Senate Select Committee on Mental Health and Addiction

Testing. Good morning. The Joint Committee on Mental Health and Addiction will come to order in 60 seconds. We ask members to make their way to room 1100 in the swing space, and we will be getting started in 60 seconds. You ready? The Joint Hearing will come to order at this time. Good morning to our members and guests. It's important, as always, that we maintain decorum during the hearing, as, of course, as customary, and any individual who is disruptive may be removed from the hearing room.

For today's hearing, each panelist will provide their testimony as listed on the agenda prior to taking any public comment. Once we have heard all the testimony, we will have public comment period. For those who wish to provide remarks on the topic of today's agenda, it is indeed an honor to have this Joint Hearing with Senator Wiener as we begin to make sure that we make it clear.

Just because we have made some historic decisions when it comes to our mental health system, that does not mean it is the end of the discussion. It means that we still have work to do and our work will not stop until our population is stabilized and they are receiving quality and timely services that meets their individual needs.

Therefore, we will continue to meet with stakeholders, meet with those who have lived experiences, so that we can continue to make sure that we are getting the feedback necessary on what's happening on the ground. But then, most importantly, that we do something that we don't do usually. And that is once we have made big decisions in terms of any issue, we are not just checking off this box and moving on.

We are going to make sure that we continue to check on this progress and based upon what happens on the ground, ensure that we continue to make those corrections as necessary. So at this time, I will hand it over to my colleague, Senator Wiener, for his remarks.

Thank you, Assemblymember Jackson it's great to be able to collaborate between our two houses because mental health treatment access is an incredibly high priority in the Senate, in the Assembly, for the Governor and for the people of California. For many, many years, mental health was treated as secondary, frankly, as a personal failing. If we think about how many times in life when someone has been suffering from anxiety or depression or trauma, the reaction by society is sometimes just snap out of it.

Just be strong, just get a grip and as if it were a personal failure. When we know that a disease of the brain is no different than a disease of other parts of the body, and we would never tell someone with cancer or heart disease to snap out of it, that is completely illogical and it's also illogical to have that reaction for someone who's suffering from a behavioral health problem.

So we have been working very hard for years in the legislature to expand access to mental health treatment. We have passed groundbreaking laws to force insurance companies to cover more mental health and addiction treatments. We have expanded resources within medical and elsewhere to make sure people can access treatment. We have strengthened conservatorship laws so that people who cannot make decisions for themselves can receive the care that they need in order to get their lives back.

And we have made huge investments in expanding the mental health workforce, a workforce that does not have enough professionals in to begin with, a workforce that is increasingly burned out due to heavy caseloads and inadequate pay. And so we made some, I think, very smart investments a few years ago to try to shore up the workforce that we have and create more pathways for people to enter that workforce.

And so today we're going to receive some, I think, really informative updates about where we are in terms of workforce, in terms of treatment access. And I'm really looking forward to the discussion today and as we continue to pass strong pro mental health treatment, pro addiction treatment public policy. Thank you.

Thank you very much, Senator. Colleagues, any remarks at this time? Okay, well, we will hear from experts about training, specifically primary care physicians and trusted community members about expanding behavior, health care delivery, and creative approaches to retaining and attracting clinicians. And so if the first panel will come up, and, Senator Wiener, you can lead us off.

Thank you. So our first panel has to do with progress in workforce development in the mental health space. So I want to first welcome Dr. Janet Coffman, who is the co associate director for policy programs at UCSF's Institute for Health Policy Studies and co director of the Master of Science in Health Policy and Law Program. We'll start there.

And then I'll also just note that the other speakers in this panel, and you can all come up, is Robert McCarron, the director of the UCI Train New Trainers Primary Care Psychiatry Fellowship, and then Mayra Angeles Hernandez, the behavioral health programs manager at Vision y Compromiso. So we'll hear from our speakers in that order. Thank you.

Well, thank you very much, Senator Wiener, Assemblymember Jackson, and all the members of the committee. It's a pleasure to be with you today. And I see, yes, we've got the slides up, so really appreciate being with you. I'm going to try to do two things in my testimony. First, very quickly, just a little bit of level setting and background and context.

Then I'm going to give you sort of a framework about how we might think about behavioral health workforce development, and then cite a couple of examples before I turn it over to my colleagues who I know are going to talk about some examples of programs in greater detail. Next slide, please. So why does behavioral health workforce matters?

Well, I think Senator Wiener and Assemblymember Jackson have indicated that, but just to emphasize, demand for behavioral health services grew during the accelerated during the COVID-19 pandemic, particularly among young people. And so demand is increasing. And Californians had big challenges in accessing behavioral health before the pandemic. And I think it's fair to say that those challenges have become greater. And we have many Californians who have unmet need for behavioral health services.

We also have some areas of the state that have shortages of behavioral health professionals, particularly the Inland Empire, which Assemblymember Jackson represents, and the Central Valley that Assemblymember Arambula represents. And we also know that the race, ethnicity and languages spoken by behavioral health professionals do not match California's population and language being particularly important for behavioral health.

Because so much of behavioral health treatment involves forming developing trust with your providers and being able to speak candidly and openly about your challenges and to have a provider who understands your language, your cultural context, the way in which you think about your mental health and substance use needs. Next slide just really quickly, who constitutes the behavioral health workforce?

Well, I think we often think about the folks in the middle oval here, behavioral health professionals and paraprofessionals, psychiatrists, psychologists, social workers, marriage and family therapists, peer providers. Those folks are tremendously important. It's also important to note that our primary care c clinicians provide a lot of behavioral health services, particularly to those folks with mild and moderate mental illness. And they're also increasingly called upon to care for folks who have substance use disorders.

And then over on the right, first responders, our police, our firefighters, our paramedic EMTs. These are the folks who respond when 911 is called and often meet folks with behavioral health needs when they are in crisis and when they are in the most dire need of help. I'm going to skip through, in the interest of time, some slides and get to number eight, behavioral health workforce pipeline.

And so this is just a framework to think about the different levels at which state and others could intervene to address our behavioral health workforce challenges. And beginning in K to 12, through undergraduate, to graduate and postgraduate education and into practice. And I'm just going to, in my testimony, the remainder of my testimony highlight what we have up there in the northwest quadrant, career exploration for K to 12, and then talk over in the southeast quadrant, enhancing the knowledge and skills of primary care providers.

If we had more time, I could talk a lot about everything else on the slide. But I think just these two. I think diagonals are important for two real key aspects of the challenge. And so for career exploration, I want to talk about a program we have at University of California Called "Change SF." And career exploration is important. I mean, this is a trite but true saying you can't be what you can't see.

And many of our young people, particularly our young people in low income, minoritized communities, don't have a lot of experience with behavioral health professionals. Now, they probably have some idea what a doctor is and what a nurse is, and if we're lucky, they've been to a dentist or a dental hygienists care. But they may not have much exposure to behavioral health professionals to know what they do and to know why that might be a career path of interest to them.

So that's why this career exploration and as well as mentorship and support is so important. So change SF is a partnership with San Francisco Mayor London Breeds Opportunities for all initiative, which is really overall an initiative for paid work based learning and mentoring for young people from low income and minoritized communities in San Francisco. And so this program, which is run out of our Department of Psychiatry and Behavioral Health Services, provides paid work based learning and mentoring to youth aged 13 to 24 from diverse backgrounds.

Now, it's a small program, only 15 participants to date, but those participants have really gotten multiple opportunities to learn about mental health, be mentored by faculty, have an exposure to different career paths, and three of them thus far have been hired by UCSF after completing the program. And so they're working and saying clinical research coordinator positions where they're continuing to be exposed to careers and behavioral health and be mentored by our faculty and staff.

So I think this is the type of idea that really could be taken to scale. And the paid piece, of course, I don't think I need to tell you, but it's so important for our young people from lower income communities. Families are struggling, particularly in places like mean, our cost of living is high across the board in California, but it's particularly high in San Francisco. Then these families, families have, lower income families have great difficulty enabling their young people to have unpaid experiences.

They need to, at least often, certainly after out of high school support themselves. So now let's turn to the other end of the spectrum, and I want to talk about the University of California Psychiatric Mental Health Nurse Practitioner Certificate pProgram. And I think we want to think about this as a program that helps to upscale and enhance the ability of nurse practitioners to care for persons with mental health and substance use needs.

And so this is a program for nurse practitioners, nurse midwives and other advanced practice nurses. So people who already have completed their education say to become a nurse practitioner and are already out there working, say they're working in a family, a family community health center, maybe they're working in a pediatric practice, internal medicine practice. And the idea is that they can spend a year completing the education to become a psychiatric mental health nurse practitioner on top of their existing credential.

And so this is a partnership among fall four UC nursing schools. I mean, it's a little unusualist. And UC, we tend know, sometimes have our own little fiefdoms and territories. You're nodding because that is just the reality of the university. And so this is remarkable partnership and an example of what I think we hope to see, would like to see more of.

And it's predominantly online, three intensive in person sessions so that folks have know camaraderie and cohort with one another and get to know their faculty better, but intentionally, mostly online, so that it's available to people wherever they are in the state. So if you're up in Modoc County or you're down in Imperial County, someplace that's distant from a UC nursing school, this is available to you. And the clinical training is across California.

So you do your didactics in person, online, and then all your clinical training is across the state. So it's a great way to upskill people who are already serving some of our communities across the state, but particularly our underserved communities, to better be able to meet needs. In closing, I'm a professor, so of course I've got to tell you what I think. So these are just some recommendations.

And first off, I know this is a really tough budget year, a very difficult year to ask for anything. But I do think it's important to not delay the distribution of the General Fund and Mental Health Services Fund revenue that's allocated for behavioral health workforce development. I mean, there are a lot of hard choices that are going to have to be made, but there are consequences in this case to delay.

I think it's also important to continue the support for medical reimbursement policies that foster innovative team based care. The state already did that with the legislation in 2020 that created certification for peer providers in medical. I mean, that's exactly the kind of thing we should be doing. And I think we should support the behavioral health workforce development provisions of Proposition 1.

Now, I think there's understandably differences of opinion about some parts of Proposition 1, but I would hope that all of us see the value in putting more resources into behavioral health workforce because we can't expand services, facilities for people without the workforce to care for them. Thank you very much.

Thank you. I will now go to Robert McCarron.

Good morning, Select committee chairs and members. Thanks for having us here and thanks for taking the time to meet with us and learn with us. My name is Robert McCarron. I'm a professor in internal medicine and psychiatry. So I treat cancer and diabetes and stuff like that, but also psychiatric conditions like depression and anxiety. I'm an associate dean in medical education at UCI and the director of education for the Susan Samueli Integrative Health Institute.

But here to talk to you as director of the Train New Trainers Primary Care Psychiatry Fellowship. I'm going to start with the problem, though, if that's okay with you. One out of three of us in this room will suffer from a substance use disorder, crippling alcoholism, for example, meth dependency. One out of five currently have a psychiatric disorder, and in our lifetime, half of us will struggle with a psychiatric disorder.

Hot off the press from the Journal of American Medical Association, maternal mental health is the leading cause, the leading cause for pregnancy related death in this country. It's not good. One out of three adolescents report serious psychological distress. And among this group, suicide is the second leading cause of death. Opioids, the number one cause of accidental deaths among grownups in this country. And depression, among the number one top cause for disability worldwide, including the State of California.

When I'm on call in the emergency room, there are patients who are waiting, not necessarily days, but in terms of a week or more. And that includes kids, six year old kids, eight year old kids, not a good thing from an outpatient perspective, referrals take a long time, not weeks, not weeks, months. Several months, actually. And people are suffering and at risk during that time. So here's the thing I want to convey to you.

70%, or in some cases more, 70% of our workforce, our behavioral health care workforce is not delivered by psychologists or social workers or even folks like me, psychiatrists. It's delivered by primary care providers and emergency medicine docs. Here's the problem with that. Many of them didn't get the training. So as an internist with three years in residency, zero minutes are required. Zero minutes are required for clinical training in psychiatry, for PAs, in the State of California, two weeks are required.

Now, when we get out and go and practice, 40% to 50% of our day is working with patients who struggle, struggle and suffer with anxiety, depression, substance use disorders. We need to help this workforce, because, in fact, this is the workforce. As Dr. Coffman alluded to, there are many people and disciplines included in the workforce, but primary care providers are at the top of that list. So if we can go to the next slide, please.

UC Irvine is, I would say, on the cutting edge of innovation in creating unique fellowships that provide this training nationwide. We help them do a better job at what they're already doing. We're not teaching them to do other stuff every day they're doing this. They're helping folks who are struggling with behavioral health issues. We're helping them do it better. And as an ad bonus, we train them on how to train other people in their clinic or their region.

So we're not just saying, hey, this is good stuff, let's learn it. We're going a little bit further with that. Next slide, please. So we have three different programs that we've run for several years. The primary care psychiatry fellowship. Also our child, adolescent or pediatric psychiatry fellowship, and our newest primary care training and education in addiction medicine, or PCT. Next slide, please. So, in a nutshell, what we do is we provide targeted training during non clinic hours.

So these folks are still working and seeing patients in the busy primary care setting. We're telling them about common psychiatric issues with a focus on three things. One is prevention. Two is how do you diagnose it quickly. And three is how do you treat it? How do you partner with your patient to treat it? And these are the things we focus on. We have published outcomes in peer reviewed, high impact medical journals showing the following.

Number one, evidence of increase significant increases in knowledge in overall subject matter after they graduate from the program. Number two is increase in self efficacy. 60% of ER docs are burnt out as of 2023 data. We see the same with emergency medicine, internal medicine, family medicine, et cetera. So we're able to show these findings.

I'm also happy to say that we've partnered with Inland Empire Health Plan to look at data showing that our graduates are more likely to diagnose early depression and treat with antidepressants relative to those who didn't go through our program. In Moreno Valley, in Inland Empire, we also show that our graduates are prescribing much less opioids for treatment of chronic pain relative to those who didn't go through our program.

A couple things just to point out, our faculty are unique in that they are psychiatrists, but they're also ER docs or family medicine doctors or internal medicine doctors or pediatricians. Right.

And the thing that's really neat about this and that I want to convey to you is that we don't stop after one year. We provide at no cost, ongoing career long training. We know that learning shouldn't stop. We have 1200 alumni and they continue to learn with us, hopefully for the rest of their career. Next slide, please. This is an overview on how we've been growing. We want to continue to grow.

HKI provided us funding in 2021, and we've used much of that funding already, which is a good thing. We've trained so many clinicians, and there's many more that we want to continue to train. So these are just some topics that we cover. I want to point a few out. Provider wellness. Provider wellness. We need to make sure that we're taking care of our own right. A lot of our clinicians are struggling. They really are. In the child and adolescent psychiatry realm.

We cover a lot of topics. Substance use disorders, adolescent behavioral health, family focused care. And then, of course, we cover a very comprehensive overview. When it comes to addiction medicine. We've been lucky to partner with the state. This has been replicated. Kentucky is doing this. We're working with Tennessee, United Arab Emirates and many other municipalities. We partner with many health plans like LA Care, like Kaiser, like Inland Empire Health Plan, and many, many others. We'd like to keep this going. We'd like to grow.

We'd like to continue to train new trainers in this area. I'll end with this. 86% of our learners, of our alumni come from designated underserved areas, not just in California, but nationwide. This is a replicable model that comes from us, from the State of California. Thank you so much.

Thank you very much. Next, like to welcome Mayra Angeles Hernandez. Response.

There you go. Hi, thank you for having me today. My name is Myra Angeles. I'm a behavioral health program manager at Vision y Compromiso. I'm also a marriage and family therapist and a doctor in marriage and family therapy. But I primarily work with Vision y Compromiso, which is an organization that supports Promotores, or as other people might know it, community health workers. And so I relate to a lot of what they've been sharing. As a clinician, I understand the burnout and the frustration with being able to provide services to the community. However, our organization works very unique with the Promotores as they are community members and they work more as like liaisons and advocates for the community. So essentially my role, or a lot of us in Vision, is to train these Promotores to be able to support the community while there's the bridge and where they're attempting to get services. And it's just taking a while to get to that point.

So we provide any type of education, mental health, addiction, well being, to be able to. One of the things that Promotores do is they are now providing support groups and mental health. So they'll go to the community and primarily in Spanish, they'll provide any type of education, whether it's like parenting groups. Some topics are like addiction, anxiety, any type of mental health that the community is needing at the moment. We train them, we supervise them, and they work as that bridge while they get the services.

And so there's just been a lot of lack at the moment with funding to provide grants, to be able to continue to provide that education to the Promotores. And then. Sorry, I have a PowerPoint, so I'm kind of going by the one I have right now. So the Promotor, essentially what they do is it's the promotor community and then the healthcare.

So they're kind of that person in the middle who they go to the community, they let us know what the community is needing, come back to us, and we try to provide any type of support so they can continue to do these support groups or other activities to support the community. One of the things that we are seeing is just the fear the community is having at the moment with being able to accept services.

A lot of them are Hispanic, so being able to understand that or normalizing mental health has been a challenge lately. So we do work a lot with the Promotores to decrease the stigma or help them teach the community to decrease that mental health stigma that they might have. So that's some of the training we do along with.

We also have a few departments, so we have a Promotor Institute, but we'll teach them how to be a Promotor, a workforce, training for Promotores, technical assistance so they can understand how to be able to go to the community. And then we've recently added a lot of mental health awareness, mental health training, and not just mental health, also health, any health issues that the community is struggling with.

So we're really focusing on being able to train these individuals so they can be that bridge when the community is lacking services or support to be able to get those services. And then a lot of advocacy is what we've been working on with the Promotores. So we do manage a lot of projects to support them. But that's essentially what compromiso does, is we go to underprivileged communities.

We target a lot of Hispanic or Latino communities, but there's just overall, whomever is open to be able to hear what we offer. We'll train these Promotores or community health workers so they can go and provide that information to community and then they come back and we supervise them as well. So that's just a little of what we're doing at the moment, the trainings that we've been providing them with. But mental health has been one of the biggest, I want to say in 2023, working with Vision on that, biggest challenges that we've seen with the community, not just with stigma, but also just being able to get the funds to serve the community. But that's kind of what I have. Thank you.

Thank you very much, colleagues. Are there any questions? Assembly Member Bauer-Kahan.

Thank you. I want to thank both chairs for setting this up and for all of you for being here. It's obviously a critically important conversation, as the statistics that were cited indicate, and obviously just what we see every day. So, first of all, I want to start with the Promotores. I knew about them in the sexual reproductive health space, but it's so critical to have trusted community Members in all healthcare spaces.

So I just want to thank you for that because I think it's really brilliant that you're doing that and sharing and spreading that knowledge. I wanted to start with some of this work around primary care physicians, really as our gateway into behavioral health services. So I have three children and at my postnatal appointment, the first thing they did was screened me for behavioral health concerns after having a baby.

Now, it never happened once while I was pregnant, so I thought your statistic around the impact to pregnant women prenatally, the fact that we're not doing those screenings is really fascinating because it was pretty straightforward. Right. It was a survey that was done. They could identify if I had the need for care and gave me that care, moved on. But I wanted to ask about that. Are we training in other spaces? Right. I think in the pediatric space, we do those screenings periodically. But when I go to my primary care physician, I've never been given a screening. So I just wanted to ask about that.

Well, there should be screening, and there might be two reasons for not getting screened. The first is knowledge, expertise in that specific area. And two is time. In certain parts of the state, primary care clinicians get about seven and a half to 10 minutes per patient. And when you're trying to deal with diabetes and pain, arthritis and depression all at the same time, there's just not enough time.

Right.

And so those are two things I can think of. Yes, preventive services task force is very clear that this screening should be done and to go further, care should be given if the screening is positive, that's a third barrier. Third barrier is right, you're waiting 3-4 months sometimes to see a psychiatrist if you do screen positive. So those, I would say, would be the three barriers we're working on. The first, which is, how do we provide expertise, build knowledge in this area?

And you cited working with a bunch of healthcare systems. Are you working with our federal qualified health centers or smaller ones? I know that mine in my community is trying to integrate behavioral health into their primary care model, but I think that's a really important place to get folks that are underserved.

About 50% of our learners come from FQHCs or lookalikes, and that's within and outside California.

Okay, that's awesome. And I also wanted to, Dr. Coffman mentioned our very difficult budget this year. I think that I want to touch on the cost savings that goes along with ensuring that we treat people preventatively rather than letting them get into crisis, because, as you mentioned, they end up in ERs, they end up hospitalized, and it is much more difficult, I can imagine, to treat folks at that point in the behavioral health spectrum. And so I think these preventative services could really be a cost savings to us rather than a cost in the long run. Did you want to touch on that?

Yes, I think that is an excellent point, that we know that early screening and detection and treatment of any mental illness certainly improves the quality of life and well being of that person, and often, by extension, their family. And certainly with, let's say, depression and anxiety. Getting prompt treatment can enable somebody to stay in the workforce and be productive. With schizophrenia, other mental illnesses, those are obviously more challenging.

But again, early treatment can really make a difference, certainly from somebody, the likelihood that someone will end up homeless, and certainly with addiction, if we can ideally prevent to start with, but if not treat, where and when more and more medication assisted therapies are available, that, yes, I think in the long run, it definitely does make a difference to invest in the workforce so that people who have mental health needs have prompt access to treatment.

Well, thank you all. I think this is really important, and I really appreciate this focus on our primary care physicians. I chair this Select Committee on Reproductive Health, and we just had a hearing on menopause. And one of the things that we were learning about is that many of the women who go into menopause that have mental health needs are treated with the wrong kind of treatment, because at that point in your journey, you need different kinds of treatment.

And so the more people understand around behavioral health, at different points in the patient's life, I think the better off the treatment will be. And I think the training you're giving is so critical to get more people the care they need, because just recently I was talking to one of my school districts that cited a staggering number of 51-50s per week coming out of the school districts. And so, as you said, right now, it's our firefighters who I know we're going to hear from. It's our school professionals who are at the front line of this. And we really need to be getting our healthcare professionals in the game in a more meaningful way. So, thank you.

Thank you, Assembly Member Arambula and then Assembly Member Pellerin.

Thank you, Mr. Chair. I'm going to begin with the importance of making sure that we have a diversified workforce and expanding access to many beyond the medical doctors, the DOs to include our nurse practitioners, our physicians assistants, our community health workers, and, yes, our Promotores. And so I wanted to follow up, Ms. Coffman, on a comment you made that just resonates so much with me. You can't be what you can't see. Having a grandfather, Zacharias, who never learned to read.

It's hard for so many of us to envision ourselves as the future providers of tomorrow. And so we have to figure out how to break down some of those barriers. And there are consequences towards the decisions we make within this budget that don't allow us to continue to diversify our workforce and to address our language and cultural competencies that we need within the providers of tomorrow. And so I was drawn towards your points that Latinx are underrepresented in all licensed behavioral health professions.

All is a powerful word and shows a real need for us to make sure that we're continuing to make those investments that I wanted to figure out if our behavioral health workforce pipeline is tied into our health profession pathway program. Are we able to, with a new program that HCAI is establishing, ensuring that we're opening up those avenues for pipelines for those within the behavioral health workforce as my first question.

And then for Dr. McCarron, if I could, I wanted to follow up, as it seemed that you said you had funding from HCAI that was one time in nature. When does that funding expire? And do you believe that we're done needing to train new trainers or is there a need for continued funding from us to make sure that we're providing that information?

So thank you. Senator Arambla, my understanding is that the pathways programs are intended to expose young people to a wide range of careers. I want to be careful on the, if someone from HCAI is here, I think they'll have more details, but I think that is the goal. And certainly I think that's very important that those pathway programs expose young people to behavioral health careers, among others, because it is, I think, for whole health, so important.

And I mean, we have fantastic, you know, the doctors academy in your area, fantastic program for preparing people to be physicians, including psychiatrists. We need even more of that type of program to encourage our young people from our low income Latinx, black, and I should say southeast Asian, Asian communities as well. Behavioral health, I want to really resonate there that in some health professions we have large numbers of folks from various Asian ethnic groups.

But when we look at behavioral health, particularly when we look at, say, our master's level clinicians and our substance use, meaning social workers, marriage and family therapists, and we look at substance use providers, we really don't have the same representation. Yet we know from looking at the data that many folks, from as many people from Asian Pacific Islander backgrounds struggle and suffer with substance use and mental illness, just like other ethnic groups. And so we really need a workforce in behavioral health that fully reflects the population.

Arambula, thanks for your question. Well, just to be candid, my concern is not receiving the funds that were allocated to us a year and a half ago. So that's the concern with the budget issues. And so this was timely. When I was invited to come here, I didn't realize that's an issue and that the deficit has increased seemingly over the last month or so. Our funding, it's a five year, so it's five year funding.

But as I mentioned earlier, we've been so successful in training so many people that next year we run out of our funding for to train folks in our child adolescent psychiatry or pediatric psychiatry program. In answer to your other question, and I'm biased, I'll say, but most definitely, I see this as a 10 to 12 year plan to train up.

And in addition, off of any funding that I'm receiving, I'm working closely with ACGME, the national organization that oversees residents and fellowships to try and change at a national level the residency training. So we may not need TNT in 10 years. Right. And so the training will take place during family medicine residency, internal medicine residency, pediatric residency, et cetera. Thank you.

And I would just elevate that. We're in a crisis right now that requires us to continue to make those investments, and it's only gotten worse over the last couple of years. And so the original legislative intent was for us to make sure that those professional pathway programs were diversifying and as expansive as we could, as well as that this funding would eventually go towards training those new trainers. And we have such a need for it that I believe we should continue to make sure those dollars go out.

Thank you.

Thank you, Mr. Chair.

Assemblymember Pellerin.

Thank you. And thank you so much for your testimony and being here today. Yes, we're in a mental health crisis and we need more experts like you having your voices heard. From personal experience with my family, I've been through this mental health journey and it's complicated to navigate even when you have connections and, you know. So I understand there's a huge workforce need and facility need here in the State of California. Do we have numbers on that, on what our targets are and what our needs are?

Thank you. Assemblymember, let me follow up with you on specifics, but we've certainly done work on that and provided. But I think we're talking, looking over the next decade, I want to say something around the neighborhood of 4000 more psychiatrists. I want to say 15,000 to 20,000 more of the social workers, mental social workers, marriage and family therapists. And HCAI is doing some work to come up with more updated estimates and projections for that.

And I should say, I think is important and I think maybe you'd agree, important as train the trainer in all of this work to enhance the ability of our primary care providers to care for those with behavioral health needs. We also need to invest in training psychiatrists so that they can be the trainers and so that they can be available to coach primary care providers and also to really care for those folks with schizophrenia and other really complex disorders that really require a higher level knowledge.

And, you know, we've done great work in California over the last decade or so in increasing our funding for primary care residency programs. We haven't done as good a job in funding for psychiatry programs. And again, yes, this is a tough budget year to make investments. But again, if we really want to solve this behavioral health workforce crisis and improve access, we need to be thinking of investing in psychiatry just as much as we absolutely, positively need to be thinking about investing in training community health workers and peer providers, because it takes a village to care for all of us with behavioral health needs.

I think my best guess is in my lifetime, we won't come close. And that's the reality. It's just a matter of numbers, but it goes beyond what's happening in California. It's a national issue, and funding for residents and fellows is just difficult for so many reasons. So I think it's important to train up the workforce that's doing this stuff now as best we can and do a better job of that, actually. But thank you for your question.

I understand. And I think it's so important when somebody does come into a facility for something else that might be physical health related to also do that important screening on behavioral health. I have a bill, AB 492, that would do that with anybody going in and seeking reproductive health services. They would also be screened for behavioral health and then referred out for that kind of treatment if needed. It's just so critically important. We do everything possible.

I know that if I were diagnosed with cancer, I would immediately be able to get into a Doctor, immediately get treatment. My insurance covers everything. But when I have a mental health crisis, that's not the case. And I have to struggle and try to find somebody to see me or see my family. And as you said, it's months out sometime, and then you private pay and then have to seek reimbursement on that. So I hope in my lifetime we get some parity here between physical and mental health care. And any ideas on how we can improve that?

Well, we have the federal law and the state law. I think it's all about enforcing that. Right. And so I think social workers, psychologists, psychiatrists, all Clinicians should be encouraging their patients to talk to their legislators and reach out to the right people and say, listen, here's what's happening to me. And I think it's all about enforcement right now to try and make sure we can do the best to enforce these laws.

And I think if I, yes, enforcement and also workforce development as well, so that we have enough. And particularly, I think one of the challenges in behavioral health compared to, say, primary care is we do have a number of providers that are in private pay that may not accept commercial insurance, let alone MediCal. I don't know that I have a good answer. I mean, some of it is enforcement, some of it is reimbursement. It's a complex problem, but it does make it, I think, that much more challenging in behavioral health relative to, say, primary care or cancer care.

Colleagues, any other questions? Yeah. Senator Cortese.

Thank you, Mr. Chair. And being a good chair, I know you're moving the agenda along instead of speaking so much yourself, but I wanted to give the chair a plug for holding a prior hearing that I participated in talking about this very issue of reimbursement, utilization review. His very important legislation, I think it was SB 855 a couple of years ago. We have introduced additional legislation again this year, SB 999.

Two things I'd, I'd like to hear a more specific reaction on is, you know, what your experience is with utilization review denials. What you see with that, if you're seeing the same types of things with certain reimbursement carriers and providers that seem to be kind of off the charts in terms of a percentage of denials or short term reductions in care based on termination of insurance coverage. And the second thing is, I'll just kind of ask you a compound question.

It's a little bit of a slightly different subject in terms of mobilizing people. I very much appreciate what you just said. Having spent an awful lot of time in the field as a county supervisor prior to this, as a big city vice mayor, working with people in recovery. We, on the one hand, encourage them to be apolitical, even through our 12 step programs, wherever those programs are, on the outside, in prison, everywhere else, to be anonymous and, in effect, not to come forward and to protect the anonymity of their peers who are in these situations. How do you see us mobilizing after decades of tradition? I think it's beyond stigma. I think we've actually sort of taught this as a way to encourage people to seek help.

Look, it'll be anonymous, obviously, in the healthcare side, we have HIPAA and other ways of doing that, but it seems very difficult. I believe if that wasn't the case, this chambers would be full of people who are in recovery or seeking recovery, telling their stories, because that's what people in recovery do, they tell their stories, but we're not seeing that. We don't see that at this hearing. We don't see it that at prior hearings. Any comment on either of those things? Thank you, Mr. Chair.

Well, I'll just mention just really briefly, we are experiencing, on a regular and routine basis, denials, and it affects our patients. I'll just give you one example. This is a very nice woman who I've seen for years suffering from profound depression, crippling depression, and it took us a year and a half to get a procedure called TMS, transcranial magnetic stimulation approved. A year and a half. During that time, she attempted suicide twice. And this is pervasive. That's just one example.

I will say that the changes, the bold steps that the state has taken, that all of you have taken to move the historic mental health changes has changed the way we see mental health in the State of California. I believe, and I also believe that it's changed the way Clinicians see mental health. So all good. And I think those legislative and funding changes, albeit difficult now, particularly with the budget, I think are important and result in a different viewpoint for how we see behavioral health.

Okay. Not everyone has to respond. We're going to need to move on. So if there's anything burning, answer feel free. But not everyone has to respond to every. So was there anything in particular? Okay, great. Yes.

I actually want to give my perspective as a clinician, if that's okay. So prior to working with vision for like a decade, I worked in rehabilitation centers. So I have a lot of experience with just insurance and all that. And just kind of as a clinician, one of the things I saw was just a constant lack of motivation. There was when insurance would cut patients off that really needed that support.

And just as colleagues stated, there was many times where I had clients who, fortunately, whether it was overdose or any type of suicide, it just happened for the clients were just cut off from one day to another. And as a clinician, which is one of the reasons why I decided to leave that population, because it was very frustrating to not be able to really do something to give the support for those people that really, really needed it and wanted it. But that's just my perspective as a clinician, and it was just a pattern. I worked on many rehabs and it was always pretty much the same, but it's just my perspective as a clinician.

Great. Assembly Member Waldron.

Yes, thank you. I appreciate that we're having this hearing in the first place. It's very important, especially here in California. I was wondering your thoughts on when we look at behavioral health treatment options, what's offered or what's covered? It really depends on what county you live. Know, just the way that we Fund things, just the way through the county systems and everything. LA County can offer patients very different services or options than, say, Lassen county or Modoc County.

I represent a district in Southern California that's very rural. We have 18 tribal governments. Access to mental or behavioral health is deficient, obviously. Just your thoughts on how can we deal with this disparity between what county you live in, what options or coverage is available, how we can get more accessibility in the rural areas, and do you think Prop one, how can that address, since we're taking the funding back, will we be able to maybe deal with that issue in some regards? Just your thoughts on that.

Well, you know, for ill or for good? In California, we sort of have this pattern of devolving responsibilities to counties and giving counties. This is not just behavioral health. So I think that the motivation behind the provisions of Prop one of having some more money at the state level is good, and hopefully that will result in some more standardization across counties.

But I think just across the board in California, that's something we need to grapple with is how much, whether it's MediCal enrollment, whether it's corrections, how much do we want to devolve authority to our counties who are very different from one another versus at a state level. And I think the just reality in rural areas, as we face a deficit in workforce and many of our folks in communities like yours are either uninsured or dependent on Medi Cal, and that contributes and makes it that much harder to meet their needs.

Great. Well, thank you so much. We really appreciate it. And we will now move to our second panel regarding community engagement. We've now heard from experts on the progress and the challenges around the behavioral health workforce. So now we want to talk about current programs and pilot programs that are in progress around the state, the various ways that they can contribute to addressing the mental health crisis.

These next panelists have a strong commitment to healthcare justice and can speak more about how collaborating and peer to peer support can be transformational in serving communities. So we have three speakers. Brett Feldman, Director and co founder of USC Street Medicine. Dave Gillotte, the co chair of the Firefighter Behavioral Health Task Force, CPF, California Professional Firefighters 7th District Vice President and President of LA County Firefighters Local 1014. I'm sorry if I mispronounced your name. Got it. Good. I'm sensitive since my name gets mispronounced all the time. And finally, Dr. Vimal Bhanvadia. Did I pronounce that correctly? Bhanvadia.

Yeah, that's perfect.

Okay, great. Got it. A physician with advantage healthcare services. So why don't we go in that order that I listed you. We'll start with Brett Feldman.

Great. Hi, my name is Brett Feldman, and thank you, Senator Wiener and the committee for allowing me to come and talk to you today about what's going well in the world of behavioral health care and care for our neighbors experiencing unsheltered homelessness. What's going well is street medicine, which is defined as the direct delivery of health care to people who are unsheltered, which is 75% of our homeless population in their lived environment.

I've been practicing street medicine since 2007 and now serve as a Director for street medicine at USC. We provide about 10,000 office visits a year, except our offices are under the bridges. We also host the California Street Medicine Collaborative, which is our statewide organization. We have about 130 organizational members and have a pretty extensive workforce development and education arm, which trains and equips others across the state and really across the country to do this work.

But the reason why I'm here today and the reason why street medicine needs to exist is because people experiencing unsheltered homelessness can't access health care the way the rest of us do. And so you start with extreme poverty plus social isolation. Then you add severe and untreated physical disability, substance use disorders, and mental illness. And then you top it off with a healthcare system that was never designed to serve them in the first place.

In California, we've done a great job of making sure folks are insured. Between 60 and 80% of the people were insured, but only 7% are actually able to access their PCP, and only 3% are actually able to be seen by behavioral healthcare. And so, in response and a recognition of their sacred humanity, we go to the people first to deliver an understanding love, and then the same quality of care on the street that you'd expect in a brick and mortar clinic.

Our teams are made up of doctors, PAs, nurse practitioners, nurses, social workers, and many others. But the backbone of the teams are our community health workers, the people with lived expertise in homelessness who act as our street guides and make sure that we don't lose anybody. But we also know that healthcare is more than an office visit, even if that office is literally on the street. So we dispense medications, draw labs, do ultrasound, EKGs, all in the patient's lived environment.

And this approach is distinctly different from mobile medicine or rv medicine, where you park the rv, people leave their encampment, even if they're worried about everything being stolen, to go to the rv. Instead, we go to the people with pickup trucks and backpacks and deliver care in their environment, where they feel most comfortable. And at USC, we've had very good results doing it this way. For example, we've shown we can decrease hospitalization by 70%.

But as it relates directly to behavioral health, because that's the charge of this committee, there are three continuums, where we serve as that keystone, that stabilizing piece within the continuum. The first one is just access to behavioral health care, which you already heard a lot about. And so last year, we published the California Street Medicine Landscape analysis, which showed 70% to 80% of our programs are diagnosing and treating mental health conditions.

We've had to train ourselves up to practice at the very top of our scope of practice as primary care. And the reason is because in that same report, if you add up the total number of street psychiatrists in the state, you get five ftes. But we've actually had good results in doing it this way. For example, we prefer to use long acting, injectable antipsychotics. I give one injection, it lasts for a month. It's never lost or stolen or traded or degraded by the elements.

It's just in there. And so using that treatment, for example, I remember giving bullet his first injection behind Carl's Jr. for his schizophrenia. And in a few months, I look forward to watching him graduate as a drug and alcohol counselor to go back to the community to serve. I remember giving Jose his first injection also for schizophrenia, outside of his broken down Corolla, where he lived with his family and two little girls.

And after treatment, he was able to organize himself enough to complete housing paperwork, register his girls for school. And one of the happiest days was seeing little Amelia, who, at the age of nine, went to school for the first time. I remember her leaving her Corolla, going to school, and she was so proud of herself, but I think even more proud of her daddy. The second area where we serve as that cornerstone is in housing.

Since 2018, at USC, we've housed between 30 and 40% of everybody we see. And the reason is because medicine is seen as an instrument of peace, where we can build these trusting relationships quickly, start treatment immediately, and then refer into housing. And while they're waiting five months, six months a year for housing, we continue to follow them, so that when housing does come through, number one, we know where they are, we haven't lost them.

And number two, their physical health is improved, psychiatric conditions are improved, they're using less drugs, and housing is more likely to be successful. And then, finally, is our role in crisis prevention and post crisis management. Crisis prevention because if they're being treated for psychosis with antipsychotics, if they're using less drugs, they're less likely to have a crisis. If they do have a crisis, when crisis comes, if they decide not to transport, we come on site and take over care.

If they do take them to the hospital, we also go to the hospital and then follow them on the street to continue care to prevent the next crisis. And so right now, we're at this really critical point in our history of street medicine, where we're transitioning from this Robin Hood grassroots movement into mainstream healthcare.

And we've gotten tremendous support from the Administration, from a lot of you in the Legislature, and from DHCS, to the point that we now have 57 programs across the state, with another 20 in development in 34 different counties. So this is not just in the big cities. And so moving forward, as we're thinking about legislation, the goal would be to make it that anybody wanting to go to the street to deliver care is able to do so without bureaucratic barriers, because there needs to be more of us to go to the people with love and solidarity.

Thank you very much.

Thank you. That is a great transition into me speaking to you, because I also practice street medicine. And one of the greatest things about coming to workshops, hearings like this is we're going to go talk outside of this room, because we share a common district and many ways that we can pool our resources to assist and help each other right on the very streets that he's working on and that I'm working on. So thank you for the opportunity to come here and give you some testimony.

Thank you for this not only bipartisan but both sides of the aisle committee who is tackling probably one of the greatest issues in front of us right now in our society. And with that. My name is Dave Gillotte and I'm a fire captain. I started out in Lakeside Fire Department down in my Assemblymember Waldron's district for five and a half years. And I've been with La County fire for 30 years. I was a paramedic for 12 and a half of those years.

And I supervise paramedics in one of the hardest hit and underserved areas in La County. That's the Florence Firestone Watts Willowbrook areas. And we deal with crises that we're talking about here daily. I also chair the California Task Force on Behavioral Health. I co chair it with Kristen Thompson. She's out of Newport Beach fire Department. She's actually a nurse. And she is an extremely amazing co chair for our committee.

And our committee is made up of both labor and management, which I think is super key because if you don't get buy in from the chiefs, if you don't get budget allocations to do what we need to do, every bit as much as the union pushing it on behalf of the firefighters and paramedics in the streets, then we don't get things done.

I'm honored to talk to you about a microcosm of behavioral health that I hope gives you a view into what's right, how it can work not only for firefighters in the example I'm going to give you, but also how that translates down onto the streets. If we had similar programs, really bolstering up the testimony of everybody coming here today about getting more clinicians, about getting access, about education and about service delivery, so that we're not just taking patients to the emergency room when they need follow up care or actually care in the streets, dealing with behavior health and drug addiction. So how did the task force come about?

In 2016, we had two years where a leading cause of death for firefighters, outpacing all other combined causes of death, cancer, heart attacks, traumatic injury, vehicle accidents, responding on the way of the fires, all the things you see on TV. The number one cause of death for my members was suicide. And that was a wake up moment for us and a wake up moment for me. And that's why I, along with my colleagues, got involved in the California Task Force on Behavioral Health.

And what have we done first? You've heard a lot about it. We had to break down stigma. Let me tell you about firefighters. And we're tough, we're hard. We don't want to ask for help. And I think that goes for probably everybody in the room here. You heard some numbers earlier today. And I said, wow, one in 3, 1 in five. I go, who is it? And who wants to raise their hand and say, I have mental health issues. You know, who does? Nobody.

And so we need to break down the stigma of accessing behavioral health. And we've done that with firefighters by working to form not only this task force, but we have a peer support team now that runs up and down the state. And in La County we have over 250 trained peer supporters. These are firefighters, paramedics, nurses from the field.

So I'm looking into my brother and my sister's eyes, who also does my job, but they have some training in how to recognize some of the symptoms of post traumatic stress and cumulative stress that I might be having at work. And probably about 10 to 12% of our membership. And I have 3500 members plus family. They need professional help, they need peer supporters, and they need, we call them culturally competent clinicians. And I'm going to hit on that too.

We do have a huge shortage of clinicians training that you heard today. Train the trainer and the resources. And you asked how we can get clinicians to come into the fold and raise their hands, in my opinion, humbly. And we have a health insurance plan that we run for La County firefighters, self funded indemnity plan with anthem blue. We negotiate and set a lot of our own benefits. But what we're doing is we're offering to the Clinicians that are taking our training program.

It's 3 hours of CE, and they're actually coming out and riding along with us to become culturally competent for my workforce, firefighters. So they know how to talk to my firefighters and counsel my firefighters. We're offering them better than table rate, we're offering them better than workers comp rate, and we're paying them in 30 days. And let me tell you what happens. You have a long line of clinicians saying, I want to treat firefighters.

So think about that as we work to clear some of the roadblocks and hurdles to have insurance cover mental health, but also to recruit clinicians that will take the training that you're hearing about here today, get that training. And part of that is we're going to take care of them in so many ways. The other reason why I got involved in this was I had a fire captain in Huntington Park who was a good friend of mine.

We used to ride the bike every morning and had the unfortunate experience motivating me of having to join my fire chief and go to his house with his wife and his kids and open that door and see the look in her eyes as we told her, her husband, who was one of the top fire captains on our Department. You would have never guessed it would have been him. The epitome of what a fire captain should be and a paramedic.

He had taken his own life in a warehouse behind a dumpster in Ventura, and the Ventura firefighters went to high school with him, and they knew him. And I decided at that moment, just like you, I'm not going to give up on this, not only for my firefighters, but for the public I serve. We're seven years into this behavior health task force, and we've come a long way.

We have to make hard decisions on funding and allocations of resources to put behavioral health into the fire service. But I'm going to tell you that with our peer support program, our culturally competent clinicians, we have been able to reduce the depression, the anxiety, the suicides, and the issues in the fire service dramatically. And this can also be a model that you use out on the streets.

I told you where I work, and I can tell you we are also part of a pilot program in the state for people that we treat to use telehealth and to use what essentially would be like FaceTime, but it's HIPAA compliant telehealth. And we have three doctors on the La County fire Department. We have nurse practitioners, and we have a connection with our paramedics.

And we'll go out and diagnose that somebody, in fact, can be cleared medically and does not need to go to the emergency room. And we take them to a mental health treatment facility. And we have seen a dramatic reduction in the repeat calls to 911. We've seen a dramatic reduction in the expense of firefighters, paramedics going out in the field and treating these peoples, sometimes 34--5 times a day.

And just recently, I had a young woman who's a single mother with three kids living in a motorhome on my streets. And we got her into Nexus over in Martin Luther King Hospital through this program. And she came back to our fire station and brought cookies and said, I just wanted to thank you, because where you got me and the treatment I got and getting back on my medicines and having access to street care, things being delivered to her house.

She is up and running in an apartment with her three kids. And that is an example of how it can work when we do it right and we fight hurdles to be able to do that right. So I encourage you to clear the way for us to be able to use outside the box programs like that. I'll just go ahead and close right there by saying, firefighters, we were taking our own lives at a rate higher than all other causes of death.

And it was the moment when we decided to form the task force and treat mental health differently, to break down stigma, to clear access, to provide resources like you're hearing here today to our firefighters. And we have dramatically reduced suicides and or depression and anxiety and relating to that, the people that we treat in the streets. If we were to have programs like you're hearing here today that mirror what we're doing for firefighters, you can see a dramatic reduction in the behavioral health issues in the street and probably related costs associated with it. Thank you.

Thank you.

Good afternoon. Thank you guys for the opportunity to speak in front of the committee and share with you the work that Advantage has been doing over the last decade or so, supporting the most at-risk patients in our state. My name is Vival Bhanvadia, native Californian, went to undergrad at UCLA, graduate school at USC, and have spent the better part of my career focused on creating solutions with state agencies to get care delivered to patients with behavioral health issues.

I'm excited to speak to you all about last mile solutions that will ensure that the dollars that you guys are allocating for patients with behavioral health are maximized and patients get the best care possible. Advantage Healthcare Services is dedicated to improving the health and wellness of our communities through integrated pharmacy solutions anchored in clinical care, and it's designed to optimize outcomes, support achievement, and manage population health management goals.

As a high touch provider, we have a suite of patient centric, community based services designed to address medication access adherence gaps, and work through social determinants of care to make sure that patients get the right care at the right place at the right time. To date, we've served about 100,000 MediCal beneficiaries that deal with substance use disorders and behavioral health issues, and about 10,000 parolees.

The way we do this is through something called Enhance Medication Management Services, where you take an integrated team, benefits planner, social worker, case worker, nurse and pharmacy, clinical pharmacist, to support patients that require care, versus a core pharmacy service, which is just a technician filling the medication and a pharmacist dispensing the medication. A great example of this was in 2016.

We met with the parole department at the downtown Los Angeles office, which is their largest parole unit, and we launched a pilot where we understood the gaps that the parole department had. And the gaps we identified were that patients generally were not able to access services in general. And because of that, social workers, case workers and others that worked in the parole setting were unable to really focus and move forward care delivery.

So one of the things that happened through that pilot was understanding what the social workers and parolees felt was difficult when receiving care. And we were able to interview thousands of parolees and many, many social workers across the state. And the goal of the program was to create something that was very patient-facing.

Destigmatized care became really repeatable because if you've ever dealt with people with behavioral health issues, they need consistency when they come back and try to access care, and a feedback loop so that the care team that was supporting the patient had the ability to know where the patient was in their care cycle, particularly with their medications.

And the biggest beneficiary, I think, was the security side of the house, the parole agents and such, because they were able to understand that their patients, like my colleagues stated earlier, had a long-acting injectable, and knew that they were on medication for 30, 60, 90 days. Through our learnings, we realized that one of the pillars of the quadruple aim, which is to reduce caregiver burden, was probably the most important in the parole setting.

Many of the social workers indicated to us that 5% of their panel took up 50% of their total time. They were not able to spend time with their entire panel because they were managing 51-50 risks, and they were not able to kind of navigate through some of those activities without advanced notice and exposure.

So we came up with a way to indicate by kind of incarceration status which patients were due for what treatment well ahead of time, so that they can be scheduled and things could be done in advance. And what we learned about the parolees was that they were managing social determinants that we often kind of understand, right, food insecurity, transportation, the ability to access care.

But then there were other social determinants that we don't think about, I. E. when we first onboarded, the first thousand parolees in the Los Angeles district, north of 50% never had a medication filled. And when we asked them why, they would state the medications were sent into a gang territory where I wasn't going to go pick up my medication and things that we just don't think about as normal, everyday citizens.

So we had to work on figuring out how to deconstruct those challenges and ensure that they were able to get access to care in a way that was consumable by them, and reduced total caregiver burden so that the parole agents, case workers, social workers, and MDs were able to successfully do their jobs. And ultimately, we found that with an integrated system, we were able to get people coming out of parole on 9.3 months of consecutive care.

And when transitioned to the next side of care, we got them on 14 months of consecutive care. Great savings to the system, great savings to the payer MediCal, and a lot of secondary benefits, reduction of petty theft, spread of communicable diseases, and ultimately just a safer environment to kind of exist in. For us, the lack of reimbursement meant that this project was a labor of love for the organization.

It's been self funded since 2016, and we continue to fund it because we've touched so many parolees over the years. But to scale programs like this and programs that drive people to the last mile are really important. And I think that what we've done and what the committee here has done, passing California Medicaid pre-release coverage, it's amazing. I mean, it's a really important first step, and you have to commend it.

The concerns that we have are that you have facilities like Twin Towers, which is often referred to as the largest mental health facility in the country. Many of the patients, while incarcerated, are getting access through DGS to LAIs and other therapies that work. But when they're discharged, there's no soft handoff.

I think ultimately, as part of our responsibility, we have to kind of encourage these facilities and the community partners to communicate and maybe have a workflow to ensure that these patients stay on the therapies that allow everyone downstream that we're funding, case workers, social workers, MDs, the opportunity to really succeed at their responsibilities. Because our team looks at the problem we have in behavioral health as a quadratic equation with all variables, no constants.

And if we can get one of the major constants, let's call it medication delivery, consistent, then everything else starts to figure itself out. And you have a real shot in the field of making sure that each subsequent opportunity to communicate with that person matters. And ultimately, I took this opportunity to speak to everyone here today because I look at my organization and everything that everyone here is doing, as we are empathy extenders. They're human beings that do the work every day in the field.

They care, they're overburdened. They do more work than they possibly can do. And it's up to us to empower them to have more time so that they can touch more lives. This historic funding that's flowing through the system right now could really be incredibly impactful if that last mile is considered and we're able to pull the patient through that last mile so that the change that we all hope to happen starts to be realized. So that's what advantage does. And thank you for your time.

Thank you so much. And before we get to questions, I just want to sort of comment. One theme that is running through both of these panels, and I think it is just so clear, is that in California is sort of at the extreme end here, we need much more flexibility in allowing people to provide support and care for people struggling with behavioral health challenges. We get so caught up with rigid scope of practice issues and reimbursement issues for peer support, et cetera.

And it's always a huge fight. I had a mental health workforce bill a couple of years ago, it ended up not passing. We didn't need it because so much got incorporated into the budget. But the one piece that we were going to move forward was having UC do a scope of practice study around mental health workforce. Just a study. And it caused a mega uproar that we were even asking the question and asking for a study. And I respect a lot of the groups.

These are major groups I work with a lot. I have great respect for them. But it just is a reflection of how tense the situation is around scope of practice and licensure requirements. And there is so much work to go around. People don't need to be territorial here. There is profoundly, exponentially more work than we have the professionals to provide. So we need to allow people to practice to the full scope of their training. We need to relax some of these jurisdictional boundaries.

And I know some people get upset when I say that, and we need to allow more types of people to provide this treatment in the field, and we need to do that quickly. And then I'll stop. I can go on for a while about this. A friend of mine who I've known for a long time, he lived in San Francisco, then he left San Francisco to become a psychologist. He went, I can't remember where in the country he went. It was in Pennsylvania, I think.

And he became a licensed psychologist in Pennsylvania. And he wanted to come back to San Francisco to work as a psychologist. He didn't, because the barriers to transferring in an out-of-state license for a psychologist were, he would have had to retake like a third or a half of the exact same courses that he took in Pennsylvania in order to do that. It's outrageous. And we just lost a psychologist because of that. And that plays out over and over again.

So we need to do things differently. I'll stop. So questions or comments anyone? Assemblymember Pellerin.

So thank you for all the work you do out there. It's so critically important. And one of the motivating factors for me to run for State Assembly was to be a voice and a face around mental health. My husband of 25 years died by suicide November of 2018. Successful attorney, had everything going for him in the care of a psychiatrist, and just gave up. And the impacts of that are tremendous. And I'm grateful for this hearing today.

I'm grateful for the work we've done around 988 as well, and having that emergency hotline where someone can call in the event of a crisis, but we still don't really have the mechanism, as far as somebody to come to their house. The mobile mental health care, I think, is so critically important as well, and then places for them to go to get the treatment that they need.

But the work we need to do around removing this stigma is so critically important that we need to be talking about this. And the work you're doing out there is just so incredibly important. And do you interact with the 988 system at all? I'm just curious about how that helps in your profession.

We do. I have the LA County Board of Supervisors, the five most powerful women in the world, arguably. All five my friends and I know my place, and I work hard for them. I integrate with them in how the 988 system is going to be rolled out, but also up here at the state, when legislatively we look at how we define that.

I have public safety dispatchers who, by the way, they're not part of the post traumatic stress bill for firefighters, lifeguards, EMTs, and paramedics. I want to thank everybody here. We do have a study that we're going to do to try to bring them in. But can you imagine taking the phone call? And we brought in testimony with one of my public safety dispatchers about a suicide that was completed in the desert on the other end of a phone and zero help for her.

We now have a system where we can help her in LA County, we're pushing that. But, yeah, we do interact with 988, and then let me give you another perspective that'll just kind of blow you away a little. I'm in my 36th year as a firefighter and a paramedic and a captain. Now, my son is three years on with LA County Fire Department. He works one station away from me.

We teach behavioral health and breaking down stigma and accessing proactive care, which, by the way, proactive mental health. I'm going to leave this out. There is the cheapest form of medicine that you all can put into service. Reactive crisis care is expensive, and that's true in the workcom system, but it's also true in the EMS system, out in the hospitals, and so along those lines. I asked him the other day, hey, can you go to dinner with me? Let's go hang out.

He's old enough to go have a beer and a steak with me or a piece of swordfish. And I said, can you go with me? And he said, oh, I can't. I have my quarterly telehealth online telehealth mental check-in appointment tonight. I can't go and I said, oh. Then he looked at me and he's smart. And he said, you know, the union provides this benefit, right? And I go, of course I know that. And he said, well, you take advantage of it, don't you?

They teach us in the tower. And of course he saw it on my face. I had never taken advantage of it. And he says, I'm going to sign you up tomorrow and you're going to begin doing what I'm doing and what you're teaching. And he broke down stigma with me. So I do a quarterly check-in now. So we've come a long way, I think, in the streets.

When you look at street medicine, when you look at training clinicians through any types of programs where we can actually break down stigma by, and somebody said, you can't beat it if you can't see it. I also think if you can't see it, then you don't know really what's going on out in the streets. And breaking down stigma has to do with getting people that can talk to people that are in these situations and bring them out of the cracks.

And I'm going to tell you, people are dying with their rights pinned to their chest in my district, okay, they're living at standards less than wild animals in the streets I work on. And if we don't do something different, and I'm so ecstatic to hear Senator Wiener lead the charge on saying, we got to get outside the box, we got to do something different.

Whoever heard of street medicine before? Coming out, and I was just talking earlier, we have individuals that live along the metro blue line in my district, a ton of them. And I've been able to work with, I didn't know street medicine, but clinicians that came out and brought prescriptions to people that are challenged behaviorally on the streets and addiction and different things like that. And actually once they got their medicines, they're not leaving the train tracks, but they become functional.

They can eat, they can take care of themselves, clean themselves in that environment. So I think that speaks to getting outside the box. And anything we can do to break down those barriers will help deliver the care that you've heard here today.

Thank you so much for bringing up proactive care. That's absolutely essential to getting us to our goals and having the prevention and starting them young in our schools with our kids.

Assemblymember Bauer-Kahan, and then Assemblymember Waldron.

Thank you, Senator. Thank you guys all for being here and for the services you provide to people where they need it most. I love the way you know, meeting people where they are with empathy, all of you. It's really so critical that we think about this that way. And I think when I was young, people died by suicide in silence. People didn't talk about it.

And the fact that we're all here talking about people dying on our streets and elsewhere is so critical to making sure that we solve this problem. So one of the things I think that Assemblymember Pellerin touched on, which is really critical, is that we need people who are out there in our communities serving people in a mental health capacity. And I think whether it's our physicians, our pharmacists, or our firefighters, you guys are out there meeting people where they are.

One of my fire departments worked very closely with our police department to say we'd had a couple of incidents where force was used with people in mental health crisis. And the police are the first to say they do not want to be the ones responding in a mental health crisis. They aren't trained, they don't know how to do it, and they don't want to do it. But they are currently the only people who are available to answer those calls.

And I know that our fire departments are really stepping up in that way. And so one of my departments actually instituted a training program for their EMS folks to make sure that when they went out on these mental health calls, that they could be the ones who responded. When they responded, they did so with adequate training. And so I wanted to touch on that because I think you're talking a lot, Chief, about being the ones who serve folks on the streets in mental health crisis.

But I think it's also really critical to talk about how we're training up our firefighters and our EMS folks to do that, because it isn't, I believe, a part of the fire academy to learn how to treat people in mental health crisis. So can you touch on what LA County is doing in that regard?

Well, there's a lot that we're doing, but with our recruit firefighters and then in our training in the field, I ran probably 20 to 30 calls a shift on the streets of Florence, Firestone, Wattswood, busy areas. Shootings, stabbings, car crashes, diabetics, heart attacks. Take your pick. Cancer. But at least a quarter, five to seven of my calls per day are mental health calls. Addiction.

Sometimes they just send the engine out, not the paramedics, because the dispatcher is able to ascertain that we're not in a crisis that requires the paramedics. So we can keep the paramedics ready to go somewhere else and we get training on how to deal with patients from a psychiatric point of view. The other thing, I'm going to give a little shout-out for law enforcement, LA County sheriffs, that's who I work with. I work with LAPD as well.

There's a lot to do to clean up, a lot that's going on. But my law enforcement brothers and sisters, many of whom come from my district, they have MET teams and PET teams now. And when we get them out, one of the greatest tools that we have is 5150. We use it. We try not to. We try to talk to the patients and bring resources like you've heard here today into the picture.

And oftentimes we can do that and voluntarily get them to not go to the emergency room, clear them via telehealth and take them to a mental health facility or take them to a location where I can hook them up with three chests. And so we're getting that training and learning how to do it. The MET teams and the PET teams, those are through the law enforcement entities and they've done pretty good work when they get out on scene.

But just frankly, the call volume is too large. Like everything else, there's just not enough resources.

Yeah, and I will say I carried the 98 Bill and LA County is really leading in many ways in mental health crisis response. So I think it's great you're here to really share what LA County is doing because I think there's a lot happening in LA that we should be replicating throughout the state. And yes, my law enforcement agencies that have those teams, they're not even on 24/7 because they just don't have the resources to do that. Right.

And mental health crisis doesn't go to sleep at night. So I really appreciate it. I think I mentioned it earlier, but the statistics around this are just so staggering. I was just reviewing the CDC data on youth mental health crisis and 20% of kids are thinking about suicide and 10% of kids are attempting suicide, according to the CDC.

So it is just staggering how many people are suffering amongst us and we need to do more and we need to make sure that everybody who is in the midst of people who are suffering is there to support them and get them the care they need. So I want to thank all of you for being a partner in that great.

Assemblymember Waldron and then Senator Allen and then Senator Cortese.

Thank you. I'll just touch on two things really quick. The firefighter issue. The first responders is a really critical one. My son is an EMT firefighter with Cal Fire, and I worry all the time about that type of thing. They go from one call to the other. There's no time in between to address it.

And I think the more organizations like the California Task Force on Behavioral Health that you're working with, the Corey Iverson foundation, when Corey Iverson, the firefighter from my district that died in the, you know, his wife is working on that. So critically important to raise awareness of reducing the stigma, letting folks know they're not alone. The communication aspects of it are huge, and the strong support systems are critical.

But I also wanted to mention that I've worked for many years in the incarceration space, and the lack of support and treatments accessibility when people leave prison is staggering. And all the work I've tried to do through the years has been on that reentry side of things. I had a bill this year that couldn't get through approaps because it costs money. But basically I wanted to set up a department that focused directly on reentry services.

And because of the budget issues that can't even be looked at, we're trying to hire an individual who will just focus on that because I think it's so critically important with the mental health issues, behavioral health, that we can reduce recidivism by a substantial amount if we support people when they leave prison, instead of just leaving them to maybe hope that they can access a service that's available.

We've tried to do incentives for just as involved persons to stay into treatment, reducing their parole time on the other end, the longer they stay on funding into county jails so they can get services there. My bill was actually the 90-day enrollment into medical prior to release from prison that was enrolled into the budget, into CalAIM and still has not been implemented.

CMS supported that the federal side, first state in the nation, and we need to make sure we're accountable, that we can actually get that to happen, because it'll be really important to streamline folks coming out of prison. They actually have someone already available in Medicaid MediCal that they can access treatment both for behavior health, substance use, and also mental health. So.

Well, first of all, thank you. Thank you for this great hearing. Thank you for the discussions. I love your story, David, about your interaction with that member of the Department who was calling you out for not taking advantage of the service.

That's a great story, and I think it's something, it relates to the humanness of this as we all try to navigate our interaction with this system and all the supports that are out there, but that are oftentimes, for whatever reason, we're not as inclined to access. I wanted to just ask one question, specifically to Brett. It's my understanding that California's current policy only allows for counties to provide services to those who are experiencing severe mental illness.

Can you give us a sense of how in Los Angeles, and maybe Mr. Gillotte can speak to this, or Dr. Bhanvadia as well, but specifically to Los Angeles, how the county is meeting those needs and what sort of gaps that we should work on to ensure network adequacy for folks with severe mental illness? I guess street medicine teams such as yours, even if you have a psychiatrist, you're not allowed to provide direct services. So, could you walk us through the rationale behind it and whether we ought to look at changes in that direction? Love to hear about it.

Yeah. Thank you. If there's one thing that I'd like to get-

Places like Venice Family Clinic, I'm just thinking about all the groups out. Family Health Center. Anyway, sorry.

Yeah, no, no. As act related to behavioral health, if there's one thing that would help, it would be changing that. And the reason is because, and I mentioned in the beginning, we run the California Street Medicine collaborative with 130 organizations. So we have a sense of what's going on across the state in addition to LA. But in LA specifically, where we have DMH, which is probably the most extensive DMH, I would guess they have.

How they address people experiencing unsheltered homelessness is with their home teams, and they focus mostly on conserving folks. And so if you're not ready to be conserved, there's not a way to provide ongoing care. And each team only takes care of a very small amount of people. And so the vast majority are not being served at all, which is why our teams are providing the highest level of care that we can provide.

And so in one of our statewide meetings, we were talking about how some of us, including USC, but others employ psychiatrists and use them to help us with our most severe patients, make a diagnosis and a treatment plan. But then it's carried out by the rest of the primary care team, but folks aren't willing to hire more because they can't get reimbursed for it.

So, we really need to open up the door for anybody wanting to provide psychiatric services on the street to be able to do so.

So, can you walk me through why the rules are the way they are? Your best understanding.

My best understanding, and I do street medicine, so I'm not an expert in this stuff, but my best understanding it was that there's something in place. Maybe it's the MHSA that makes it that put the counties in charge of this. And so, the counties can bill for serious mental illness, but only the counties. And so, for the rest of us that want to provide care, we are providing care for the same diagnoses but can't get reimbursed for it.

You can't act as a contractor agent or a servicer to the counties and get reimbursed through the counties, as happens in so many other contexts.

Yeah. So we've talked about that with different counties across the state, and it comes down to they're having trouble funding their own stuff, and subcontracting with us would mean we would have to share the same pot of money.

Is that your understanding as well, Mr. Gillotte?

Similarly, we have this alternative transport destination pilot program. San Francisco was the first department in the nation to try it. We have nurse practitioners and paramedics on our rigs or doctors. Medical doctors. We have three medical doctors on our department. We're fortunate in that way. And our whole program is funded by our department. Even though the counties could reimburse, there's no.

Your county department?

I'm a county department. But what we are doing, and I think opening everybody's eyes to, is when you look at medicare and billing, that we can get, know if you had a medical issue in the field, we can get reimbursed for that call. Why are we not getting reimbursed through medicare for a mental health call? That we take a patient to an alternative transport destination or to a clinic where they can get the care that's different than the emergency room.

We only get it if we go to the emergency room. So, breaking down barriers on how we actually run the calls, the follow-up to that is how we can get funding and payment for that.

We've been spending a ton of money from the state on homelessness, homeless services. There's not enough money. Some of the recent, what is it, $15 billion or $13 to $15 billion? Recent allocations from the state. Is it any of it going to these services? And what's stopping everyone from having adequate funding to address these challenges?

Yeah. So, for street medicine in particular, a lot of our programs. So when I started this program in 2018, we were the second in Los Angeles and the 6th in the state. Now there's at least 14 in Los Angeles and 57 in the state. And most of that growth has been because of a lot of the funding that was made available from DHCS. And it was short-term capacity building funding.

A lot of it, like HEAP, Housing and Homeless incentive program is due to expire in about a year and a half. And so we're working as quickly as we can to get contracts in place with the managed care organization so that we don't hit this cliff and have to think about not treating the people that all these programs have been treating. And so we've been trying to negotiate with the plans. The rates haven't, most of them are just offering standard rates.

And there's a number of reasons, if you're interested, on why the equitable thing to do would be for street medicine to get reimbursed more. So that's everything within Medi Cal. But then there's all this stuff that we do outside of Medi Cal. So, for example, the crisis response stuff, Medi Cal is when you go to an individual who holds insurance in a specific plan that you have a contract with that you're willing to Bill, but crisis call doesn't function like.

And so presumably it should be funded out of these collective and pretty robust state funding efforts through the counties and locals.

Yeah, I think so. Because you can't ask a street medicine team who relied, just like you can't ask a clinic who's relying on billing for managed care to respond to people that they're not under contract with. And so that's what we would be doing in street medicine, which we actually do now, but it's not a sustainable model.

I mean, ideally there'd be someone who goes and tries to make sure we're collecting whatever we can from the Federal Government to help at least offset some of the Medicaid related costs or Medicare. Gee, okay, well, this seems like an area that needs some work on our side. And Mr. Jolly, I'd love to hear.

I'll just add something real quick. And I know we're short on time, but I think getting the services we're talking about here, which as Senator Wiener said is they're not in the box. If I were to go out and run a call and take that mentally ill patient with all the issues that could be treated by either street medicine or alternative transport destination, and I take them to the emergency room, I get full reimbursement.

So where's the incentive to reach out to street medicine, have them on the rolls? Where's the incentive to not take them to the emergency room, but get them to the alternative transport destinations, mental health facilities, drug addiction centers, when in reality, if we're doing these things that we're talking about here today, we will not have the cost of the emergency services responding to them and taking them to the emergency room. Think about the offset that's there.

And I think we're going to have to get outside the box, like the Senator said to say, we're going to approve some programs that aren't in the box and we're going to get reimbursement for it. And then let's study what works and what doesn't and make sure that we keep funding what's working.

And if I can just add one more important thing, they're at a distinct disadvantage because right now, when they get called to a crisis response, there's two options. Number one, this is not a crisis, in which case they leave the person there, but something probably prompted the call, or it is a crisis, in which case they transport them.

The hospital keeps them for one day or three days, and then they go back out onto the street and both result in the person back out onto the street without reliable connection to care. And so that's really street medicine's role, is they would refer to us and we would continue care. Okay, we're going to have to move.

Quickly because I'd love to work on this.

The Assembly goes into session. Yeah. Thank you, Senator Ashby.

Well, I can be very quick. Hello, .... It's nice to see you. I just wanted to say to my colleagues, really, that I have SB 1180, which deals with this issue and allows medical reimbursement for ambulances to drop off at alternate sites that are more appropriate for mental health and behavioral health services.

So any of you who would like to sign on to that Bill with me, co author, I'd love to have you just holler at me, let my office know there's no way to stop the revolving door nature of this if we just drop people off at the emergency room. My husband runs the local emergency room in Sacramento.

All he can do is hold them for a little while and then release them, and then you can bring them back if we really want to stop that and be effective. We need more than 988. We need more than street medicine. We need longer term service provision and people who write out a plan for success. And there is no reason why firefighters would drop somebody off when they can't be reimbursed for that call.

It's not a fair thing to ask them to do, although many of them are doing it. Many of them are Sacramento, I know is doing that. I'm sure LA is, too. But it is not a sustainable program, and there's no reason for it to function that way. So thank you all very much for your work, and I'm honored to carry. That Bill and would love to have any of you sign on. Thank you, Senator.

Thank you, Mr. Chair. Just a question for Mr. Feldman, and a short answer is fine. If it's too complex for today's hearing, we could talk afterwards and connect with my office. But we were doing medical center, I think, is the second largest public health and hospital system in the state, in my county, in my district. And while I was a county supervisor back in 2014, we were doing in the largest encampments, what you're calling street medicine now, I think.

And I participated in that as an observer and shadowing what was going on. The heartbreaking thing was that we would get folks like you're describing into a patient physician relationship on a first name basis, where they would be visited in their tents or in the large encampments, like the so called jungle. We'd get them on an epic system. We'd have a file on them, and then they'd be swept, and all of a sudden, we've got no contact again.

And that has been a recurring issue in the 10 years since 2014 when we first started doing that. How do you deal with that?

Yeah, it is a huge issue. And there was just a study published that it actually increases mortality whenever there's a sweep. A number of things, one that's part of the work of the community health workers is we call it a homeless advanced directive, where we ask them, if you were to move, where are two places you'd be? And then also we try and figure out what their daily routine is. So just like you and I, they have a daily routine.

So if their encampment gets moved, but I know that they're going to panhandle on a certain corner at noon. I'll just meet them there at noon. We still sometimes can't find folks, but it helps.

Got it. Thank you.

Thank you very much. Okay, we'll go to our final panel. And do you want to call the.

Yes, our final panel is new developments promise of the pipeline panel. We appreciate everyone and we would like to call the next panel up, Ms. Campa Ramirez and Ms. Clark Harvey. And you may begin when you're ready.

Thank you. Appreciate you, Mr. Chair. Thank you so much to all of the Members here today. We will, in the essence of time, be brief. Good afternoon. Aracely Campa Ramirez here on behalf of California Life Sciences, we serve as the trade Association for the Companies and research institutions that are doing the innovative work in the mental health space. Thank you again for the opportunity to provide comments here today.

We've heard from our prior speakers about the challenges surrounding mental health and the severe scope of the problem. Research in this field is equally challenging. The brain is complicated, and knowing how to address many of our mental health challenges without adverse side effects has stymied researchers and frustrated patients for years. We heard a couple of prior speakers talk about the stigma around mental illnesses, oftentimes not taken as serious as physical illnesses.

And in many cultures, mental health is still very much taboo, making it difficult for those suffering from it to get the help they need. However, we do have a lot of promising technology through the pipeline. We're optimistic that there are new products that are being yielded that can change the lives of patients suffering from a variety of mental health conditions. So I want to just dive briefly into what this industry is seeing and what's coming down the pipeline.

We're seeing a lot of significant progress in this space. Over the past decade, biotech companies have made tremendous strides toward understanding mental illnesses and developing innovative treatments by leveraging a growing scientific understanding of the brain. Researchers are developing new treatments and bringing therapeutic advances for patients who are not helped by current standards of care or those experiencing negative side effects.

So, for instance, we currently have approximately 160 medicines that are in development that are targeting common mental illnesses, all of which are in clinical trials or awaiting review by the FDA. We heard some astonishing facts earlier. Some of the numbers. We have 54 medications that are currently in the pipeline for depression, which affects about 8.4% of adults and 17% of adolescents in the US.

We have 35 in the pipeline for schizophrenia, 35 for anxiety disorders, which we know that more than a third of adults in the US and many adolescents experience anxiety during their lifetime. We have 33 for substance abuse disorders, 13 for bipolar, eight for attention deficit hyperactivity disorder ADHD, which is one of the most common childhood disorders, affecting a combined nearly 20% of children and adolescents. In the US.

Now, as mentioned earlier, Dr. McCarron talked about California being a leader, and we are as well when it comes to neurological research. And understanding the brain is key to understanding mental health disorders. So we're glad that in California, we're very, very proud that we have over 60 companies that are working on later stage mental health medications for these conditions. One of our Member companies in San Diego is investing $2 billion in a new facility. They have over 600,000 lab space.

They're working on neuroscience research and development. We have companies working on developing medications for conditions that have never been treated before, like anedonia, which is the inability to feel joy or pleasure. And there's a strong focus on quality of life, which I really want to point to because really, what we've seen in the last few years, we've seen medications that really are game changers in the quality of life for patients.

So, for example, we've seen long acting injectables, which have come in, and instead of having to do, like, oral treatments or having to go in to the hospital, to the care facility every day or weekly, monthly, these medications now through the injectables, can be done, like every three months, for example, where we've really seen this. And I know that there has been some conversation around maternal mental health and just how prevalent that's been.

We're very proud that one of our Member companies, just in August of last year, announced the first oral medication for adults with postpartum depression. The drug Zurin alone was approved by the FDA. It's a 14 day treatment that's oral, which is, again, just a game changer compared to where we've been in the past. Postpartum medication has been off label medications. It's been months and months. The earliest you'd start to see changes is in about six weeks, but could take months to really see some change.

And so for mothers who are nursing, they'd have to stop nursing completely, just out of options. And with a treatment like this, that's 14 days, it's oral, it's short. Women can resume nursing afterward if they so wish. So just really some significant changes in what we're seeing. Again, some stats that were mentioned earlier already around mental health.

So I will skip that in the essence of time, but wanted to flag that we're also looking beyond traditional pharmacology, and we're trying to really meet people where they are with major investments in prescription digital therapeutics. These digital applications are approved through the FDA. They're supported by real world clinical evidence. Just like any other drug that goes through the FDA approval process. And these are software based therapies that are used to treat and manage a broad spectrum of diseases and disorders.

They can improve patient health, reduce the cost of healthcare, which was talked about earlier, especially in this space. We're also utilizing AI.

We've heard a lot about AI as far as the chap, GPT and others, but we have so much of this in the healthcare space, and it's been around, AI has been around since the healthcare space, and we're excited to see that a lot of our research institutions are really utilizing it to understand the brain better than ever and to really get into the why behind a lot of these mental health disorders.

So we're very excited to what the promise of AI can really lead to in mental health space. Some of the state investments were mentioned earlier. I know Ms. Bauer. Khan's Bill was discussed with 988. We were excited to see that. We're just heartened overall that over the past 10 years or so, we've seen significant investments and then more recently, the governor's mental health movement, helping to build nearly 25,000 beds and units, nearly 46,000 treatment slots, including inpatient, outpatient and counseling.

$5 billion to train and support. We talked about Healthcare workers earlier, 65,000 Healthcare workers over the next five years. So all of this, coupled with what we're seeing coming up with Prop one, we're hoping that all of these investments in mental health services will only continue to address prevention, early intervention, the technology and training that we need.

So with that, I'll just state our biotech and research institutions are committed to addressing the stigma of mental health illness and researching and developing medicines to improve the health and well being of those struggling with these illnesses. The treatments in development today represent the continued commitment of our industry to advance new therapies for a wide range of mental illnesses in the diverse patient populations impacted by them. So that concludes my remarks. Thank you.

All right, I have 10 seconds. Yeah, left. Please do hold on a few minutes. Well, greetings, Mr. Chair, and the Members who have stayed. I know you have a busy schedule and places to go, but I appreciate your commitment to hearing us through. I'm Dr. Le Ondra Clark Harvey. I'm a psychologist by trade. I'm the CEO of the California Council of Community Behavioral health agencies. We're a state advocacy group for behavioral health clinics across the state and all of your districts.

And I'm also the Executive Director of the California Access Coalition, which is a diverse group of patient advocates and pharmaceutical industry reps and we join together to advocate for access to behavioral health medication and treatment. So being a leader of these groups allows me to have a unique vantage point on the pulse of the spectrum of behavioral health care, from clients to providers and clinics to novel treatments that my colleague just spoke about.

Yet my education, my clinical training and research did not prepare me for the breast cancer diagnosis that I received at the height of the pandemic in 2020. This experiences has allowed me to more intimately understand the intersection of physical and behavioral health, the holes in the system of care, and possibilities for change. I considered myself to be a professional advocate, yet I still can't figure out my insurance bills. My colleague to my left discussed some exciting opportunities for advances in medication treatment.

I currently sit on SAMHSA's maternal mental health task force and Dr. McCarron highlighted it earlier. There is a lot of energy around new medications and also lifting up community practices that work, the things that we already have in our toolkit. And that's what I'm going to focus on in my last 5 seconds of testimony. So there are many opportunities to bolster existing treatment modalities and programs in your district, as was well illustrated earlier.

These are the Low hanging fruit in my opinion and these approaches to care are culturally sensitive and thus effective, but they just need to be funded and scaled up. I'm going to share a few of them that already exist. Nine88. It was mentioned earlier. So CBHA represents about a third of the call centers who do an excellent job, but their staff is highly consisted of volunteer workforce. That's a problem.

We cannot sustain operations throughout the state with the growing mental health need as a result of the pandemic with volunteers at the call centers. The certified community behavioral health clinic models is something that we all need to be paying attention to. This is a program where we have federal funds to support the expansion of services. Basically, clinics in your respective districts are getting $1.0 million to expand services. That's a great thing.

But California has not signed on to the demonstration waiver, meaning that they're committed to supporting these clinics and actually being the administrator of funds. So we have the Federal Government giving funds directly to clinics and the clinics are bolstering these programs and serving more people without a promise of continuation. What if they don't get granted the funds next year? What does that mean for care in your districts?

Telehealth it's not novel, it's been around forever and our Association has been advocating for years for flexibilities in relaxing all of the regulations, and we've been met with a lot of pushback. We're a very careful state here. But when the pandemic hit, all that went out the window, and it was allowed wonderfully, and it was successful. But since then, we've gone back to business as usual. So we have payment disparities and multiple barriers for out of state practitioners. And Dr. Kaufman discussed the workforce challenges earlier.

I'll move on to digital therapeutics. Using technology apps to provide incentives for meeting treatment goals is promising. And our state, I have to give them credit, is utilizing one of these programs for substance use disorder treatment. So that's very exciting and something that we have to continue to follow. I'll mention, as my colleague did as well, artificial intelligence. These technologies are designed to be extensions of the human mind. That's scary. But we have to make sure that we're tracking that.

We're making sure that these are adequate and appropriate. They really can help promote efficiency and limit administrative burden. And I'll give you an example. At CBHA, one of our business Members is pioneering an app that will transcribe and analyze therapy notes and capture patterns in clients'behaviors to help predict symptom occurrences, reoccurrences, and potential crises. They can actually predict if this person may potentially have this disorder or act in this way. It is scary. It is new, it is real.

We have to be able to make sure that what's happening is safe. So what are the barriers?

Well, as chair Wiener shared earlier regulation, so stringent licensed reciprocity laws and poor and uneven reimbursement rates for services happening all over the state and impacting the ability for these Low hanging fruit interventions to be exercised. We have two Members that have telepsychiatry businesses, but they can't get their providers, their virtual providers, to provide services. In California, because of regulations, we have another who is more incentivized to serve non medical patients because reimbursement rates are so disparate.

So there's also many promising therapies and treatment modalities on the horizon, which I'll summarize shortly. One is psychedelics. 30 states have introduced legislation, and two states have passed laws via ballot measures recently governing the use of psychedelics. California just saw legislation last year from one of our chairs, chair Wiener. Mobile Apps is something else that we have to pay attention to.

Given the global shortage of psychiatrists and the lack of mental health care and access in rural region, Apps have emerged as a viable tool to bridge the mental health treatment gap. For example, 60% of people who own a smartphone have downloaded at least one health app. There are over 300,000 health Apps on the market, and I'm hearing that every day there's 200 popping up.

More than 15,000 of these apps relate to mental health, but only 20% of these apps are created in consultation with a behavioral health specialist. So we have people that are having great business ventures, but not necessarily having the technique that's needed to be able to create apps that are going to impact individuals who need help.

I'll skip ahead to close out, but I think it's really, whether it's scaling up the workforce or relaxing telehealth regulations, state government really has an opportunity here to provide oversight and influence on what is available and how it's delivered. So, as always, CBHA and the access coalition Members are here to provide technical assistance and partner with all of you. Thank you for the time.

Thank you very much, colleagues. Any questions or comments at this time for this panel, seeing that we really want to thank you. Obviously, what's also going to be important is please provide your testimony to the staff you've been in contact with so we can make sure that it gets to all of our Members. And particularly what has been helpful is also some of the more things that we're starting to see in terms of the future.

The innovations that are coming up is at some point, again, we're trying to say, what is the next step here? Right? We have made some progress, but we know that we still have a long way to go, to be quite honest, when you still continue to look at what's happening on the ground, the figures we continue to see. And so we want to thank you.

But please make sure, and for all panelists, please make sure that we receive your testimony so that we can digest it further and be able to hopefully take it into some more continued legislative recommendations. Thank you so much for all of our panelists. Now, we will now move on to anyone wanting to provide public comment. Your excuse, if you would like. Yeah, please come on up. State your name and affiliation, and we ask that you please keep your comments. Very succinct.

You got it. Hi, it's Claire Conlon here for Biocom California, representing our 1800 Members across the state, including biotechnology, pharmaceutical, medical device genomics, diagnostic companies, as well as research universities and institutes. Medication access is an important tool for people experiencing serious mental illness. Delays to treatment because of utilization management can have costly consequences both for the state and the patients. And so I'm here to echo the comments of the patient advocacy groups and University folks. Thank you.

Good afternoon. Tara Gambo Eastman with the Steinberg Institute. Really appreciate the conversation today. It was so helpful and just really wanted to briefly highlight the importance of the workforce discussion throughout today's hearing and highlight one piece of information that was asked for during the hearing around what our needs are around workforce. The Steinberg Institute has recently leveraged Federal Bureau of Labor Statistics to estimate what our long term workforce needs and behavioral health will be.

We estimate it's about 375,000 professionals across the different types of occupations, or about 32,000 people per year. So that's quite a bit of work ahead of us and look forward to partnering on that. Thank you.

Please make sure that we get that information to myself and Senator Weiner's office, please. Thank you. Any other public comment at this time? Seeing none, I want to, again, thank all the panelists. I want to thank my colleague, Senator Wiener, for participating and working together and actually being the leader of this Joint Hearing. Obviously, as we get closer to a lot of things going on, we're being pulled in multiple directions.

But no matter how busy things get, we want to make sure that the public and everyone involved understands that this mental health journey that we're all on remains a top priority. I want to thank my colleagues for participating, and it's very important to know 98% of both the Senate and the Assembly Select Committees have participated at some time here under also recognizing the importance of this issue. And most importantly, want to thank the staff, particularly Senator Wiener's staff, for doing a lot of the heavy lifting.

Of course, my staff for helping to herd us, those of us who are cats. And so I want to thank them very well. Again, we will continue to engage on this issue. We will continue to making sure that we have further discussions and ensuring that we do all that we can to make sure that we continue to move forward and we don't go backwards, especially as we go through this very challenging budget time. So at this time, thank you very much, and we will adjourn this hearing.