out last question, top of page 73 is a lot of the data regarding the long acting injectables that I'm trying to. It's pretty convincing. When you look at the homeless who are IST and the use of the long acting injectables, have we determined whether this is statistically significant, or are we working with researchers to make suggestions based on this data? There are trends, but I'm just trying to understand if this is. Are we able to create actions out of it?

Yeah, I think currently we are working with our medical directors, working with UC Davis, and has been for a number of years, to kind of quantify and track the number of individuals and the types of individuals that are coming into our state hospital system. And we find that nearly 70% of those that have been admitted to a state hospital have one of the three highly treatable diagnoses, and that's schizophrenia, schizoaffective disorder, and bipolar disorder.

And just by virtue of those types of diagnoses, we also know that those are really effective with treatment by medication. We're also working with. We do have an extensive PRN, pharmacist, and psychiatrist team who are constantly looking at new research. And so it's just by virtue of also just the information that is coming up through that pipeline and the new research and literature out there on the effectiveness of the medications and how they do support individuals stabilizing to be able to transition.

That's part of what we've been highlighting as far as recommendations to our county partners in establishing some of these county programs.

And I'd just love to add to that. We rely heavily on long acting injectables at a county level throughout the state, and we know they can be highly effective. What we also know is that providing long term medical care to somebody who's unsheltered and hard to find and hard to make sure that their labs are okay and all the different parts that go with that is really challenging. And I just can't stress enough. Homelessness is the underlying variable more than the lack of treatment.

We know how to treat people. It's just very hard to do when we can't find shelter for them.

With that, I will thank very much this panel, and we will move on to issue nine. Issue nine is on the Department of State Hospital Criminal Offender record information data trailer. Bill, you will have J. C. Thompson, who's the Deputy Director of the hospital strategic planning and implementation at DSH, to present this issue. Welcome and please begin.

Thank you. Good evening. JC Thompson Department of State Hospitals The Department is proposing changes to two sections. First, penal code Section 1115 and WIC 4040. Welfare and institutions code 4040 requires DSH to conduct research and evaluation studies which have an application to mental health policy and management issues.

This proposed language would amend penal code section 1105 to include the Department of State Hospitals as a named agency having statutory authority to obtain access to criminal offender information through the Department of Justice for the specific purposes of conducting research, program evaluation, data analytics, and legislative reporting on areas with important implications to mental health policy and management. Access to this data will assist the Department in studying program outcomes related to IST solutions program such as diversion.

The second code that's proposed for changes is welfare and institutions code 4046. These changes would clarify DSH's ability to exchange criminal identification and information numbers with the California Department of Corrections and Rehabilitation. So this data exchange promotes accurate record matching of the data necessary to perform this research.

Next, we have Jana Lauder, DSH Research Data center.

And I just echo everything that J.C. Thompson just said, but if you have any questions, I'll be happy to answer them.

Department of Finance.

Nina Hong, Department of Finance nothing further to add.

LAO

Will Owens, LAO. We have no concerns with this proposal.

I will thank very much this panel, and we will move on to issue 10. Issue 10 is on the Calaim justice involved initiative. First, we have J.C. Cooper, state Medicaid Director. Please begin when you are ready.

All right, thank you. Over 400,000 adults and youth are released from correctional settings every year from prisons, jails and juvenile facilities, and at least 80% of those individuals are eligible for medical. In January, California became the first in the nation to be approved to offer targeted Medicaid services to someone while incarcerated in prisons, jails and juvenile facilities for up to 90 days prior to release.

The intent of the demonstration is to build on community based care and to really ensure that we are working to stabilize, diagnose and do a coordinated reentry into the community to see better successful outcomes for individuals as they transition into the community. Since October of 2021, the Department of Healthcare Services has convened a statewide Advisory Committee informing this policy. The entire time we were negotiating with CMS, we've appreciated the feedback of that Advisory Committee.

It had sheriff Department, probation, CDCR counties, managed care plans, community based organizations. We will continue to convene that group as we're also working through some implementation design and feedback as well. People who are now or have spent time in jails, prisons experience disproportionately higher rates of physical and behavioral health diagnoses and are higher risk for injury and death as a result of trauma, violence, overdose, suicide than people who have not been incarcerated.

Incarcerated individuals who have a behavioral health disorder are more likely than those without a disorder to have been homeless in the year prior to incarceration, less likely to have been employed prior to their arrest, and are more likely to report a history of physical or sexual abuse of people incarcerated in state federal prisons. Nationally, the mortality rate two weeks post release from prison has been found to be 12.7 times higher than the normal rate that is significant.

One of the core pieces of this waiver is focusing on that reentry to reduce that cycle for those two weeks upon release. We do know there's a lot of data that shows upon release, someone will immediately go to an emergency room where they can oftentimes be admitted or they go into the community, they stop taking their medication, and then they, within six months or within the two week period, show up in an emergency room or get admitted as well.

Additionally, while we know incarcerated individuals often face significant, complex medical conditions, we know for the past decade, the proportion of incarcerated individuals in California jails with an active mental health case has rose by 63% in California, and we also know that the overdose rate for individuals incarcerated is three times the higher than the national rate. Additionally, the issue of poor health outcomes and death for individuals for those who have been incarcerated is a critical health equity issue because in California, people of color are disproportionately incarcerated.

For example, incarceration rates among black men are 4000 per 100,000, Latino men 1000 per 100,000, whereas men of all other races and ethnicities 314 per 100,000. So the disparities are clear in regards to needing to intervene. Additionally, our goal is to provide an opportunity for physical and behavioral health care interventions at earlier opportunities to reduce acute service utilization and adverse health outcomes while providing a coordinated reentry into the community for incarcerated individuals. What I would also say is we come to this with experience

in California. We had whole person care pilots from 2016 to 2021 that had demonstrated improved outcomes. Many of these pilots aimed to increase access to housing and supportive services for people leaving incarceration. An independent evaluation showed that focusing on reentry and doing a coordinated reentry while someone is incarcerated prior to release showed an improvement in regards to someone being connected to housing supports upon release into the community.

Additionally, the pilots who chose to report the information reported the number of incarcerations that occurred for those ages 14 and older, the jail incarceration rate decreased from 18 incarcerations per 1000 Member months to six incarcerations per 1000 Member months for those participating in these programs so demonstrated success here in California with the pilots in taking this statewide. Under this initiative, individuals will receive prerelease services. It can include case or care management services. It can include treatment services, diagnosis and assessment services.

It will also include services like MAT or medication treatment, as well as warm handoffs to our county behavioral health partners, which is required for someone with serious mental illness or substance use as diagnosed or identified while incarcerated. To ensure that we are continuing that treatment. The goal is to really identify that within the incarcerated setting, connect them to trusted partners, whether county or community based organizations, and focusing on that reentry.

Additionally, upon release, everyone will receive a medication, prescription or DME for anything that they need and they will be focused on enhanced care management for our justice population, which will focus on coordinating all of the services needed once they are in the community. That would include connection to our community supports like housing, supportive services, or for example, someone could be discharged from jail to one of our recuperative care settings if the coordination can happen timely.

In addition to the waiver we are also proposing, what's also approved is 561,000,000 for what we call providing access and transforming health or path dollars for the justice initiative. These dollars are really to help counties and CDCR, as well as our county behavioral health and sheriff probation partners be ready for this proposal. We've been releasing guidance in regards to these funds and look forward to partnering with them as they implement provisions of the prerelease. Incarcerated individuals will go live no sooner than April of 2024.

CMS and the State of California did have to negotiate a number of readiness criteria that counties would have to demonstrate prior to being able to go live, and we need the path dollars to get into the hands of the county so they can be prepared for the services that they are doing. Counties will have up to 24 months to elect to go live anytime between that April of 2024 through April of 2026 to go live with prerelease services.

We do look forward to implementing this and partnering with our county partners to do this. We do think this is one of the pieces in Cal Aim that truly can change the trajectory of someone's life, and we look forward to working with the Legislature and our partners to implement this initiative.

Next we have Phoebe Bell, Director of Nevada County Behavioral Health Association.

All those things. Thanks. So first off, I just want to stress that county behavioral health departments are super excited about California's first in the nation waiver to allow for Medical enrollment and reimbursement for pre release services, incarcerated settings, and really appreciate the work of the state in making this happen. I just highlighted minutes ago much of the work that counties already do in this space. We are deeply committed to serving this population. Just wanted to add a couple of other quick things.

Nevada county is one of 37 counties in California that's participating in the stepping up initiative, and we pull together all our partners that intersect in this space to talk together about how do we do better by this population.

We also are a county that through a grant from the OAC as an innovation incubator project, we're able to bring in data analysis resources that have really helped us better understand this population and their ebb and flow through our systems, and really have helped inform some great initiatives and programs and recently led us to being recognized as an innovator county through the stepping up initiative, one of a few in California.

And then lastly, we know that our MHSA funded programs are highly effective at keeping people out of jail. We see almost a 70% reduction in justice involvement for our clients enrolled in FSP. So we are excited to be partnering with DHCs to help shape this really exciting benefit and just wanted to flag a few things which we think are just areas of concern that I think the state is also aware of.

But one of the most critical aspects of this policy is the idea that people are in jail for a while. And what we know from our data work is that 70% of jail bookings are in jail for less than three days, and the vast majority of those are in jail for less than 24 hours. And so how to work with that population is a pretty critical component of how to operationalize this idea and make it effective.

We also know that the unpredictability of when people are getting released makes it very challenging as well. And courts and jails go back and forth on that, and this can make warm handoffs and transportation a big challenge. We want to flag that this fee for service model inside the jail, where corrections facilities are deciding who and how services are provided, just needs to have the same kind of quality assurance expectations that we have at a community setting so that we have comparable services.

And then lastly, we really want to flag that workforce is going to be a challenge. We really support the build out of using peers in this space and other creative solutions because the workforce issues are so massive and we don't want to get into bidding wars with our jails. About the few clinicians that we have out there left to try to recruit.

So by bringing this Medical reimbursement into the fold, we can begin to develop the systems and accountability structures to tackle these issues and improve the quality of services. We're excited about that.

Department of Finance.

Guadalupe Manriquez, Department of Finance. Here to answer any questions.

LAO.

Will Owns LAO. We have no concerns with this proposal.

I'll bring it back to the dais. I'm a huge fan of the proposal and want to appreciate the Administration for bringing it forward. The two thirds reduction that occurs from the program that you stated here today, going from 18 down to six is very good data and it's a strong reason and rationale for us to be extending medical in.

I'm trying to bring in what Ms. Bell had talked about though, about being in for three days or less than 24 hours to understand how we can realistically provide those supportive services and align those housing supports. And so I just love to have you comment on that if possible.

Sure. So we have segmented all of the data and we've worked very closely with our sheriff probation in CDCR to understand. Obviously for someone in CDCR, they're going to probably be able to maximize the full 90 days for individuals in the jails. We do know that there's a large portion that are in and out within 24 hours. Most likely they will not be able to take advantage of this initiative. I just want to be really frank there with individuals.

We also see on average statewide probably closer to a week and 14 days where you do have some opportunities to at least assess, diagnose, and have a small amount of information that come and go out. We're actually working on policy and we have a small work group focusing on the short term stay. How do we maximize a short term stay versus those who are longer? We do know we have individuals in the jails who do have longer period of time.