Assembly Budget Subcommittee No. 1 on Health

Can you hear me? Perfect. Good morning. We will now begin the committee hearing, Subcommittee Hearing 1 on Health. We have two issues that we will be discussing today related to state hospitals. Staff is recommending action today on issue number two, so I'm hoping that the members of this subcommittee will be able to make their way to the hearing room. I would like to first welcome our first panel that will give a general overview of the department and discuss the two proposed budget items.

I would like for Stephanie Clendenin, Brent Houser, Sean Hammer, Joseph Donaldson, and Will Owens to come. And whenever you're ready, you may begin your presentation. And please start with your name and the department that you represent. Thank you.

Good morning, Chair, members. Stephanie Clendenin, director for the Department of State Hospital Hospitals, and I will provide an overview of the department and the proposed budget and provide a caseload and program update as well. The Department of State Hospitals manages the California State Hospital System. Our mission is to provide evaluation and treatment in a safe and responsible manner by leading innovation and excellence across a continuum of care and settings.

We operate five state hospitals throughout California with over 6000 inpatient beds that include acute, intermediate, skilled nursing, and residential recovery levels. We have a conditional release program, which is a system of community-based services operated in partnership with county behavioral health departments and private providers that is designed to transition patients back into the community following a placement in one of our inpatient settings.

We also have partnerships with county behavioral health programs, private providers, and county sheriffs to provide community-based restoration, diversion opportunities, and jail-based treatment programs for individuals who are committed to the department as incompetent to stand trial. The individuals who are served by our system of care are mandated for mental health treatment by either a criminal or civil court judge or the board of parole hearings. The majority of the individuals we serve are forensic commitments.

They have either been either committed or have been accused of committing crimes that are linked to their mental illness and come to us directly through the criminal courts or after they have completed a sentence at the California Department of Corrections and Rehabilitation. With respect to the department's budget, the proposed budget for fiscal year 24-25 totals 3.4 billion, which is a decrease of 85.3 million or 2% from the 23 budget act.

With 12 proposed new positions in budget year, we also reflect current-year savings related to changes in implementation timelines for new programs and bud capacity approved in prior budget acts. The decrease in funding is primarily attributed to re-appropriated dollars for IST solutions that were one-time and were scheduled to fall off. Would note 10 of the 12 positions are not actually new positions and are more reflective of obtaining approval for permanent authority for 10 limited-term positions.

As it relates to our caseload estimate, the department is projecting a census of 8163 by the end of this fiscal year and 9267 across its programs by the end of fiscal year 24-25, and the increase is primarily related to expanding capacity for treatment of individuals who have been found incompetent to stand trial and primarily through the expansion of community-based restoration and diversion with some small increases in capacity and census pond at the state hospitals and jail-based competency treatment programs.

I will also provide an overview of our program updates that are generating savings or funding requests for the DSH metropolitan increased secure bed capacity project. We reflect a one-time savings of 9.6 million in current year. This project, which originated with a capital outlay project in 2016, added security, fencing, and infrastructure to an existing patient building at this hospital so that the bed capacity could be utilized to treat forensic patients to help address our IST waitlist.

This savings reflected updated assumptions regarding activation of the remaining beds for the mission-based review initiatives specific to direct care nursing and treatment team in primary care. In the 24-25 Governor's Budget, we are reflecting a savings of 15.6 million in the current year and savings reported are due to delays and challenges experienced in hiring positions that were authorized for the patient-driven OEM operating expense and equipment update the department is requesting 10.8 million in budget urine, ongoing to support the increase in patient-driven support costs within the DSH system specific to utilities, pharmaceuticals, and foodstuffs.

For the infectious disease prevention item, we're requesting 25.9 million in 24-25 and 7.7 million in 25-26 and ongoing for expenses expenditures related to infection control measures to continue to protect the health and safety of DSH staff and patients. Additionally, DSH requests permanent funding and position authority for the 10 limited-turn public health nurses positions in fiscal year 24-25 and ongoing to ensure compliance with public health guidelines and regulations.

As it relates to our conditional release program for DSH is not guilty by reason of insanity, offenders with mental health disorders, and incompetent to stand trial patients. DSH assumes a one-time savings 599,000 in the current year as a result of delayed admissions at a Northern California statewide transitional residential program within our conditional release program, and we anticipate a total contracted caseload of 945 in 24-25.

Lastly, as it relates to capital outlay, we are proposing 50.5 million in public buildings construction Fund for the construction phase of the DSH Metropolitan Central Utility Plant Replacement Project. The project includes the replacement of the existing plant located at DSH Metropolitan that presently supplies steam for hot water and central heating, as well as chilled water for air conditioning to 32 patient housing and administrative buildings.

At this time, I'd like to turn it over to Mr. Donaldson with the Department of Finance and our Department of State Hospital's Chief Deputy Director Brent Houser to provide information on the psychiatric loan repayment program, proposed reversion and an overview of workforce efforts that is requested in the agenda.

All right. Thank you, Chair. Joseph Donaldson, Department of Finance. The governor's budget reverts 14 million total with 7 million general fund in 22-23 and 7 million mental health Services fund in 23-24 for a state hospital loan repayment, retention, and recruitment program. This program was administered by the Department of Healthcare Access and Information. These are unspent and unencumbered funds being reverted as a solution to the budget shortfall. Additionally, this program directly impacts terms and conditions of state employment.

Unions may collectively bargain for any program impacting the terms and conditions of employment in accordance with the Ralph C. Dills Act. I also note that while the governor's budget does include this budget solution of reverting this 14 million, I would want to highlight that within the 23 Budget Act, Department of State Hospitals had a BCP for the psychiatry workforce pipeline recruitment and hiring retention program.

The department received seven total positions and an ongoing appropriation of starting with 6.5 million in 23-24 and then increasing to 8.3 million in 27-28. This appropriation that was included was for the development implementation of pipeline recruitment and retention initiatives to sustain and grow dishes psychiatric workforce. From there, I will hand off to my Department of State Hospitals colleague for more additional program specifics.

Great. Thank you, Joseph. Good morning, Chair. My name is Brent Houser. I'm the chief deputy director of operations for the Department of State Hospitals. While my colleague from the Department of Finance spoke specifically to the psychiatric loan repayment program, the agenda also requested that the department speak to our workforce challenges more broadly as well as strategies to improve recruitment efforts specific to psychiatrists.

Recruitment has been historically challenging for the Department of State Hospitals and has only been exacerbated as a result and during and after the pandemic. While DSH is not alone in our staffing challenges, we certainly present some unique challenges specific to our employing our workforce due to multiple factors. First, the individuals we treat are some of the individuals with the most difficult-to-treat behavioral health challenges, some at risk of significant violence level.

This, coupled with the geographic locations of some of our facilities and nationwide shortages make recruitment very challenging for the Department of State Hospitals. As a result, we have implemented a multifaceted approach to our recruitment and retention efforts now, highlight a few of those apologies for lack of brevity. There's a number of efforts underway, and I'll just provide a brief overview today.

We've specifically implemented strategies across four different domains focused on marketing and outreach, streamlining the hiring process, expanding and developing training programs, and then employee compensation. Focusing on the marketing and outreach aspect of what we're doing traditionally, we focus on attending job-related fairs hosted by colleges and universities.

In recent years, DSH has expanded the use of these methods as well as identified new strategies such as contracting with a marketing firm to find more innovative ways to reach prospective candidates that we haven't historically used, whether that's through social media, virtual career fairs, and online platforms. Specific to streamlining the hiring process, we've received feedback over the years that the civil service hiring process has been rather challenging, particularly for individuals that do not have prior public sector experience.

As a result, we've taken steps to reduce barriers to employment, such as implementing one-day rapid hiring events where we're able to provide contingent job offers same day, as well as developed a dedicated recruitment unit to guide psychiatry candidates through the hiring process. Additionally, focused on the third domain, DSH recognizes that and compensation and benefits are a critical topic as it relates to recruitment efforts of our workforce.

While the California Department of Human Resources is the control agency who leads negotiations with bargaining units, DSH does participate with CalHR in the collective bargaining process, which has recently resulted in various compensation increases that are reflected in the most recent bargaining unit agreements. For psychiatry specifically, the most recent bargaining agreement reflects a 15% pay differential for on-site psychiatrists, a general salary increase, retention bonus increasing incrementally up through year seven, and a healthcare provider recognition payment.

While those above strategies have been very helpful to the department and are necessary, overall, DSH's most important and effective recruitment method has been through the development and implementation of training programs. As an example, DSH developed its own psychiatric residency program in partnership with St. Joseph's Medical Center and DSH Napa. Our first cohort of seven residents was stood up in July of 2021. The next cohort size is starting in July of 2024 and is up to 10 residents now.

Not only does this program enable the department to add psychiatric personnel and direct patient care roles, the ultimate goal is to also serve as a pipeline to employment with the Department of State Hospitals. Since it's been our experience that the folks that we train generally stay with us, but certainly not everyone. With respect to the 2023 Budget Act investments that Mr. Donaldson highlighted in his testimony, I'll just provide a few brief updates.

DSH received resources to add a second residency program in partnership with DSH Patton. We've identified a learning institution to partner with to create a new psychiatric training program. It's anticipated this program would have four to seven residents per year. In March of 2024, the ACGME or Accreditation Council on Graduate Medical Education visited, and its pending formal approval. Related to expanding psychiatric fellowships and resident rotations, DSH has numerous engagements, either completed or in process, with many universities and hospital systems across California.

Just to highlight a few, we have partnerships at UCLA, UCSF, Stanford University, Riverside University, Loma Linda, UC Davis, and Community Memorial Health System. While most of these updates are specific to psychiatry, DSH utilizes many of these strategies across our clinical, nursing, and safety-related classifications. This concludes our testimony on issue number one, and we're available to answer any questions. Thank you for the opportunity to present today.

Thank you so much for, for your presentation. Since we ended with the psychiatry loan repayment program, let's start there. Refresh my memory again why you didn't use the money?

It's Joseph Donaldson, Department of Finance. Not that it was purposely not used. It was just the funds had not been implemented or were in flight. So when we were determining, you know, holistically at possible budget solutions, finding solutions that were not going to disrupt programs in flight, we identified this as a possible proposal, but noting that while this specific appropriation was selected for reversion, state hospitals already had other programs related to recruitment and retention that were not disrupted by this proposal. So that was the rationale for that selection.

Okay, maybe I should rephrase the question. Why was this loan repayment program not started?

So, in terms of implementation, as noted, so this program was collaboration between both HCI and DSH, or Department of State Hospitals. The implementation was underway at the time of developing of the governor's budget. In terms of the specifics of why these dollars were not, you know, ultimately implemented, the dollars were not encumbered. I would need to circle back with more information from our colleagues, Department of Healthcare access information, but at the time of developing the governor's budget, these funds were not encumbered.

So that was the rationale for identifying this as a possible solution. So, in terms of limitation, the funds were on flight. So when it was identified, this program would not be, there was no disruption, that funds were not already in flight as compared to other programs that were already underway.

Right. No, I understand why they looked at it and said, okay, these funds are not being used. We're not going to disrupt anything. My question is why were the funds not used? Do you have enough psychiatrists?

Speaking, I think just from on the periphery, since the program wasn't budgeted in Department of State Hospitals. I understand in working with HCAI and trying to develop this program that it was a new program and there was a lot of work that needed to be done to create an application eligibility criteria as well as that process. So that is, while I can't speak for HCAI, that is my understanding, in addition to their priorities and implementing the numerous programs that workforce programs that they're responsible for implementing.

With respect to your question, do we have enough psychiatrists? I would say we certainly have lots of challenges with recruitment of psychiatrists and we do have to rely on contracted psychiatrists. While our preference and all of our strategies are aimed at relying on civil service psychiatrists, we do have to rely on contracted psychiatrists.

So I think I would say we would certainly seek to employ and recruit more civil service psychiatrists, which are programs that I spoke to briefly on training programs are trying to establish, introducing those folks in a training environment at DSH, having them complete the residency and fellowships with us and hopefully staying on board with us, which has been proven to be a successful ability for us to recruit civil service psychiatrists.

Right. And I applaud your efforts for that. Having gone through a residency program myself, I understand that it takes a while to finish your residency program before you can get to that point where you are actually hired as an attending or a civil servant psychiatrist. Additionally, yes, a lot of people do stay where they trained. Not everybody does. I am an example. I trained at Cook County in Chicago, and clearly, I'm here back in California right now. So my question still stands. Do you have enough psychiatrists, civil servant psychiatrists today?

We have enough psychiatrists today to meet our patient care needs. However, we would one day seek to not have any contracted psychiatrists and it would be all civil service. So I would say there's more.

You don't have enough civil service because you're contracting right now? Is that what you're saying?

No, I'm not saying we can't. We have an inability to consistently hire and recruit civil service psychiatrists. So in order to continue to meet patient care needs, we do have to rely on contracted civil services. But as we hire more civil service psychiatrists, we will attrition contracted psychiatrists, for example.

I understand that. Today, today, do you have enough civil service psychiatrists?

Today, we have enough civil service psychiatrists to meet the needs of our patients.

Okay, so you don't have any contracted?

We do have contracted. We have about 130 civil service psychiatrists and about 49 to 50 contracted psychiatrists.

So if you have enough civil service, why do you have some that are contracted?

We do need to rely on contractors at this point to fulfill all of our patient care needs. So in the ideal world, we would have zero contracted psychiatrists, and that's what we're seeking to do.

Okay. So it doesn't sound like you have enough civil service, which is why you have contracted, to kind of fill in those gaps. You mentioned yourself that there, and I've seen it through the paperwork, that there is an issue with recruitment at this time. Do you think that having in your pocket, in addition to all of these other things that you're doing, including, you know, the pay raise and the retention bonus and all of those things are great? Do you think the ability to give a loan repayment program, would that be attractive?

I think given the healthcare staffing challenges in our system across the board, any number of programs that support recruitment and retention would be beneficial to the department. However, I also recognize that in a tough budget situation, that we have to make difficult decisions for programs that impact baseline services or not. And in this particular situation, while that program would be beneficial, it was a necessary item in order to meet a balanced budget.

I don't mean to go a roundabout way of answering your question, but I think that's how in a budget shortfall situation, there are difficult decisions have to be made. And I know that the governor's budget is starting point for engagement with the Legislature on making some of those difficult decisions.

Right. So. And we do have to make difficult decisions. Right? But I think one of my concerns is that we know that we have a behavioral health crisis here in our state. Looking at the numbers and the trends of the patients or the individuals that you all see, those are going up. And yet we had a tool in the toolbox that is a loan repayment program that would have complemented what you're already doing, and that was never implemented.

I would have loved, loved to have gone to a place that had a loan repayment program. Many providers would love to go to a program that has a loan repayment program. The fact that this was appropriated and never used is quite honestly disappointing because we saw that there was clearly a need to get more psychiatrists and gave the tools to use to get more psychiatrists in, and it was not used. And so we'll continue to discuss this, but I do know that this was one of the Legislature's priorities this blown, and I would like some follow-up as to why the program was not started.

Thank you. We have a number of different pathways that individuals discharge from the Department of State Hospitals. As it relates to individuals who are incompetent to stand trial, those individuals, when they are discharging as either competent or not likely to regain competency or reach their maximum commitment time, they actually are returned back to the jail. And then from the jail, they are discharged back to their county programs.

So we actually, within the incompetent to stand trial solutions budget package, proposed positions and funding to assist with our efforts to help connect individuals who are being returned as incompetent to stand trial back to their county programs and working to ensure that not only are we providing discharge information to the jails, because we do have to provide that continuity of care between us and the jails, but also working with our county partners to further strengthen their ability to get information for those individuals.

Because some of them do have rapid discharges from the jail. We may return them as competent and, very shortly thereafter, their charges may be dropped. There's also a number of efforts that are outside of the Department that are working to strengthen the ability to provide services for individuals with serious mental illness in the community, and particularly those with justice involvement. One of those being the county Justice-Involved initiatives and the 90 day in reach program. So some of those efforts were also helped to ensure that individuals that were returning from the state hospitals are getting connected to care.

Thank you. And you mentioned the delay in the admissions in the Northern California Statewide Transitional Residential Program. Do we know why there was a delay?

Yeah, we actually worked with our provider to pause admissions proactively to help strengthen the program, recognizing that we needed some additional training and program development there and then began and then have recently restored admissions and are working to fill that.

Were there issues that occurred?

I don't remember recall off the top of my head the very specific concerns that were being addressed at this time, but we can certainly follow up.

Thank you. And, you know, again, looking at the trend, your numbers are going up. You have a waitlist of individuals that need treatment, and yet the proposed budget is a slight decrease. Do you believe that you're going to be able to achieve everything that you need to with an increase, a continued increase, in your patient load, and, I would assume with that increase, probably an increase in the severity of the cases that you're treating. With the decrease in your budget, what do you foresee in the future?

So the decrease in the budget was actually related to one time dollars that primarily that were falling off just as the natural movement from last fiscal year one time dollars not carrying over to the current fiscal year. So we're not substantially reducing the Department's ongoing operations in any way.

I'd also note that we haven't gotten to the next item yet where we'll talk a little bit more about the incompetent to stand trial population, which was major driver for the recent years and investments and the driver for the waitlist. I'm happy to report that the waitlist is substantially down. And we'll talk, I can provide, you know, a greater in depth update when we get to the next item.

But overall, what we're seeing this year is that, you know, we are, we have rapidly implemented the IST solutions. Our waitlist for the incompetent to stand trial population is substantially down. We're also seeing a stably that the referrals this year have somewhat stabilized to last year where we had historically seen year over year growth in referrals. So right now all the indicators are looking pretty good as far as our ability to meet the and provide timely access to treatment for individuals that are being referred to the Department.

And what do you think, from your standpoint, would be the most important accomplishment of your Department over the last year?

The ability to reduce that waitlist substantially and provide timely access. I'm very proud of the entire team for all of the great work that they have done in partnership with our county providers, our county sheriffs and private providers. There's just been a huge amount of effort in implementing all of the IST solutions and rapid implementation to ensure that individuals are getting time lacks to care.

Okay, good. Can you explain the findings of the Mission-Based Review and how it has impacted your Department?

Yes, I'll actually hand that over to colleague, Mr. Houser, to address.

Good morning again. Specific to the Mission-Based Review, I'll just provide a brief overview and some of the findings and a little bit of background about this approach. It was a review, a multi-year collaborative effort with the Department of Finance that looked at several areas and operations of DSH, primarily around an analysis of past practices and staffing methodologies to make sure that they continue to be adequate for what we've experienced in the past decade as an increasingly shift to serving of forensic patients, as well as increasing aging patients.

The Mission-Based Review specifically had five different components. There was hospital forensic departments, 24 hours care nursing, protective services, which is our hospital police, treatment planning and delivery, and then workforce and retention. As part of this components assessment, this engagement reviewed current staffing standards and practices.

It did propose new data driven staffing methodologies that accounted for shifts in population, as well as the need for relief factor so that we have adequate coverage to provide care to our patients. And ultimately, what it found is that the Department needed additional resources. And this Mission-Based Review resulted in five proposals across those five different components that had added resources, positions, and funding over a period of five years, and we're still in the process of implementing those proposals.

Director Clendenin mentioned that we are reporting some savings, as we are having recruitment workforce challenges and hiring all of these positions, but we have filled a great number of them. For example, on 24 hours care nursing, we received around 335 psychiatric technician positions. We filled around 180 of those positions. And what the Mission-Based Review identified is, for this particular classification, it provided a dedicated resource to conduct medication pass on each of the units.

So prior to the Mission-Based Review, this was a position that would be considered in count, and someone would have to do medication pass to our patients while counting towards the licensed minimum counts. What we identified is this was an area of opportunity that had some safety issues. So the Mission-Based Review identified this post should be someone's dedicated position, and that's what we were in the process of continuing to implement.

And as I mentioned, we have hired about 180 of those psychiatric technician positions and continue to implement efforts to do so. There's much more related to the Mission-Based Review. I can go in a bit more detail on some other aspects, but I'll just check in with you, Chair, if you'd like a bit more detail.

So do you believe that, overall, that this review that you had was beneficial to your operations?

Most definitely. I think, specific to DSH, it allowed us to do a few different things to build more consistent practices and standards that served as a baseline for us to make adjustments every year based on shifting demographics, based on patient... For instance, if we're serving more individuals identified as incompetent and stand trial, that may drive workload for more court reports or something like that, and allowed us an ability to make adjustments to staffing accordingly. It also, I think, brought more data driven decision making.

So we were using what we're seeing in shifts in patient and their needs in order to align staffing with those resources. So it has been tremendously beneficial, and we certainly continue to work towards implementing it and also make adjustments as things change, as what we're seeing in the population that we serve.

Well, I'm very happy to hear that it is helping and that it was of benefit. I think the Assembly should probably encourage the Administration to conduct more of these reviews of some of our other departments. But I will turn it over and see if Assembly Member Bonta is good. And now that I am not the only one, we're going to pause and call roll.

[Roll Call]

All right, well, I want to thank you all so much. We will end this first panel, and we will move to our second panel. And on the panel, Stephanie, you're staying, Christina Edens, Joseph is staying, and Will. Welcome.

Good morning. Stephanie Clendenin, Director of Department of State Hospitals. Issue number two on the incompetent to stand trial solutions, as of Governor's budget, the Department of State Hospitals is projecting the savings of 58,573,000 in current year related to several incompetent to stand trial solutions, including their Jail Based Competency Treatment Programs, community inpatient facilities, and Early Access and Stabilization Services, and request two positions, position authority only, to support efforts related to the IST growth cap implementation.

By way of background, over the past decade, the Department of State Hospitals had experienced significant growth in the number of individuals found incompetent to stand trial on felony charges and referred to the Department for competency restoration, with year over year growth in IST referrals outpacing the Department's ability to create sufficient additional capacity. Until recently, despite DSH efforts to expand treatment capacity, IST referrals outpaced DSH's efforts and resulted in an ongoing waitlist for individuals needing restoration of competency services.

Additionally, as a result of the impacts of the COVID-19 pandemic and necessary infection control measures that we had to implement at the state hospitals during the first two years of the pandemic, the waitlist and wait times increased significantly. As a result of a 2015 lawsuit by ACLU regarding the time that IST defendants were waiting in jail to be transferred to DSH's treatment programs, the court ordered the Department to initiate substantive treatment services within 28 days for IST defendants.

The court set a deadline for the Department to achieve the 28 days, which was originally February of 2024, and also set interim benchmarks for the Department to achieve towards meeting the 28 day requirement. Last fall, recognizing the impacts of the pandemic, the court reset the deadlines, and we are now to achieve the 28 days by March 1 of next year, and interim benchmarks have been set for 60 days by March 1 of this year, 45 days by July, and 33 days in November.

The 2022 Budget Act included a significant investment towards additional IST solutions. These solutions, along with other investments in prior budget acts, included short term and long term strategies centered around two primary goals. The first, to initiate treatment services for IST individuals within 28 days as required by the court, and then increase community based restoration and treatment and diversion options with the goal of reducing criminalization of individuals with serious mental illness.

As a result of rapid implementation of the IST solutions, easing of pandemic impacts on our DSH facilities, and other efforts we've had underway, we have seen substantial decrease in both the IST waitlist and wait times. During the pandemic, in January of 2022, we had reached an all time high of 1953 individuals on the IST pending placement list, and times to treatment were averaging over 140 days. As of March 18, 2024 we had only 426 individuals on the pending placement list.

426 individuals represents less than one month's worth of referrals. As this fiscal year, we are receiving an average of 486 referrals per month, and the average time to initiating treatment for IST individuals in February 2024 was just 12 days. At this time, I'd like to turn it over to Chief Deputy Director Edens to provide some updates related to the specific short term and longer term solutions and the savings we are projecting.

All right. Good morning, Chair. Can you hear me okay? Okay. So in the short term, we've really been focused on meeting the 28 days as required by the court through implementing a number of different strategies, all really aimed at reducing our waitlist. Because, if you can imagine, we had a backlog of individuals as we were receiving, continuing to receive, a number of referrals every month.

And so the strategies that we've been focused on in this last year have been, one, performing IST reevaluations for individuals who are awaiting transfer to a treatment program to see if they've restored a competency and no longer need restoration of competency treatment. As of Governor's budget, we completed over 4800 re-evaluations, of which 32% of those individuals were found to be restored to competency and did not need to be admitted to a DSH treatment program and were returned to court.

We're also implementing what we call Early Access and Stabilization Services, or EASS for short, in our jails. Under this program, IST individuals receive stabilization and treatment services at the earliest point possible in jail while we work to coordinate placement to the least restrictive treatment setting available within the IST continuum. As of the Governor's budget, we implemented EASS programs in 44 counties and growing. Despite the rapid implementation of this program, there are still several large county programs anticipated to be implemented in the future.

Thus, there is a one time savings in the current year of $20 million for this program. We're also expanding our Jail Based Competency Treatment Programs to provide additional short term treatment capacity. There are currently 424 JBCT program beds across 24 counties, and we are reporting a net savings of 8.6 million, also in the current year, for this program as a result of updated timelines associated with finalizing contracts for new and expanded programs. Additionally, we are utilizing community inpatient facilities.

These are local IMDs, MHRC programs to provide restoration of competency and stabilization services. As of the Governor's budget, we've contracted with five community facilities for a total of 173 beds located in Sacramento, Yuba City, Anaheim, Bakersfield, and LA. We've also executed a construction contract with Crestwood Behavioral Health for the activation of 36 to 40 mental health rehab center beds located in Fresno County.

Due to the lengthy negotiation process required to secure our additional contracts, we're also projecting a one time current year savings of 30 million for this program. In addition to increasing bed and treatment capacity, we've implemented care coordination and waitlist management teams within DSH's patient management unit to utilize a patient centered approach to placement. As of Governor's budget, these teams have been implemented within our DSH's Patient Management Unit to serve all 58 counties. We're also implementing the Felony IST Growth Cap Program.

This program aims to address the increasing rate of referrals to the Department by establishing a baseline number of IST determinations for counties based on fiscal year 21-22 rates and assessing a penalty if the county exceeds the referral level by a certain threshold. The Department worked with county representatives to finalize the parameters for this program and has issued baseline IST numbers for each county, final IST data for fiscal year 22-23, and currently the Department is in process of finalizing reconciliation of the final referral data with counties.

Based on our preliminary 22-23 referral data, there are potentially 11 counties that may be issued penalties associated with an increase in IST referrals. Those penalties range anywhere from 34,500 to 13.6 million for a total value of 26.1 million. DSH is requesting position authority only for two positions to support the significant data needs to operationalize this program, which were not contemplated during the initial development of the original IST solutions budget package. In addition to these shorter term actions, we've also been focused on the longer term strategy of building out community based treatment and diversion options for the IST population.

These strategies are primarily centered around expanding felony IST community programming via community based restoration and diversion programs. To support these programs, one time infrastructure funding has been allocated to establish up to 5000 beds in the community to serve IST individuals. We've executed a contract with Advocates for Human Potential to assist the Department with the application and funding process for this infrastructure funding.

As of the Governor's budget, applications are being accepted on a rolling basis, and four counties have submitted proposals to AHP, and contract negotiations are underway to develop 412 beds to house felony IST defendants, and 26 additional counties have expressed plans to submit applications in the future. Also, specific to Los Angeles County, we've expanded their program.

Since 2018, the Department has had a partnership with LA County to implement community based restoration and diversion programs in that county, and in the last year, in the summer of 2023, we executed an updated contract with the county to expand this program from 515 beds to 1344 beds, which will be phased in over a five year period.

We're also working to establish permanent diversion and community based restoration programs, which will be basically operated out of the infrastructure funding that we're currently working on, and those programs will be in all other counties across the state. The IST solutions budget package included the ongoing funding to permanently implement IST diversion as our 2018 IST diversion pilot comes to an end. Current progress in this area includes contracting with a consultant group called Capstone Solutions on the permanent statewide programming structure.

We facilitated a number of webinars for counties to provide information about the process for applying for permanent diversion program funding, and we've issued a letter of intent process to assist in prioritizing the counties that are ready to begin planning and implementing permanent diversion and CBR programs. The first round of those letters of intent were due by March 31 of this year.

In addition, to support local program planning, we're also awarding county stakeholder workgroup grants to support behavioral health and criminal justice workgroups established to work on diversion and CBR program efforts and to identify and implement strategies to reduce the number of individuals being found IST on felony charges. To date, we've executed contracts with 32 counties to implement the state stakeholder workgroups. And, with that, that concludes my presentation. Happy to answer any questions.

Thank you so much for your thorough presentation. I'm going to see, Assembly Member Bonta, if you have any questions. I would like to commend you all on, first, reducing your wait time and also implementing all of these different approaches to deal with your IST population. It's incredible hearing about all of the different programs that you have going on, how you've thought outside of the box in order to comply with trying to get people in quickly but also ensure that you're restoring them to competency. What is the average time length to restore an individual to competency?

It does vary.

It does very. I have that data handy. Hold on, let me just pull it up really quick. So the average length of time that someone stays within our programs as an inpatient is usually, on average, about 131 days. And then, for outpatient programs, those are actually designed to be longer term treatment programs. So they're averaging about 409 days as of last year.

But to restore them to competency, how long does that average?

That is the timeline for the total length of stay with us. So that would be them restoring to competency and returning them back to court.

So, when you have that 28 day requirement, are you meeting that?

So the 28 day requirement is effective March 1 of 2025, so next year. Currently, we are, as of March 1 of 2024, the court's benchmark is for 60 days. We are, on average, providing treatment within 12 days, as noted in February's data. Our most recent report that we just filed with the court that was data through the end of February reflected that 98% of our admissions are meeting the 60 day timeline that we're currently required to be meeting.

And what factors do you think are kind of going into the increase in your IST population or the number of patients that you're now being referred?

Yeah, we looked at that over the years and really started studying this population sometime around like 2015-2016 timeline, as we started to see the increase in the number of individuals being referred. And our initial response was just to activate as much capacity as we can, open up all of our state hospital beds, and see if we could address the waitlist.

And as that referral base kept continuing to increase, then we started to look at what is happening and what could be potentially contributing to increases in our IST referrals. Ultimately, looking at the data, and we have an incredible partnership with UC Davis. We had about 10 years worth of IST data from our Napa State Hospital that we had with UC Davis, and really gave us opportunity to take a look at that population and see if there was any changes over time across our IST commitment.

And, ultimately, we didn't really see any change in demographics. There wasn't really anything that stood out from... It's not an aging population. We didn't see any changes in the demographics. The one thing that we really saw that really stuck out was there was a data field that we were capturing was the number of prior arrests. You know, how many IST had 15 or more prior arrests before they came to us.

And we saw a substantial increase over time in the number of individuals that were being referred to us with this high number of prior arrests, which are opportunities for engagement. But what was interesting is that, with those increase in the number of prior arrests, it wasn't an aging population, so they were just seeing increased criminal engagement.

So then, ultimately, we then started to look at this population from housing status, and then did a study on our population during the time to look to see what percentage of our population was unhoused at the time of arrest. And the numbers are escaping me off the top of my head. It was approximately 50%. Chris, I think you know it better than I know.

It was about 50% of the individuals that were being admitted into our state hospitals were unsheltered at the time of arrest. And when you include those that were in sheltered, a sheltered homeless status, it was well over 60% of the individuals coming into our system were homeless at the time of arrest. In addition to that, we did partner with DHCS to match up our Medi-Cal utilization data to this population.

We also found that about 45% to 50% of the individuals had not accessed Medi-Cal mental health reimbursable services in the six months prior to leading up to their arrest. I think we also, in addition to not finding that there were any significant demographic or diagnostic changes in the population, we had also noticed that there was not a significant change in the number of individuals that were coming in with sort of a methamphetamine or substance use disorder.

There was or there was not?

There was not a significant change in the time period that we were looking at. And so, really, between the homeless status, between the lack of accessing community services, we really hypothesized that folks were, basically, they're in this untreated homeless status. They are acting in ways that are making people feel uncomfortable, and they are interacting with law enforcement. That is then getting them into situations in which they are then now landing felony charges and coming into our system.

And so that partnership with UC Davis and that research is what has led us on this path to expand our IST continuum beyond just state hospitals and inpatient programs, through the Jail Based Competency Treatment Programs, but really focused on the long term strategy of building out community based programs, CBR and then diversion programs, while individuals are IST. Because folks can be in that IST commitment status for up to two years. So utilizing that into time to stabilize, get folks settled into long term treatment, and then closer to home, so that we can then facilitate a warm handoff to ongoing community and housing services post-IST commitment.

That's an interesting finding, and I'm glad you guys looked back at the data. So, essentially, lack of access to care and lack of housing led to increased, like you said, interaction with the police or law enforcement, which then led to their diagnosis of incompetent to stand trial and then getting into a whole system. And so if we can fix those things early, then we don't have that incompetent to stand trial, we don't have that interaction with law enforcement. So thank you. All right. Now, there is a trailer bill that we were supposed to be receiving from the Governor's Office. Do you all have a report on anything?

Thank you, Madam Chair and Members. Matt Aguilera, Department of Finance. So, I apologize that the language is not in public, and we're still working on that. It's under internal review, and I hope to have it posted very soon on the DOF website for public consumption. And I would respectfully ask that the Committee hold the item open, if possible, before we finalize the health trailer bill.

Well, I'm sure that you all are aware that all trailer language is supposed to be in by February 1 so that we can have open discussions, transparency prior to us moving and voting on anything. And, you know, one of the things that is extremely important is that we have that discussion, that open discussion, and that transparency. And saying that it is over two months after February 1, I am actually going to entertain a motion to reject the proposed trailer bill. Okay.

[Roll Call]

Okay. That passes three to zero. Timeliness is important for our constituents. And, with that, if any of my colleagues have anything else that they want to say about this hearing. Nope? All right, well, at this point we will, I really appreciate everyone for coming. Before I adjourn, I will open it up to public comment if anyone has anything that they would like to, any comments that they would like to make.

Thank you, Chair, Committee, and staff. Ryan Morimune with the California State Association of Counties, here to provide some brief remarks in regards to issue number two. First and foremost, we appreciate the Administration and Department and Legislature as well for their significant investment and ongoing efforts over the years to reduce the IST waitlist. And we share that goal of looking upstream, as noted earlier, before an individual comes in contact with our criminal justice system.

But as, specifically, excuse me, specifically as it relates to the Department's growth cap and penalty program, which is part of the larger IST solutions package, despite county opposition, we remain committed partners in implementation of this. And again, I thank Director Clendenin, Deputy Director Edens, and all staff, but we hope that we can continue to develop strategies and solutions after taking a look at year one of implementation and the data and what that's telling us and how we can make the program a little bit less punitive.

And lastly, you know, just as shared by Committee, we look forward to reviewing trailer bill language and hope that counties are included in that conversation, given that many of the IST solutions are led or require county level services and staffing as well. And so again, thank you for the discussion and appreciate it.

Thank you, Madam Chair and Members. Geoff Neill representing the County of San Diego, also on the same item as my colleague Ryan. Just want to point out, as he did, that the proposed budget does still include the penalty for the County of San Diego. This will be an estimated direct county funding. This penalty, estimated to be $6 million, for the number of justice involved individuals that judges deem to be incompetent to stand trial. I think the county would like to see a lower penalty amount.

We know the penalty dollars do come back to the county as directed funding, and I think, at the very least, the County would appreciate having a date certain by which those funds would be returned so that for budgeting certainty and so they would know when they could implement the required programs with that funding. Thank you.

Okay, well, thank you so much for the public comment. And, with that, this hearing is adjourned. Thank you.