Assembly Standing Committee on Health

Good afternoon. Oh, yeah, I forgot about that piece. So anyway, good afternoon everyone, and welcome to the Joint Assembly Health Committee and Budget Subcommitee one hearing on the status of recently enacted mental health initiatives. Before we get started, I want to acknowledge that while behavioral health encompasses both men, mental health and substance use disorders, today's hearing will focus on mental health. That's not to dismiss the serious challenges that remain in providing meaningful sud treatment and services. However, today we'll spend our attention on mental health.

As you'll hear today, it is estimated that nearly one in seven adults statewide experiences a mental illness of some kind, and one in 14 children have a serious emotional disturbance that limits their functioning in family, school or community. California is experiencing a mental health crisis. In response to this crisis, over the past few years, the Legislature and the Administration have established numerous initiatives. These initiatives are all aimed at improving our mental health system to better serve Californians.

Some are housed in education, some in housing, and many in the health arena. Those initiatives, ranging from infrastructure buildout to workforce development to the redesign of how services are delivered, are numerous, complex, costly and have various durations and timelines. Few, if any, of the initiatives are actually operational yet. As such, it's too early to evaluate the programs and their success in improving the mental health status of our residents. It is not, however, too early to learn how the initiatives are progressing.

It's our hope that this hearing will provide a better understanding of the major initiatives and the impact they're having on the agencies, departments and stakeholders engaged in their development and implementation. We want to know how all these initiatives are affecting organizational capacity, with staff working on any number of different initiatives all at the same time. Want to know how these initiatives are being coordinated across departments, agencies and stakeholders, what their success criteria are, and how these programs will ultimately be measured to determine overall success.

Want to learn today if there are challenges or obstacles to implementation, what those are whether there could be legislative action that could help alleviate those challenges so that these initiatives can come to fruition. This hearing is not to revisit the merit of the initiatives or consider policy or direction changes, but to set the table for the Assembly, laying out all the new ongoing efforts and how we could facilitate them, not adding new initiatives that could further burden entities already stretched to maximum capacity.

I want to thank you for being here and turn this over to Dr. Arambula. Would you like to say a few words?

Good afternoon. I would like to begin by thanking Dr. Wood for spearheading this hearing today and for inviting someone to be a joint sponsor of this hearing. Mental health is an issue that continues to be a high priority for so many of us. I would also like to thank all of you who are here today for participating in this hearing. I am grateful for your commitment as well to these issues.

As we learn about the recent extraordinary budget investments and policy initiatives in mental health today, my hope is that we can keep a few issues in mind. First, we're reminded this year of the state's economic and revenue volatility. There will always be years like this year when we have less to spend, and therefore, we need to ensure that the investments we make when we do have surplus resources are spent in a way that is sustainable.

We need to make sure that we're investing in systems and structures that can continue after one time funding ends. Secondly, as we all know, the state saw unprecedented budgeted surpluses over the past two years, and we chose to prioritize mental health by investing billions of dollars, which takes years to spend appropriately and effectively. This was the right thing to do.

Yet in deficit years, unspent funds inevitably become vulnerable, and we must commit and recommit to these dollars and to keeping mental health a priority for our state. Third, and perhaps most importantly, the most glaring gap in the state's response to the current mental health crisis is that we have not actually responded to the crisis that it is.

We must acknowledge how much attention that the Administration has put into this issue with the transformative investment in the children's and youth Behavioral Health initiative, the behavioral health infrastructure continuum, and other strategies. But these are programs that will take years to implement and will serve Californians well into the future. Take the Children's and youth Behavioral Health initiative as an example. I'm optimistic and hopeful that this initiative will, in fact, fundamentally transform the mental health landscape for children and youth in California.

But realistically, this sea change will help and support the next generation of kids, not the kids out there at this very moment who are struggling with depression and anxiety and don't know where to turn for help. The initiatives that the state has undertaken are critical for our future, yet so many kids and adults are struggling and suffering today. Collectively, we should be responding to our state's mental health crisis with the same urgency and gravity as we responded to COVID.

It is our responsibility to make government work and to meet this moment and crisis head on. Let's get to work, roll up our sleeves, and look forward to today's conversation. Thank you.

Thank you. Dr. Arambula, any comments from other Members at the Dais? Okay, seeing none, we'll go ahead and move on to our first panel our first panel includes Katie Heidorn, Director of state policy for the California Healthcare Foundation Andrea Rivera, senior legislative advocate for California pan Ethnic Health Network Ryan Miller, and Will Owens from the Legislative Analyst Office.

Good afternoon. Thank you Mr. Chair and Members, for inviting me to speak with you today. My name is Katie Heidorn and I'm the Director of state health policy for the California Healthcare Foundation. We're an independent, nonprofit philanthropy that works to improve healthcare systems so that all Californians have the care they need. We are especially focused on making sure the health system works for Californians with low incomes and for communities who have traditionally faced the greatest barriers to care.

Let me see if I can get the slides. There we go. Today I'm going to talk about the sources of our data on mental health, the prevalence of mental health conditions, and Californians access to mental health care. First, the sources. Most of the information that follows can be found in our July 2020 publication, Mental Health in California waiting for Care, which includes data from federal and state reports as well as commissioned analysis. One thing you'll notice, all of the data precedes COVID.

That's because getting good data takes time, and while the COVID pandemic is winding down, we are definitely still in it. Yet these data are still relevant and give us a good baseline from which to analyze the pandemic and post pandemic data going forward. I'm going to start with a recent statewide poll by CHCF published just two weeks ago. The survey was conducted in English and Spanish among a statistically representative sample of over 1700 California adults.

This graphic shows the urgency of dealing with mental health issues in the opinions of Californians. When asked about 10 different health priorities, half of Californians said that making sure people with mental health problems can get the treatment they need, it was extremely important to them and more than more for any other health care issue, and another 33% called it very important. You can see it topping the list on the right side of the slide.

So let's explore mental health prevalence in California. Mental illnesses are common chronic health conditions for year 2019. Overall estimates and the estimates for subpopulations show only minor changes from previous analyses over the past 10 years. In 2019, one in 26 adults in California, almost 4%, experienced a serious mental illness, which is defined as a diagnosable mental, behavioral or emotional disorder resulting in functional impairment that interferes with or limits major life activities.

At much larger percentage, about one in seven californian adults, or 14.4%, experienced any mental illness. In other words, they had a mental behavioral or emotional disorder, regardless of the level of impairment. This category includes people whose mental illness causes mild, moderate or serious functional impairment. Among children 17 or younger, one in 14 children, more than 7% had a serious emotional disturbance, which means a mental, behavioral or emotional disorder that substantially limits functioning in family, school, or community activities.

The prevalence of mental illness varies by geographic location among adults. The orange bars the prevalence of serious mental illness range from a high of 4.9% in the northern and Sierra region and 4.8% in the San Joaquin Valley to a Low of 2.9% in the Greater Bay Area. The average is 3.9%.

Children are the blue green bars the rate of serious emotional disturbance among children across California regions varied less, from a high of 7.8% in the San Joaquin Valley to a low of 6.8% in the Bay Area, the average is 7.3%. This slide shows how prevalence varies by race and ethnicity for adults. Rates of serious mental illness varied considerably among racial and ethnic groups. American Indian and Alaskan native adults experienced the highest rates of mental illness.

The orange bar the blue bar shows that black and multiracial adults also had notably high rates of serious mental illness. On the right, you see that serious emotional disturbance in California children varied only slightly by race and ethnicity. And finally, rates of serious mental illness and serious emotional disturbance vary by income. Did we miss one whoop? apologies. I think these might be out of order.

I'll move on to the next slide, but just note that rates vary by income and both children and adults mental illness far is far more common at the lowest income levels. zero, are we going backwards? Sorry folks, my apologies. It's very sensitive. Just a note for my future presenters up here. The next few slides use a different measure, serious psychological distress, which comes from the California Health Interview Survey. It is broader than the serious mental illness and serious emotional disturbance definitions cited previously.

While the measures of serious mental illness and serious emotional disturbance are relatively stable over time, this survey based measure shows significant increases between 2015 and 2019. And again, this is pre COVID, so it'll be really interesting to see how this measure changed during COVID and what it looks like post pandemic. Across every subpopulation of adults, the rate of serious psychological distress increased.

In particular, on the left side of the slide, you'll see that it is approximately twice as high for gay and lesbian adults as for heterosexual respondents, and over four times as high for people who identified as bisexual on the survey. As for straight people, the right side shows rates of serious psychological distress by race and ethnicity. Again, every group saw an increase between 2015 and 2019. Rates are highest for the multiracial group and lowest for the Asian group.

We also see stark differences in serious psychological distress by age. In 2019, nearly 30% of young people ages 12 to 24 experienced serious psychological distress, approximately double the rates just four years earlier. Rates of serious psychological distress decline with age and were under 5% among those aged 65 or older. This chart shows that among California adults with any mental illness, slightly more than one third, or 37%, reported receiving mental health services, which include treatment, counseling, or prescription medication.

During the past year, 63% reported not receiving care. Adolescents are slightly less likely to get care for their illnesses than adults. This graphic shows that between 2016 and 2019, only about one in three California adolescents who reported experiencing symptoms of major depressive episodes during the past year received treatment. About two in three did not receive treatment. And for my last bit of information here, I just wanted to share information about acute psychiatric inpatient beds.

These beds are used for people who require 24 hours care for a psychiatric crisis, and we have a chart that we'll follow up with with the Committee. But just a note. Over a 20 year period from 1998 to 2017, there was a significant decline. The number of beds per 100,000 population decreased 31% over this period as 35 facilities either closed or eliminated psychiatric units. And with that, I want to say thank you so much.

I know I've gone through a lot of data, appreciate the patience with some of the technical difficulties. I'm glad to be the person up here. Got to try it first. It's been a wonderful opportunity to speak to you today. Thank you.

Thank you. And we'll hold the questions until the panel is completed. So please, our next speaker.

I can just go ahead and get started here while the slides go up. And so good afternoon, chaired Members Andrea Rivera, senior legislative advocate with the California Pan Ethnic Health Network. CPEN is a multicultural health advocacy organization dedicated to the elimination of racial disparities within our health systems. Since 1992, CPEN has mobilized and advocated communities of color throughout the State of California to advance equity and improve health outcomes for all Californians.

We envision a world in which community informed solutions are at the center of decision making spaces. Mental and behavioral health conditions are on the rise. Californians are in crisis and urging state leaders to invest in the well being of our communities. The public health emergency ravaged the state and left vulnerable communities with severe anxiety and stressors caused by job loss, food insecurity, and lack of health care coverage.

But these inequities are nothing new and we've known for quite some time that our mental health care systems were not adequately meeting the needs of BIPOC Californians. In September 2021, CPEN published a report on the disparities within our medical managed care system. The chart here shows data on non specialty access rates between 2016 to 2020. You'll notice that despite the study increase, access remains exceptionally Low across different racial and ethnic groups enrolled in medical. The same is true for access rates aggregated by written language.

While access rates for Spanish speakers trickles up, AAPI communities have remained relatively stagnant and in some cases demonstrate downward trends. However, the most egregious disparities can be seen when we compare access with utilization rates. A recent report from AAPI data and UCLA found that one of the major reasons AAPI communities don't access mental health services is attributed to the lack of knowledge about their options and lack of linguistically appropriate support. The message is loud and clear, California can and must do better.

In 2022, CPEN sponsored SB 1019, which was signed into law and required medical managed care plans to conduct linguistically and culturally responsive outreach on mental health benefits. And while direct outreach to community Members is important, this law is also unique in the sense that it includes providers, and they must also receive information on Medical benefits so they can also inform their patients.

Research from CPEN, which contained interviews with primary care physicians, exposed limited understandings of managed care services among providers, especially if these services were provided outside of their FQHC. This interview captures how challenging navigation is for physicians and the disbelief that providers expressed when attempting to understand what their patients go through if they don't speak English as their first language. So how do we look ahead?

Solutions must focus on communitybased care models, improving methodologies that can help us understand underlying barriers and move away from criminalizing mental health across the continuum of care. It is imperative for California to expand our use of evidence based practices to include community defined practices, as this will improve the ways in which we can appropriately respond to community needs.

Community defined evidence based practices derive from what a community considers healing and are most commonly defined as a set of practices that may not be empirically measured but have reached consensus and acceptance by the community that uses them. An example can include group therapy or talking circles, which have been used for hundreds of years by Native American and indigenous communities. These practices are often overlooked and underfunded by westernized care models and treatment models.

Since 2009, the California Reducing Disparities Project has piloted the integration of CDEPs and treatment to mental health conditions for black Latinx, AAPI Native American and LGBTQ communities. CRDP provides grants and technical assistance to community based organizations and supports work to combat mental health disparities in culturally responsive ways. It's innovational programs that offer robust support for community informed solutions that have inspired CPAN and others to advocate for additional necessary investments, such as the Health Equity and Racial Justice Fund.

Many behavioral health providers do not collect or inadequately collecting information on communities of color and LGBTQ communities, therefore rendering the underlying barriers nearly invisible. Furthermore, recent data from HKI shows that black Californians continue to be seen in hospital ERs for mental health crises far more than other populations, and implicit bias continues to be a persistent problem within our healthcare workforce.

In September 2022, CPEN compiled key survey findings on cultural and gender responsiveness within emergency services, and this was part of our larger people power for public health project. The data showed staggeringly Low levels of comfort with emergency services for BIPOC and LGBTQ communities, and over 20% of respondents from each racial and ethnic group noted law enforcement as a barrier to crisis care integration and use of community connected providers, and trainings on racial and implicit bias are key to the development of equitable crisis response models.

28% of gender nonconforming and 25% of transgender respondents stated peer support workers as their preferred provider, and nearly half ranked community health workers as their preferred provider.

The generational trauma of treating mental health as a public safety issue is deep, and as we look to implement 98 and mobile crisis response, CPEN is urging many of the leaders that are sitting here today to build a system that not only prioritizes racial equity, but that it responds to it by using community connected providers and trained mental health professionals as the primary responders.

I'd like to end by stating how important mental health is for BIPOC Californians, and over the last two years, we've seen significant one time investments to address some challenges.

But I'm here to remind you that California's communities of color have ongoing disparities and that we need long term, comprehensive resources to build on what is already working and to ensure that equity, particularly racial equity, is embedded into any new policies that are contemplated or implemented as a result of the body of work that you all do with this legislative session. Thank you.

Thank you very much. Move on to our next speakers.

Good afternoon, Chairs and Members. Ryan Miller from the Legislative Analyst Office. You should have a handout in front of you here. My colleague Will Owens and I will be walking through it, providing an overview of major recent behavioral health initiatives. We've been asked to provide an overview of five major recent initiatives, the Children and Youth Behavioral Health Initiative, the Behavioral Health Continuum Infrastructure program, behavioral health bridge housing, the Care program, and the behavioral health components of CalAIM.

We were also asked to do a detailed analysis trying to capture behavioral health augmentations pretty broadly since 2018,19. The results of that analysis can be found in a table at the end of the presentation. We had detailed 11 and a half $1.0 billion of total funds, General Fund, federal funds and other state funds going back to 2018,19 the bulk of which were provided in the last two state budgets.

But a few words about that analysis and about the slides that I'm about to walk through. First, we were looking at public community mental health, and so there were additional augmentations, say for the Department of State hospitals that weren't captured in the exercise. Also, we were not looking at private insurance or Medicare, so there would be other types of behavioral health efforts in the state. And we also were kind of focused on the health and human services program area.

So there have been some additions in K 12, for example, that wouldn't have been captured in this analysis. But overall, I think that we've captured the bulk of it, and that's feeding into some of the figures that I'll walk through here now before we get into the major initiatives. And so if we turn to page five of the handout, you'll see a flowchart here that shows that illustrates the financing of delivery systems for public community mental health in California.

There are four main funding sources for public community mental health local realignment funds, the Mental health services Fund, the state General Fund, and federal funds, of course, because of the Medi Cal State federal partnership. Note here that the state General Fund provides a fairly small portion of overall financing for the public community mental health systems. Also note the relative size at the bottom of the county mental health services box compared to the state services.

And that illustrates really how large of a role counties play in providing mental health services in California. They provide specialty mental health for Low income individuals with the highest behavioral health needs. So on the next slide, we're going to look at how that county mental health services box has changed over time. And so on page six, you'll see a bar chart here that shows that base annual funding for community mental health at the county level has actually about doubled in the past 10 years.

This is the combination again of realignment, MHSF, federal funds, and the state General Fund. Now, I think we'll go ahead and note that while this is one side of the equation, and it's a pretty notable revenue growth. We're unable to say too much about whether the extent to which that revenue growth has been sufficient to cover increased costs at the county level. But again, note the General Fund share here.

The state General Fund really having kind of a small role in the annual base funding for county mental health. Turning to slide seven, this page is going to show a bar chart that illustrates really the huge change in the General fund's role in kind of augmenting that annual base funding for county mental health services. This is really predominantly in the last two state budgets, really mostly for the programs that we'll walk through momentarily, but a few notes about the funding here.

So this is just showing the General Fund, and I think we're trying to illustrate here the state General Fund changing. Of course, there were additionally federal funds and other funds that are shown in the table on the back of the figure. But this figure shows almost $9 billion of General Fund resources that have been committed over a multi year period. I mean, really, when you think back to prior to 21,22 it really is a remarkable change in the General fund's role.

Now, as you'll also notice in the chart, about three quarters of that, nearly $9 billion is one time or temporary funding. And in the last few fiscal years, you'll see that about 600 million or so represents the ongoing funding that's been committed to. So again, this is a subset of the total funds. But if we were to show it in total funds, really that same picture would be true, that really the bulk of it is temporary in nature.

And so with that, I think we'll just provide a high level on the five major initiatives that we plan to cover, the first being the children and youth behavioral health initiative. This is a large multi year package of spending augmentations across several departments in the health area, $4.5 billion of total funds over a multi year period. So really a huge package, 3.4 billion of that is coming from the General Fund.

In General, the focus of the children youth Behavioral Health initiative is to transform service delivery by adopting a more prevention oriented approach a couple of ways that the initiative does. This is the virtual services and econsult platform.

That's a virtual platform for children and youth 25 and younger, regardless of payer source, which is also a pretty notable change in the way I think we've typically provided health services, but through interactive exercises and games and screening tools and so forth, the platform will identify youth that have significant behavioral health needs and refer them to licensed providers.

Another example of this prevention oriented approach is the addition of dietic services as a covered Medical benefit, which is a model of care that provides integrated physical and behavioral health services for children and youth and their families.

The CYBHI also builds capacity for behavioral health services in schools through grants to schools, providers and other entities, incentive payments to medical managed care plans, and also notably, over $200 million from the mental health student services act that was created by the Legislature in 2019,20 that builds county school partnerships and increases access to services.

One last notable aspect of the CYBHI is also a huge increase in workforce funding under the initiative, $800 million over a few fiscal years, including funding to develop a behavioral health counselor and coach workforce. Next we'll talk about the Behavioral Health Continuum infrastructure program. And so, as many of you know, a key focus of recent behavioral health augmentations in the state has been to fill gaps in the behavioral health continuum of care.

The continuum providing a wide range of services in a variety of settings that try to meet individuals needs as they sort of move through the continuum and have differing needs of care. And so to try to increase the number of facilities to provide care, the behavioral Continuum Infrastructure program provides $2.2 billion. It was created in the 21,22 budget. DHCs is administering the program. Cities and counties and nonprofits and other entities are eligible entities, and the funds can be used to construct, acquire or renovate facilities.

Four of the six rounds of this funding have gone out, and by the end of the fiscal year we expect that about $1.7 billion of the 2.2 billion will have been awarded to recipients. But we also note that the Governor's Budget proposes to delay the 6th round of grants totaling $480,000,000. Next, the behavioral health bridge housing program.

In General, state funded programs in recent years to address homelessness have not really had a specific focus on individuals at risk of homeless experiencing or at risk of homelessness, and that are experiencing a behavioral health or a mental health challenge. So in response to this, the 22,23 budget included $1.5 billion over two fiscal years to provide bridge housing, which is transitional housing meant to transition individuals from homelessness to longer term housing options. But this housing would also include behavioral health services.

Funding is being provided to counties and tribes. DHCS is also administering this program. And last week $908,000,000 for counties was announced, with applications due at the end of April. And here we also note that the Governor proposes to delay $250,000,000 of this program from the upcoming fiscal year, the budget year to 2024,25. And so now I'll hand it to my colleague, Will Owens, to cover the care program and CalAIM.

Thank you. Will Owens, Legislative Analyst Office so I'm going to just briefly touch on two more programs that we were asked to discuss today, the care program or the community assistance, recovery and empowerment program. So this is a new judicial process that is currently underway, and the purpose of this program is to provide a variety of behavioral health treatments and services to individuals with acute mental health needs so individuals can be referred to the program by certain Members of community.

And if a court, along with a behavioral health professional, determines the individual eligible, that person would have access to a care plan or care agreement that would provide a number of behavioral health services, including but not limited to housing, stabilization, medication, and other services. So currently the funding has been for 88 million last year, and the current proposal is 52 million for the current year. Eventually, at full implementation, the estimated cost is around 214,000,000 a year.

In General Fund, we will note, as we had discussed in a previously released report on the major behavioral health proposals in this year's budget, that there is a lot of uncertainty in terms of the number of participants and the overall cost of the program.

We note that because of the subjective nature of determining who is and who is not eligible, as well as kind of the uncertainty of who will actually apply, that it's hard to say at this time what the true number of participants will be and therefore what the overall cost of the program will be moving forward. Secondly, I'm going to talk about CalAIM. So as many of you know, CalAIM is massive series of reforms to the Medical program.

While there are specific reforms and initiatives that address behavioral health specifically, a lot of these initiatives are much broader than that and cover a wide variety of topics. So one piece that we highlight a couple specific initiatives in our handout. But one piece that I want to talk about right now, briefly, is the proposed behavioral health community based continuum demonstration. So this is a waiver that is currently being processed and has yet to be submitted to the Federal Government.

But what this would do is allow federal reimbursement for behavioral health services provided in short term institutional settings. So to receive federal approval, state and counties are working through the waiver and through a number of other programs and initiatives attached to this waiver to expand a community based continuum of care. Part of that continuum of care, as my colleague had talked about earlier, are things such as the Children Youth Behavioral Health Initiative, the infrastructure program, as well as the behavioral health bridge housing.

So the point of establishing this robust continuum of community based care is to really limit the number of individuals who would ultimately need to receive behavioral health services in these short term stays, as well as reduce the total length of stays in these settings. As discussed, these are just a handful of the many, many initiatives that have currently been undergone in recent years, and that will conclude our presentation, and we're happy to answer any questions.

Yeah, thank you. I do have a couple of questions, and this is for Katie Heidorn and Andrea Rivera. For those individuals that responded they didn't receive treatment for their condition, can you offer insight into what the primary reasons might be? And I'll kind of follow that with did they try to access care? Weren't able to connect? Did they not know where to go for care? What might be the obstacles?

I think those are great questions. I don't have that detail in front of me. I'll need to go back and check the data source to see if those types of follow up questions were part of those surveys.

Yeah, I think for CPEHN, so specifically with the report that we did that know, I think some of the underlying issues with disparities within our Medi-Cal managed care system, a lot of what we received as far as responses for folks not understanding how to access their mental health services were just related to lack of awareness and just how our mental health system delivery is provided to folks.

So what we found is that a lot of community members actually thought that they had to go to their county in order to schedule an appointment with their provider, but that's not necessarily the case for managed care. And as we know, you can set up an appointment through your managed care plan. And so there's just a lot of, a lack of understanding within communities of color of where to even begin that process, just because of how our mental health care system is set up. And that just leads to different factors and contributes to the confusion for communities of color.

Okay, thank you. I just wanted to note on the graph, Katie, you had one of the graphs you had on adults with SMI and children with SED by region. And I'm curious, has there been any follow up as to why the variations within regions? Is there something specific about... Obviously, not all regions are created alike, but is there any follow up or a deeper dive into that piece?

Yeah, I don't want to speculate, but I do think we probably have other data and other reports that could get to that issue that I'd be happy to look through and provide to the Committee.

And then I guess my final question for you guys, and then I'll have a question for the LAO, is that when you look at the increase in populations between 2015 and 2019, those are really dramatic in some situations. And so do we have any handle on this? Is this better recognition, better outreach, or is this a huge jump in the need for services?

Yeah, I think those are great questions. I will just point out, as I did in my presentation, when you look at the incidence of SMI and SED. Those are relatively flat over time.

Correct.

And then the data source is actually a survey of people saying, how are you. It's a different type of metric. And so I think that there's something in there that we should probably go back and look at. I don't have the data on that, but I just want to make the distinction between the two. I think that that's important.

Yeah. And I may not have been clear. I was looking at the 1 bar graph is a serious psychological distress. So, I mean, when you go in the multiracial category, 10% to 20% in a four year period, that's 100% increase. So it is what is going on? And as I said, is it better recognition, more people seeking care, or is there something else that we don't have our handle on? So anyway.

Yeah, good question. I'll take that back. I don't know that we're going to find it in that data set specifically. But looking at what happened in 2015 and 2019, I think it's something we can look around. Thanks.

Well, you both do such amazing work that we're just going to give you more.

We love more. Give us a list.

Thank you. And the question for the LAO, as you noted, as we're seeing with the budget going forward, lots of delays in funding. From a perspective, I'm going to ask, you may not want to answer this, but does it make sense? I know it takes a while for some of these programs to get up and running. And I guess what I'm going after is, are there potential unintended consequences for this that are going to affect mental health care for people in California?

Well, we actually did an analysis, of course, of both the delays that we mentioned here, but also the other health related proposals that would delay and reduce workforce spending, for example. It's an important consideration, of course, and our office actually produced kind of a framework for the Legislature to consider in how to think about which recent augmentations to maintain.

And generally speaking, I think that we had suggested the Legislature look at trying to minimize disruptions to populations of concern, trying to perhaps look at reducing or delaying longer term efforts rather than those that are more kind of targeted at really acute needs. But the budget problem this year is significant. And so given that, I think it's reasonable that we would be looking to all program areas potentially for reductions.

And based on what we've heard from the Administration, I think that in general, they were really trying to protect, and they may be able to kind of speak for themselves too. But I think they were trying to protect services now for people and looking to these longer term programs in order to achieve some savings. And I think we would also note that in our judgment, we think it's likely that the budget problem may actually grow between now and the May Revision.

So getting back to these particular delays, I think that we had found that the delay to the Continuum Infrastructure Program was reasonable. I think, again, given all the context on the nature of the budget problem, the size of the budget problem, and everything else. But the 6th round of funding that's being proposed for delay is actually funding to meet the outstanding need remaining after the initial five rounds.

And so it seemed to us, based on our conversations with the Administration, that actually, we think that it may actually be, in some ways, almost a silver lining to take a little bit more time and really try to make sure that that funding is being used well, especially if even on the Administration's budget projections, we may be looking at a somewhat prolonged period of constrained budgetary resources. So potentially all the more important.

Regarding the Bridge Housing Program, I think that we had suggested kind of deferring that until the May Revision because some of the details of that proposal at the time of our analysis were not finalized. But certainly that is a program that's meeting a very acute need and a very high legislative priority.

But to the extent that the Legislature may consider alternative solutions, again, kind of going back to the bigger picture, I think that we would urge consideration of finding at least an equivalent amount of delays or reductions. I hope that's helpful.

Absolutely. Thank you.

Thank you, Mr. Chair. My first question will be for Ms. Rivera, followed by Ms. Owens. I wanted to follow up on your primary care physician interview findings that came within your Medi-Cal managed care plan mental health services brief, and I was hoping you could speak about the poor awareness among the primary care physicians about the non-specialty mental health benefit, as well as the challenges in finding available mental health providers, as well as if you can share the top recommendation from that paper regarding integrating mental health referrals into electronic mental health records. Would love your comments.

Yeah, thank you for that question. And so part of what we were hoping to accomplish with the interviews with primary care providers is really understand, I think, what are some of those other barriers? We knew that there was barriers for community members in accessing mental health, but there's various different pieces to those puzzles. And so part of what the interviews accomplished here is that we were able to understand more of those nuances that providers face.

And so some of the challenges that providers talked about are just, for example, not receiving direct information on what are some of those providers that are in our FQHCs or maybe in the surrounding areas that we might be able to refer our patients to. But then there's also just very limited understandings of what Medi-Cal benefits are. Right. And that's just like an education issue that is for everyone, community members, providers, physicians.

And so part of what we did or what CPEHN did to start to address some of these issues is SB 1019. And so that bill was very much informed by a lot of the findings that came out of this report. And what we did there was to make sure that health plans are also holding up their end of the bargain. Right.

They're contracting with the State of California. It's their obligation to make sure that services are actually being provided to community members as well. And part of that is making sure that there's direct information that is provided to those community members, but also the providers and physicians, so that they can better understand how they can navigate their patients to different services or benefits that may be available to them.

Can you speak specifically to how it varies from the specialty healthcare referrals? Are we on an even playing field here when we're referring mental health referrals, as we would for needing an endocrinologist as an example? And how do we make sure we have that parity within our system?

Yeah, that's a really great question. I'll just say that this report is very specific to non-specialty services. It doesn't necessarily contain those findings related to specialty services. And so there may be some follow up that we can do directly with your office to get you a better answer to that question.

I would love it. Within the report, many of the interviewees comment that those systems are not the same. So when you have variations in how you're making referrals, you're creating a hierarchy within healthcare. And there's a need for us to make sure that our systems are the same for both health care and mental health care. I'd like to transfer now to Mr. Owens, if I can.

I didn't hear within your proposal or your presentation here today one of the findings that was in your behavioral health proposal handout that came out. And so I was hoping you could comment on the one time establishment of the 375 million that is going to be for the behavioral health payment reform.

And in light of the fact of our current budget problem, can you make recommendations on how the state can recoup some of that 375 million that the state used to help counties with their cash flow constraints, which are resulting from our CalAIM behavioral health payment reform.

Sure. So I'm not sure if at this time our office is prepared to make specific recommendations onto how that 375 million would be recovered. But just as kind of a general overview, this behavioral health payment reform, this was statutorily required within the same enacting legislation as CalAIM.

And so the purpose of this is, as counties shift to this new behavioral health payment methodology, there will be a period of time in which the counties will not only be paying providers for behavioral health services, but will also need to provide the non-federal share of costs to the state to then draw down federal reimbursement. So, in essence, counties will have a period of time where they'll be making almost a double payment before they can receive federal reimbursement.

And so the purpose of this 375 is to help alleviate some of those cash flow issues that will initially be the case until federal funds are received under the new payment methodology. As I said, at this time, I think there are a number of things that could be done to maybe recover this payment over time. However, like I said, at this time, our office hasn't put out those recommendations or done a full analysis of that, but we can absolutely work with your office and get back to you and maybe talk about some of those options.

I look forward to that conversation, as in this budget year, we need to make sure that any revenues that we're able to recover from our partners, that we're doing just that. And as this is important for us to do with the behavioral health payment reform, it's also important that we work with our partners to make sure they're paying what they should be paying as well. I look forward to those conversations, and thank you for highlighting it within your report and look forward to that follow up. Thank you, Mr. Chair.

Assembly Member Jackson.

Thank you, Mr. Chair. I think my first two questions are, my first question is for Ms. Heidorn? Heidorn?

Heidorn.

Heidorn. Heidorn and Rivera. Is California in a mental health crisis today?

Absolutely.

Yeah, definitely in a mental health crisis.

Do you believe that this budget reflects that we're in a mental health crisis?

As you're going to hear more about today, there has been significant movement on this in the past several years, significant expenditures. And I think, as Chair Wood mentioned earlier today, that a lot of these funds have yet to be, programs have yet to be implemented and also have yet to be, monies have yet to be expended. So there's a lot there. So I think that there's a lot. And this budget, I think is implementation movement. And I think, as my colleagues down the line here said, some of the delays the LAO has said make sense. So I think we're watching and waiting to see what the impact is as these all get implemented.

And then I think for CPEHN, as it was noted in some of the testimony here, we've seen a lot of, and I think in particular in recent years, a lot of one time investments, which are great because we are starting to address some of those disparities. But what we really need to see are those ongoing investments and looking at projects like the California Reducing Disparities Project. That's been around since 2009, but it's still technically a pilot project. It just continuously gets extended.

And so these are some of the issues and programs that we know that do have positive outcomes, especially for communities of color. And so these are the kinds of programs and additional investments like the Health Equity and Racial Justice Fund, that we would like to see so that we can make sure that we are continuing to push that needle forward. And furthermore, I would also say our state is currently in the process of looking at how we can implement a mobile crisis response benefit for Medi-Cal.

But there's so much more that we could be doing to really understand how we can take that pilot project that will be around for hopefully the next five years and really create a statewide model that can implement all the best practices and make sure that we have components of racial and implicit bias for those responders, making sure that we're collecting demographic data.

There's so many challenges with the lack of data that is collected that doesn't really allow us to appropriately allocate resources to different programs and services to community members. And so those are some of the things that CPEHN would like to see as far as what we can be doing to really respond to the behavioral health or mental health crisis.

So I agree that we are making some tremendous investments. However, because a lot of that, we won't see the benefit of that for some time now. It doesn't seem like we understand that next year is not the crisis, right now is the crisis, right. The number of suicides that we have are now more than two times higher, and it's now the second leading cause of death among individuals under 34. People are dying at historic numbers right now.

And so even though I see infrastructure being built, I don't see the bleeding being stopped right now. Right. And so my thinking is, how do we get to that part? And a part of it, I think, is our thinking about physical harm versus mental or emotional harm. Right. If mental health was a physical harm, we would say you broke your arm. We need to fix it now. The way we're treating mental health, we're saying you broke your arm. You know what?

We're going to maybe order an Uber. We're going to go around, and we're not going to handle it immediately. Matter of fact, try walking it off, and then maybe we'll get to it. Right. And so I think we need to make sure that when we think about what's happening on the physical side, that we respond equally as urgent to the mental emotional side, because as we can see, they both lead to death.

And so what do you think are some ways that we can make sure that our systems are responding better to how the real world is happening as opposed to preserving a system? For instance, my brother is on the streets right now because of mental health. And I was able to, after he had a very rough episode, meaning things were broken. And when he sat down, I finally convinced him to go to an urgent care mental health facility. Right. That's stuff that can happen right now.

But the problem is that, say, for instance, we don't currently do same day billing right now. If I had to wait to make an appointment for my brother to get help, on the day of that appointment, the chances of him still being willing to go is zero. We're talking about minutes, not hours, about getting someone the help that they need. Right. And so what other things could we be doing, like same day billing, so that when you get there and you are in need of both physical and mental emotional support, you can get both at the same time. What are some other things we could be doing with our system to make sure it reflects the current situations on the ground?

I think for CPEHN, a lot of this looks like really focusing on those community care response models. We do already have investments to expand community health workers as a workforce within California. But unfortunately, with the budget that was proposed in January, even those programs have been delayed. But there is some hiring and recruiting that is already taking place through community based organizations. CHWs have been around for a very, very long time.

It's only been until recently that California has started to recognize them as a reputable healthcare workforce. But these individuals have been in our communities for decades. And so I think for CPEHN, it looks like really utilizing those community connected providers, those CHWs that are in their communities every single day, that come from the communities that they serve, that they share those same lived experiences. Those are some of the examples of the responders that we could be using today to really tackle some of those mental health disparities that our community members are facing.

Just a couple of additions, just two examples of the many things out there. And I think, as my colleague said, this crisis is now, and it was before, and it will continue. I think a really interesting finding from the pandemic, and many gains were made over the pandemic in telehealth. Some of the data that we found from Community Health Centers was that when you did a telehealth visit for behavioral health in particular, the no show rates plummeted to zero. Really incredible.

Isn't going to solve your same day billing problem. And also really interesting to see that a new tool in our toolbox takes care of some of those no show rates. A second thing is that the Department of Healthcare Services recently released an all plan letter allowing for street medicine with some of those local community response teams that are on the ground right now.

And so the health plans, again, have a new tool in their toolbox to partner with community providers to go in and meet people where they are right now. So there's lots of long term workforce work that's going on, lots of major reforms in the behavioral health system going on that you hear a lot more about today. And there are some things that are happening right now as well.

And of course, we're seeing the very high rates of mental health disparities, number one being our Native American brothers and sisters and African Americans being second in terms of disparities. What do you believe accounts for those disparities?

I'm going to let CPEHN take that one, but I feel like you've done so much work in this. We have as well, but you can take this one.

I think, particularly for when we're talking about Native American and African American communities, we know that those are communities that are really struggling, particularly with mental health. But there are some strategies going back to those community defined evidence based practices that have already been in use and we can continue to use. And so some of the things that I talked about during the presentation here were really starting to invest in some of those community accepted models for treatment.

And so one of the examples was talking circles which Native Americans and indigenous communities have been using for hundreds of years, and that sort of translated into what we know now as group therapy. Right. But there's so many other different community forms of healing that our western medicine simply doesn't recognize. And that's part of the problem here.

We need to be able to make sure that we're creating space to not just use those evidence based practices, but also incorporate the community defined practices that have been successful far beyond our modern medicine system. And so those are some of the, I would say some of the practices that we can really look at when it comes to Indigenous and African American communities that have been in use and have been proven to be successful.

So if you ask the professionals in our own communities, this is why we say racism is a public health issue. Right. You're talking about the two communities that have the most impactful, the most devastating historical trauma and continued discrimination. And, of course, some of the most impoverished communities. Right. The more impoverished you are, the more likely you're going to have mental health issues as well. And so I think we need to continue to make sure that we understand that and to do those things. I think, lastly for the LAO, do you know what, California stands amongst the 50 states in terms of mental health investments?

We don't have that in front of us, but we'd be happy to take that back and get back to you. If I might add though, to the previous conversation as well, I would just note that the Governor's Budget represents one starting point for this year's budget. But there are certainly a lot of alternatives that could be considered. For example, the alternative that Chair Arambula mentioned regarding the behavioral health payment reform. And so we're eager to assist the Committee as you proceed in considering the budget this year to make sure that the budget reflects legislative priorities.

Thank you, Mr. Chair.

Thank you. Assembly Member Fong.

Thank you, Mr. Chair. If I may ask, start with LAO, and of course, if the other witnesses would like to chime in. Wanted to kind of hone in on the CARE Act. Certainly, there's multiyear funding across the judicial branch and the health entities. I've noticed that in the appendices, we go from a $52 million General Fund allocation to $214 million annually. And, of course, that grows over time. So is that because there's more counties that are going to be participating or having to implement, or is there something driving the exponential rise in budget?

Yes. Hello. So our understanding is that that is mainly as counties come online. So currently, there are two cohorts of counties that will be implementing the CARE Program. The first cohort of counties will start in October. Currently, LA County is anticipating to begin in December of 2023, and then the remaining counties in the state will begin in December 2024. So it's more an issue of timing as these cohorts come online kind of halfway through the fiscal year.

By the time all counties are fully implementing the program is that's when we're going to see that 214 million. But I will note, as we discuss here and in our analysis, a lot of those ongoing costs are extremely uncertain because there is a lot of unknowns in terms of the number of participants moving forward.

So in terms of, if I could follow up on that last statement. From a sustainability standpoint then, how do we budget and assess the implementation of the CARE Act with those unknowns out there? There certainly was a lot of consternation and focus on the CARE Act and the creation of it. And now that it's into law and we are trying to implement it, it seems to me that there's a lot of uncertainty in terms of what is required to make sure that it's successful.

Absolutely. So currently, there is in statute an annual report that has a number of data points that would greatly help in determining the efficacy of the program as well as understanding how many individuals actually will participate. However, that is not going to come online until right before the second cohort starts. So we have a couple of briefs, one from the health side of things, another from the judicial branch.

In both those analyses, we recommend for the time being just initial one year of funding for the CARE Program, along with some more immediate data of reporting from counties, from courts, from the Administration to better understand and have a better sense of what maybe that multiyear funding would look like.

Now, if I'm reading this appendix correctly, we start from 52 million, and then I think you aggregate two budget years to 574. And then you have a $715 million allocation in 26-27. Is that correct?

So if you look on the appendices, the 23-24 is the budget year, which is that 52 million that you noted. And then the next column will actually be three years.

Three years.

I don't have the number right in front of me, but there's another year, the 24-25, and then starting in 25-26 and ongoing is where there's the 214 million estimate. The final column is just a total through those 2018 through 26-27. So that 715 is all inclusive.

Okay, so the 574 is three years in aggregate, and then you have the 52 million for one year.

Yeah. 52 million is the current, is what's currently in the budget proposal.

If you could just, I don't want you put on the spot, but what would the annual be of the 574? So if it's 52 this year, what would it be the next three years? So it's 214 the next year after that.

Yeah, so it is 214 beginning in 25-26 and then ongoing. As far as, I don't have the number right in front of me.

Is it around there?

It's in between the 52 and the 214. I think it's a little over 100 million in the interim year, but we can follow up with that.

Okay. And then my last question is, it seems to me that the CARE Act and the CARE Court, there's the judicial component, and then, of course, there's a lot of services that's going to be provided by a number of programs and entities, whether on the county level, on the state level. How do we properly account for the true need of the CARE Act and the CARE Court?

There's the court component, but then, as my colleagues have mentioned, the actual services and need to provide mental health assistance. That is, of course, the crux of the need. How do we properly account for the efficacy and the budget needs of the CARE Court?

So the funding that you see here, this is specifically for the court costs and the county behavioral health staffing costs of providing assessments, of actually running the CARE Program in the court to determine eligibility, provide the evaluations, staff time, court time, all of that.

The actual costs of behavioral health services and other services that would be provided pursuant to a care plan or a care agreement, those would be covered under kind of your traditional, if the respondent is eligible for Medi-Cal, it would be covered under those services, whether through state, counties, however that is. As I mentioned, there is a reporting requirement within the statute that would kind of lay out the services that are provided under care agreements and care plans.

And so we will have some level of data to understand what exactly is being provided, the individuals, what services they accessed, what services they were unable to access. And so there is a fairly robust reporting regime to allow us to better evaluate the program once it's fully implemented.

To give the opportunity to Ms. Heidorn and Ms. Rivera. I mean, are there things that we need to be cognizant of as the CARE Act is being implemented? What would you advise?

I think from the California Healthcare Foundation, we're very interested in what those annual reports are going to look like. We really enjoy data and crunching that data. I think we're also very interested, I think, similar to what CPEHN thinks about how is this working on the ground, interviewing folks, providers, people in the court system, et cetera. Are there barriers? Where are these systems breaking down? I think from our perspective, this is sort of a classic example of multiple systems having to work together.

The judicial system at the local level, the county behavioral health system, the Medi-Cal system, all working together. So there's going to be a lot here to dig into from both the consumer perspective, from the multiple systems perspective, from the payment perspective, and from how are we all accessing services perspective. So a lot more to come.

And I think for CPEHN, I will just say that when CARE Act was moving forward to the Legislature, we were not necessarily on board during that time. But we do recognize that CARE Act and CARE Court is here.

And so part of CPEHN's, what we envision for our role now, we are a part of the work group that is supporting the implementation process. And we really see it as our role to make sure that we're elevating the voices of the grassroots leaders that we work with, the community based organizations that we work with, and tribal organizations as well, all folks coming from the community and really making sure that their perspectives are heard as CARE Court is being implemented.

I certainly appreciate that. I think to the Chairs, I think the concern is the sustainability of this program, especially when we're serving a very vulnerable but a population that has tremendous needs. I think the sustainability of the funding and going from 54 million for a few counties to then 200 million for every county and then going down to 100 million for all the counties, still. That becomes a really interesting challenge because that doesn't make a whole lot of sense that all of a sudden we're spending or investing significantly less money when we have a larger population that we're serving. Thank you.

Thank you very much. Dr. Weber.

Good afternoon. Thank you all so much. It's always the hardest for the first panel. Ms. Heidorn, the survey that you did, did you say that it was offered in English and Spanish?

Yes.

Okay. And, you know, given the fact that California is so diverse in its ethnic background and also in the languages, is there any particular reason why you just focused on those two? And are you concerned about the results of your survey that it may not actually show the significance and the need of mental health since there was a large proportion of Californians that could not participate in the survey?

Yeah, I think, thank you for that. This is an annual poll that our foundation does and really meant to just take the pulse of Californians. And so we use the two most prevalent languages in California. But I really appreciate the comment. We'll take that back. We're very committed to equity, and so thank you.

Yeah. Thank you so much for that. Especially since this is done on an annual basis and we're trying to get a sense of the pulse of mental health perceptions and needs. I would strongly recommend, especially given what Andrea was saying about making sure that all voices are heard, that you expand that outside of just English and Spanish. My other question is, just for anybody, do we know how many mental health providers actually accept insurance?

Okay, thank you. Yes, there definitely is a mental health provider shortage here in California. When I would put in referrals for my patients to see a mental health provider, I felt like it would just disappear into the ethos. But I think that's one piece of the puzzle that we need to increase that pool. However, we have a whole nother pool of mental health care providers that are out there, but they don't accept insurance.

So it's great that our insurances cover it, but if the providers are not accepting it, then we're not helping the people that we're trying to serve. A lot of my patients would come back. They'd found someone, but it was just too expensive. I'm really concerned about our adolescents, our children, and their mental health. Recently, I looked into a child psychiatrist. To see a child psychiatrist initial visit, because they do not accept insurance, is $1,500 for the first visit.

And if you want to continue, it's $500 per session. After that, $500 for an hour for a child psychiatrist. Now, if you just want to see a child mental health specialist, that's around $200 a session because they're not accepting insurance. So it's great that we have it in our Medi-Cal programs and we have commercial insurances, but the reality is that the reimbursement rates, especially for Medi-Cal, have been too l ow for all medical specialties that we're talking about mental health right now.

And also dealing with some of the commercial insurances is just too much of a hassle to get their funding reimbursed. And so we have mental health providers out there that are seeing patients, but it is extremely inequitable because if you don't have the money, then you cannot see these providers.

And so as we're talking about budget, as we're talking about where we should be putting our money, we really need to be talking about how we can increase reimbursement rates within our medical system to allow those providers that are out there that are seeing patients to actually open up the doors to more people because they will start accepting different forms of insurance. There are a large proportion of mental health care specialists, whether they're psychiatrists, psychologists, just mental health therapists, that do not accept insurance.

And we need to fix that here in California.

Thank you. Anyone else? Okay, Mr. Ramos.

Thank you. Mr. Chair. Just a couple of questions for the demographics and the cultural aspect. It's talked about using talking circles in some of those areas, but some of the questions within the Native American population, that does suffer from a higher rate than any other group here in the State of California and now bringing awareness to it. It's been a long time coming where you've been talking about reaching out to Native American community here in the State of California, but utilizing talking circles.

Who is administering those? Is it Native Americans? Administering it to Native Americans peer to peer? Because then we know that when you do peer to peer, there's more opportunity to move forward on programs. And if it's working in one area, we know that through the history of the State of California, there's been historic trauma inflicted upon California's first people. Relocation, genocide, atrocities. It has pushed the Native American community into far reaching rural communities.

So are we looking at making sure that we're not just looking at a cookie cutter approach where it's just one size fits all, but we're able to adapt and change as the demographics of the terrain change also? That's one question. And then looking back on a bill that we moved forward in AB 2012 was created the office of suicide prevention, and particularly called on collecting data where that data would be collected.

So then we would know where to send those resources to the most vulnerable in the State of California, so that data would prove resourceful to identifying the areas and the upticks. And still to this day, the demographics within a Native American community is higher, 3.5% higher than others in the State of California.

So while I welcome we're able to talk about now the impact on Native American in the community, we want to ensure that those that now are going into the talking circles, and we talk about culturally responsive care, that each one of those areas in the State of California has a different culture. My tribe, Serrano, and Kuya, each tribe, Serrano has a different language, different culture. Kuya has a different language, different culture. And you'll find that throughout the whole State of California.

That's why I'm asking about being able to adapt to the communities that we're truly wanting to serve and serving in a peer to peer meaning. Those that understand that culture would be able to lead that discussion so it wouldn't be more of a paternal approach of here's what worked other places, and it should work here that we're doing that resource and that outreach.

Yeah. Thank you for that question. I'd be happy to follow up with your office and provide you with a more detailed backgrounder on the different organizations that work throughout the State of California to really tackle the mental health disparities through the California Reducing Disparities Project. And there's actually a pretty lengthy list of organizations that vary from Santa Clara, San Diego, Alameda County, all over the state. Right. And it really talks about what are those different traditional healing practices that those organizations offer in the communities that they.

And through the chair, I'd love to have that meeting, but also looking at statistics of the outcomes, have they been successful in their approach and what it is that's being the resource that's being used in tribal communities? Because we know that. And to my colleagues statement, we are in a crisis. We've been in a crisis of mental health.

It's just now that we're getting to the point of seeing it in the budget moving forward and being able to discuss it and breaking, quite frankly, the stigma of mental health in the State of California. I have one more question, Mr. Chairs, on the budget.

We had a presentation on a Power Point that showed the funding for the state, and I know we're talking about budget constraints and those things, but one of the things that I'm interested in seeing, we've seen the growth through the state, the Federal Governments, and those, and the money going to that. But are we monitoring the local level, the counties, their input from General Fund, local jurisdictions as well, because we know that homelessness, mental health becomes the number one priority in a lot of local jurisdictions.

But we have to make sure that local jurisdictions are leveraging the dollars that they're receiving from the state, the Federal Government, and even through the local bonds that are through realignment. But are local jurisdictions diving into their General Fund to leverage dollars coming from the state?

And I say this as far as being a former member from a county Board of Supervisors here in the State of California, that we received certain amount of money from the state, and because it was a priority, we deemed a priority, we dove into general funds, local funds to leverage those dollars to create successful programs.

So it would be good to see that growth also, as we continue to see the state and the Federal Government continuing to escalate the payments going out on mental health in particular. So do we know if the local governments have increased or even leveraged or even put in some of the local revenues to tackle these issues.

Thank you for your question. There are a lot of examples and anecdotes, I think, that we hear over the years about local counties putting in county general funds into mental health. I would note that on a subsequent panel, I know that there are county representatives who may want to speak to that as well. I don't think that we're aware of a data source that sort of compiles that and would allow for that kind of analysis to some extent.

I think that is a little bit of an open question, and that's why I think we wanted to kind of caveat the figure showing the growth in the revenue, as you pointed out, with kind of the question of to what extent is that revenue sufficient to cover increasing costs. So.

Mr. Chair, the question is trying to identify if we're seeing this as a crisis here in the State of California, is that also trickulating to the local governments to see the leveraging of dollars we put X amount of dollars in, is those dollars being leveraged to create successful programs that brings the wellness of individuals in our community? Thank you, Mr. Chairs.

Thank you. With that, I will thank this entire panel for their presentation. We will now move on to our next panel on a department overview of initiatives, status and impact. While they're making their way forward. I will introduce Stephanie Welch, who is the deputy secretary of behavioral health for the California Health and Human Services Agency.

Melissa Stafford Jones is the director of the Children's and Youth Behavioral Health Initiative at the California Health and Human Services agencies. Tyler Sadwith, the Deputy Director of behavioral health within the Department of Health Care Services. Jacey Cooper, state Medicaid director for the Department of Health Care Services and Toby Ewing, the Executive Director for the Mental Health Services Oversight and Accountability Commission. Can we please begin with Deputy Secretary Ms. Welch?

Good afternoon, Assemblymember Wood, Assemblymember Arambula, it's nice to see you. Nice to be here this afternoon and meet some new faces for the new year. Thank you for inviting health and human services today to come and provide a high level overview of where we are in terms of implementing some of our behavioral health initiatives.

I will also take my opportunity at the MIC to talk a little bit about the Care Act and the implementation there, and then I'm going to turn it over to my fellow panelists to give some more specific updates. We are excited to have this partnership with you.

I think in my time here, we've talked a lot about how we have a shared priority, and I certainly heard it in both of your opening remarks to put behavioral health first as a priority for the state and that it focuses on really improving both the mental health, the well being, as well as services and ongoing supports for Californians who have the most vulnerable needs.

We share this commitment with you and frankly, many of the dedicated people who will be on the panels following us and prior to us. This is an issue that all of us care deeply about, and that's an opportunity because we can work together. These behavioral health initiatives I know might seem disparate. I think we're working hard to identify for all of you, as well as our stakeholders, that they are connected thoughtfully and that they provide.

Our goal is to provide tools to anyone, anywhere at any time for their unique behavioral health challenges. And I say this often, but it's very true. The best method to prevent a behavioral health crisis is an equitable, accessible behavioral health system that delivers high quality care and timely care. And those are the things that we're working on collectively through our initiatives. We have all been there, and I have heard it today, and I appreciate you sharing your personal story.

Assemblymember Jackson we have been there for a loved one. We have been there for a friend, a neighbor, a coworker, or someone who could be suffering significantly. Maybe they are even lost to us. Maybe they're unhoused on the street. Maybe we are supporting someone for the first time to reach out courageously for help.

Every part of our behavioral health system needs investments, from prevention to crisis services to long term care for those who are the most sick and vulnerable, from children and youth to older adults. I believe that our initiatives are working collectively to address that large charge.

As I mentioned, my colleagues will be providing some more details on the status of implementation, but I wanted to share with all of you a couple of things that we've learned so far and some early successes, echoing what we just heard in the panel before us. Nothing is more clear in doing this work in the first few years than the fact that communities of color, people who identify as LGBTQ plus, are extremely experiencing a different behavioral health system than those who are caucasian.

In particular, they carry a heavy burden, a heavier burden than many of many other people. We remain committed to advancing equity and diversity and inclusion and really radically reimagining how people get their behavioral health care, whether it's through the children and youth Behavioral Health initiative that's really driven by youth and family voice or to our equity and practice transformation.

Provider payments led by DMH making sure that behavioral health is included as part of that work with our Medi-Cal managed care plans and also internally at agency through the work of our justice equity, diversity and inclusion work group that is working across departments to create an equity dashboard so that we are actively both internally measuring the progress that we're making in reducing disparities.

So progress and early success I think we often hear that maybe we are trying to do a little bit too much with a little bit too little, and most certainly maybe a little bit too fast. I think that we really recognize that there are decades of stigma and discrimination, as well as historic underresourcing of mental health and substance use disorders that cannot be addressed overnight. But we do believe that we can double down our efforts in really, frankly writing this wrong.

We do need to acknowledge this universally at the Legislature and amongst our stakeholders, that we are working hard under these pressures. In addition to new initiatives, we are also streamlining programs. As mentioned earlier today, it's not just new initiatives, but it's also using our CalAIM program to really make things more efficient for Californians. We are also working hard to enforce laws and regulations that provide all Californians access to care through our mental health parity enforcement programs.

As we continue on this journey, there are elements that are more visible in terms of progress, and then there are other things that will require quite a bit of patience and some time. Some initial successes. Specifically, I wanted to share with you, last month, California's 988 suicide and crisis lifeline centers received nearly 30,000 contacts. That's in one month. That resulted in an in state answer rate of over 90%. In fact, close to 92%. That's up 6% from last year.

So with the investments that we had with the partnership with the legislature, we've really been working hard to increase our capacity to take calls, online text, I'm sorry, online chat and text.

Our Behavioral Health Continuum Infrastructure Program, through both rounds, 3 and 4, has awarded projects that have resulted in 88 new outpatient facilities that will be built that will increase our capacity to serve people by over 200,000 slots, and 65 residential facilities will be built to increase the state's treatment bed capacity by 1672 beds dating back to 2018. And I know the focus of today is mental health, but I thought this was a really important accomplishment.

The Naloxone distribution project has distributed over 2 million kits of Naloxone to over 3300 organizations in all 58 counties, resulting in more than 130,000 overdose reversals. Our Department of Healthcare Access and Information has awarded over $229,000,000 in scholarships and loan repayments to support both current students as well as behavioral health professionals cover the cost of their education. We have also awarded nearly $100 million in training programs that will expand training by nearly 900 social workers, over 700 psychiatric mental health nurse practitioners and 45 psychiatrists.

Funding will also bring three new BSW programs and four new MSW programs and two new psychiatric residency programs to our state. We look forward to working with the legislature to identify ways in which we can bust through implementation barriers. I guess is what I would say. We need your mind, your touch points on the ground in your communities to help us solve problems. There is a lot of work to do.

I don't want to not be clear that I think we are very aware that there are capacity challenges, but as you have all brought to our attention today, there is an incredible need out there. And so while we have capacity challenges and we say this often, it's time to take a breath, take care of ourselves, but also plow forward. Now, briefly, I wanted to provide a few points about the Care act, and I appreciate all of the discussion about it previously.

As you know, this was signed by the governor in the fall as SB 1338, the eligible population for the Care Act are individuals who are living with untreated schizophrenia spectrum disorder and other psychotic disorders, and we do estimate that in our state that range of individuals is somewhere between seven and 12,000 people. In addition, these are people who have to be suffering from severe mental illness and different levels of disability.

Care is intended to be a new process where individuals can be supported and served by existing programs. It is intended to be compassionate upstream diversion and to prevent more restrictive conservatorships and incarceration. Both are also costly things to do that institutionalize people often. Implementation is two phases, as we've mentioned, with cohort one counties implementing in October of this year and cohort two counties in December of 2024.

The Los Angeles County has signaled that they will be accelerating their timeline and implementing by the end of December 2023. We have been very encouraged by the dedication to these timelines that our county partners have made. We want to support them to be successful in addressing these urgent needs and in particular the urgent needs of people who are most often unhoused and not receiving any kind of mental health treatment.

So a couple of status highlights in particular, in November of last year, our Department of Healthcare Services released both $26 million to our cohort one counties to support startup and then another 31 million to all counties to support their planning and implementation for care. Last week, as was mentioned, the Department of Healthcare Services released nearly 1 billion of the 1.5 billion that was made available to county behavioral health.

To apply for behavioral health bridge housing care, participants are prioritized, but that's not the only use for the funds agency, the Department of Healthcare Services and the Judicial Council meet regularly to coordinate all things related to both policy issues and training and technical assistance for care. We host opportunities to engage with cohort one counties to listen to their challenges and to help them problem solve. Our next meeting is in a couple of weeks. We have also launched our Care Act working group.

We met on February 14. That particular group, as Ms. Rivets mentioned from CPEN, consists of equity advocates, disability rights, legal aid peers, family members, behavioral health providers, housing advocates, hospitals and other subject matter experts. The point of the working group is to bring people who are working in the field with strong expertise to the table to help us discuss implementation issues as they are happening. I actually think that that working group is one of my most promising aspects of the Care Act.

Both DHCs and JCC are diligently working on their training and technical assistance strategies, and the JCC is working on rules and forms. That's procedure so that the courts know how to implement similar or being able to touch on some of the questions that came to the previous panel. I do want folks to know that there is an independent evaluation of care. The initial report comes to the Legislature in three years, with a final report in two years following that.

We intend and have talked very publicly about how we will use the independent evaluation to identify racial, ethnic and other demographic disparities. We will also assess a causal inference and descriptive analysis on the impact of care on our overarching disparity reduction efforts.

As part of our behavioral health initiatives, DHCS is also developing an annual care report, and it'll include health equity assessment to inform disparity reduction efforts, and with that, I'm going to pass it to my colleague, Melissa Stafford Jones, who is the Director of the children and youth Behavioral Health Initiative. Thank you.

Good afternoon. Chair,Wood, Chair, Arambula and members of the committees. As Stephanie said, I'm Melissa Stafford Jones, Director of the Children and Youth Behavioral Health Initiative at the California Health and Human Services Agency. As you know, the CYBHI is a five year, $4.7 billion initiative working to reimagine and transform the system supporting behavioral health and well being for children and youth into a more coordinated, equitable, youth centered and prevention and early intervention oriented set of services and supports.

CYBHI is a core element of the governor's master plan for Kids'mental Health, which really takes an all of the above cross sector systems overhaul approach to improving children's well being and to accessing the supports and services that they need, including meeting children and families where they are, which, as we know, in addition to home. Another key place is in education settings is in schools and partnership between those sectors is critical to these efforts.

As we heard earlier this afternoon, the need for our youth in terms of mental health continues to be significant and urgent with children and youth continuing to struggle. As has been noted, it has been the case over the last decade with increasing mental health challenges. And I know we all saw the CDC data that came out recently from 2021 showing that both girls and our LGBTQ plus youth are particularly continuing to struggle with increased sadness, increased levels of violence and increased risk of suicide.

The legislature's and governor's recent budget investments and actions underscore the commitment to solutions we are working across multiple fronts, as was noted earlier today, the importance of working on Shorter term efforts, midterm efforts and long term focused efforts to improve youth behavioral health. I often refer to the CYBHI as the and initiative, not the or initiative because, as deputy secretary Welch noted, we need to work across that entire spectrum and different parts of the initiative are doing that.

So, for example, in terms of some of the shorter term work that is happening, the California Department of Public Health is implementing a targeted youth suicide prevention campaign and work is already underway in terms of getting in place the partners to be able to launch that campaign. We've established a mental health resources hub on the California Health and Human Services Agency website.

You'll hear more from my colleagues at the Department of Healthcare Services, but there are grant funds already being awarded in order to scale evidence based and community defined evidence practices this fiscal year. So these are all work that is underway at different time horizons, as was noted earlier.

I also want to share that we have heard loud and clear from our partners over the last 18 months of the work of the children and youth Behavioral Health initiative that simply doing more of how systems operate today, how they operate now, is not good enough. It's not sufficient and will not allow us to build the systems and services youth and families need for mental health and well being.

We have particularly heard this from youth themselves, who have challenged us to redefine treatment to include not only clinical services, but things like arts activities, mindfulness, access to safe parks and green space, access to peer services, relationships with caring adults. Youth have highlighted the importance of something discussed earlier, which is culture and culturally relevant services. As healing youth have told us that they need systems to stop waiting until they are in crisis to support them.

They want support earlier and that they want a behavioral health workforce that looks like them, speaks their language, comes from their community and understands their lived experience. They also have asked youth and families in particular have asked that the harm that systems have caused to the mental health and well being of youth, families and communities, including the specific communities mentioned.

Our Native American and black communities must be recognized in order for them to trust that all the work we are doing to improve systems will truly support them.

What youth and families want and need to improve behavioral health is at the center and guiding the work of the children and Youth Behavioral Health Initiative, which, as you can see from this slide, the work of the CybHI really falls into four major categories, workforce building up the infrastructure we need of these cross sector systems that we call the ecosystem, thinking about coverage and all payer financing and public awareness and reducing stigma.

All of the efforts that you see on this slide are led by and coordinated across multiple departments within CalHHs. You'll be hearing in a moment from the Department of Healthcare Services, who I know will cover a number of topics, including some of the critical work they are doing under the Children and Youth Behavioral Health Initiative, including the development of a new virtual services platform, scaling of evidence based practices, increasing brick and mortar capacity, and multiple efforts to support school linked behavioral health supports and services.

CYBHI over the last 18 months has been progressing with research, planning, design, partner and stakeholder engagement, and now actively moving across many of these components that you see here into the implementation phase. And our recent progress is summarized in a progress report that I think we shared a link with all too, that we published at the beginning of this year. A few examples of that work which is really deeply grounded in equity.

We actually have an equity working group made up of folks from across the state, from multiple disciplines, including people with lived experience, who is helping to create a framework for equity that we are applying to the work of the children and youth behavioral health initiative, as well as incorporating into the work of our evaluation. We have selected Mathematica as our evaluation partner.

We are working with them to finalize our outcomes goals with a very strong focus on equity, but meanwhile we are implementing critical aspects of the initiative.

So, for example, in the workforce arenas you can see here, there are significant investments and as the LAO report noted in workforce within the CyBHI, $37.6 million in grants were provided to support the training of 703 psychiatric mental health nurse practitioners and 45 psychiatry residents and fellows over $10 million was distributed through scholarship and loan repayment programs to increase the number of behavioral health professionals working in shortage areas. As you heard deputy secretary Welch mention, HKI also launched a social work education capacity expansion program.

HKI also launched the new Health Professions Pathway program, awarding $40,000,000.23 of which is through the CYBHI, and grants to 20 organizations that will support nearly 32,000 students in exploring behavioral health careers. Also work in terms of peer to peer services, which we have heard loud and clear from youth is a huge priority for them, and the peer personnel training and placement program has awarded $9.5 million in CYBHI funds that are projected to train and place over 1700 new peer personnel specialists into the behavioral health system.

There's also a new trauma informed training for educators being developed by the Office of the California Surgeon General that will begin beta testing this spring and be available to all educators free and publicly later this summer. There are also campaigns for addressing stigma reduction, raising awareness about aces and toxic stress, and, as I mentioned, focus on targeted youth suicide prevention that are under development, including funds that will be going to trusted community based partners who are working in the most impacted communities.

We have heard directly from youth that stigma, including and particularly with families and communities, remains a barrier to accessing the supports and services that they need, and that work on stigma and awareness is critical to the work we are doing at the same time to increase access to services so that those connections can be made. So thank you for the opportunity to present today and look forward to answering any questions you may have about the work of the Children and Youth Behavioral Health Initiative.

Good afternoon. Jacey Cooper, state Medicaid director and chief deputy director of the Department of Health Care Services. So today DHCs is going to focus our comments on the behavioral health continuum infrastructure program as well as CalAIM. But of course, I will be available for any other questions. There were as many things on the first panel that came up. Outside of that, we'll make ourselves available, of course, of anything on the children and youth.

I would just two notes on the infrastructure dollars, $2.2 billion really focused on closing those critical gaps. The Department of Healthcare Services released in November of 2021 an access assessment. It clearly showed that we have gaps of both mental health and substance use facilities and services across the entire State of California. Those dollars are so critical to fill those gaps so people can get access to the services that we're talking about today.

So probably one of the most important pieces of those one time funds that was mentioned earlier by the LAO to really help the future needs of individuals across the State of California and then CalAIM. Of course, everyone knows that a multi year initiative really focused on many things.

There are a number of behavioral health initiatives that Tyler Sadwith will walk through for you today, but it touches anything from allowing for reimbursement prior to a diagnosis, simple barriers that were in place prior to CalAIM being put there, to payment reform, to documentation reform. These initiatives just went live in 2022 and we know it will take time to fully implement across and then there are some coming up, so I will now turn it over to Tyler.

He's our deputy director of behavioral health services and he's going to walk through some of our current status on these items.

Great. Thank you Jacey and hello and good afternoon chairs and members of the committees, it is an honor to participate in this joint informational hearing. First, I'll provide an update on the Behavioral Health Continuum Infrastructure Program, or BHCIP, for short. To date, DHCS has awarded $1.1 billion through four rounds of grant funding under BHCIP. Each round of grant funding is designed to target key gaps in the state's behavioral health facility infrastructure.

All BHCIP resources are primarily designed to ensure care can be provided in the least restrictive setting by creating a wide range of services and supports. So just to quickly walk through those four rounds, in round one, DHCs awarded more than $163,000,000 to 49 county, city and tribal entities, which has led to 245 new or enhanced mobile crisis response teams throughout California. In round two, DHCs awarded $7.2 million to support 32 county and 18 tribal entities with planning grants.

In round three, the department awarded $518,000,000 to 43 launch ready projects to build or expand behavioral healthcare facilities. These funds will support 36 new inpatient and residential facilities to offer 1176 new treatment beds, as well as 40 outpatient facilities, which will offer over 120,000 new annual treatment slots. In round four, the Department awarded $480,000,000 in grant funding to 54 projects focused specifically on facilities that provide care for children and youth.

These funds will support 29 new inpatient and residential facilities to offer 498 new treatment beds, as well as 48 outpatient facilities to offer over 74,000 new annual treatment slots. Both of those rounds that I mentioned include tribal entities as grant awardees. This spring, the department will announce grant funding for round five, which will address significant gaps in the crisis care continuum with consideration in funding priority for those entities that provide immediate crisis services to individuals in need. Round five consists of $480,000,000 in grant funding.

The 6th and final round of BHCIP funding focused on unmet needs, as the first panel described, is currently in the planning phase with an anticipated release in fiscal year 24-25 and fiscal year 25-26 as proposed in the Governor's Budget. We are pleased with the level of interest to participate in BCHIP. However, we have been seriously challenged with difficult decisions in making funding awards.

The statewide demands for behavioral health continuum infrastructure and infrastructure expansion, as described in the Behavioral Health Needs assessment report that we published last year and, as demonstrated by the volume of requests under the BHCIP program, simply exceed the available funding authorized under BHCIP. Now, I'd like to provide just a brief overview of CalAIM behavioral health policy initiatives that the Department is implementing to improve the efficiency, cost effectiveness, and quality of behavioral health care in the Medi-Cal program.

DHCs Medi-Cal managed care plans county behavioral health agencies and behavioral health providers are launching an array of delivery system improvements. These include updates to access criteria for mental health and substance use disorder services, including, through a trauma-informed approach for children and youth, to eliminate unnecessary barriers and ensure members can access the care that they need.

These include a new no wrong door policy that is designed to ensure members can receive covered services immediately, regardless of the delivery system or the door that they walk through in and initially seek care. Under no wrong door, members can receive services during the assessment process even before a diagnosis is established. Standardized screening and transition tools are being implemented across the entire state for Medi-Cal youth and for Medi-Cal adults seeking mental health care for the first time.

This means that Medi-Cal managed care plans and county mental health plans will use the same standard set of tools to make effective and timely referrals to the appropriate delivery system for care, regardless of which county a member lives in or which managed care plan they're enrolled in.

The department is implementing reforms to behavioral health documentation to streamline clinical documentation requirements and compliance requirements, with the goal of improving member experience, reducing administrative burden, and allowing providers to focus their time and energy on providing direct patient care. And finally, DHCS recently released its concept paper to implement outlining the approach to implement behavioral health administrative integration, which is a multiyear initiative that builds on all of these CalAIM reforms.

By 2027, medical's specialty mental health and substance use disorder programs will be consolidated into a single county based behavioral health program operated under a single county integrated contract with the state. I'd like to now focus the remaining comments on a few calam initiatives that are yet to come under behavioral health payment reform. DHCs will change the way behavioral health care services are reimbursed to counties. This consists of eliminating the current cost based methodology reimbursement model and adopting a fee schedule.

This will go into effect on July 1st, 2023. The new payment rate based fee schedule will create financial flexibilities for counties. It will support them to innovate in ways that improve quality and access to behavioral health care, including potentially through value based purchasing and shared savings arrangements, including with Medi-Cal managed care plans and contracted behavioral health providers. The proposed California Behavioral health community based continuum demonstration waiver seeks to improve care for adults living with serious mental illness and children with serious emotional disturbance.

This demonstration has multiple components, all of which are designed to expand access to community based behavioral health care. It will also allow California to draw down federal matching funds in some facilities called institutions for mental diseases. This will allow our Medicaid dollars to go further. DHCs intends to apply for this waiver in 2023 and begin a phased implementation in 2024.

Through the waiver, the department aims to expand the continuum of community based behavioral health care available to Medi-cal members, improve the quality of care in inpatient and residential settings strengthen transitions from these settings into the community for step down and continued care enhance county accountability and oversight and support the implementation of new benefits through incentive programs, robust technical assistance, and practice transformation supports for counties and for providers.

Some examples of new services that will be covered under the waiver include an expansion of evidence based therapies for children and youth on a statewide basis expansion of evidence based services such as assertive community treatment and supported employment services that counties can cover on an opt in basis a cross sector incentive pool for Medi-Cal managed care plans county child welfare agencies, and county mental health plans to drive improved outcomes for child welfare involved youth intensive outreach and engagement provided by culturally competent community health workers rent and temporary housing specific to populations with mental health and substance use disorder and housing needs and finally, an opportunity for counties to cover short term inpatient and residential mental health care, including in facilities that are IMDs and not eligible for Medi-Cal today.

Finally, in January of this year, California received a federal approval for first in the nation coverage expansion under our justice involved initiative. This will allow the department to cover a targeted set of Medi-Cal services for high risk individuals who are in state prisons, county jails, and youth correctional facilities who are preparing to reenter the community. These services will be covered during that 90 day period during the reentry process.

These 90 day services is just one component of a multifaceted initiative to improve access and to coordinate behavioral health care for individuals returning to the community from a justice setting. These services include coverage for all medications, including psychotropic medications for mental health care, medications for addiction treatment and counseling.

The department is working with the prison system, county jails, youth correctional facilities, county behavioral health agencies, and Medi-Cal managed care plans to implement policies for warm handoffs and linkages to community based behavioral health care to ensure people reentering the community receive continued care. This initiative will be implemented on a phased approach beginning April 2024, and we're actively engaging stakeholders.

So these are just a few of the mental health initiatives that the department is implementing me, including some of those that have been mentioned by other panelists. I'll stop here, and we're happy to address any questions you may have.

Thank you. Chair Wood, Chair Arambula and members of the committees, appreciate the chance to join you today. My name is Toby Ewing, I'm the Executive Director of the state's Mental Health Commission. I want to give you just a quick overview of the portfolio that we have consistent with the goal of the hearing. Talk to you about where we are in this work, some of the challenges we see and how we're moving forward.

We are partnering with the Department of Healthcare Services and some of the other agencies in terms of rolling out key components of CYBHI, and so I'm not intending to cover that piece. The commission is an independent state agency. We're advisory to the governor and the legislature.

Some of you we've worked with for many years and understand that we have a range of functions, many of which were outlined in the original initiative passed by the voters, that is the Mental Health Services Act, and others have been adopted over time through legislation or specific budget direction. We were formed as laid out so nicely in the information packet through the passage of the Mental Health Services Act, which is one of several primary sources of funding for mental health care in California.

It's often thought of as sort of the glue that sticks other pieces together, and there's a couple of pieces that I just want to highlight. In the Mental Health Services Act, one is mandatory set aside for prevention and early intervention, as Mr. Sadwith has pointed out that the state is moving through modifications to our Medi Cal package to be able to do more upstream work with federal funding with Medicaid dollars.

Mental Health Services Act also sets that aside, and there's also a significant set aside for innovation, which we're very excited about because it represents this opportunity to recognize that we're doing some things that are not working as effectively as we need to and that we have opportunities to try some new things. The commission works in a range of areas through direction from the budget process. We provide grants, nothing near the level of funding.

I feel like I've got one candle on my birthday cake after the hundred or so candles were just announced. But we're working in some key areas that are very significant in terms of California's continuum of care. Just want to highlight a few of these. We have an initiative focused on early psychosis, one of the biggest challenges we see, and I think this had come up in some of the comments earlier.

It can be very difficult to access specialty care, particularly for people who are in these early stages of psychosis. And we know from federal research and research around the world that if we intervene early as in any other area of healthcare, we get a better outcome. The United Kingdom has established a goal of two weeks for getting someone into effective early psychosis programming within the first onset of their psychotic episode. The average duration of untreated psychosis in the United States is about 18 months.

In conversations with our partners at UCSF, Stanford, and UC Davis, we estimate that the capacity today to deliver highly effective early psychosis care is about 10% of what it would be if we were able to respond to the onset of psychosis across California's population in a given year. We see those kinds of challenges translating into high levels of need around homelessness, hospital involvement, including state hospital involvement and incarceration.

So we're working with partners to really roll out and scale access to improved early psychosis care. In partnership with county behavioral health departments, really led by them, we're rolling out what we call allCove Youth Drop-In. It's a globally recognized model in half a dozen countries around the world that is integrated care for youth, that is primary physical health care and basic mental health care, including access to psychiatry where necessary, with a very strong referral model. It's a phenomenal program.

We have two sites open in California and we're working with partners to open up additional sites. We are working to roll out an emergency psychiatric assessment, treatment and healing strategy as partnerships with hospitals designed to reduce the need for psych beds where that's possible through stronger partnerships between county behavioral health and hospitals. We're working with the Department of Aging to roll out some evidence based models that are targeting older adults through the Mental Health Wellness Act.

We're providing funding to incentivize county and community partners to opt in and support some of these new innovative approaches. And I mentioned we're partnering with the department around the evidence based practice and community defined evidence practices. I'm going to hold off on the Mental Health Student Services Act because I want to provide a little more detail on that at the end of my comments. In addition to grant financing, we review and approve county innovation spending.

There's a set aside, it's roughly 100 to 150 or in some years, $200 million for innovation. We've been able to actually help facilitate multicounty learning collaboratives designed to reduce justice involvement, to strengthen full service partnerships to enhance community engagement to address disparities. All of these are done through robust community engagement at the county level.

And what the commission has been able to do is use small amounts of state money to facilitate multi county investments that actually scale and learn consistent with what is happening within CYBHI but over a longer term, we hope, because it's really leveraging the ongoing resources that the Mental Health Services Act creates. We have a data analysis and transparency role, as reflected in our title of oversight and accountability. It's very challenging to work with data in this state because of how our systems have historically been designed.

But our goal is really pretty simple, which is to provide policymakers and the public with clear and reliable access to information on finances, services and outcomes. And I'm happy to some of you we've worked with over the years, but happy to answer any questions about that work. We take on policy projects as part of our advisory role to the governor and the legislature. And these are sometimes multi year projects where we dig in on a topic, we understand what's working, what's not working, and identify solutions.

We have three projects that are underway at the moment. The commission last week adopted a report on mental health in the workplace, which we will deliver to your offices and to the committees relatively quickly. It really focuses on actually leveraging the workplace as an opportunity to support resiliency and to improve access to care.

So while the state has made dramatic investments in school mental health, recognizing that schools are where children are, and if we want to be successful with children, we have to meet them where they are. For a significant percentage of adults, the workplace is a source of stress, and it's a source of hope and healing and resiliency. And so we've worked with private sector partners to really understand how we can leverage the workplace as an opportunity.

The World Health Organization and the US surgeon General has done similar work, and so we look forward to sharing that with you. We are about to review, and I hope, approve, a report on prevention and early intervention that really shapes opportunities to think more expansively about prevention and what that means in the mental health space, our shared understanding, our models around prevention and overall health care often are much more robust and better understood.

So this work is really about bringing some consistency to how we think about prevention. And then lastly, we have a project that is really just getting started on the impacts of firearm violence, looking at the intersection of firearm violence and mental health, both in terms of drivers of violence, as well as being able to improve how we respond to the trauma that is associated with firearm violence across the state. We welcome the opportunity to share this with you over time.

We work to elevate the voice of the community through the budget allocations that you've provided. And we do a lot of work to listen and actually engage, particularly at the moment, around elevating the voices of youth and young people consistent with the work that you've heard about. I'll end with some little more detail on the Mental Health Student Services Act. Because it's a signature initiative of the legislature and the governor. It's consistent with what's happening and a component of what's happening in CYBHI.

We currently have somewhere in the range of $300 million in grant funding allocated to support school mental health. The commission's goals in releasing these grants really were pretty simple to create a fiscal incentive to strengthen the ability of our county behavioral health departments and our local education agencies to work together.

So many of the rules make it hard to work together in terms of how we collect data, the definitions we have, how we finance, and so mental Health Student Services act grants were really about building partnerships across county mental health departments and local education agencies. We are in 57 of the 58 counties. We have one county that just felt they couldn't do it because of staff and workforce and all of the other funds that were coming down.

So we're almost everywhere in the State of California, but we're not quite. This funding has really been used to do a handful of essential things, cross agency coordination, supporting training, providing clinical care. Many of our local partners are really investing in wellness centers that are youth driven. When you talk to young people, oftentimes they'll say it's not as important to have clinical care in the school.

What's important to have is respect in the school, and they need safe space to actually decompress and to feel okay about who they are in that space. There are communities that are making substantive investments in suicide prevention, youth, and community empowerment. We're seeing these partnerships expanding beyond the original domains of the legislation to include probation departments, social service agencies, and others, including migrant student services.

And we think that's particularly important because of the kinds of challenges that those students and families in particular face because of the nature of economic instability, and being migrant in California makes it harder to have that foundation of connectedness and support. We're building out a technical assistance strategy consistent with direction from the legislature and the governor that's really peer to peer focused. One of our challenges that I think you'll hear from all of us is that so much of this money is short term.

It's one time funds, and so we're really working with our local partners to build out a TA strategy that is peer to peer focused so that communities can learn from each other in ways that can be sustained well after short term funding is gone. We're really trying to think strategically about the long term approach to both learning and scaling.

Over time, we're building out an evaluation and data reporting strategy that is designed to be responsive to local needs while also asking state level questions and giving answers that will be relevant to policy making as well as programming decisions across the state. As I mentioned earlier, that's actually more difficult to do than it sounds because of the complexity of a state this size and the diversity around our geography, our demography, and the nature of the kinds of services that are being offered across the state.

This is not a one size fits all approach. There's tremendous variation. Clearly, many of the challenges that you have heard about and will continue to hear about face all of this work are workforce sustainable financing, coordination of services and payments. Because these are systems that haven't been designed over time to grow together. And so beginning to learn together and figuring it out is difficult. And how disparate local governments can best work together in systems that often were not designed.

The geography of counties and school districts don't match in many cases, or they're so expansive. I'm thinking, Dr. Wood, of some of your district. Right. It can be very difficult. That was very fast. I appreciate the opportunity to cover so much ground. What I'm most excited about is to answer any questions you might have. Thank you again for the chance to be here.

Thank you. I will bring it up to the dais to see if any members have questions. I will begin with Dr. Wood and then Dr. Jackson.

Great. Thank you. Great panel. A lot of information here. Really appreciate that. Just a couple of observations before I get into my questions. Mental illness is obviously long term, but apparently our funding is not. It's a huge challenge for us going forward. I heard from the Department of Healthcare Services we have a huge need. It's oversubscribed, which means we don't have enough resources, which means there's a lot of people that aren't going to be able to get help.

And now we're looking at potential delays in how funding is put out because of our budget challenges. These are just observations. It's not an indictment by any means, but it's a challenge for us. So you all obviously have an ambitious, huge workload here. Part of what I want to ask is then I'll have a final question here. But we're implementing a lot of programs. We're doing that. The implementation of the programs cannot be the measures of success.

So what are the measures of success going to be? Have those systems been designed because the data is going to be critical for us to be able to decide with the billions of dollars we are investing here. Have we made progress? So how are we going to measure that? Because it isn't going to be participation. It's not the infrastructure, it's the result. So how are we going to measure that?

I'll start, and then Tyler may be able to add some things. I just want to point out a few. While there are a lot of clear one time investments, there are a number of things that we've been talking about that are also long term, including the new waiver that Tyler quickly went over. It adds significant number of pieces, and it also draws down on federal funds in ways we are not drawing down federal funds. So maximizing those federal funds is going to be important.

And those are all long term initiatives. They are not short term. So I just wanted to point that out because we are trying to maximize both. We do need some short term kind of infrastructure, capacity building workforce dollars in the system, because there's clear gaps. But we're trying to tie those and everything that we're funding with short term dollars to a long term funding source, whether that is the waiver or the psychosis work being done.

That's being built also into the Children and Youth Behavioral Health Initiative. It's also been built into the waiver to make sure that there is a sustainable funding source for that. And we're drawing down federal funds, whereas we're not always maximizing that to the degree today, which is always important for us to do. So I just want to make sure that we are looking at it.

All of these one time investments are tied to long term sustainable funding resources, which is really important for us to understand because right now we're really focused on getting grants out, which is really important, but it is to tie to that longer infrastructure. So I wanted to tie on to that. It also talks about. So when we're looking at what does this mean in regards to outcomes, we will be looking at a number of things at the Department of Healthcare Services.

So we are implementing a different part of CalAIM, but touches all of our delivery systems is our population health management piece. The reason why I raised that is it is going to specifically be looking at utilization and then outcomes. So we'll be looking at the utilization of services, including behavioral health services. It will be looking at both the non specialty mental health being commented on earlier. What are those trends of prevalence and or utilization?

Are they increasing and then breaking that down by race, ethnicity, language, et cetera. We'll also be looking at not just utilization and that would include the specialty mental health and sud side as well. We'll also be looking at outcomes. So we released our comprehensive quality strategy last year as well. And one of the core components of that is increasing access to behavioral health services and integrated behavioral health systems.

So one of the measures that we are looking at specifically there is also how we're doing across the systems where someone has to touch both sides. We have our managed care side, we have our behavioral health side, and there is a quality measure around looking at if someone goes into an emergency room with a mental health or substance use disorder issue, are they being tied timely back to services? And we will be reporting on that measure publicly.

I think those are the types of paces where we're looking at both utilization and quality outcomes to see, are these things moving the needle where we want them to look at those trends over time? I think the hard part data sometimes can take a while to show up. We have a whole year of claims lag. Those things will take time for us to get those reports up, but we're very committed to looking at those pieces. And Tyler, you may want to add any additional pieces.

Thanks, Jacey. And thank you, Chairwood. I think it's an excellent question. I don't have much to add. I think just to sort of further layer into how Jacey framed it I think. You know, the goal of the Behavioral Health Continuum Infrastructure Program really is to support the physical expansion of behavioral health facilities. So obviously looking at metrics there, but that's sort of an investment in the ability for providers to deliver care and people to get the services they need. So how do we know we're being effective there?

I think through all of the CalAIM Behavioral Health Policy initiatives that I mentioned, we're looking at different performance monitoring approaches that are specific to each policy, including qualitative and quantitative data, surveys with our county partners, surveys with the plan, surveys with consumers, looking at some sort of ad hoc data analytics. Doing some analysis of our claims data to see did these initiatives result in an uptake or increased penetration rates for different populations, as well as, of course, tying it to the more standard quality performance systems that we have.

The comprehensive clinical quality strategy, which has new behavioral health care measures specifically at the level of county mental health plan in the DMCODS counties and the California Behavioral health community based care demonstration, as Jacey mentioned, is a five year waiver. Our federal partners will require an independent evaluation. They will require quarterly and annual reporting on a standard set of monitoring metrics. Those are process metrics. They're also sort of endorsed quality measures. And I think that will really be a great way to assess the performance of all these initiatives sort of being rolled into that waiver.

Dr. Wood, could I just add, I think in listening to even our responses, as you can tell, each one of these behavioral health initiatives has a very robust data collection evaluation component of it. And I think what I'm hearing from you is, what can we do to make sure that these are all working in concert, that we have a bigger picture about are we making a difference in people's lives?

And I can tell you that we have started to have some internal discussions about how do we take probably what I would characterize as anywhere between 8 and 10 major behavioral health initiatives that we've been working on in the last two years and understand how they're all collectively adding to the same outcomes. How are they all reducing stigma? How are they all increasing access?

And so we have internally started to have some of those discussions, and you can correct me if I'm wrong in what you were getting at, but I do think that we could certainly go back and think about ways in which we can provide that information. I can tell you, I talk about these initiatives a lot to a lot of different groups, and it's really, frankly, overwhelming to understand all of them and how they work in concert. So please know that we are thinking about that and also would appreciate any of your other suggestions on how we could provide you meaningful information that's digestible both in the short and long term.

You. Thank you for that, and thank you for the answers. And I guess, really, the point that I'm getting at is the next question. And as I look at the CHCF study, they talk about the prevalence of serious mental illness with adults, serious emotional disturbances with children. Rates of illnesses for adults are highest in northern and Sierra and San Joaquin Valley regions, and they have been since 2009. They have essentially remained unchanged. So we're doing a lot here. It's now 14 years.

What are we doing to help in these regions that have the highest rates? Because clearly what we've been doing for the last 14 years isn't working. My question becomes, how much BChip money is going to some of these smaller regions? Are they getting, and this should surprise no one. Are they getting technical assistance in some of these smaller counties? Because you talked about one county that can't work with you because they're overwhelmed with what's coming in now. So what are we doing to focus on, or how do we, are we getting the technical assistance? Are we getting a proportional share of resources to the areas that have the highest rates.

So when it comes to BChip, we did do an allocation across the state to ensure that we were preserving dollars for certain parts of the state, for example, the rural north. I don't have those numbers in front of us, but we do have a breakdown of how we're looking at that. And we did that specifically because we knew we wanted to make sure dollars were being spread to certain areas. So I do think we're taking that under consideration.

I think you raise a really good point, though, I'll be honest. We're seeing that not just in behavioral health, we're seeing it in other parts where the Central Valley or rural north have larger disparities with the new HPI index that came out during COVID I think is actually quite remarkable. It is plotting to those exact same areas. And as we're seeing the Aces scores that are being released and an amazing report that came up, it is plotting to those exact same areas.

So those communities are greatly impacted in a number of ways, including how they're accessing health and behavioral health services. And we are thinking through a number of mechanisms that we can do. Right now we're focused on the managed care side and making sure that we are thinking about how do we even pay our managed care plans to make sure in those areas we are paying a higher rate for higher acuity, for more complexity. And to start addressing those pieces, we probably need to do more work when it comes to behavioral health, though, to be honest with you, one place that we are doing it, which is different with how we're doing payment reform, it is a different rate for every single county. There are different factors that come into play in those counties. So for example, the rural north where they have maybe less utilization, but they still have a fixed structure. We need to make sure that we're adjusting for types of things like that. But I just want to acknowledge your comment.

I think there are some things being done, but I think there's probably more we can do in regards to acknowledging certain parts of the state that have really clear holes. And now in the last two years, we have more data than we've ever seen before in regards to hotspotting, and we should be able to do more targeting in regards to that.

There's also been pretty extensive technical assistance done through the various pieces, thousands and thousands of hours of technical assistance, even on documentation reform and other pieces. But still there is a lot hitting the system because of the crisis and the need. But just wanted to give you a few examples of ways we're doing that and others can add.

I appreciate know I think like ACES scores, for example, Humboldt County, twice the state average, twice the state mean I can give you statistic after statistic. We're not talking about substance abuse here, but I've got three counties that are off the charts there, which leads to other bad outcomes as well. The plea is always going to be technical assistance for smaller counties that are already overwhelmed, and the data shows that the rates are higher in those areas. It's just like, what are we going to do?

I don't want five years from now to say, have the same report that says we've done all of this, and yet the same regions that have the last 14 years anyway, at least, are still the highest prevalence anyway. Thank you.

Dr. Jackson.

Thank you very much, Mr. Chair, and thank you all for being here. I have a series of questions, but just know that my voice tends to modulate a lot. My hands start waving sometimes. Doesn't mean I'm mad. It just means I get excited. So I'm glad there's no colleagues here, so they're all safe. Ms. Welch, is California in a mental health crisis?

I would say that we have a challenge across the continuum. So again, I really do try to take every opportunity to lift up the importance of investing, preventing crisis. So, to answer your question, yes, and we need to focus across the entire continuum.

Thank you. Mr. Ewing, is California in a mental health crisis?

I think undeniably. But I'd also recognize that California has made a level of investments, most recently through CYBHI, particularly focusing on children. And because of the Mental Health Services Act, it has access to resources and strategies that are unrivaled across the country. We hear from states all the time, people in other states who are commenting that they don't have the opportunities that we have.

So while our challenges are profound, as evidenced by your question and the comments that you heard in the earlier panel, we also have opportunities that are richer and more meaningful than other states. And some of it is because of the complexity of this state. We have academic research institutes that are unrivaled. We have population diversity and tools for community engagement that are unrivaled. We have an incredible wealth of community behavioral health partners across 58 counties and thousands of community based organizations.

So, yes, we're in a crisis, but we're also really well poised to respond to that. If we can get the kind of alignment between these programs and the resources that have recently been made available and the community needs that are out there constantly looking through the lens of disparities that is about race and ethnicity, but it's also geography and it's also age, language, status. So hope that answers the question.

Thank you very much. I am mindful that, number one, we're doing great strides and we're looking at the workforce. As someone who has a master's and doctorate in social work, of course, I'm loving the expenditures there as we're beginning to build out the system we should have had long ago, no doubt about that. And we're making sure we're taking the long term. From a social work perspective, we are always trained.

The first thing you do is get people out of crisis mode and stabilize the population right, out of crisis, stabilize. And similar to what we did with COVID-19, similar to we did with homelessness, the State of California, I think the Governor threw his kitchen sink at it. He might even threw his dog at it. To making sure that we did what we had to do to respond to the crisis.

My concern is I don't see that same energy on the mental health front to get people out of crisis and to stabilize the population. A few things that I would just really urge us to really look at. I keep saying, talking about same day billing, Ms. Cooper, because we know we have a workforce shortage, but there are hospitals and clinics right now who have the appropriate professionals.

But because the system says we should need to do it a certain way, we're not meeting the current needs of what people might need when they're already there. One thing we're always taught in social workers is once you got them once, you might never get them again. So give everything you can do everything you can while you have them, because the chances of you having them again are very slim.

So it is my hope that the least we can do, the least we can do is unlock the barriers like we did with the other crises. We destroyed silos. We said, we don't care whose jurisdiction this is, we don't care whose pot of money this is, right? We're going to meet the needs of the population and then the system is just going to have to respond to it, whether we've done it before or not. Secondly, or thirdly or fourthly, Ms. Stafford Jones, you're doing God's work.

My first programs as a CEO of a nonprofit that I created 10 years ago was youth mentoring programs. And we did universal a screenings. On average, our young people had a three. If you just looked at African Americans, it was already an average of a four. My concern is this, the US surgeon General says that particularly with young people nationally, mental health is a crisis, and he prescribed many things to be done.

My concern is that many of the things that he's prescribed, his first five weren't on there. We're not doing universal screening. Our first surgeon General of California said we should have been doing universal screening, whether it's a PHQ, whether it's ACE screenings. Either way, we can catch things before they become a crisis. And we are not focusing on the best ways of dealing with this crisis right now. My concern is that because we focused on training teachers, we're treating them like we treat law enforcement.

We just throw a lot of stuff at them and make them be the ones to do things. There's a profession for this, to be able to do the screenings and create the assessments and create the interventions appropriately to be able to do this. This is not in the plan. We're not requiring schools to making sure they have mental health professionals on campus. We're hoping that they do. We might provide them incentives. Right. But at this time, we know that we need them on campus right now.

And even though the telephone and online intervention in terms of mental health, great. Especially great for introverts and folks that might not have a hard time trusting caring adults by us not having a mental health professional on campus where they can build relationships and work with them, to preventing mental health from getting even worse, which will save us money in the long term. Right. Sometimes I think we need to go back to basics when it comes to the personal relationship.

And then lastly, what I learned from dealing with my own brother is when he was willing to, I would say the day before, about one or 02:00 at night, and he agreed for me to take him to mental health urgent care facility. By the way, I lived in Moreno Valley, the largest city in my district, over 200,000 people in that city. And there wasn't a mental health urgent care facility. Even though there was a county hospital in the city, there wasn't a mental health urgent care.

So I had to take him outside of the city to take him somewhere. That morning, I woke him up and I said, you ready? And it began the battle already. I almost lost that war. It took me an hour or two to convince him not to change his mind again. And then when I got him there, he got a prescription, everything was fine. He began taking his medication. And this is not an exaggeration, he's 39 right now, and at 39, I met my brother for the first time.

I met my brother for the first time after 39 years. But then when it was time for him to renew his prescription, guess what? His prescription and diagnosis didn't make it into his medical records. And I could not get him to go back to the urgent care facility to get a prescription because he would have had to check himself right back into an overnight facility. So we've got to do something, which means he went back into psychosis, ended right up back in the streets.

We've got to fix that problem where if you enter into an urgent care facility or anywhere and you get a prescription, it should be put into their primary medical records, no matter where they go. Because all he had to do was click a button online in his prescriptions, and the problem would have been solved. But he wasn't willing to go back to the urgent care facility. These are everyday things we could be doing right now.

So these things are great, great investments, but we've got to get people out of crisis, and we've got to stabilize the population. And the things that I outline are just some things that we could be doing right now if we just break out of silos and we don't reinvent the will in many cases. So I am obviously willing and able to work with each and every one of you to make these things happen. As you can tell, I'm very passionate as some of my top priorities.

I'm grateful for the discussions that I've had with both chairs on these issues as well. But it's time for us to act like it's the crisis that it is, because I rarely hear us saying it's a crisis in everything that we do. So looking forward to working with all of you. Thank you very much, Mr. Chair.

Assemblymember, Villapudua, followed by Dr. Weber.

Thank you, Mr. Chair. First, thank you to both panels. You guys were great, great news to see what you guys are doing. It's scary, though, that this might just be, like, one time funding. That's what I was looking through when it came to the funding part, because, first of all, I'm from San Joaquin county. We were the third highest hit when it came to EDD, Imean it was all hands on deck for us.

And it still know, because we're not just dealing with EDD, we're dealing with crisis within our district that is very hard for us. Labor is an issue no different than my colleagues here. But I do got to agree with Mr. Ewing that I think that one size fits all is something that we need to really look at, because my district might be different than some of my colleagues and how they act and how they do things.

And I don't blame my county for maybe not getting the funding. I sometimes will hear folks going, God, it's so hard to apply for grants. It makes it so difficult. And sometimes I'm the one that is calling my county, hey, are you going after these funding? I don't want to be that person. It's not that I don't want to do my job.

I want to make sure that whatever the state is doing, that they are kind of doing the follow up to make sure that counties are, and I'm sure they are, but I want to make sure that we are, because if they're not and not going after those dollars, I want to make sure. I want to make sure that we are applying for those. I'm glad to hear about.

It was great to hear Dr. Weber mention about Medi Cal and reimbursement, because I used to come here for years and knock on those doors and be part of this cattle call through the hallways. Asking for that. And I'm still hearing this, and I'm glad to hear that today we're talking about reforming that. That's beautiful because we got to get the funding to folks that really want to do the job.

I mean, when you're hearing that cost us $1,200, $3,000, having no insurance, there are some doctors out there that want to do it, but sometimes they'll say, Mr. Villapudua, it's not that we don't want to do it sometimes. And it's not that it doesn't pencil out, it's the reimbursement, getting it back to us. They're six months, eight months before they receive their funding. I owned a business.

I know if I don't get paid and I have to pay my workers, at the end of the know, we're going to close those doors down. I've seen that done. I've seen our hospital struggle and barely make it. I know there's a hospital in Merced that one of my colleagues. Was it Merced or down the road? What is it? Montana? Madera. That closed down. That's scary because those are hospitals within our district that help our community.

In my district, I saw more and more of the clinics shut down, and I'm on the know, yelling and screaming at my county colleagues of, why are we doing that? Because those are important. Because not everybody has transportation. Not everybody can go to their doctor or the hospital. But when you have clinics within your district that you can walk to get to that have been there for years. We got to continue to support those. So mine was more just a comment.

Thank you for bringing up what was said and what was spoken here. But I hope that we're not talking about this 2, 3 years down the line, and I hope that the funding are going, and I hope that we continue to make sure that we're providing for those who are in need. What we learned during the pandemic really surfaced up. Right. But these issues have been happening for many years. This just brought it to the surface. It brought it to us. And I just want to thank you for what you guys are doing. And thank you, Mr. Chairman,

Thank you. Good afternoon. Thank you all so much for all of the information, for answering all of our questions, for listening to our concerns. I agree with you, Stephanie. When we talk about mental health, it is a continuum of care, and we need to make sure that we are looking at each and every part of it.

When I listen to some of where the funding is going, when we talk about building and expanding inpatient facilities and urgent cares, that's oftentimes when people have gotten to that point of a crisis. And the best time to really start treating mental illness is early on. And with the exception of a few, like schizophrenia, that just kind of show up.

Oftentimes when you're talking about depression, anxiety, even certain types of bipolar disorder, there are clinical signs that you can get to before it gets to the point where they need to be in the urgent care or in the emergency room or hospitalized. And so that's why I focus so much on the outpatient providers, because they can help prevent somebody. But also for someone who is hospitalized, when they're discharged, they need to continue their therapy, they need to continue their care. They need to go somewhere. So I will ask the same question that I asked the other panel. How many mental health providers do not take insurance?

I was asking about that when you asked that previous question, Dr. Weber, and I don't think we have that information. I can say that early on when we were thinking about the workforce crisis, I just want to acknowledge that we did listen to providers who were not necessarily part of our networks. And I would just share with you that one of the things that they said was one of the biggest deterrence was actually just how much time they had to put into all of the paperwork.

And so I do think that while it's not immediate, some of the work that our Department of Healthcare Services is doing to ensure that our clinicians are spending time being clinicians and not spending time processing paperwork in the long term is going to be incredibly valuable. And then I will also say, as somebody who's a social worker, the more that we can do to encourage people to see the value in public service, to give back to their communities, these are all values and themes that are really put into our workforce programs. And I feel very hopeful.

I know it's not immediate, but I feel very hopeful that at the end of this decade, when I'm starting to go into my twilight years, that my colleagues in my field look very different than me and that they're there to serve their communities. And so I know we have more work to do. I didn't specifically answer your question. I actually think it's a really good question. That's one of the reasons why we had that listening session probably about a year ago.

And I can take that back and see if they think through with my colleagues if there's any way we could maybe get closer to that number. But of course, we know about the payment piece. But really, what I heard from really people who are dedicated to this field is, let me have more time being a clinician, let me have more time with my clients. And so we're really trying to think creatively about how to support them in that. I don't know if you guys want to add anything.

Yeah, I'll start. And then Tyler can to her .1 of the biggest pieces that we heard when we went around the state and talked to people for CalAIM was the administrative burden tied to documentation, specifically in the Medi Cal program. And what we saw and uncovered is that there was just this layering of both federal requirements and state requirements that just compounded in a way that was untenable for people. And so we have kind of rolled out the first phase of documentation reform.

We did roundtables with providers and heard very quickly there are still some barriers or pieces where it's not flowing all the way down to the providers. Maybe there's some changes at the county, but not all the way down. So we are doing a second iteration, and Tyler can provide some more details around that because we do think it was critical piece of what we heard. Also some of the barriers under CalAIM where we weren't reimbursing.

And when we first heard it, when we went around the state, we said we're not doing what we weren't reimbursing for services prior to a diagnosis. That's silly, right? So that went live in January of this year to make sure that people can have that earlier intervention, that assessment, those screenings be reimbursed for those services and then being connected. We were creating barriers for co occurring diseases, someone with mental health and sud creating too many barriers for providers to do handoffs.

Those pieces have been removed, but these are early at this point and we need more time to get some of those pieces in. And I'll let Tyler speak to some of the additional kind of documentation pieces that we're looking to do, because we do think provider burden has been one of the barriers. And we are also comprehensively looking. Your question earlier on payment for behavioral health, specifically even in the non specialty mental health, it's actually one of our highest paid rates in MediCal right now.

We pay at about 95% of MediCare compared to primary care, is sitting lower than that. So we're looking at that and why we put even a 10% increase for primary care, because we know that's one of the entries into it. And that's why children and youth is focused on e consults for primary care doctors to tap into consultation for mental health services.

So we're trying to move in various ways in that space and really acknowledge your comments of something to continue to work at, especially that earlier intervention, that primary touch, because if we can intervene earlier, we know we can hopefully reduce some of that crisis that we're seeing across the State of California. And Tyler can maybe provide some additional details on the documentation reform pieces.

Thank you, Jacey, and thank you for your question, assembly member. It's a great question, and when you asked it in the first panel, I couldn't help but laugh to myself because it's just the issue of private pay and it's not unique to just, it's pervasive and a core problem, I think. I happy to provide more details about the documentation reform, and I'd also like to acknowledge your comment that the investments under BChip and inpatient and residential beds are key and needed.

But it's helpful to think about the full continuum of care, and people should be able to access medically necessary services, not just end up in an institutional level of care, because that's what's available. So I think it's helpful just to contextualize the BChip investments within the broader array of services that are sort of being covered under CalAIM and that are proposed to be covered under the California Behavioral health community based care demonstration. So under CYBHI, a big focus on upstream subclinical supports.

CalHope has provided this, bringing behavioral health care to where students are, as Mr. Ewing said, in schools through the fee schedule under CYBHI, the student Behavioral Health Incentive Program that the Department is implementing, we implemented peer support services, which went live in medical on July 1, 2022. We are implementing a new medical mobile crisis benefit, partnering with our county partners on that.

Under the new waiver that we briefly described, there is a variety of outpatient evidence based models, including assertive community treatment, supported employment, forensic assertive community treatment, coordinated specialty care for first episode psychosis, which Mr. Ewing also touched on community health workers within the behavioral health delivery system, and, of course, rent and temporary housing.

And under enhanced federal funding we received under our HCBS spending plan, we're supporting behavioral health navigators to be embedded inside emergency departments so that when folks show up, they're able to provide that sort of peer based support and just warm touches to connect them to care. So just wanted to sketch out that continuum. With respect to documentation reform, in July, we did issue preliminary guidance that was really focused on clinical documentation requirements that were part of our historic MediCal program.

We've heard from our county and provider partners that they were onerous, they were burdensome, they took time away from providing care, and so we streamlined a lot of those requirements and really aligned it with how documentation is done in medical care, sort of consistent with the spirit of parity.

Since the release of that guidance, we continue to hear from all of our county and other implementation partners that there continues to be an array of, shall we say, sort of intersecting requirements, including a number of federal requirements on clinical documentation for behavioral healthcare services that remain a problem for providers.

We haven't yet fully achieved the goal, so we are working with our federal partners to request waivers of flexibility for everything from targeted case management requirements, federal substance abuse block grant documentation requirements, mental health block grant documentation requirements. We're looking at federal guidance on peer support services. We have documentation requirements that are in the settlement terms of class action that the state has settled. We're actively exploring opportunities to sort of consolidate those as well.

So we are holding intensive working sessions with key partners to lay out. Here's the scope of remaining barriers in streamlining clinical documentation. Here are our proposed solutions. What are we missing? Will these proposed solutions work? So we're in that roll up your sleeves planning phase right now and later this year, look forward to releasing a second round of guidance.

Well, thank you all so much for.

I don't have the answer either. The commission has really been trying to identify ways to actually leverage commercial insurance, the marketplace, in addition to work that the State of California has done on parity for several years to actually build incentives into commercial insurance so that it isn't just do you take insurance, but does insurance actually cover what it is you need? There's a lot of complicated pieces to your question.

One of our concerns also is wanting to avoid a scenario where we're growing a mental health workforce that is not responsive to community based needs or is not accessible because of your question. Right. Are we facilitating a workforce that is set up to result in individual private practice that creates the very scenario that you're talking about?

And so we're hearing from community leaders and community members who are concerned that as we move to push and grow this workforce, that we need to make sure that the workforce is actually responsive to the community needs that the public sector is concerned about, including those individuals who have insurance, so that we're not cost shifting off of the commercial coverage side onto the public benefit side, which unfortunately we see too much of, particularly in the higher ends.

MediCal is the best game in town, unfortunately, and that's not true in other aspects of healthcare. We see know all across the board in conversations, is the public sector is actually often quite better at coverage. And how can we then leverage the lessons from the public sector and to ensure that, consistent with CYBHI, that the goals are payer agnostic, who's paying shouldn't determine the quality of care. Thank you.

Yeah, no, thank you so much for that last comment. You are correct. I think what I'm saying is because of a variety of factors, reimbursement rate, the amount of documentation, a lot of mental health care providers just don't take insurance at all. And you do have to pay out of pocket if you get those services. But we definitely don't want to switch over to a situation where they will only take either out of pocket or Medi Cal and not the commercial insurances.

So thank you so much for highlighting that. And also the fact that if we are putting funds and resources into increasing the pool of mental health care providers, that we have some kind of accountability on the other end, that since we are helping you, when you go out into practice, you see all patients, regardless of their payer status. And thank you so much for the documentation working on that. That's a pain in all specialties. I think those of us that see patients are well aware of that.

And also, when you talked about the elimination of the need to have a diagnosis in order to bill is huge for primary care providers because oftentimes if someone doesn't have access to a mental health therapist, it's the primary care provider that is doing that initial evaluation, potentially counseling, potentially prescription, but it's not necessarily in their expertise or specialty to actually say you've got this because they haven't seen someone that can give that official diagnosis, but they have spent the time, energy and effort.

So thank you very much for working on that. I would just conclude by saying that I think it's extremely important to really work with mental health care providers, whether it's through their association or whatever, to do a robust survey to see just how extensive this issue is right now for providers that are not taking insurance.

It is a little disappointing for me to ask, and people have no clue how many providers that we have that just don't take insurance at all because we're throwing money at different programs in different areas. And we may not even be tackling a huge part of the problem, which is there aren't providers that people can go and see because they cannot afford to do it out of their pocket. And we can talk about prevention as well.

I mean, the screening part to my colleagues question, but if you screen and you have no place that the patient can go, that is very troublesome. I remember when we implemented universal depression screening at my children's hospital, and I'm a specialist, I'm not a primary care doctor. All of us specialists groaned because what were we supposed to do with these patients that screen high on the required depression screening? They can't go to a mental health therapist.

Yes, if they're suicidal, we'll send them to the emergency room and they'll get care. But if they are not to that point, and they need to be prevented to get to that point, what do we do and where do we send them? And so we need to make sure that we are working on all fronts to make sure that documentation, billing, workforce are available for all patients regardless of their ability to have insurance or not, so that it's not a burden on any particular individual or family. So thank you.

If I could, I just wanted to add you heard mentioned in the CYBHI, the fee schedule for schooling to behavioral health services. And I think structurally, I think it might be something for us to think about and see what we can learn from this approach, which is it is saying that for the services that end up being included in this fee schedule, which is under development now, so it's not finalized, but it will apply to all payers, both medical and commercial.

So I think it is meant to think about sort of structurally, how do we streamline access to meet kids where they are, which is often at school, and if they're provided this service that's part of this fee schedule, it will be billed to commercial or MediCal. It is really regardless of payer. So I hope that's something we can maybe. Obviously, we're working to develop that and implement that led by the Department of Healthcare Services, Department of Managed Healthcare. But I think structurally it is really meant to try to tackle some of the issues that you are raising in terms of access from a universal payer perspective.

I'll bring it up to the chair for a few questions if I can. I'm going to begin with uplifting some of the comments about needing to have alignment to connect properly and to have timely care, and wanted to focus on a person, if I could, who disease progression may move from mild to moderate to severe to understand what the alignment is between the medical managed care plans and the county mental health plans, we heard earlier that there will be a same standard set of tools as well as a single integrated contract with the state by 2027. But what type of coordination is occurring currently between the county mental health plans and the medical managed care plans?

Thank you chair, for the question. So under CalAIM, there are several behavioral health policy initiatives designed to address this specific issue. One really is the statewide screening and transition tools, which I mentioned, which you're referencing. So under that initiative, there are a standard set of tools that the managed care plans and the county behavioral health plans county mental health plans will use when individuals.

There's a tool for adults when adults call, and then there's a separate version for when youth call, or when someone on behalf of a youth calls seeking mental health care for the first time. That's really designed to provide standardization across MediCal, regardless of where you live. So based on your clinical need, the best place for just an initial assessment. It's not a determination of where you're going to get services, it's just the referral for an initial assessment.

That's this standard screening tool to really guide those referrals. But you are referencing specifically when someone, say, might have mild to moderate health care needs and they're receiving non specialty mental health services from the medical managed care plan. If their condition progresses or destabilizes or intensifies and they need specialty care, what does that look like? The other piece that I didn't touch on in the interest of time are standard transition of care tools and the accompanying policy that goes with that.

So those transition of care tools are really designed to address that specific scenario. We know adults may move between those two delivery systems. The non specialty and the specialty, and even more so we know children will as well as they develop. The transition of care tools are really designed to ensure that when someone is in one of the two delivery systems, either non specialty or specialty, and a clinician makes a clinical decision with a patient centered, shared decision making process, that they would either benefit from receiving care in the other delivery system, or that they would benefit from receiving new services from that additional system so they could actually receive care from providers in both systems at the same time.

The transition of care tool is designed to guide the coordination between the two systems. So it's sort of a standard set of information that the clinician must provide that they can work with their plan to communicate and coordinate how either that member would transition from non specialty to specialty, or that member would continue seeing the provider that they're seeing and receive concurrent treatment, new non duplicative services from the other delivery systems. So that's another component of that policy.

Thank you for that update. We'll follow up on Dr. Weber's question, if can and I will just frame it differently. I think we're asking the same question, but we have rules regarding when you can get urgent need. If you have a mental health crisis, you are required to be seen within two business days. And we also have for non urgent, it's 10 days for a provider and 15 days for a psychiatrist.

Are we meeting those network adequacy standards and will uplift, if I can, the information we received from the California Healthcare Foundation, where nearly two thirds of adults didn't receive treatment in the previous year to make sure that we have networks which are adequate.

So I don't have the exact answer, but we can get you information. We do have a process of looking at timely access, and there's a difference. When we look at network adequacy, we look at time and distance, how fast you can get to somebody within your county, and then timely access. So from a request, from either an urgent or a routine appointment, how long does it take to get access to those services?

I don't have the exact stats in front of us, but we'd be more than happy to provide you with the outcomes of our last determination of both of those. And we do have parts of the state where we do need to improve those network adequacy pieces, but we'll be happy to provide you those reports.

I'll get one level deeper if I can. Currently, some of the Medi-Cal managed care plans are subcontracting with the managed behavioral health organizations, and I'd like to know if we're also monitoring their network adequacy and whether or not this will improve with CalAIM.

Yeah. So there's two things that we're doing there. We actually launched in November of last year a special audit of all of our managed care plans specifically tied to access to mild to moderate mental health services. I don't have the outcomes of those special audits at this time, but we will have those next year, and we are looking at that. The other piece that I would flag is really looking at how we are using our new contract that will go live in 2024.

One of the pieces that managed care plans are required to do is provide us detailed analysis of network adequacy at their subcontractor levels. So right now we do it kind of rolled up only at the prime contract is what we call it level. Starting in 2024, all managed care plans will be required to show and deem network adequacy at the subcontractor level, which would include their behavioral health subcontractors. So we will have that in the future, that will be required to be publicly posted on their website, and we will make that available to the public as well.

Thank you. I'm going to follow up, if I can, on the behavioral health payment reform that we mentioned earlier. In light of the budget year that we're in, I just want to get a sense if the administration is amenable to working with the legislature on potential solutions to address that.

Thank you for that question. We're happy to engage in those conversations. I do think from our perspective, this is such a critical transition for our county behavioral health partners, a very big transition from cost based reimbursement to IGTs and making sure that they can have a short term, essentially dollar flow in order to make that transition.

We think is critical to success for our county behavioral health partners to be able to do this, which is why we put it forward in regards to a short term cash flow available to those counties for that big transition. We don't want this to be a barrier at all in regards to the importance of this big transition. This is the first time we've done BH payment reform in California and that is why we put it forward. But happy to offline with you in regards to the details of that.

Thank you. My final question will be for Toby Ewing, if I can. First, I just want to congratulate, yesterday was his day off and he took my call late in the afternoon. And I just always appreciate when public servants are willing to avail themselves regardless of the day or time.

And so I just want to acknowledge that off the top. We know that the Department of Finance does quarterly updates on the Mental Health Service act revenues, and the most recent update was significantly over projected revenues and wanted to see if you could briefly comment on that, as well as to understand where we are for these to land in county coffers.

What's the timing for these funds to be expended, and what are some evidence based practices that you might recommend to counties to implement if they were interested in utilizing these resources more imminently? As an example, would you recommend the early psychosis care or the youth drop in, or the wellness centers? Hoping you can provide some other examples as well.

Thank you. And I just want to comment on your earlier question about time and distance standards. I mean, I can tell you my personal experience, no, we're not meeting those standards, even if I mention where I work. And I can tell you that there are waitlists in probably every community today that go well beyond those time and distance standards. And I think the challenge is both on the private sector side and on the public sector side.

And it's complicated by capacity, by specialization, by the appropriate match between needs and realities. And so, as was mentioned earlier, in terms of you may be able to access an urgent care center, but that doesn't necessarily mean that you get the follow up that is necessary to keep you out of that urgent care center down the road. In terms of the finance question, we're waiting for an update from the Department of Finance on expected MHSA revenues.

The early indications in terms of fund condition statements are suggesting that last year, the last budget year, we received more funds than we had anticipated. There's variation across counties in terms of how they use MHSA funds. The LAO's table shows that MHSA is roughly a third or a quarter, but in some counties it represents a much larger percentage of overall funding. It does vary across counties. Some of that has to do with how much they prioritize drawing down federal MedicAID Funds.

So that variation complicates the question a little bit. But we also see wide variation in how quickly counties tap into MHSA revenues. As we've discussed in the past, some counties are using MHSA revenues in what could be described as real time, and other counties, they'll face a 12 month or longer lag in terms of accessing those resources. I'll point out that there are often very good reasons for that, including delays in reimbursement. And so the comment that was made earlier about lags in billing.

I don't know all of the rules and the history of the rules, but I do think it would be prudent to begin to explore whether or not we can support the ability of our community partners to create more dynamic financing systems that are responsive to the volatility that happens on the revenue side. In some instances like this, a lag actually can be to our benefit because you can use where you have had increased revenues at a point in time, but you haven't used them.

You can use them to offset a decline in revenues in a future year. But the fiscal rules have been confusing for the commission in terms of being able to track revenues and expenditures and unspent funds, particularly around revenue streams that are not MHSA. Our conversations with community leaders, I should say the Mental Health Services Act, prioritizes community engagement in terms of the design of the care delivery system and how resources are being used.

And one of the most common questions from community is how much money is available and how difficult it can be to understand mental health finance. I think the LAO does a phenomenal job laying it out at a point in time, but even in the packet today that shows the flow of dollars. It references, I think 2018-2019 revenues and in subsequent reports, it shows dramatic change since that fiscal year.

And so that's indicative of how difficult it is for the public, much less policymakers, to really get a sense of what we should be doing today with what might be one time funds to, as you pointed out, invest in these kinds of capacity building or short term expansions of opportunities that are more prevention oriented. The commission's take is consistent that we don't have enough resources to sort of pay our way out of the crisis that we have with the system that we have.

We have to be thinking about ways to prevent and do intervention and to get bigger bang for the buck. Be much more efficient with the resources we have, particularly in a fiscal environment like we have today. Volatility can actually help us do that, particularly as counties are less inclined to rely on large short term growth for base funding, which means some of those resources can be available for short term investments consistent with what the state has done, for example, through CYBHI as state revenues, state General Fund revenues also fluctuate. I know that's not quite the answer you're looking for, but that's the best I can do at the moment.

It would seem that our county partners who are receiving MHSA dollars should be utilizing those dollars to the best of their capability. Since we are all acknowledging the crisis that we're in today. So I'm wanting to make sure we have the latitude to allow the fiscal flexibility, but also believe those dollars are best utilized and spent and want to again uplift the evidence based practices that you've identified that work in certain counties.

To encourage counties to consider looking at those options, to spend those dollars and understand that it's difficult for us to look at the financing, but would really ask our partners at the local level to be focused on the prevention and early intervention so that we can spend those dollars as imminently as possible.

Thank you. I think we would agree that it would be important to set clear and consistent goals, statewide goals, and then to support the ability of local partners to get there, including around the issue of screening. That's a very frustrating scenario and I don't think that we would be satisfied if that question were asked around childhood leukemia or similar health care. Right.

With stigma and other challenges, we have sort of given ourselves an acceptable level of space to say, I don't want to screen for major depression because I can't do anything about it. That would not be acceptable if it was something else that cost the lives of Californians. I think part of that is being strong and declarative around the goals that we're trying to meet and then working with our community partners to get there within the resources that we have. And that means getting creative. That means focusing on capacity building and it means leveraging all of the resources and talent we have to be successful.

Final, I'll just soapbox for half a second before I pass it back to Dr. Wood. We identified many of the disparities that occur geographically and in particular to the San Joaquin Valley. I'll uplift that we have of the number of psychiatrists per capita is LA and the Bay. And oftentimes it is access to providers and thus am looking towards the administration to continue to make investments into communities that have been historically underfunded.

Thank you, Mr. Chair.

I just want to thank this panel again. I think it's no coincidence that you see on the panel here or the dais here for people who have experience with patients and not all mental health patients, obviously, but there's a passion here and a desire to see these issues, see real progress here in California. So, none of us are going to apologize for that fashion. I certainly won't. And we look forward to continuing to work with you as we move forward. So thank you very much.

Appreciate it. We're going to move to our final panel, and while they're coming up, I will go ahead and introduce the panel. We have Zach Friend, a supervisor from Santa Cruz County who's the chair of their Health and Human Services Subcommittee, representing the California State Association of Counties, or CSAC. We have Scott De Moss, the County Administrative Officer for Glenn County, representing Rural County Representatives of California; we have Michelle Cabrera, Executive Director of the California Behavioral Health Directors Association.

Christine Stoner-Mertz, the Chief Executive Officer, California Alliance of Child and Family Services. So please, supervisor, whenever you're ready.

Thank you. Chair Wood, Chair Arambula, and honorable members, it's a real pleasure to be here today with you. As was noted, my name is Zach Friend, Chair of the Santa Cruz County Board of Supervisors and Chair of the California State Association of Counties Health and Human Services Policy Subcommittee. So, I'm here representing all 58 counties.

First, I'd like to just begin with some gratitude, not just for the fact that you're still here, but for the fact that there have been historic investments and partnership made by the Legislature and the Governor toward counties to deal with homelessness, behavioral health, and the intersection with all those issues. As many of you know, though, there's no greater front line than counties, and there is no such thing as success in any of these programs without the counties themselves succeeding.

And there's no model by which the success can occur without counties succeeding. In the expanse of what's been talked about today, which ultimately the counties will be leading, can't be overstated. Dr. Jackson, I thought about. Let me just pre-answer your question. Yes, we have a behavioral health crisis right now in the state of California, and it's acute within Santa Cruz County. In fact, we are at the second half of the chessboard with that. The first half, if you were to double for every square, that might be manageable. But now we're on the exponential side of the chessboard for behavioral health, for homelessness, for housing. Right. And counties are excited to lead all these initiatives that are coming our way, but we do have some obstacles that we should acknowledge and have been tacitly acknowledged by previous panels that may make it challenging for us to make it successful because these are people that we're discussing. These aren't just programs.

Dr. Wood, as you noted, the success isn't the implementation of it. The success is transforming the lives of tens of thousands of Californians, which is why we all ran for office in the first place. So, under this umbrella of capacity, I'll outline three quick challenges, and I'll get to opportunities for us together. It's workforce, its timing, and its resources. The workforce crisis isn't unique to us, but let me just mention Santa Cruz County: 30% vacancy rate in our Behavioral Health Department, 30% even higher with psychiatrists.

We contract out with wonderful community based organizations like used to run Dr. Jackson. They have a 20% vacancy rate in those positions in Santa Cruz County. And nearly every single one of them has come to us in a mid-year budget request asking for about 20% additional funding in order to help recruit and retain the staff that they have. So there is a workforce crisis, there is a timing crisis.

The reality is that what we need is flexibility, not just with funding, but also with timing for some of these implementation. When we talk about CalAIM, when we talk about care courts, we're talking about a six to 18-month implementation. And there are dozens more programs that are coming down the pike toward counties. And we just need to be realistic about what those time frames are going to be and how success is measured.

Because if you don't have the staff to do it to start with, and we want to lead these programs towards success, we just need to make sure that we have the timing for it. And last deals with resources, a lot of, as has been discussed, these are one-time funding, as the LAO said that 75% of the funding is one-time. Well, these are all ongoing commitments to the future.

There was a question from a former county supervisor up here earlier about what's the general fund impact. Well, in Santa Cruz County, it's 20%. 20% of our general fund goes toward exclusively backfilling the funding that we don't get from either the state or federal government to cover these health and human services programs. We use that money to help draw down state and federal funds, in particular federal funds. But that's a 20% impact that could be used for other things. Right.

So there is a direct, significant impact on our general fund and day-to-day, as we're making very difficult choices. I chaired a Board of Supervisors meeting before I came up here today on that. So where are the opportunities? Well, I think that there actually are some actionable things that we can work together on to really help move this forward. One of them is when we have these various funding opportunities, and there's a lot of acronyms associated with them.

If we could streamline or consolidate the application and reporting processes, that would make a big difference. Because when you're already missing 30% of your staff, you want them doing direct work with people that need it most. You don't want them dealing with applications and grant reporting components. Number two is just flexibility of funds.

Although I totally understand what Chair Arambula was just referring to, at the end of the day, we can't have a prescriptive component to funding because every county is different, as was noted by your colleagues that have since left. So having some flexibility built into us because we are your trusted partners for actually implementing this on the ground. The third is the one-time versus ongoing commitments. I mean, that's just something, I think, that we have to structurally work on.

I mean, I'm guilty of it as well when I do my own budgets at the county level. But at the end of the day, these are ongoing commitment programs with massive investments and need ongoing investments. And the last are just timelines that are realistic. Because the one thing that we don't want is to have something viewed as a failure just because of the timing of implementation wasn't possible. Any of these programs, taken individually, any of them would be viewed as monumental.

Collectively, though, we've moved into that second half of the chessboard that was mentioning to Dr. Jackson, which means it is quite a lift to do it. We want to lead this. We're committed to do this. We just need to make sure that those timelines are realistic. But I got to say, I'm here today because I'm excited about this, and I'm so honored to be in front of you and all the work that you've done in that way.

We're here because we're going to transform those lives of future generations of Californians. People don't know our names, may not be born yet. We can do it, though. Two divergent paths on the second half. Dr. Jackson, I believe, and I truly believe, that we've been given that opportunity and responsibility as elected officials to change that trajectory. And so I'd like to do it with all of you. Thank you.

Thank you very much. Supervisor. Mr. De Moss, thank you.

Thank you for the time today, and most importantly, thank you for the investments that you're making in our systems of care. However, as was mentioned, we are facing some very significant problems that can be overcome with time and attention. But timing, it's a key issue. And one of the things that is driving problems in our systems is our workforce. Much like other counties, we have significant shortfalls in staffing. We're actually running about a 20% vacancy rate in our behavioral health system.

However, when you consider the fact that in a small, rural county, our systems are made up of fewer employees, driving more responsibility to each person, having that deficit of staffing is a major issue. We can try to address it with different incentives and workforce opportunities. But ultimately, in my little county, one of the big problems we've run into is the fact that there's nowhere for people to move, nowhere for people to live.

So now we are trying to address that by folks living in other communities commuting into our little county to provide care and services. And those kinds of things make it even harder to attract individuals because every county is facing the same problem. In this workforce shortage, you've brought up a number of infrastructure programs, and Glenn County is fortunate to be one of the BCHIP recipients. We are getting funding to build a children's and families outpatient facility.

It's going to be tremendous and it's going to help transform what we're doing. But the ability for such a little team of folks to put together one of these competitive grants, the effort that we had to go through to identify the match that, say, a better-funded county may not have that difficulty, but being small and having limited resources, it almost makes it defeating to try to apply for these different competitive grants because we just don't have the staffing capacity.

And sometimes, the grant match just makes it too big of a hurdle for us. We are also one of your Care Act implementation countries. We're one of the two smalls, and we see that as a real opportunity to help transform and bring more people into treatment.

In our little county, we have amazing partners in our court, and what I am learning as we're going through that planning process with our court partners, our internal county partners, our external stakeholders is that it takes an absolute team approach for something that is as monumental as the Care Act to be implemented. Even in a county where we estimate there's somewhere between 10 and 20 individuals, that is our population, that we believe will be impacted by the Care Act.

And it may not sound like a lot, but in our little county, that's actually a large opportunity for us. And so we appreciate that. But one of the things that drives timing is staffing and so we're already working to bring on the staffing so that we can actually start a pilot for it.

Our goal is to start a pilot in the summer so that we're actually running folks through the treatment side of the program ahead of the actual October start date. Program flexibility is really important to small counties with a limited workforce and the same responsibilities as larger counties. Oftentimes people wear a lot of different hats, and so giving us the flexibility for our team members to wear those different hats.

And if there is a way for us to address all of the paperwork that goes along with treatment. I spent several years in behavioral health as an employee myself, and one of the things I did as the compliance officer for the Department was responsibility to look at what was going on with our clinical staff and the care they were providing, and the documentation that supported the Medi-Cal billing that we were doing. And that is such a struggle for folks, especially younger folks coming out of school.

When they go to school, and they get their master's in social work, they're not taught how to build Medi-Cal; they're taught how to diagnose and treat. And so some of those elements, as they enter into the public sector workforce, it can actually turn them. And then maybe that's why we're having trouble figuring out where we have providers in our communities. Lastly, and I'm trying to keep my remarks short, I do have a recommendation.

In talking with some of our rural counties, now we think that there are some elements that we can work together. And so we believe that putting together a working group to focus on solutions to meet the gaps in service delivery and infrastructure for rural California might go a long way to help us.

We think identifying flexibility and programs to address the unique challenges that we face in the small counties, those under population of 250,000, and then having rural set-asides in some of these one-time funding programs so that even though we don't have the excellent grant writers on staff or the ability to match a larger grant for a big infrastructure investment, that we can still throw our hat in the ring and do better for the people that live and work in our county because it's our responsibility to make our county the best place in California to live and work.

And so that's what we're trying to achieve. And we appreciate the opportunity to talk about that today.

Thank you. Thank you very much. Appreciate it, Michelle.

Good evening, Chairs and members. Michelle Cabrera, I'm the Executive Director of the County Behavioral Health Directors Association, representing our county behavioral health leadership and safety net. First, I just want to commend the committees for an excellent hearing and conversation today, which really underscores the importance and the urgency of the shifts that are happening beneath our feet.

To say that our public behavioral health safety net is managing a tremendous amount of change is an understatement, as in addition to all of the various initiatives we discuss today, there are even more concurrent system changes happening outside of what we've been discussing. There really literally has never been a time before that has been more intense for mental health. And it's not just at the systems level, right?

I mean, collectively as a people, we are starting to awaken and see that for far too long, across both public as well as private plans and providers, we have treated behavioral health needs like a nice to have. And really, I just want to thank Dr. Jackson for - I'm sorry, Dr. Weber, for mentioning and really talking about this disparity in treatment and how we address behavioral health across public and private systems.

They are interwoven, they do interact and they do play out across both systems in important ways that we will need to untangle over the next generation. I'll take an opportunity to touch on several of the initiatives that have been brought up today. First, we want to thank and commend the Legislature and the Administration for your foresight in allocating one-time funding to build out behavioral health treatment capacity through the BCHIP.

These treatment beds will help to expand our networks to serve more individuals with behavioral health treatment needs. Under the BCHIP, county behavioral health agencies account for roughly a third of grantees, and we were awarded almost half of the round 4 and 5 project awards. However, moving forward, counties will have to fund these expanded services offered by these providers, whether county, CBO, or for-profit grantees, for a 30-year service commitment without new dollars to support those treatment needs over the long haul.

At the same time, under CalAIm, we're transforming how we fund and deliver services to try to make much more of what we do matchable with federal dollars through Medi-Cal. As J. C. Cooper mentioned earlier, these initiatives, which allow us to bill pre-diagnosis, bring in new funding for the mobile crisis, and transform our reimbursement system under payment reform, are crucial to the overall overhaul of our public safety net system.

Payment reform is essential to ensuring that we move this antiquated documentation to the minute and recruitment liability out, and it will put us on a pathway to capitated value-based payments over time. I have to say that with the way that we receive funding month to month, there would be significant cash flow issues if we did not receive the 375,000,000 in funding; we wouldn't be able to essentially transition our system from the current system, which is both cost-based and requires settlement of claims over time years. In fact, with the upfront payment of services under the IGTs. In the years ahead, we will be faced with additional changes, and one example is the CYBHI, which changes existing relationships that we have with schools in fundamental ways.

Today, as county behavioral health agencies and medical health plans, we bring county behavioral health services to schools in over 85% of counties throughout the state. Investments such as the MHSA have provided us with the seed funding to expand those footprints.

And while the proposed fee schedule will realign incentives for schools, counties, and providers to increase behavioral health services on campuses, there are only so many individuals today who are qualified to do this work, and I will just say most of them, again, to Dr. Weber's point, already work within the county behavioral health system. So counties have embarked on, in addition to this, intensive planning for year one of care court, and we appreciate the bridge funding allocation, which is again a one-time allocation.

We're grateful for the additional 26 million for cohort one counties to help Kickstart CARE Court. And yet, we're concerned that over the long run, the funding criteria for bridge housing may not provide the flexibility needed to tailor our local housing solutions to the needs of our unique communities and that there's no sustained earmarked funding source for housing related to CARE Court.

Housing barriers in Humboldt, for example, are vastly different than those in San Diego counties, and the degree to which courts will be able to assist us in tapping into public housing resources really does remain to be seen. I can tell you that for a majority of our clients, the issue is not their reluctance to receive treatment or housing but actually the devastating lack of housing altogether that is available to our clients.

Often, our more needed, more complex clients are screened out of housing precisely due to their conditions. In other parts of the state, such as Glenn, there's simply no housing to be found. I have to note that while the Administration has proposed to delay investments in expanding education and training for behavioral health workforce, it has not taken its foot off the gas in moving forward with these and other various initiatives.

Unless the workforce investments roll out timely, we will simply be shuffling our workforce statewide from one sector into other sectors, minus those cash pay clinicians. And we won't be as focused on our high needs and more complex clients, leaving holes in the safety net where services might exist if only we had the humans to deliver them. If we keep our focus on sustaining workforce and housing, California is poised to have one of the most innovative, accessible, and effective behavioral health systems in the nation.

To summarize, the status of our various investments to date, whether through CalAIM, behavioral health infrastructure, or CARE Court, is under construction. But the impact has already been profound. Thank you.

Thank you.

Thank you, Chairs and committee members. My name is Chris Stoner-Mertz. I'm the CEO of the California Alliance of Child and Family Services and a proud social worker. We are a statewide association of nationally accredited nonprofits serving children, youth, and families through safety net programs in all 58 counties. Our members provide behavioral health services through the specialty mental health system as well as in contract with managed care plans. And yes, Dr. Jackson, we have a crisis.

In fact, with some partner organizations, we recommended that we call that crisis out for children and youth in particular about a year ago as it relates to CalAIM, we're excited about the initiative outlined by DHCs, and we've partnered with the state and counties in helping to craft guidance and to develop a system that will truly meet the needs of our most vulnerable Californians. We see this reform as an opportunity to address racial inequities, reduce burdensome administrative barriers to care, and expand and diversify the workforce.

We see opportunities under payment reform to increase the federal financial participation for the public behavioral health system. Components that many have already talked about under CalAIM that we see as potential game changers include the criteria for eligibility to specialty mental health services that reduce the need to have a diagnosis. There are no wrong door policies and documentation streamlining requirements. These components of the initiative have been in place for only six months to a year, and it does take time to implement these.

But we continue to work with our partners at the state and county to ensure that that implementation does, in fact, get felt at the provider level, similar to the county behavioral health program. Seeing this issue around the workforce, we, too, did a survey of our members and found that they had vacancies very close to between 30 and 40% in many of their critical positions. For CBOs, the changes in eligibility criteria, particularly for children and youth, are historic and critically needed.

Removing those barriers for youth to access care and be assessed for the right care can literally save lives. DHCS's vision for reducing administrative burdens at the county and provider level is long awaited by CBOs, whose staff spend 50% of their time documenting services rather than providing them. So to your question about the availability of services, we can do something about that now.

Each of these components are still very much in implementation, and as a provider community, we are concerned about the lack of uniformity across the state. We've identified some of these discrepancies and continue to work with our state and county partners to hopefully realize the vision of increased and equitable access to care and reduced administrative burdens. As we move closer to July 1 and the implementation of payment reform, we remained concerned about some of the limited communication and collaboration with service providers directly.

The level of detail that has to be worked through as counties change these payment models is significant, and I cannot underscore this. The counties themselves are taking significant risks as they transition to these intergovernmental transfers, and providers similarly are taking risks under this change from cost settlement to working with the counties negotiating and working through their contracts. As providers are asked to provide their cost to counties, they're looking at their former budgets rather than prospectively.

There's a lot of detail behind this, I know, but just to give you the general sense, it's very critical that providers are given the information that is needed to understand, both at the state and county levels, how those systems are being built and how those rates are being built. Of course, it's essential that these contracts and the adequate rates for these services are in place by July 1 in order to ensure that medical beneficiaries who need these services have the adequate network of services.

Finally, the Children Youth Behavioral Health Initiative is an effort that we are very supportive of, and we believe the vision and the efforts are well placed. We continue to work closely with both CHHS and DHCs in work groups and task force for each of the components as they are designed and developed. Of particular note, we're pleased to see the efforts to support and expand and diversify the behavioral health workforce.

Grants provided through HCI to universities, organizations, and students will certainly have a positive impact on our current workforce crisis, and grants for infrastructure through the BHCIP initiative and for the implementation of evidence-based practices and community-defined practices are welcome efforts. We similarly have concerns and have addressed these to the Administration around some of the delays in funding and would like to see an emphasis on making sure that those funds are made available so that we can, in fact, expand and diversify the workforce.

We've offered feedback to the Administration on the implementation of CYBHI and the importance of ensuring support for existing providers as changes are made in the system so that we can really align with the needs of children and youth as well as their families most effectively. The community-based organizations we represent are embedded in the communities they serve, represent the communities they serve, and understand the cultural and linguistic needs of youth and families.

Ensuring support for workforce stability in nonprofit behavioral health organizations, as well as ensuring that all reforms support our existing robust network of community based providers, will be critical in order to realize this vision for these initiatives. Thank you.

Thank you very much. Dr. Arambula, question?

Yeah, I'm going to start if I can. I wanted to get an understanding about some of the partnerships between our counties and our local educational agencies. Have we designed effective incentives to enable those partnerships to flourish, and what are some of the challenges that counties are facing in establishing those partnerships to provide?

Mental health services to our kids, if I may, Dr. Arambula? Michelle with CBHDA. So, county behavioral health agencies, as I mentioned before, our partnerships with schools go back decades, really, to when counties once upon a time held other responsibilities related to school-related mental health and residential treatment that was transferred to the schools subsequently. But we've remained in partnership in many cases. And so there's a real sort of web of different kinds of arrangements, right?

In some cases, we're contracting with CBO providers, or we're directly delivering services on campus, or sometimes we contract with school-based psychologists and other Clinicians, and we train them in how to deliver medical and other mental health services so that they can serve all the student's needs. It gets super complicated because schools have one set of responsibilities under federal and state law to educationally related mental health services, and we have a different set of responsibilities under Medi-Cal, EPSDT for children and youth. Right.

And the analogy that I like to use sometimes is the student who, let's say they are super academically inclined, right? They do really well in school, they're active in sports, but maybe they've got debilitating depression, and they're at risk for suicide. That student wouldn't meet the criteria for educationally related mental health services because they're doing just fine in school, but they still need something for their well-being, for them to be functioning as a human. And so that's where that partnership is really crucial right now.

One of the biggest challenges that we have, as I mentioned before, is that there's this shuffling. There's not a reserve of clinicians who specialize in working with children and youth who are just sort of waiting to get pulled into expansion of services at schools.

And so a lot of what we're seeing right now is that schools are actually, with funding through CDE, hiring away master's level clinicians to work for the schools, either our former staff, our former staff who then assess children and refer them back to us. But we've got holes now. We no longer have those master-level clinicians to deliver those higher-level services. So, we really need to be thoughtful and intentional about the workforce piece.

That's why we keep going back to the workforce, and we can solve the workforce challenge. I don't want to present this as a sort of, it's not dystopia. We just need to expand education and training so that the pipeline is there with an eye, ideally toward some of the racial, ethnic, linguistic, and other disparities that we have. Right. And provide the right kind of incentives to get the right students in those schools so that, eventually, we do have that pool that we can build out from.

But it's not there today. And so today, there's the shuffle happening, and that's really seriously problematic. There are other issues, but I know, it's late.

Due to the lateness of the hour. I'll ask one last question regarding partnerships, and I'll focus on full-service partnerships. I'm trying to get a sense if these are being fully funded by the counties, as is required by the Mental Health Services Act, and if full-service partnerships get the support they need to maximize their effectiveness. What else should we be doing in this regard?

I can take this one as well. Full-service partnerships are the whatever-it-takes model that's primarily funded under the Mental Health Services Act. So, Mental Health Services Act funding is actually quite split up. It's categorical, right? 80% has to go to community services and support, and then within that, 55% has to be spent on full-service partnerships. The question is, are we maximizing them?

The bottom line is yes: every single county has full-service partnerships, and usually a variety and an array of different kinds, different flavors of full-service partnerships that touch different populations. And because of this flexible MHSA funding, we're able to do a lot of really innovative things that, today, Medi-Cal doesn't pay for, such as outreach and engagement. But we really need to be equipped with other resources to really maximize the benefit of full-service partnerships.

So, for example, we surveyed our members and found that in one year, we brought roughly 18,000 homeless individuals into full service partnership treatments. But we could only house roughly 7000. These are statewide numbers. The remaining 8000 individuals we could not house. And so, if you can imagine, we've invested time and energy to build trust with somebody to get them into treatment. We've got them in treatment voluntarily. We don't have a home for them.

And so then we just have to hold on to them as much as we can and hope and pray that we're going to be able to connect them with those housing resources. That's why that's sort of the sort of core point, right? The workforce and then the housing resources are really essential to helping our safety net do what it really does know how to do.

We could level up and get our full-service partnerships to full-fidelity sort of community treatment, for example, that the state's proposing under the IMD waiver. But we need the staffing and housing resources to really realize that vision that the state has about us doing more evidence-based practices and those sorts of things.

Happy to follow up in more detail. I simply want to ensure that we're meeting those percentages that the Mental Health Services Act required. And earlier we heard that revenues were projected to be higher. Thus, I want to ensure we're meeting those thresholds as it is, the full service partnerships that are there designed, intended to help with both the homelessness issue and our jail populations.

If I may just follow up with one quick note on that because counties have let us know that they're restricted in terms of only being able to pay for housing with CSS funds under MHSA. And so if we were to spend CSS funding to build a home, for example, or purchase a building to house clients in FSPs, then that counts against us with the percentages.

And sometimes, it might be the best use of a one-time bump in MHSA funding rather than building out a program over the long run that we don't know if we can support because the MHSA will drop. Right. And so those kinds of dynamics sometimes come into play with some of these percentage calculations. And so I just wanted to let you know that there are some reasons behind that.

Look forward to the conversations. Thank you.

Dr. Jackson. Any questions? Okay, just a couple of questions, and then we'll be going into public comment. But first of all, thank you again for being here and sticking with us, considering the lateness of the hour. So this question is kind of for all of you. We've heard about workforce. Actually, I sat on a workforce commission back in 2017. The report was issued in 2018, and it was like, we need workforce in this space.

And here we are five years later, and I don't know how much progress we have made, but when you see the numbers and the challenges and the strain on the existing workforce here, it feels like we're treading water. At the very least. That was more of a statement than a question. But I'm curious, the question for all of you, and please be candid, how close are you to being what we'll call opportunity-rich? In other words, how close are you to reaching maximum capacity?

Happy to jump in. We're there. I liken what we're in the middle of as being in a money-blowing machine where you've got money blowing all around you, and you're trying to grab at it, but you just don't have enough arms. Right. So there are opportunities. But I loved what Zach said about timing. Right. That's such an important thing for us to be thinking about.

How do we actually roll this out in a way that we can take advantage of the funding that's available without folks simply saying, I'm out; I can't do it anymore, which is certainly what we've seen. Lots of not just staff but leadership as well in our provider community are saying, after COVID, I just can't keep doing this.

Yeah, so that's a really good question and something that we dealt with as the Governor's office reached out to Glenn County related to the Care Act, sat down with my team, the behavioral health director, the health and human services director, a presiding judge, and we talked about the opportunity that was presented to Glenn County financially with the incentive dollars for being an early adopter.

Secondarily, the opportunity to help craft something that would help the people in the county in which we lived and worked, and thirdly, the opportunity for the extra technical assistance that would come with being in that early tranche of individuals implementing the Care Act. And my behavioral health director is a great guy. You know, I felt really honored to listen to him talk about the fact: "You know, Scott, this presents an opportunity for us to do something in our community that will benefit folks, will give us an opportunity to make investments that we wouldn't otherwise be able to make, and we're going to end up doing it anyway and may not have some of these opportunities."

So, if we have to wear one more hat, and given the fact that we're shortened workforce, we're willing to do that because it's what's going to be best for Glenn County and the people that live. So, you know, the incentive that has been provided to be an early adopter is extremely important for us to be successful. As Mrs. Cabrera mentioned, we don't have any housing in Glenn County for our programs. 100% of our placements are out of county.

They're in Shasta, they're in Sacramento, they're in San Francisco. And our staff end up driving all over the state to check on those folks that we have placed, and that's costly, and it's time taking, and it really does wear down on our providers in our, you know, we're very fortunate to be one of the early adopters of the Care Act because we're going to take that and we're going to invest that to make it better for Glenn County. But we just keep adding hats.

And so I think my behavioral health director would probably tell me that he's probably got enough hats at this point, and we just need to get these programs up and running and implemented.

Thank you. Please.

Sorry. I might just add on it. I mean, I think supervisor friend did really lay it out pretty nicely. And on the timing piece, I'll just say there are a lot. With everything that's happening right now, I think we're trying to juggle two different imperatives. Right. It's the crisis urgency now imperative that Dr. Jackson referenced along with the, "Wait a minute, something is happening here. And we're actually going through a more seismic shift in how we culturally think about behavioral health, full stop." Right?

And as we're contemplating these mass initiatives and particularly the ones that cut across public and private, that's where we really kind of, like, get scared. I will say there's fear about what each new initiative will bring because we know that as the safety net and as the specialty safety net in California, we have the most skilled expertise and the most knowledgeable, experienced staff in the state to deal with highly complex populations.

We've got a lot to offer the state, but we would really urge the Legislature and the state to think about how do we put some protection and some guardrails around the safety net, given the mandate that we've laid at the feet of county behavioral health? How do we do this and how we structure and develop the education opportunities? Right.

Do we ask those schools that we're expanding slots in to train people for the public safety net so that they don't just go for the chase, the easy dollar in cash pay services. Do we require service commitments for people if they're going to get loan reimbursement or stipends in the public safety net? Telehealth will potentially help people with less severe needs. We do need for sure some of those upstream outpatient services, particularly for our black and indigenous populations that are overrepresented in the public safety net.

Right. They're clearly not getting what they need upstream. So I think we need to be very mindful as we're going into expansion mode of how we protect that core and make sure that we've got those reserves in place to really support from a staffing perspective, all the long term expansions that we want to make.

Great. Thank you. And I've got one comment and then one final question here. We heard, I think it was from supervisor friend, and maybe it was from you, Scott, about the simplification of the application process for grants. I can't think of anything more daunting than every time you have a grant application, you got to start from the upper left corner. And it's like, it's crazy, but that is really challenging for people.

So if the Legislature were able to do one thing to help facilitate implementation of these initiatives, short of funding and delaying the initiatives, because that's going to be challenging, what would it be? One thing that would help you? What could we do to help make this better?

I know maybe at this time of day it might be a tough question. And there's probably, you know, it's probably not just one thing. Lightning round, I guess.

So you right, it is not just one thing, but for us, as I've mentioned, the lack of housing to help people who need treatment in our communities, to stay in our community and to get that treatment would be enormous.

And one of the things we hear a lot, that there's been all these housing dollars put out there, competitive grant processes, large matches, not exactly a clearly identified funding stream to make that match because you're stealing from Peter to pay Paul, and then you're spending even more on your full-service partnerships because you're having to travel out of county. And we're a county that we use all of our MHSA. We have our prudent reserve, but outside of that, we use our MHSA 100% every year.

We don't have excess carryover. And so as some of these other programs are coming forward and the comment is made like, well, hey, why don't you just add that to your MHSA? Well, for us, it's like, okay, what MHSA Program are we going to stop providing in order to add this new thing? So, you know? That's, that's where we are in Glenn. And I think that was about three things, but that's my answer.

Much appreciated. Thank you.

I do think that the reporting and the sort grant, let me back it up. Behavioral health has historically, from the federal level on down, been kind of a block grant here and a grant, grant there, here, grant there, grant everywhere, grant, grant. And we've got the results to show it, right? Everybody goes, why are things so different across the state? Well, I didn't get XYZ grant, right?

And so I do think that part of that shift needs to be that we double down, that we put a ring on it, that we commit to behavioral health over the long haul. And so that requires looking at the way that we approach behavioral health with a different eye. And then on the flip side of that, our county safety net, we are local government partners who are accountable at the local level as well as at the state level.

I can tell you that our governments take their compliance and their requirements very seriously. And so I think we have maybe gone a bit overboard in terms of some of the onerous reporting and other contracting requirements that are tied to some of these investments. And it is the sort of thing where it's a death by 1000 paper cuts. Like some people are literally on the edge.

It's like, if I've got one more thing that's not, again, client centered or client focused, that comes as a string with this, I might as well just say no because it's going to drive my staff out rather than bring clients in and support the vibrance of our system. And so when we raise these things, it's not coming from a place of sort of profiteering and wanting to line our pockets.

It's really about how do we keep the lights on, how do we keep things moving, and how do we hold our staff from really burnout, which is threatening the system as a whole.

Great. Thank you.

That was a very hard question, but I had a chance to think about it, and it really does come down to competitive reimbursement rates for service providers. That's what drives therapists and other professionals out of the public behavioral health system. And we have to ensure that you can get as good a living working in the behavioral health system on behalf of Medi-Cal beneficiaries as you can providing that service for someone who can write you a check.

Great. Thank you. I just want to say thank you again to you as a panel. It might be the lateness of the hour or my age or something, but as you're talking about hats, I'm sitting here thinking of beach blanket Babylon and enormous hats and one more hat, and it's like, yeah, so it must be clearly low blood sugar here. But thank you so much for everything you do for people and appreciate you being here this afternoon.

So with that, I'm going to turn this over to Dr. Arambula, who's going to do our public comment.

Thank you very much. If you will come forward to the microphone, and you are welcome to provide your public comment.

Hello, Chairs and Members, Tara Gamboa-Eastman with the Steinberg Institute really just want to acknowledge the tremendous investments that have been made in the recent years and thank the Administration, who's doing such hard work to implement them, and you for holding this hearing. We think it's really going to contribute to a successful implementation of all of these programs.

Like many of the comments today, we're concerned about the proposed delays to the workforce funding, given the crisis, and the need for the workforce to implement the ambitious program set forward. Finally, on behalf of both the Steinberg Institute and the Kennedy Forum, we're eager about the implementation of 988, the Mental Health Crisis Line, and look forward to partnering with the Administration and the Legislature on forthcoming TBL. Thank you.

Thank you.

Mr. Chair. Both Chairs, bidding Members. Toni Tugara, on behalf of the California Teachers Association. It's been stated the state has invested close to $5 billion in one-time dollars in the children, youth and youth behavioral Health initiative from the Assembly Democrats budget plan. We support the possibility of reevaluating the timing of the planned one-time initiative expenditures as they relate to LEAs and to adjust the LEA-related plans to possibly shift initiative expenditures authorized in 20 to 23 to later years.

We also support HCAI Workforce Funding to include pupil services personnel. Those are credentialed school nurses, social workers, psychologists, and counselors. HCAI currently funds scholarships for nurse anesthetists and psychiatric nurses, but not credentialed school nurses, psychologists, or social workers. Also, to address the LEA needs around physical and behavioral health, we support incorporating AB 483 and SB 551 into the health budget trailer Bill, both of which address the sustainability issues that were mentioned by Assemblymember Arambula in his opening statement.

There is also interplay between the initiative and the $4 billion investment in community schools, where sustainability is also critically important, and we remain concerned about the evolving wellness coaches 1 and 2. We look forward to working with the Committee on these issues and personally want to thank Dr. Jackson for sharing his story. Thank you.

Thank you.

Good evening, Doctors. Karen Lang, on behalf of the Solano County Board of Supervisors, here to try to shed some light on a very specific thing happening with respect to CalAIM in Solano and Sacramento counties. As of July 1, the state is proposing to shift the provision of care from the state to Solano and Sacramento counties for about 7,000 people who are the most severely mentally ill in those two counties. This has been under work in the works for two years.

The counties have consistently and repeatedly asked for the Administration to identify the funding to follow this population since this arrangement predates the 2011 realignment. So taking money out of the 2011 realignment and taking that away from the other 56 counties. So I know this is not a Salano and Sacramento delegation here, but your counties are going to have less money in the growth because they're going to give some growth to the two counties to pay for this.

But even with a little bit of money, it's a fraction of what the two counties think that they need and they cannot begin to procure for the services, which it sounds like you have a lot of familiarity with. They cannot hire the doctors until they know how they're going to pay for the services. And on July 1, 2023 the state has told the two counties that this is going to be their responsibility going forward.

So it sounds like you understand there's a crisis, it's going to get a lot worse. In Sacramento and Solano counties. They have no doctors to care for this population. They can't contract for it without money. They're asking for your help. Your staff has been wonderful. You were able to get us a little bit of extra time to begin with.

We're nowhere farther down the road in terms of being able to pay for this service and to hire these doctors because they don't have enough money to do it. So we're asking for your help in slowing this down and not making a crisis even worse and do no harm. So thank you very much for listening and for hanging in there with us. Thank you.

Thank you.

Kelly Brooks, on behalf of the Urban Counties of California, first, I'd like to thank all of you for the hearing and the robust conversation this afternoon and to thank the Legislature and the Administration for the historic investments in behavioral health over the last several budget cycles. I just want to emphasize that the boards of supervisors understand how important the delivery of quality behavioral health services are.

Counties are responsible for providing services for many vulnerable populations, children and youth in the foster care system, individuals in the justice system, and homeless individuals. So we're not going to improve outcomes in other systems if we're not doing a good job. On the behavioral health side, this is sort of critical. And to the mission, to the work that counties are doing, I just want to say ditto on all of the workforce issues. Urban counties have them, too.

Our membership includes counties from the Central Valley and the Inland Empire who have even more acute workforce shortages than other places in the state. We look forward to partnering with the Legislature and with the Administration on improving behavioral health services in California.

Thank you.

Good afternoon, Chair and Committee Members. Stephanie Estrada with Cruise Strategies on behalf of Sacramento County. We're here to raise similar concerns from Karen and Solana counties on the stage transition of care from Kaiser medical specialty mental health services patients to Sacramento Solana counties. We request that you provide the two counties with sufficient funds and time to properly care for these fragile individuals. Thank you.

Thank you.

Thank you, Members and Panelists, for this hearing. My name is John Drebinger, Senior Advocate with CBHA, the California Council of Community Behavioral Health Agencies, which represents mental health and substance use community-based organizations across the state serving over one million Californians. We appreciate the agenda of this hearing, especially its focus on workforce, school-based behavioral health services, and documentation reform.

I wanted to note that we, along with co sponsoring organizations, have a Bill specifically addressing documentation reform AB 1470 and look forward to continued dialogue with DHCS on the matter. We're also working with a coalition of nonprofits on a package of bills addressing some of the nonprofit contracting and grants issues discussed today. And I also wanted to concur with my colleague Chris that adequate rates are essential for moving forward and responding to this crisis.

We and our Members stand ready to support and partner with the Legislature in its work to address California's behavioral health crisis. And thank you again for your leadership today.

Thank you. Seeing no further public comment, I will take that as the conclusion of public comment. As we are winding down, I will take a second to thank all of the participants in today's hearing, starting with the Administration, to the Commission, to the Legislative Analyst Office, California Healthcare Foundation, and many of the stakeholders who participated.

I want to especially uplift the Governor and his Administration for all of the work and investments that have occurred all of the last few years that allow us to have the transformation change that we're looking at as a state. I am grateful that we have put in the hard work and look forward to our continued partnerships going forward. With that, we are adjourned for the night.