Senate Budget and Fiscal Review Subcommittee No. 3 on Health and Human Services

We are in mental awareness month. We're going to be talking about behavioral initiatives. Really excited to see how we're going to take such a huge lift of Prop one and help that come to fruition. So really looking forward to the conversations. One little change in the agenda on the item 0530 for the Office of Youth and Community Restoration. We're going to actually be pushing that and not be hearing that today. We're going to be pushing that till next week.

Just to give more time for me to read through the report that just came out yesterday. Okay. With that in mind, we're going to do Department of Health Care Services. We got Department of Public Health, the Mental Health Service Oversight and Accountability Commission, the new title that we're going to be hearing on it and we're going to be starting with the Department of State hospitals as well. And we're going to be starting it off with a panel on Prop 1 and what our vision is.

So I'd like to invite those who are going to be speaking on this to come on up. We have representatives from DHCs, representatives from CDPH, Lao, Department of Finance and representatives from the MHS OAC. I also like to welcome back up the ED from our county Behavioral Health Directors Association of. California. Are we all here? zero yeah. Doctor Tomas. Doctor Boss. I'm guessing that's Toby next. Michelle. That's Toby. And then. All right, we're being blessed with two Michelles today. All right, we'll start off with DHCs.

Good morning. Chair Michelle Boss, Director of the Department of Healthcare Services. I don't know how we do the slides. I think we have a slide deck. Or do I do it?

We got. I think we might need your help.

Thank you very much. So this morning I'm going to provide an overview of Proposition One. As you know, Proposition One was passed by the voters in March of this year. It is a two Bill package essentially representing SB 326 from Eggman last year and then AB 531 from Irwin. I'm really proposing statewide efforts to reform and expand California's behavioral health system.

Some of the goals of Proposition one were to improve statewide access to behavioral health services, increase behavioral health treatment facility infrastructure, expand housing and infrastructure for Californians with the most significant behavioral health needs, increase investment in expanding the behavioral health workforce and expand investment in early intervention services with a focus on children and youth. Two of the components of Proposition one are the Behavioral Health Services act and the Infrastructure Behavioral Health Infrastructure Bond act. And we'll speak to both of those.

As part of this presentation, the Behavioral Health Services act, or BHSA, replaces the Mental Health Services act of 2004. It reforms behavioral health care funding to prioritize.

We're gonna pause. We don't see the slides just yet.

oh, I haven't moved it yet. Sorry. This is just a quick overview.

Okay. So nothing should be shown right now.

It's not displaying. It's not that cover. There we go. I don't know. Hands are in my lap right now. Prioritize services to individuals with the most significant behavioral health needs, adding the ability to use these dollars to serve individuals with substance use disorder needs, expanding housing and interventions, increasing the behavioral health workforce. And then just as a summary, the Behavioral Health Infrastructure Bond act authorized about 6.4 billion in bond funds.

So with regard to the Behavioral Health Services act, really the key pieces, one of the key changes related to the BHSA compared to the MHSA is a change in the revenue distribution. Under BHSA, 90% of the revenue goes to our county partners and 10% goes to statewide investments. And we'll go through each of these in more detail. But just as a summary of the local dollars, 30% housing interventions, 35% for full service partnership programs and 35% for behavioral health services and supports.

And then at the statewide side, statewide investments, 3% state admin generally across many departments, 3% for workforce and 4% for prevention at the Department of Public Health. And the next slide here is just really a sample BHSA allocation. Your agenda includes information on this as well. Just really representing, just, for example, 3.5 billion in BHSA revenue. And of that, the vast majority, 3.1 billion going to our local county partners. And you could see the split of the allocations there. I won't go into those details.

As we know, the weight of behavioral health challenges and crisis are really not carried equally. And so as part of BHSA, we really are focusing on eligible adults and older adults who are chronically homeless or experiencing homelessness, or at risk of homelessness, in or at risk of being in the justice system, re entering the community from prison or jail, at risk of conservatorship or at risk of institutionalization, and then for our children and youth, focusing on those who are also chronically homeless or experiencing homelessness or at risk of homelessness, in or at risk of being in the juvenile justice system, reentering the community from a youth correctional facility in the child welfare system, or also at risk of institutionalization.

We know that through strategies that are culturally responsive, we can reduce health disparities and improve health outcomes. You know, we are part of our effort, and we'll go through this in more detail, really thinking about how do we reduce silos for planning and service delivery and setting clear principles that are rooted in equity.

How do we think about stratifying our data and the strategies for reducing health disparities as we look at our data and plan for interventions that are very specific to the populations that we want to serve, really advancing community defined practices as we think about how to reduce health disparities.

Again, recognizing that targeted interventions or targeted programs are often the most effective in reaching some of the populations that may be experiencing disparities and then also just recognizing, wanting to have more diversity and more kind of vast experiences as part of the different advisory groups that have been included or a part of the BHSA. One of the key features of the BHCA is the county integrated plan for behavioral health services and outcomes.

Today under MHSA, there is a local, robust planning process that really is focused on MHSA funds only under BHSA, really thinking about all local, state, and federal behavioral health funding. So it's the BHSA dollars, opioid settlement dollars, some of the federal grants realignment dollars, FFP or federal dollars, and behavioral health funding.

On the Medi Cal side, as well as part of the integrated plan for behavioral health services, our counties will be working with a robust set of partners at the local level to think about how to come together to put this plan together to consider what are the communities or the region's behavioral health needs.

Also thinking about how to maximize opportunities of other planning opportunities, such as the Medi Cal managed care population needs assessments, the work that our local health jurisdictions do with community health improvement plans, and how these plans can bolster and work together and not be in siloed and kind of work separately from one another.

Excuse me, through the chair, if I may. 1 of the partners that I didn't hear you mention was just private insurance and the private market. We're also including them because they are also a funding source that should be able to come in with some of the population.

Yes. And so as part of that, we also have, the BHCA also has requirements with regards to counties maximizing commercial coverage and maximizing opportunities to contract with each other. And so they are part of this, the requirement for kind of even the transition between, you know, maybe the more mild to moderate and specialty, and how that works both ways from counties to plan, plan to counties. And that is a key requirement as part of this planning effort.

Okay, I didn't hear you mention that part. I just wanted to make sure that's in there.

Another key piece of this is really, again, just the outcome and accountability component of this. So that three year plan that will be used to identify how counties will use their dollars as part of the three year planning process and then annually after the fact, essentially reporting to the state and to their communities how these dollars were used, what were the funding levels that were achieved, how data on workforce, for example, data on quality metrics, kind of the work through how state behavioral health outcomes and county local behavioral health comes, what was achieved were the benchmarks are, and then also thinking about how we do this from kind of a stratified data perspective as well, to really understand the disparities and the outcomes by population.

What happens if there's unspent dollars?

Pardon me?

What happens if there's unspent dollars?

That will be part of the conversation. But today, I mean, it's just to actually have an understanding the transparency of what is available, what's happening at the local level with all the different dollars and the sources that can be used. And so then that's where conversations can be happen. Can happen.

These dollars can easily roll, potentially rollover. Right. Or if. Is there an allocation that has to be spent annually

on BHSA Dollars?

Yes.

Well, it's kind of part of the three year planning process. And so unspent dollars can go into the Reserve or can be kind of rolled over.

So, yeah, and we'll talk about that in a second as well. Other data that will be included as part of the outcomes and transparency report is information on services provided to persons not covered by Medi Cal, including commercial insurance, Medicare and uninsured. So again, to get a better comprehensive understanding who are counties serving and where, maybe some funding sources that may be opportunities to look to maximize as well.

Now I'm going to speak to the first, one of the first buckets in the local allocation, the housing intervention program requirements. As I mentioned, 30% of the local dollars will be used for housing interventions. And this includes dollars for rental subsidies, operating subsidies, shared and family housing capital, and the non federal share for certain transitional rent. 50% of these dollars are prioritized for interventions for individuals who are chronically homeless. Up to 25% may be used for capital development.

We have an exemption for small counties with regard to the 26-29 planning cycle dependent on their local data in the houses, housing and homeless space. And it's not limited to individuals who are in full service partnerships or persons enrolled in Medi Cal. So this is kind of the broad populations that the county serves, and then also recognizing the flexibility for the larger counties or the medium sized counties as well, to have some exemptions from this 30% requirement in future planning cycles.

A little bit more on housing and interventions. Want to just recognize that, that we will be working closely with our counties and various stakeholders on kind of defining these as well, and how they interplay and interact with some of the other housing efforts that are underway as well. Full service partnership requirements. So the second large category of spend at the local level is 35% for our full service partnership programs.

And this includes services, mental health services, supportive services, substance use disorder services, including medication and assistant treatment, community defined evidence practices, assertive community treatment, forensic assertive acute treatment. So those are referred to as act, in fact, supportive employment, high fidelity wrap around. All of these things are going to be required as part of what FSP means today.

We plan to establish and work closely with OAC and other stakeholders the different levels of care in FSP today, FSP is generally not as standardized as where we would want it to be. So defining levels of care with FSP and recognizing kind of the need to build out a bit of a continuum for FSP to ensure we have an understanding for the services provided to individuals.

And Director, would you call all of the things that you listed as targeted interventions when you. I know you use the term targeted interventions a lot, so I want to make sure I understand.

Sure. And I think about some of the community defined evidence based practices. Really, those are some of the targeted interventions. Assertive community treatment, for example, is kind of high fidelity, that there's a pretty prescribed kind of what that means. And so it's some of these other community defined practices, evidence based practices that are. Can be to be a little bit more targeted in terms of what populations are we are hoping to serve.

Director, in this section for FSP, at the bottom, I see some like housing. So would you say the 30% we just talked about on the for allocated for housing interventions, you can tap into this pot as well to use for housing.

The housing is actually the 30%.

30%, yes. But under 35, you also have to support maintaining housing as another eligible.

Sometimes you need services that might be needed to support an individual maintain.

So it would be just the services versus the first 30%.

True housing.

True housing. And we're defining that as all everything, tiny homes, transitional permits, and part of housing.

And the 30%. Yes, and that's what we'll still be working with stakeholders to put a little bit more understanding into those terms. But yes, that's one of the broad categories. Each of these. This is kind of, you know, we're at the point where we have some high level understanding and kind of goals and vision. And I think it's the next level of, as you think about what does this actually mean and what is allowed and not allowed. Right.

Because the first 35% you talked about for housing ultimately most likely is affecting this population.

Yes.

Thank you. I have a question. That's okay. Sorry. Thank you. And I apologize for being a few minutes late. Is there a traditional process that we're going to follow or because of these new allocated dollars, are we going to try to think outside the box and do things differently that are more effective than what we've had in the past for all the money that is spent on housing and homelessness?

And the reason why I asked that question is because I want to know how the RFP process is going to work. Does that go to the counties, to the state, or to each individual county? If somebody is going to come and apply for some of these funds to provide wrap around services or is there going to be an RFP process? Do you guys already have the selected vendors? Is it already predetermined?

So these dollars are all at the local level. These are dollars that go to our county behavioral health departments. And so counties will rfp or contract for the different services as they do today. And, you know, I think part of this is that local planning process also bringing in more funding sources, more programs, more kind of what I call contributors to the kind of the behavioral health system as they think about what is kind of the overall vision for their community.

And so recognizing, I think this is a bit of a different way of doing it than today where it is just the BHS or the MHSA planning. This is a broader conversation at the local level.

So it's all so county funds will be allocated, the state will give the county money, and the county will allocate the funds to the suppliers or the individuals that will take on the services. Yes, provide the service or service providers resources come out from Prop one. Are they going to be allocated from the state based on size of the county, the population of the county, what's the metrics like?

I know that, and I'm not trying to speak for my colleague at the end of the dais over here, but we represent rural communities and for instance, the way that the state allocates transportation dollars, we maintain more highway between the two of us than the cities of San Francisco and Los Angeles altogether. But we get the fewest dollars. So we have the highest medi Cal population base, the highest, you know, rates of housing and homelessness issues because of the Central Valley piece.

And I know they're in big cities, too. But how is the allocation going to be given to the counties? Is it based on population, based on size, based on Medi Cal recipient? Based on what?

So there was no change to the kind of the way the dollars will be allocated to counties or MHSA to BHSA. And so there was no change in that allocation. I can get back to you on specifically how that works, but there was no change to that as part of Prop one or BHSA.

And all construction bids for new housing or anything like that will be strictly county by county?

Correct, these are all local dollars. So these dollars will go to the counties, and counties will use these dollars to do the projects that they plan for.

Okay. And then, like, what? Is there any restrictions? And I guess this is what I'm thinking about. You know, I don't want to say I put my name on Prop one because I really deeply care about the veterans that are out there on the street. And there was $1.0 billion, and I basically made the comment that y'all can keep squandering the 6 billion, but the other billion that's out there for the veterans, I want to make sure that our veterans are taken care of.

I've looked at organization like nonprofits, tunnels, towers, different organizations that, like, buy a hotel room next to a VA clinic and they house like 400 veterans off the side of the street with wraparound services, and they have matching dollars that come from foundations. Are we just going to, is there a way to think outside the box to do things differently so that we can make sure that veterans get the housing they deserve?

Or are we still stuck with, and I'm not trying to be negative, but project labor agreements and you can't do this. And all the issues that prevent us from building housing and providing housing, are we thinking outside the box or are there restrictions?

So the housing dollars are allocated to the Department of Housing and Community Development as part of the Infrastructure Bond act. So there's those dollars and then there's the 30% that go to the local level. There were some streamlining efforts that were part of AB 531 to really try to streamline some of the construction and kind of the ways to build out housing and behavioral health treatment.

And so those are kind of, I think, ways to think about how we can streamline the process to build out these, these housing and treatment settings.

So did I understand you right that only 30% of the housing dollars are going to go to all the 58 counties and the state is going to keep 70%. Why did you just say 30%?

So of the local dollars and maybe I'll go back to the slide. So this is Behavioral Health Services Act revenue dollars. 90% of those dollars go to the county and of those dollars 30% go to housing interventions.

And then 10% goes to the state for admin for workforce and prevention. In addition to these dollars there is the bond act which has about 6 billion in funding for housing and behavioral health treatment facilities and I'll speak to that in a minute. I have a slide on that one as well.

Okay. And that's including the $1.0 billion for veterans.

That's on the right, that's on the bond.

Okay. The bond side. Okay. I apologize. Thank you. Okay.

I think we were here. Okay, thank you. I think we're on this slide now. Just circling back on full service partnership treatment. Not quite right. zero, sorry. Where is it? Thank you. There you go.

Thank you. Just circling back on FSP again, these are the services related to an individual who meets the criteria for FSP, and we plan to build out the levels of care there. One of the questions in the agenda just to kind of highlight was the kind of today, 51% of MHSA revenues are for FSP. That includes the counting of federal dollars. Under BHSA, it is 30. It is. The requirement is on just the FSP dollar, so that 35%.

So thereby, we expect more dollars will be available for FSP spending as counties build out this program. Okay. Priorities for the use of early intervention funds. So this is the 35% behavioral health services and supports bucket under the local dollars. And this includes early intervention workforce education and training, outreach and engagement, capital facilities, technological needs and innovative pilots and projects. This is kind of where a lot of the service dollars will be allocated.

A majority of these dollars must be used for early intervention services, and these services really do assist in the early signs of mental illness or substance misuse detection. And a majority of those dollars must be used for early intervention for services and supports for children or people 25 years and younger. Really the importance of early intervention recognize, reduce negative outcomes, that early identification, and really the thinking about how do we reduce disparities.

We know we have some pretty robust, community defined, evidence based practices that are working well today. And I think part of the work is, part of the work with OAC will be to identify a statewide list of what are some of these practices, and then potentially eventually requiring our counties to implement those statewide practices. And so recognizing the importance of engagement with our stakeholders in the definition of these as well.

Can I get a copy of those slides? Sorry, Madam Chair.

Yes, of course.

Director on SUD treatment. Previously we were talking about capacity building and so forth. It seems like we need a lot of capacity building on the SUD treatment side. Are we looking at prioritizing certain things and streamlining those over others? Hopefully, Michelle here says yes.

So I will also say as part of the BH connect our federal waiver before the Federal Government, the 2.4 billion in workforce development substance use is definitely on the list. High list of kind of. We know we have a shortage of substance use professionals, and so thinking about how we build out that workforce as well.

And then as counties plan for the use of these dollars, they do need to think about what their local data reflects in terms of, you know, what are the populations that are with the most significant needs and how they build out, whether it's mental health, substance use, kind of behavioral health, or code type services. Thinking about the populations that they need to serve and thinking about how they build out their programs as well.

A lot of it is flexibility on the counties.

Yes.

Right. To them, for them to determine what infrastructure capacity they need to build on. Okay.

Okay. And then in terms of the questions related to changes to county's ability to manage their prudent Reserve, a BHSA funding, just want to highlight a few changes. Under BHSA, the prudent Reserve was reduced from 33% to 20%, except for small counties, which is at 25%. Also, the ability to transfer funds to the prudent Reserve from all of the different local buckets that I just walked through. The reserve levels must be addressed during the three year integrated planning process.

And any changes to county requirements that must be met for accessing prudent reserve balances will be discussed during the revenue and stability workgroup. This workgroup was created as part of BHSA and is really bringing together kind of county partners to think about how to look at revenues over time.

Prop 1 or Prop 3, the predecessor revenues, you know, up and down, given that the relation to kind of the tax and thinking about how to understand the revenue and provide some stability to the counties as they think about their planning. And then finally wanted to note the flexibility counties have to move dollars between those different buckets that I just walked through, 77% from one category to another for a maximum up to 14%, really.

Again, to allow counties to understand what their local needs are and do a little bit of movement of those dollars depending on the data and community input. And again, those changes would be subject to the department's approval and would be made during the three year planning process. So there's complete transparency in terms of how those dollars will be used and moved around.

And then finally, just wanted to highlight that as we talked a little bit about that local planning process and recognizing that this is, you know, a significant amount of work. It's new work in terms of kind of bringing together more parties, thinking about more programs, and thinking about more revenue sources, the ability for counties to use additional two and up to 4% for small counties of their local revenue for that planning work, and kind of the development of the integrated plan.

And so want to just kind of recognize this. This is, you know, a new workload for our plannings and really thinking about how to work on building out that integrated plan, then, in terms of our overview of new substance use disorder services, as I mentioned at the beginning, is now allowing these dollars to be used for individuals that have SUD only needs.

And again, as I mentioned, really working with our counties and our counties really looking at their local data, their local needs, to understand what types of programs they need to develop. Again, you know, MHSA or mental health, substance use only co occurring type programs, etcetera, and thinking about how to plan for that as well. Wanted to provide just a quick, high level timeline in terms of the guidance that the Department will be releasing.

There's a lot of new requirements, a lot of new guidance, and a lot of new defining that we need to do and work with our counties, providers and partners as we think through that. We've started our stakeholder process. A couple weeks ago, we had a public listening session on the bond, and we will continue to have at least monthly public listening sessions on broad topics as part of BHSA. We anticipate bond funding will begin in 2024.

So in the coming months and planning to release guidance on kind of how we're thinking about the rounds and the release of those dollars. Our first kind of big policy guidance that we plan to release is related to the integrated plan, and we are planning to release that in early 2025. And the importance for that is counties need to understand what they need to put together for their integrated plan that starts July 2026.

And so giving counties 18 months advanced kind of policy direction on what is included in that plan, 18 months advance so they can start working with their stakeholders in the development of the July 2026 county Integrated Plan.

How many rounds for the bonds are we anticipating?

We're still working through that, and we will, we'll be releasing information soon on that.

Who are the stakeholders at the meetings? Like what's identified as a stakeholder and who are they?

Stakeholders include our counties, providers, advocates, persons with lived experience, various stakeholders, other state departments.

How do you become a stakeholder? Is that by invitation only?

We will have different workgroups depending on the topic at hand to really find our subject matter experts and think about who needs to be part of the discussions. As we think about all those different kind of categories, we walk through all the guidance that's needed as part of it, ensuring that we have the right stakeholders at the right meetings to provide kind of the expertise that we're looking for.

Who makes that determination? Who the right stakeholders are.

It's through kind of discussions like these and discussions with our, kind of our, you know, we have a behavioral health listserv we've been doing with all the calaim work. We have kind of different listservs of individuals who have been parts of different work groups.

So my concern is, is that we spent billions of dollars on homelessness in the State of California, and the numbers have gone up, and now we have this new dog. This new dog in the fight, the bond, right? The bond that they barely got passed and it barely approved, and there was a promise that we would not be doing the status quo, I guess.

So if we're still picking the same stakeholders that made the bad decisions that caused homelessness to go up after spending billions of dollars before, I think we should probably look at the stakeholder process, especially if they have input. And are you guys doing that? Are you using the same stakeholders that were involved in the process before to address the housing crisis or the homeless crisis that we have in California?

So the Department. In the Medi Cal space. So I can't speak to the homeless or housing space, but in the Medi Cal space, we have, you know, the partners are implementers. You know, as we develop policy, we have, whether it's the counties, whether it's our managed care plans, the individuals or the entities who actually deliver, kind of implement the policy at hand. And so those.

They will be our key stakeholders as part of this, because they are the kind of the next layer in terms of actually implementing the policy. And then, you know, I think we continue. We want to have as many individuals with lived experience as part of the conversation as well, to really understand, again, is this going to meet your need? How are we thinking about it?

And then our consumer advocates, various groups kind of representing provider associations, again, also thinking about them as implementers of some of these policies as well. But open to suggestions if there are groups that we're happy to connect.

Okay, thank you.

Toby. Is the Commission part of the stakeholder?

Yes, we are. And I'll add that the Commission provides about $9 million a year to support community voices, and those funds can be used to participate this process. If those organizations. We provide a lot of leeway for those organizations to elect how to use those funds. Those funds include support for veterans organizations, immigrant refugee groups, transition age youth, LGBT community reducing disparities, etcetera.

And so while we don't dictate how they participate in activities, because we want to make sure that it's really driven by the perspective of the communities that are represented, those funds are absolutely available to support the opportunities to participate in the forum that the Department is standing up and the Commission is there as well.

Madam Director, I was just curious, you mentioned the bond funding and the funding program or plan. Can you just clarify what's your current estimate for the rollout of the funding sequence and then the rollout of the dollars? I realize it's a work in progress.

Yes. So we will be coming out shortly with kind of the. The kind of the plan for the bond dollars, with kind of where we anticipate kind of our releases and when we anticipate making awards, et cetera. So those details will be coming out shortly.

Sort of like BHCIP.

Exactly.

Thank you.

And maybe with that, I will move to our implementation of the bond through BHCIP. Okay. As I mentioned at the beginning, AB 531 created the behavioral Health Infrastructure Bond act. So this is the 6.38 billion with up to 4.4 billion in grants for counties, cities, tribal entities, nonprofit and private sector towards behavioral health treatment settings. So these are the treatment dollars of that 4.5. 4,000,000,001.5 billion, with 30 million set aside for tribes, will be awarded through grants to counties and cities and tribes.

We have the behavioral health infrastructure program, BHCIP. We've had five rounds of that and kind of using that as the model, as we think about these bond dollars.

Director, on the 4.4 total. First point. So nonprofits will be able to directly apply without going through the county?

Yes, they can do. Today under BHCIP, we do require a letter of support because it's incumbent on kind of the reimbursement for services. So wanting to make sure that there's a connection with the county as well.

You require a letter of support from the county?

Correct.

And are these dollars applied for directly from the state?

Yes. So all of those entities apply to the state for these dollars. And we've done five rounds of grants under BHCIP through this process.

Thank you. You said five rounds of grants. Is that like five grants or five rounds of addition? Like 20 grants in a round or whatever it is, yeah.

So BHCIP was 2.2 billion and we've awarded, I think, 1.7 billion. I believe in those five rounds. So five rounds with multiple. Multiple ...

Again, probably off the top of your head, not because this is something that may not be asked, but. Or considered being asked, is when you look at the 1.7 billion that you just said you allocated, how is that divided up? Like, by city, by Los Angeles got so many billions, like by.

It's all available on our website. I don't have it. Off the top of my head. But we have a website that lists every round, every grant.

Thank you. Thank you.

So currently the infrastructure that we have for BHCIP will stay in place and the bond dollars are going to go into the current BHCIP infrastructure to continue distributing the funds through that route.

Yes.

And if I could ask. Thanks. I found my train of thought. The train went by and I'd. That didn't catch the cargo. When you're saying people can apply directly for that funding, but that should be done in association with the first look we're going to do about what everybody needs in every county. Right. We don't know what everybody's capacity is yet in the county. So how is it going to matter when we map out what capacity is needed for housing? How does that then fit with the separate process?

So these are not, these are the behavioral health treatment dollars. So the housing dollars are at Department of Housing and Community Development under different departments. So the 4.0.

Yeah, I thought you were talking about the bond.

Yeah, so the bond. So what? BHCIP is only doing the behavioral health treatment pieces of it, not doing the housing parts of it. Okay. Another program by the Department of Housing and Community Development will be doing the housing related pieces.

So it's a 4.4 billion of the 6.3 total. Only behavioral.

Correct.

But that's still. We still need to know if the county needs.

Sure. As part of, as part of BHCIP round two counties receive grants to think about their local planning. And that's how they've actually used that information to think about rounds three rounds four, rounds five. And so using some of that and just our understanding of kind of where we've made awards, we've had that all mapped out and kind of thinking about where are some of the needs that we collectively can identify?

Because I think, you know, just to echo what Senator Grove was saying, like, we've done a lot, but we need to, we need more accountability and to know that we're doing it all with a plan and achieving the outcomes that we all want.

Director? I think we're jumping ahead because I know later on we're going to be talking about BHCIP a little bit more. But that was actually what one of my questions was like, how successful were in, were we in rounds one through six? Because the definition, you know, the BHCIP was to acquire, construct, rehabilitate real estate. Do we have a list of how many new construction projects came out of this? Was this only to rehabilitate? And we painted walls on places.

This was all new construction or new capacity. So we have a list of everything.

It was successful. It's been successful as far.

I will say having everything open, these projects are going to take years to actually build behavioral health treatment. We did, we had some have open, you know, round three were the kind of shovel ready projects. Launch ready, launch ready. That's a better word. And so those we have kind of, you know, some have opened and kind of status on those and, but these dollars are going to take, these projects will take some time to actually open and finish construction, etcetera.

Okay. Are we looking at the entities that perhaps in round three for launch ready or other ones to say, hey, we need additional funding, we're going to apply now for this additional bond money to finish the project that we started in the previous rounds? Or are we looking to prioritize, just brand new?

I think it's, I don't know that we have a prioritization. I think it's a matter of capacity. And, you know, I think many projects are thinking about campus style efforts where, you know, round three might have funded one wing, round four might Fund another wing, those types of things. And there might be just new projects as well. And so I think this will be part of kind of the process as we think through the program guidance.

And again, so individuals that want to apply for these grants or things, they apply for to the state, and then they have to have a support letter from the county. Like, for instance, in just examples that people have talked to me about since Prop one has come out, Habitat for Humanity. Once they had bought a piece of property and they were working on putting 11 tiny homes there for just veterans. It's right across the street from the veteran services Department.

So they could have, you know, wrap around services and so will they be able to apply as a nonprofit to the state for those resources? And does it affect the way they build these tiny houses under construction?

I think, again, it depends on if it is truly just kind of, if it's their services or it's kind of behavioral health, whether it's this bucket of dollars or the Department of Housing and Community Development. I think, you know, probably have to have an understanding for where what, because you need veterans.

Something that's associated with treatment.

I'm working with and the people, the nonprofits that I'm trying to help get involved in this process because we have failed our veteran community thus far. These people are part of the veteran services group that are trying to do the right, that are doing everything they can, and it's placing these places to live.

So there's a housing process around or next to medical clinics that service veterans, like the veterans, the Veterans Services Department or the hospital right there that gets, that is authorized to treat veterans and veteran services. So they do have wraparound services and they can just walk across the street instead of trying to navigate a bus system or a transportation system. There's a crosswalk that they put in place. It's like four, you know, it's four crosswalks wide, like for wheelchairs and all that stuff.

Plus they have the orderlies that will come out and get them and take them there. And they have another piece of property where theyre going to do it. But its a non profit, its Habitat for Humanity, and they are sponsored by the veterans, and they just, theyre doing their best to build. And theyre probably housing more veterans than the state has. Im just being honest. Im very frustrated with the money that weve spent, and veterans are still on the street.

So my question is that this would be a brand new entity with a success rate behind them and they can apply to the state for these dollars, and they're not restricted from applying. They just have to have the application filled out and a support letter from the county who is very supportive. Does that make sense?

I mean, generally speaking, yes, that's correct. Okay. I can't, like, you know, speculate in terms of who would get a grant, etcetera, but, yeah, I mean, that's on, in the.

Who determines who gets the money? And is there a, is there a, is there a standard operating procedure so that it's just objective findings and not subjective findings on who gets the grant?

Yes, there's criteria by which all of the applicants are considered, for sure.

Okay. How do you get a copy of that criteria?

I mean, we can share kind of the framework for that.

Okay, thank you. You can share the framework, but there's no criteria anywhere on a website I can find.

I would have to check on that.

Okay, thank you.

General Roth is up.

I don't know about that, but Madam Director, I just want to, you know, I'm sort of a command and control kind of guy, and I just want to make sure that. But we're having the sidebar here, so I'll let them finish it is my chair. She can talk anytime she wants. I just want to make sure that there's some control over this process. And you spoke about a letter of support from the county.

I assume that even though subject to being corrected, that even though under this new process, applications can come in from a variety of directions, not necessarily funneled through the county, that the applications will be viewed and evaluated in the context of the plan that the county develops based on the needs in the county.

So if you're referring to the integrated plan.

I'm referring to the bond. Bond funding right now for the.

But in terms of the plan that you just referenced, are you referring to the integrated plan? That's part of kind of the behavior?

Is that included in the three year integrated plan? They have to include their funding on bonds as well.

So I think the goal for us is to release the bond dollars before the integrated plan is available because the integrated plan isn't due to the state until July 2026. And I think, you know, given the urgency of really the need for behavioral health treatment facilities, wanting to actually work on the bond more quickly than July 2020.

Well, regardless of what the title of the county needs assessment is, since the counties are generally responsible for the delivery of behavioral health services, at least at the, you know, the serious level in the county, I assume that we expect the counties to develop sort of a needs assessment based on the particular needs of each of the 58 counties and that these applications that are coming to you from outside of the county because there's a need for a county letter of support, that the county has the opportunity to weigh in on whether to triage the projects and the needs for the projects.

The county, in terms of if they want to communicate that to the Department or if they want to kind of say, you know, this county may not have, or this project may not have the support. Michelle, if you want to speak to that as well.

My concern is you have private, so you have nonprofit profit tax status. You have private operators in the private sector submitting applications for programs, and the county may look at them and say, well, we already have 55 of those beds or 55 of those facilities that we funded through state money or however they got the money, we don't really need that. What we really need is 35 of these beds, and that's not what's being applied for.

How is that communicated and how is that handled at the state level, given the fact that Prop 1 is probably, I may be exaggerating, but a once in a generation generational opportunity to, on the bond side, cite some treatment facilities of all sorts in the State of California.

We would anticipate that the county would then not submit a letter of support for that project.

And that would what? Terminate the consideration that they, I mean.

We require a letter of support.

So, yeah, I'm not being critical. I just want to make sure that the county would have the counties have the opportunity to evaluate incoming, incoming to you and say, well, that doesn't fit within our plan. I realize somebody wants to run that business and operate it, and they feel very strongly about the value of it. But, you know, we have other values that we need to have addressed. Right. Thank you.

Would you like to add anything to that specific?

I think it's fair to say that, yes, counties do have an opportunity with the BCHIP program, which is only the behavioral health treatment facilities, to submit a letter of support for any outside applicants. However, currently we don't have a lot of insight into how those decisions are ultimately made and the consideration about the continuum as a whole and how it ties back to the other priorities.

It seems like there may be room for improvement in better coordinating and communicating what the ultimate decisions are because there is a systems flow dynamic to this where you need step down, you need acute levels, you need kind of outpatient. And when all of those things are working really well, people don't get stuck in bottlenecks in the system.

Thank you.

And that concluded my presentation.

Okay, just confirm me. I think we've got another. I actually have a question on the workforce part. 3% to HCAI. This is for the HCAI Behavioral Health Workforce Initiative.

So there's, I think, two components, and I don't believe that they're here, but they have a component. And then some of those dollars will then be used as part of the match for the BH Connect 2.4 billion that we're getting with regard to the workforce on the kind of the Medicaid side. So some of those dollars will be used as the match for our BH connect workforce. And then HCAI has another kind of workforce component as well.

Yes, an agenda, background on it. Approximately 105 million annually to implement a behavioral health workforce initiative. It's, you know, to retain the county behavioral workforce in rural areas to increase racial, ethnic and linguistic diversity. I'm wondering if we're going to recreate the wheel because this Subcommitee has heard several presentations to delay behavioral workforce initiatives.

And are we going to Fund to start a brand new project where we've had initiatives in place that are being delayed or are we just going to utilize this money to then supplement the current initiatives that are in place and just stream the dollars through those so.

We can check with the Department of Healthcare Access and Information. I think, you know, the goal would be to really to get these dollars out because we know we need to develop the behavioral health workforce and I know that they are kind of working through those details as well.

Cause we have, we've received a lot of applications for those of them, if I'm not mistaken, for the previous behavioral workforce that we've had a delay. So we have applications in queue. I wouldn't want us to spend money on creating a whole new initiative when we have those ready to go and just Fund them and pick the applications that we have already in queue.

So this is why we're here, to try to not add bureaucracy, further bureaucracy. Right. So, yes, Director, if you can get back to us on that part, and I think that is it on questions for you, we'll now move on to CDPH. No, just kidding. Not Toby. Doctor Tomas.

Good morning, chair Members. I'm Doctor Tomas Aragon, State Health Officer and Director of the California Department of Public Health. I'm going to make some opening comments and then I'm going to hand it over to Katie Rosenquist, who's going to go into more details of our component. So we're really excited about this BHSA opportunity to focus on primary prevention and health improvement in this area of behavioral health for us in public health, this is an emerging area. It's very new.

Public Health in California here is at the forefront of advancing prevention opportunities through data experts and community practice. Public health has learned a lot about the impacts of behavioral health and trauma and why prevention is so important. Drug overdose, alcohol-related conditions, suicide, homicide, and mental health conditions contribute directly to mortality and morbidity through premature death, hospitalization, and years lived with disability.

Exposure to trauma and toxic stress can have long term impacts on brain development, risk behavior, as well as mental and physical health throughout life and across generations. Structural inequities and social determinants, including experiences of racism and discrimination, can increase exposure to behavioral health challenges and reduce access to supportive assets and services.

Public health and population based prevention focuses on preemptively addressing behavioral health problems by reducing exposures to risk factors and increasing protective factors through upstream and early life core strategies to promote mental health well being, foster healthier communities, and support lifelong mental and emotional resilience and well being. Examples of prevention include things like health education and promotion campaigns that are culturally and linguistically responsive and aimed at increasing community engagement, reducing stigma, and building understanding and awareness about mental health and substance use issues and healthy coping strategies.

Other examples are going to be policies that reduce access to illegal drugs to youth and adolescents whose brain is undergoing continuous development educational campaigns that raise awareness about the mental health impacts of social media and other emerging technologies on youth mental health, learning and social and emotional development. So we're very excited to be moving into this space. It's a very new area. I'm going to hand it over to Katie, who's going to go into more detail of how this connects with the Proposition and Bill great.

Thank you, Tomas, and thank you to the chair and the Committee Members. The BHS a statutory requirements mandate that a minimum of 4% of the total BHSA funds allocated be managed statewide by CDPH for strategic, coordinated and statewide population based mental health and substance use disorder prevention programs. A significant portion of these funds, 51%, will be reserved for programs addressing behavioral health prevention for populations who are 25 years or younger.

The statutory requirements also outline that these programs should encompass evidence based practices or promising community defined evidence practices, and meet one of the benefit the entire population of the state, county or particular community serve identified populations at elevated risk for a mental health or substance use disorder aim to reduce stigma associated with seeking help or mental health challenges and substance use disorders serve populations disproportionately impacted by systemic racism and discrimination and finally, prevent suicide self harm or overdose.

BHSA also stipulates school based prevention supports and programs and early childhood population based prevention programs shall be provided, excuse me, shall be provided in a range of settings. Implementation of all population based prevention programs may be statewide or in a community setting, and funding should also be used to strengthen population based strategies and not be used for early intervention diagnostic services or treatment for individuals, or supplant funding for services or supports provided by current initiatives.

CDPH will collaborate with the Department of Healthcare Services and I'll say the OAC here, but referred to in statute as the Behavioral Health Services Oversight and Accountability Commission on implementation of the overall BHSA initiative. So those are the statutory requirements. The CD BHSA initiative involves a robust planning process, including research, strategic planning, and engagement with diverse partners to develop sustainable and impactful strategies.

Initial focus will be on engagement and strategic planning throughout 2024, transitioning to operational planning in 2025 in order to prepare for the July 2026 implementation.

Quick question.

Has CDPH never engaged with stakeholders before that? We have a robust understanding when it's needed. And do we need to engage with stakeholders again?

Yeah.

We engage with stakeholders for many of our programs and work. This is MHSA. We've had one program specifically involved in the MHSA funds before the MHSA act, and we have many partners and workgroups and committees that we can be convening with about this, but we're trying to be very focused with this opportunity.

Are disparities still the same?

I would.

I'm just trying to figure out why we have to do this every single time. So I'm just trying to, like, is we can't look at. Yeah, so maybe, yeah, so maybe I'll.

Make a few comments on the stakeholder engagement. There's sort of, there's two components is because, because some of the prevention dollars are going to be coming to the state and we're going to be reimagining how we're going to do that. In order to do that reimagining, we do have to engage the locals, people who currently are providing some prevention services. We want to understand what are they doing that we may want to replicate and scale and go broader.

So that's going to be one of the major reasons. The other major reason we want to focus on is that behavioral health dollars historically has been focused primarily on people who are severely mentally ill or on the course to mental illness. We're now trying to move upstream and focus on primary prevention.

That's a big space, and that's going to require us to really get everybody together and say of these evidence based strategies that we think are really going to move the needle on behavioral, behavioral health, mental health across, across the state. What are we going to prioritize? And then how can we work with locals so that they can select from that?

And then the other thing we want to do also is that because we recognize that probably the need is more than the resources we currently have, we really want to mobilize and inspire other stakeholders, other institutions to invest in this area, especially with emerging research that's just coming out on early life risk factors for mental health, that we want to make sure that we get the word out. We have other people implementing it. I hope that. I hope that.

So I feel like we do have to do it because this really is a new space. We don't want to just assume we're going to do it the old way. We want to make sure we bring everybody along so we get everybody's input.

And we're bringing new people in. That's what you said. We're bringing in new people who perhaps focus on more preventative versus reactive.

Yes, because. Yeah, and a great example. I'll just give a really concrete example. So, for example, if you want to prevent, if you want to focus on heart disease, heart disease in a clinical setting is very different than focusing on heart disease and primary prevention, because there it's about nutrition, physical activity, reducing stress, being outdoors. And so in order, because we're moving into that space, we need to make sure that we engage as many stakeholders so that we pick the right things. We don't want to end up where we ended up before, where we end up spending a lot of money and not having impact.

Thank you. Thank you. I have the deepest respect for you, Doctor Aragon, you're a doer. Like, I mean, if they were going to make a doer commercial, you're the guy that needs to be on it because you're a doer and you get things done and you're very responsive. I just have the same question I asked the Director. What's the process? And is there a process on the website or is it in the works now? And how do you have access to the process?

So those new people that have these phenomenal ideas that are solving problems every day without the state's help can get states help so they can solve more problems. Is there a process and is that process available online?

No, we haven't developed that process now just because we are moving into this concept of population based interventions. We recognize that that has to be done. We have to co design with local stakeholders, and we recognize that money is going to have to flow locally, but we have to sort of figure out what's going to be the best way to do that.

Okay. And then as people that want to engage in the process that are excited about, because, I mean, I went and told them, they promised me they weren't going to throw this money away. Promised me it was going to be used very wisely. They promised me that they were going to use every dollar wisely. We wouldn't hear about any $2 billion programs where six people were moved off the street, none of that. No more.

And these ideas were, it's actually worked in the community, like I said, I mean, it seems simple to me that the state would put, you know, buy a hotel with 300 rooms and put it right next to the Wilshire Veterans hospital. That seems a lot less expensive than, you know, putting them on the outskirts of Los Angeles and transporting them by bus, if they can even get there.

I mean, when you think about the meeting the needs of the lived, experienced people on the street, I think that would be a thing that veterans would tell you. Well, I live 26 miles away from the hospital in Los Angeles, and it's hard to get there. And then you have people that are building housing and apartments and taking over apartments and hotels right next to veterans facilities, and that's working much better.

So I guess my question is, how do those people that you guys don't know or don't engage in, they're not your regular, typical people that participate as your stakeholders. How do they get involved in the process?

Yeah, that's a really good. The way, you know, I think about it, I'm gonna. Katie has the details, but I'll go ahead. I'm gonna just reflect on, you know, what we did with COVID is that we, because, you know, the state's so large, we usually go through the cbos and cbos and associations that represent those communities, and we work really closely with them, and we have been working really closely with them around many, many other issues. And so we have that experience.

The topic area for us here is new, and so we want to get this right and we'll base it off our early experience. The other thing I just want to add is that so the population you're describing right now, so primary prevention applies to everyone, including us.

And it also applies to them as well. And that's one of the challenges, is that you may have one condition but we want to still reach you somehow because we want to prevent you from developing another condition. And so, and that's one of the challenges of primary prevention, is that it applies to everybody, whether you have, whether you're currently ill or not.

So I want to ask about restricted dollars, too, because we have a mental health facility that has treats a lot of people on the street, and when they come into the mental health facility, the Doctor is allowed under state resources where they fill out the code section to apply for dollars. That individual that they're treating, they can treat for mental health, but they can't treat the gaping gangrene wound. They have to send them to Kern Medical center.

So is there going to be restricted dollars or are Medi Cal providers going to be able to treat the whole person in this situation? When you look at.

I don't know the answer to that question.

That's okay. I may be asking the wrong person. You brought up something that made me think of that. So I think that's something that, again, just to treat the whole person.

I completely agree. I think the mind and the body, unfortunately, for reasons that I don't completely understand, we treat them differently, but they really, everything is connected and we're moving more in that, which is what we're.

Doing with this whole Prop one. Right. We're trying. Yes, exactly. Exactly. Integrate everything.

Thank you, sir. Thank you again. I'll turn it back.

I think I just wanted to highlight. One thing just in regards to kind of bringing stakeholders that aren't normally part of the conversation. That is the whole goal with the county integrated plan, and veterans are a required stakeholder group at the local level to build that plan out. So while the state also welcomes, you know, new voices, new groups, I think it's also really important that at the local level that happens because that's where the local dollars actually get allocated.

And so kind of that partnership at the local level and really having veterans be part of that local planning process where, you know, the vast majority of these, the BHSA Dollars will be allocated, I think is really important as well.

Thank you.

So just continuing when we're talking about key partners. So CDPH will work with local behavioral health and public health, academic partners, youth, community organizations, individuals with lived experience to ensure a broad spectrum of perspectives. Engagement efforts will include conducting a landscape analysis of existing efforts and opportunities for prevention. Also recognizing existing prevention efforts through MHSA, which includes, this will include listening sessions, meetings, and key informant interviews. CDPH will be coordinating with California Health and Human Services Agency and can provide more updates through them.

As requested, as well by legislative partners. CDPH's engagement plan also includes learning from various stakeholders involved with existing initiatives, such as the California Reducing Disparities Project, also referred to as CRDP. Leveraging the experience and lessons learned from CRDP initiatives to enhance the effectiveness and inclusivity of current and future prevention programs.

The CRDP has learnings from the project, including its comprehensive report describing evaluation of phase two and an upcoming phase three report, which will both provide key insights to help inform the development specifically of the prevention strategies. CDPH values the insights, experiences and contributions of a wide range of partners by partnering with experts in leveraging the community and youth voice. CDPH's primary goal is to implement prevention strategies that are responsive to the unique needs of California's diverse populations.

And as we were alluding to, we're beginning engagement activities and we'll continue in a phased approach throughout 2024. And the process will be iterative. It will be involving continuous dialogue with partners and communities throughout the process. Thank you.

Thank you. No further questions. We're going to be moving on now to Mr. Toby.

Probably the most difficult part of my testimony today is making the PowerPoint work. I hope so. Madam Chair and Members, on behalf of the Commission whose name we're still trying to figure out, the Behavioral Health Commission, the Oversight and Accountability Commission, the Behavioral Health Services Oversight and Accountability Commission. Toby Ewing, effective Director, thank you for the chance to join you today. Director Boss has very generously offered to help with the PowerPoint because talking, thinking and clicking is something that actually is.

A woman of many traits.

She is very talented, and I have such respect. So I really appreciate the chance to join you. We want to cover a couple of very specific questions that are listed in the Committee's questions that came to us through the staff. Thank you to your staff for this work. Generally, Prop One Makes two fundamental changes for the Commission that are significant. The other changes are more sort of tonal shifts where the Commission's role is consistent with the work that we've been doing.

There's a lot of flexibility in how we do that, and we're very excited about the opportunities that Prop one creates for the state as we think about many of the challenges that, as you have mentioned, we have not been as effective in addressing as we'd like to. So I want to focus on the two, on sort of the primary questions the Committee has asked. A very significant change from an operational perspective, is the makeup of the Commission itself.

That may or may not be where the substance is in terms of how we drive transformational change, but it's important because it brings some additional voices to this body as we move forward. So thank you.

So currently, under the Mental Health Services act, the Commission has 16 commissioners, and the membership was really designed to start with consumers and family Members and providers, and to bring with them commissioners who represent public safety, education, employers and labor, as well as the two constitutional officers, the Attorney General and the Superintendent, Superintendent of public instruction, as well as a representative of the Senate and the Assembly.

The ballot measure added 11 new seats to the Commission, so we're growing from 16 to 27, and I appreciate some of the comments from someone on the Committee team about how in the world we're going to find a space. So, you know, we will make that happen. The new roles really expand the number of voices who are at the table, with heavy emphasis on representation regarding folks with substance use disorder needs or family experiences.

Certainly a behavioral county behavioral health representative, expertise on housing, ensuring that there are younger folks appointed to the Commission, and then, as outlined in the slide, people with experience or expertise in reducing disparities. So those are the very specific answer to the question about the membership change on the Commission. We are working with the governor's appointments unit to understand how we're going to get from where we are today to where we need to be.

When this takes effect relatively quickly, particularly as it affects our ability to operate under Bagley keen rules in terms of establishing a quorum and being able to do that in person, as has recently been required. And so we're excited that we will have the chance to bring so many new voices to the table.

But we also recognize that the process of making appointments, one of the changes that we asked for, and we are very grateful, was included, is the ability of the legislative Members to appoint a designee. That has been very difficult to schedule our meetings at a time where elected officials can participate, given your schedules.

The original law allowed the two constitutional officers to appoint a designee, and so we're very appreciative that Senator Eggman and the team that put this together to recognize from a very practical perspective, in order for the Legislature to have a representative in an active role, it makes sense for the legislative Members to appoint designees.

What does a peer youth mean?

So, the term peer generally refers to someone who has lived what we call lived experience, meaning they are familiar with the behavioral health system from a personal perspective, and in this case, a young person.

Okay, thank you.

All right. The sort of the General scope and duties of the Commission really don't change dramatically. Although they do evolve in terms of our relationship with the Department of Healthcare Services, the Department of Public Health, through numerous advisory roles, our work is still focused on promoting transformational change. That's the origin story of the Commission. With the original passage of Prop 63, it's been retained in Prop 1. Our research, evaluation, and outcome work is the same. We do grant making.

Most of these elements of our work actually happen through the decision that the Legislature makes through the budget process. And so that's really what drives our capacity to do this work.

Where the broader statute lays out the kind of authorities that we have, that in terms of things like advising the Governor and the Legislature, we actually don't expect to see any change in this array of functions, although how we do that is very likely to evolve as we begin to lean in and work more closely with the new functions that are being stood up within our sister agencies.

For example, the MHSA has long held that counties have prevention or the intervention funds that one of the landmark elements of the Mental Health Services act that makes California unique, certainly at the time, was that there was a specific set aside of funding for prevention and early intervention because so much of the traditional reimbursement authority is required to be used for direct treatment services. Right. Medi Cal typically didn't work upstream. There are some exceptions, and that has changed over time.

Part of the work that the Department of Healthcare Services and the Broader Administration has really been doing is opening up pathways, ways for reimbursement, funding for early intervention, and even prevention strategies over time. And so although the financing makes it look like there are some dramatic shifts in funding for early intervention, for example, under the MHSA, about 19% of the local dollars was for prevention intervention, the new priority because it's, you know, 35% of 90, and 51% of that, it's about 17% for early intervention.

So through a common combination of new policy shifts and implementation practices, we hope to see more resources available for early intervention in California, in part because of expanded availability for federal reimbursement, expanded strategies to engage commercial and other partners in early intervention strategies, and that the dollars that are available to our local partners are exclusively for early intervention, with the Department of Public Health picking up the prevention strategies.

That doesn't mean that the of community programs that are currently funded through MHSA will be sustained because of the very clear resource shifts that are required under Prop one.

One of the areas of conversation that we're having with the counties and with our counterparts in the Administration is how might we facilitate conversations with the counties to use the balance of MHSA innovation funds to support the transition from the funding strategies that are in place today to the funding strategies that need to be in place as Prop One takes effect. But part of that is really working.

Is that the only bucket of the current MHSA funding that perhaps would be unspent since innovation was essentially just swept.

On a county. No, not necessarily. It may be right, just recognizing that counties do have expenditure trends that may be more difficult to shift. But theoretically, conceptually, counties could use some of their admin funds under the community services and supports to support that kind of work. But I don't know if there are unallocated dollars. What we do know, we've partnered with the Department of Health Care Services.

We estimate it's always tricky, but there's as much as $250 million of MHSA innovation that is still coming in that has not yet been committed by counties. Under the current rules, counties received the funds. They have to set it aside. They can only spend it with Commission approval. We estimate $250 million of unutilized MHSA innovation that is available for innovation purposes through the start of the BHSA and the way BHSA was written.

If those dollars are in a Commission approved innovation plan, that use is grandfathered in. In other words, the timeline for using those dollars can extend beyond the start of the new BHSA spending requirements. We also estimate that there is as much as $800 million of MHSA innovation funds in already approved innovation plans that counties are operating today.

And we recognize, we strongly encouraged counties to be willing to reprioritize dollars because we didn't want to create a scenario where they committed to an innovation project and they learned within it's a five year plan, and in year one, they figure out it's not working. And so we create opportunities for counties to cancel innovation projects as they make decisions about whether it's, you know, suggest it's working or not, which suggests that some of that $800 million or so could be repurposed if a county chose to.

In both of these instances, the unapproved innovation funds and the previously approved innovation funds would, of course, have to go through the local planning process and be approved by county boards of supervisors, so the state cannot impose that on them. Last week, the Commission met and we talked about working with the Administration and the counties to identify, to sort of facilitate priorities for collective county innovation investment to support some of the areas of greatest concern as the local agencies make this transition.

So, as outlined on here, we have a consulting role with the Department of Healthcare Services around early intervention, around best practices. One of the areas that we've had some really significant success, primarily through supporting counties around how the user innovation funds is identifying effective practices and helping to scale them. Scaling effective practices consistent with some of the conversations that you've made this morning, can be very challenging for a variety of reasons.

But we've had some success there working with the Department on FSP standards, working with the Department around the accountability system, also with the Department of Public Health, as they stand up this very exciting population based prevention practice, and then, of course, stigma and discrimination strategies. We do have three new reporting requirements that are designed to help you and help the Commission be clear about what's working and what's not working, including recommendations for how we can increase the availability of technical assistance and support to support excellence.

Where we're learning for improving these, again, state level standards because it is about scaling and about getting better over time. And then the second area that I'll talk a little bit more about where there's a significant change, is innovation. And so our third new reporting requirement is on the innovation Partnership Fund, the history of the Mental Health Services act.

Why is there no due date on the first report? Other two have a due date?

I don't know the answer to that. This is outlined in the statute, and so we're happy to, with the. Well, cardinal rule as a presenter at a Budget Committee, never say it's the chair's fault.

Its Senator Eggman's fault?

I don't know the answer to that, honestly. But, you know, we so typically, in our relationship with the Governor and the Legislature, also recognizing that we have legislators on the Commission, we work hard to actually meet your needs independent of what the statute requires in terms of the date.

Thank you.

So we'd be happy to work with you to put a date in there. We'd be even, you know, more happy to sit down with you and talk about what would be most helpful and just meet that goal.

Thanks.

In the innovation Partnership Fund. So the Mental Health Services act was unique, again, because of this mandatory set aside for innovation. California was first in the country to recognize that we need to create a fiscal incentive as well as a political and community based incentive for continuous improvement. And we have worked very hard and very closely with our county partners. There is in the range of $1.0 billion of innovations happening across the state right now.

There are dozens of really exciting innovations that have been successful in individual communities. The challenge has been scaling those right, in part because as innovations, there's tremendous flexibility in how they use those dollars. But that flexibility isn't always sustained in terms of moving those programs from innovations to core practices through reimbursement authority or whatever the funding source that a county might pursue.

That has actually constrained the ability of counties to think out of the box, as was mentioned earlier, in part because for very understandable reasons, we do require a sustainability strategy. If this works, how will you sustain it meant that it has limited the ability of counties to sort of move beyond sort of practice improvements or system improvements. The Innovation Partnership Fund under the BHSA replaces the 5% set aside for the first five years is $20 million a year to the Commission.

And it stipulates that during that time or after that time, if the Legislature and the Governor, through the budget process, want to expand those funds, that is prerogative. It also allows the Commission to integrate the innovation, the $20 million for innovation funding, in with the Mental Health Wellness act funds. It's an additional 20 million year that you've provided to the Commission on an ongoing basis.

The goal is to provide grants to public, private and nonprofit partners to really drive innovation into this system, recognizing the broad challenges that are both at the population level and at the public behavioral health level. And so we have been working since the conversations around the Bill to develop a strategy to make best use of those funds. We are talking with organizations around the world to look at comparable strategies to really leverage innovation, to drive change in industry, in healthcare, in science and research.

And we're also looking for opportunities to leverage private sector investment to begin to lean in and support strategies to address public sector goals. There are companies and venture capital investors and others who want to actually help address disparities in public sector goals. They are generally reporting out to us that government is a black box. They don't even know who to call. And so we're very excited about this opportunity, and we are already starting to put together a strategy for community engagement around how to do that.

Toby, can you give us a couple of examples when you talk about exciting innovations

In terms of things that have currently already happened or things that are ... You know, one of my favorites is Solano county recognized very early on that they were struggling very much to meet the needs of their Latino, Filipino, and LGBTQ populations. Their data suggested that from a penetration rate perspective, Latinos and Filipinos were the least well represented.

They didn't have good demographic data on LGBTQ, but they knew, just from anecdote how profoundly difficult it was to meet their needs. Working with researchers at UC Davis, they undertook a multi year innovation project to fundamentally rethink how they engage with their communities. And they saw like 300% increases in access to care for these underserved communities.

In response to that, we funded the UC Davis researchers in partnership with Solano county and in partnership with CBHDA to greenlight any other county that wanted to invest in a similar strategy to replicate that program. And so that is currently.

That is exciting.

That is very exciting. That's right. Thank you. The beauty of this program is that at UC Davis, there's a globally recognized center of excellence that focuses on reducing health disparities. And Solano was able to reach out, pull them in, use innovation funds to try something new. Right now, that does not mean that it is scaled to every county. And so we still have a lot of work to do. And so this is an example of the opportunities that we have.

As the state thinks about standards, particularly on the community engagement side, we see profound challenges across the state, as communities often report that they don't feel that they are engaged. Right. And we see county behavioral health departments that are very sincere in pointing out how hard they work to engage communities. And so this is, you know, one particular example. Another, you know, example is our early psychosis work.

And so, you know, based on some research that the Commission did as much as 10 years ago, we identified huge unmet needs in rapid response to psychosis and in partnerships with another research institution and a handful of counties, launched a multi county learning collaborative. So, but, you know, so we recognize there's profound opportunities for that to happen. We're curious about the language and the law that requires counties to be innovative in an ongoing manner, how we can support that. Right.

We think that will be challenging given all of the tasks that counties have today to transition, given the new funding rules from where they are to where they need to be. But we are actively in conversations about how to sustain that ability, but to marry it with strategies on the private sector side, on the commercial insurance side, on the research side.

We're actively working with a number of large research universities in California and elsewhere to talk about how we can bring the knowledge that is available in UC Berkeley and UCLA and UCSF and UC Davis, et cetera, address some of the challenges that our communities are facing. One of the things that we're very excited about is we're working to strengthen this graphic.

But this is sort of this waterfall metaphor that you've heard repeatedly is, as we think about the language of the now Behavioral Health Services act that prioritizes reducing hospitalization, homelessness and incarceration, we think of the profound economic impacts there. What are the key opportunities for intervention? And so this is where our conversations with DHCs around strategies for early intervention becomes really crisp. We have focused on full service partnerships over the last few years.

And so we appreciate that the language and the law moves from regulatory requirements for minimum investments in fsps to statutory requirements with the opportunity for the state to lean in. We believe full service partnerships are this safety net service that is supposed to catch and hug and hold and support and love folks who are at high risk. Upstream from that is early psychosis. We have invested a lot of funds to support alcove centers. The comment earlier about can you deal with the depression and the gangrene?

These are integrated primary care, physical health and primary care mental health targeting teens and transition age youth. It's actually a very elegant, simple. People walk in, they get services. No questions asked kind of model. It is incredibly difficult to Fund because it is not a, it's not built around, around a pre enrollment, pre authorization kind of model.

And then, of course, our school, mental health, what we're mostly excited about in this graphic is to ask the question where aren't we investing in terms of opportunities or areas where early intervention can be most successful?

And so part of that work, and we're in discussions with the Administration, is how can we build a sort of an analytic and research capacity to really understand the cost drivers and the areas where there's the greatest opportunity for return in terms of preventing the escalation of symptoms and the escalation of costs in ways that we can really begin to reduce the amount of expenditures that the state is making through our state hospitals and other deep end institutions.

We're not saying that we don't need institutional care. We're saying we need it. We need to be working to need it less. Thank you very much. Appreciate the chance to answer any questions.

Great. Thank you so much. Our next speaker, I think we're going on to I lost my.

Closes out here, Michelle.

And I also have a PowerPoint presentation.

zero my goodness. Are you serious?

Oh my God. Thank you, Michelle. So nice. Wow, I'm really getting the star treatment today. Good afternoon, Madam Chair Members. Michelle Cabrera with the County Behavioral Health Directors Association. Today I'm going to speak to the potential impact of the changes outlined in Proposition one, including SB 32126 to the county behavioral health safety net, and will address the various questions posed by the Committee.

I do want to underscore that this is all very fluid because as we've heard today, there is a significant amount of secondary guidance that still needs to be developed. We're grateful to the Administration for their collaboration with counties in developing that guidance. These estimates and projections that I'll share today are solely based on what we know as of today and do not reflect the either positive or negative impact of future policy direction.

I'll start out if we can go to the first slide by providing a brief overview of the changes of the distribution of the BHSA funding categories relative to the current MHSA distributions, as requested. As you will see on this slide, there are several key differences worth noting in the current MHSA sort of split is on the left side with the BHSA proposed split on the right side, and I apologize. I know the numbers are tiny, but hopefully you have the hard copy.

The big change that you can see is the addition of a new housing category, which is noted here in purple. Historically, the MHSA has contributed to paying for housing to some extent for our county behavioral health clients in different ways. We have the no place like home bond, which counties are financing with local dollars. In addition, MHSA has been used to pay for housing, but often in the form of housing for full service partnership participants and boarding care rate support.

While funding for early intervention and full service partnerships appears very similar on this chart, this chart is broken out in a way that's intended to facilitate that apples to apples comparison across the old and the new categories. What we've seen in our analysis and modeling is that there are some important shifts to be mindful of in making room to expand and also which place limitations on the types of housing that we're able to Fund out of those purple slices.

And if we can go to the next slide, this is the same information just presented in a different way in this view and the prior, you can see that the dark orange slice or bar here, which accounts for what today is called community services and supports and will become behavioral health services and supports, that slice is really where we see a majority of the drop.

While the state has indicated that this pot would potentially be available to Fund an array of important priorities like technology investments, workforce dollars at the local level. Core innovations Today, this component of the MHSA is actually responsible for providing funding to core specialty mental health services, such as outpatient mental health services, crisis services, peer run wellness centers, among others. In addition, we see that our funding for FSP's actually drops under this proposal.

While I was heartened that our early intervention funds are relatively comparable to current levels, including the all important funding for children and youth under age 25, I will note that in early modeling exercises, counties have determined that because they will need to move some of their core CSS services, those ones in dark orange as appropriate, into the early intervention bucket, to save these vital programs.

They will then be limited in terms of what they can continue to fund, with implications across prevention and early intervention, as well as our current General services activities that fall under the CSS component. County's main concern currently is understanding the impact of the funding for new programs, while also important purposes with what programs we will be able to maintain or preserve, and which programs we may need to consider phasing out as we make this transition.

One aspect counties are looking forward to is the push towards greater integration of mental health and substance use disorder programs and services, which is facilitated by the BHSA. In fact, CBHDA's recommendations for MHSA reforms going back to 2019 included adding greater flexibility to allow MHSA funds to be used for SUD only services. This has been a long time county behavioral health Director priority.

However, if we can go to the next slide, this is not what is required, but it's a visual that's used to sort of make the point that if we were to evenly distribute by category funding across mental health and substance use disorders 50/50 funding levels for our currently funded mental health services, supported through the Mental Health Services Act would drop precipitously by bringing in and if we can go to this next thank you.

By bringing in a new commitment to funding housing with MHSA Dollars, counties will pursue both revenue maximization strategies like those talked about today, as well as take advantage of opportunities in the new categories to shift certain core mental health programs from one component, in this case likely from community services and supports, into early intervention where possible, if it's appropriate.

Counties are also grateful for the various options included in SB 326 that may allow for DHCs approved transfers between buckets, up 7% by category, or 14% in total. We do anticipate that there will be local impacts, particularly to our more grassroots, culturally responsive programs and services that are not traditional medical model or insurance reimbursed services and where there's no opportunity to draw down medical match Medi Cal Match. Excuse me.

Examples of these types of services include our prevention or early intervention services that attempt to engage underserved communities with more culturally responsive, less clinical interventions, such as our LGBTQ services or services targeting immigrant or refugee populations, which may have significant challenges in accessing traditional medical model interventions. I was also asked to speak to various elements of the BHSA transition, which are still very much under construction, so to speak.

For example, we do not know much yet about how the state envisions counties will integrate our traditional MHSA community engagement and planning processes into the managed care population needs assessment or the public health community needs assessment processes.

What I can tell you is that our county behavioral health agencies feel strong a strong sense of obligation to the community relationships that we've built over the last two decades engaging our community partners around our MHSA spending in addition to the programs and services that our communities have had a direct hand in developing to meet their unique needs.

We need to know more sooner, frankly, about how we will need to think about future funding requirements and the type of community planning and engagement we'll need to do in order to begin planning this year for what the new engagement process will need to look like in the future regarding the management of the inherent volatility. And we can go to the next next slide, please. Thank you.

This slide is this is an issue which we did raise with the Administration early on in the process of discussing their goals with BHSA. And this slide is just a comparison of the relative flat or stable funding sources that we have with 2011 and 91 realignment versus the structural volatility of the Mental Health Services act funds. It's extremely challenging for counties to plan over time, stable, consistent programming when we're tied to percentages of the state's most volatile funding stream.

Counties are required to develop programs on a three year planning cycle based on projections of future funding that are historically often off by a margin of roughly 30%, meaning the actual revenues that we get in a year are typically around 30% lower or higher than what we had been told in estimates and built our local plans around. And yet we're supposed to spend down.

Madam Chair, if I could ask, maybe Toby or Will? We had talked about putting something together to try to flatten out that volatility. Couldn't do it in the legislation, but there was a plan to come back to that?

Yes. So we will be establishing a revenue stability workgroup that will include the LAO various partners here to do that work. I mean, we agree 100% with what Michelle just said about the instability of this revenue source and thinking about how to think about smoothing it out or how to think about how to make it a little bit more predictable for our county partners. And so that was an issue that.

We talked a lot.

Yeah, yeah. And the sort of degree to which those estimates are off is no fault whatsoever of Department of Finance. Like, they are literally just trying to pinpoint where the millionaire's wealth will fluctuate from year to year. And that's it just turns out that's a really difficult thing to do. The stock market is not predictable. We are grateful to the Administration for acknowledging this challenge and for pulling together this statutorily required working group to try to figure out how we will address this moving forward.

CBHDA looks forward to being a part of that process as well as it really impacts the planning, the accountability for the spending, and then ultimately the quality of the reports about what happened with those dollars. Regarding funding for housing interventions, there still is a significant amount of secondary guidance that will need to be developed in order to answer the questions of how any existing programs might qualify or around the types of housing that will be able to be funded.

What I will lift up is that we have some experience through our behavioral health bridge housing currently underway to draw from, as well as opportunities under the upcoming calaim waiver to bring in new federal medi Cal funding to help offset some of the one time temporary rent needs of our clients.

While we are appreciative for being able to move our housing costs out of the FSP component in that someone's enrollment in an FSP program will no longer be a requirement for continued support for their housing, the BHSA will otherwise be more restrictive for housing than what counties are currently able to Fund. Under the MHSA, CBHDA will prioritize working with DHCs to discuss the various structural challenges our teams face every day in trying to house our clients.

For example, the fact that in practice, housing first laws and principles are difficult to enforce, and often the very clients who we're working with and trying to house are screened out by housing providers due to stigma and frankly, competition for scarce, Low income housing resources. On the topic of workforce, counties are in no way guaranteed to be recipients of the behavioral health workforce funding which is transferred from the local level to the state to be managed through DHCs and HCI.

CBHDA strongly recommends that both agencies prioritize the needs of the county behavioral health safety net ahead of other delivery systems and in particular, private sector models. We would like to see the state address regional and racial ethnic disparities, building on a report CBHDA released in 2023 and which we jointly commissioned with the UCSF Health Force center, which analyzes both gaps across the state and regional needs, including racial ethnic disparities.

In addition, we would like to see the state prioritize investments in the sort of mental health and sud care integration which we believe is compelled through the BHSA. Thank you again for the opportunity to share our perspective on implementation of Prop one, SB 326. This is really the beginning of a massive shift that we hope to see usher in new relationship with the state in driving its priorities for oversight, accountability, and improved behavioral health outcomes for California's safety net.

Are we aware of this? I'm assuming we're aware of this report that you spoke about, the 2023. I want to ask you some questions. We've been asking everybody regarding, like, you just, we're looking at this differently. The status quo, we were changing this, and some of the things that come up is, hey, the county, and I'm speaking to LA County specifically, always partners with the same organization. Grants go to the same organizations time and time again.

Are we looking at this opportunity and saying, hey, we've been providing these grants just to these nonprofits? Not to say they're not doing great work, but we want to expand and provide and open this to other kind of nonprofits to help with this work.

Yeah, I mean, I think that the sort of shaking up the community planning process to pull county behavioral health into the managed care plan planning process, into public health will, by nature, really change those dynamics, as well as the opportunity for substance use disorder providers and services to be more considered under this planning process. What I will say is that roughly half of MHSA funds today are used as a source of non federal share for Medi Cal.

It's one of our main three revenue streams, and so we use it to pay for EPSDT services for kids, for, you know, basic outpatient or crisis services to medi Cal beneficiaries. And so the relationships that we have with providers are oftentimes about ensuring that we have adequate Medi Cal networks to serve our Medi Cal population. That's really always been priority number one and will continue to be the discretionary side of our funding.

We think that we're really shifting more of that into housing and less of it into some of those early prevention type programs that sometimes we Fund today with grassroots nonprofits. And those are the programs and services that we're really going to need to engage the Department of Public Health to see if or how they can continue some of those more mom and pop grassroots organization type of services.

Did you say like promotoras? Like that?

Exactly like promotoras, yeah.

Okay.

Madam Chair, if I may, on that topic, we really have been aggressively working to make sure that we do a better job on outcome based reporting so that the drivers of decisions around finance isn't history as much as it is impact. And that's an area where the state has a tremendous opportunity to improve. And it's reflected in the BHSA. Right. There are some clear expectations that the state will enhance the ability to use existing data systems to better understand the impact that we're having.

While the contracting process is important, it's also important to really be clear and have some compelling incentives around the impact that we have. And we do have the capacity to do that. And we've talked with the Administration, we've talked with the counties about helping to support this transition. But part of that is recognizing the often very expensive and onerous data reporting requirements that are in place today that don't actually support decisions around impact.

And how might we use Prop 1Transition to rethink what the state requires so that we don't move away from compliance-oriented required, but we move towards reporting that gets to the issue that you're raising around our ability to understand what's working and what's not, and change those incentives in ways that make sure that it isn't just about sort of matching the dollars. Prop one is designed to grow the dollars that come into the system through expanded reimbursement authority.

And so it shouldn't be an apples to apples comparison of the image of the BHSA over time. It really should be. We need less deep end, very expensive care that is not eligible for reimbursement because we're doing more early intervention prevention care that is eligible for reimbursement.

And so the, so although the portions of the pie as outlined in the pie chart may not look the same, the real opportunity is to grow the pie so that the actual dollars are comparable to the historical funding that has been available under the MHSA.

And being able to scale things up like the earlier example you used from UC Davis and the three populations.

Thank you. One last question. I think, I don't know, maybe Department of Finance or Director. We briefly talked about BHCIP, and we didn't really talk about bridge housing. But are we looking if we're going to be adding some of the bond dollars into the BHCIP infrastructure? And right now there's a round six proposed for delay. Are we looking at, these dollars are going to be used as if for round six and say, and score on that General Fund savings?

Nate Williams, Department of Finance. Yeah, so the Governor's Budget didn't make any assumptions about the passage of Prop one, so the budget includes the delay. We are currently evaluating kind of all of the costs and the program specifics as it relates to Prop 1 in General, and we are prepared to and hoping to provide a little bit more at the May revision.

Well, do you have anything to comment on this whole topic?

I'm gonna have my colleague Ryan Miller come up and speak to specifically BHCIP.

Okay.

Ryan's been waiting in the crowd all day. Ready to jump up.

Thank you.

You can move that closer.

Thank you, Madam Chair and Senator Eggman. So, in assessing the Governor's Budget proposal in General and in our office's work tracking revenues over recent months, our office has said that we thought the Legislature would be wise to start looking for additional solutions with that in mind and trying to keep an eye out for ideas that may be, say, less painful than looking at program cuts and cuts to existing services.

Our office actually did recommend that if Prop 1 was passed, that the Legislature consider replacing some of the General Fund that's still expected to be spent with bond funds. So I'm happy to answer questions about that recommendation.

What were the items? Was it just on those two programs, BHCIP and bridge housing? Was there something else?

We were talking about BHCIP in particular, because, and if I may expand just a little bit, totally understanding the perspective of Members of the Committee. Also.

Trying to look at what sorts of things may be less disruptive in the near term, whereas with the Prop one funds, there's potentially an opportunity to make a swap without really changing the near term plans in terms of how round 678 and so forth would roll out.

The Legislature, of course, later on could revisit whether there would be a need to add General Fund at the end of the Prop one Bond Period, which the Director Boss earlier stated would take years, understandably, to get all the facilities funded through various rounds and built out.

I think part of our thinking was it seemed like an opportunity to consider a swap that would create a lot of General Fund savings now that could either protect programs or, you know, make, try to, you know, reach some better tradeoffs, and then in the longer term, the state might be in a position to replace the funding, you know, in the future.

So, Senator Eggman, if you want to expand on your.

Yeah, I just. It's not the disappointment to the Committee Members. I think it's more disappointing to the voters. Right. Who barely passed this, and I think with the assumption of new money not replacing money that we'd already set aside for this. So I just think that's disingenuous for the voters.

Thank you, Madam Chair. And, you know, the other thing is, if we'd known that we were going to have some supplanting here, maybe we would have increased the amount of the bond. And then the final comment is, since we're dealing with capital projects. Right. Given the cost of construction, the cost of construction today versus the cost of construction in five or 10 years, we're certainly going to be buying a lot less in 10 years than we could do today.

And I think Members of this Committee are very sensitive to cuts in the programs that come before budget Subcommitee three, in terms of the services that we provide to our most vulnerable in the state. So this would be a very difficult issue. But I think those considerations certainly have to be taken into account when we make decisions like that.

Can you, Ryan, explain a little bit more? You said there's a possibility, for example, bond dollars are coming later this year, right. We're going to start bringing those out. We don't know how many rounds there's going to be that we utilize, if I heard you correctly, utilize some of that funding as if it was the next round that we were giving, and then in a couple of years, it's about, like 3-4.

Hopefully, our budget situation is better, and then reallocate the amount that we were supposed to allocate for this last round as if that's the.

Like we did with adept, ma'am.

Is that what you're saying?

That certainly is an option, yeah, I think essentially the. The concept is replacing what is currently scheduled to be General Fund with Bond Funds.

Okay. Thank you.

I just wanted to. Maybe I'll get a mic on. There we go. Took me 12 years to figure out how to push the button, so I don't know what I would do with you. I thought I would give the. Our behavioral health directors an application to provide any comments to some of the other comments that were made just after your presentation. With your permission, Madam Chairman.

Of course.

If we're. Yeah, I mean, I think in terms of the comments on the revenue maximization, strategies to help buffer any potential service cuts. As mentioned in my comments, we are all in on that property. I do think that it is extremely difficult even today to get Medi Cal to reimburse for prevention and community defined evidence practices.

The sort of beauty of the MHSA is that it has allowed us to really go outside of traditional, what is restricted in traditional insurance and to Fund things that are super important bridges to bringing in those underserved communities. The challenging part about that beautiful Proposition is that it means that so much of the good work that we do is off book to Medi Cal, meaning DHCs can't see it in the claims.

And so it's very difficult to analyze or capture data about all of those really tremendous successes in reaching people. And I can provide specific examples, but those are some of the programs and services that in this sort of reshifting reprioritization, we're most concerned about, because there's not an opportunity today to bring in Medi Cal for those programs and services. And it's really not likely in the near future that CMS will change its opinion on some of those things. Right.

Because again, they're by definition not traditional programs and services or by definition, things that Medicaid hasn't paid for or won't. The current Administration has been really wonderful in pushing the envelope and trying to get CMS to approve things that we have not traditionally been able to do right. And so there is some potential upside there.

Part of what I'm trying to flag is that we're going to need to call it to build our first plan before many of those new waivers or permissions or initiatives are underway, is a little bit of a sort of holding on to what we can that we must, for the purposes of our Medi calc compliance, doing what we need to, to comply with all the new rules in the BHSA and then analyzing what's left over.

And of those things, do we need to try to find new funders, let them go, or give them enough of an opportunity? A heads up? Frankly, the community groups that we're funding with the MHSA that we're about to pull the rug out from under you, and I can tell you that the county behavioral health directors, the weight of that responsibility sits pretty heavy on them right now.

They're very concerned about giving those community groups enough lead time so that they know what to expect, because we've spent a long time building up that trust. Those relationships and our communities rightfully rely on many of those programs and services.

Anything else? No. Thank you so much, everyone. LAO, just, I know you came up here for BHCIP, but is there anything else to add on this whole Prop 1?

You know, nothing further to add, but, you know, we're available for questions, work with the Committee moving forward.

Thank you so much. Okay. Moving on to the Mental Health Services Oversight and Accountability Commission. I was like, Toby, don't go too far.

I can come down there and run it for you.

Thank you, Madam Chair, and I'm assuming this is on the Agenda Item on the reappropriation issue?

Quick overview: Issue One.

Quick overview: Issue One. Sorry.

I mean, I mean, you gave a--you gave it already. I don't know if there's anything else you need or want to talk about this on the Commission before we go into the reappropriation.

I don't have additional information to share in terms of quick overview, but I'm certainly, you know, happy to, you know, certainly express my deficits in pushing buttons and making microphones work. You know, I think, you know, sort of the broadest issue here is, you know, the Commission really was formed to sharpen our ability to have the impact that, you know, the voters, people of California and their clients and families we serve expect.

And, you know, we're really trying to be very intentional in working within the new opportunities that the Behavioral Health Services Act creates to be effective. We're actually really excited about a couple of areas. So one of them is the new prevention role for the Department of Public Health, as Director Aragon pointed out, right? This is an area where we don't have a lot of history and the level of funding, the fact that it's ongoing funding, the fact that it's population-based, right?

I think that, you know, is an area where we want to be very thoughtful in supporting the Department to think about how to be effective in pretty comprehensive ways, recognizing that prevention happens in areas outside of the traditional jurisdiction of CDPH.

And we're very hopeful that as the state stands up a strategy to make use of those dollars, that it really leverages opportunities in K12, in higher ed, in workforce, in the type of training we do for our public health workforce as well as our behavioral health workforce, the type of training we do for teachers, because the eyes and ears for prevention, the ways in which we support prevention, our history of prevention, as mentioned on heart disease, isn't through traditional, classic clinical-based care.

It's through the behaviors, activities, and thoughts that everybody has every day, and so similarly, on early intervention, we think this is an area of profound significance, recognizing new roles for the state to really be aggressive and we'd love to really understand from the Committee's perspective, and this is related to the accountability piece.

It would be very helpful to identify the half dozen to a dozen priorities that are necessary to really move beyond the comparison of the pie charts, A to B, and really move towards recognition that we should be pulling dollars out of our deepest, most expensive institutions, criminal justice system, state hospital system, right?

And pushing them into those early intervention pots so we're not putting counties in this untenable position of trying to redistribute very scarce, too limited resources in ways that are not having the impact that they need to be. With that, happy to answer any questions.

I had a question to the Commission on the Oversight Accountability for CYBHI, the Children and Youth Behavioral Health Initiative. Is there a report that the grantees submit to the Commission or is it just a one-time approval of the grants and then hopefully the programs are working well?

So there's a couple answers to that. So we have an explicit role in CYBHI through both the inclusion of the Mental Health Student Services Act as 20 million dollars a year to fund local partners between local education agencies, county behavioral health departments, County Office of Education, and charter schools to support school mental health strategies. So we are actually a grant provider and a partner in CYBHI in doing that. There is a reporting requirement that we are working on that is due to you.

We also--when CYBHI was structured, the Legislature set aside a portion of funds for the Commission to implement some of the evidence-based practice funding. We have a partnership with DHCS. We actually administered the competitive procurement process for rounds four and five, focusing on youth-driven and early intervention. Some of those funds, a portion, are being dedicated to build out the state strategy on early psychosis intervention, and some of those to build out the--

And all the rounds went out already on C1? Okay.

Yes, round six has not gone out, but the other ones, one through four, have gone out. DHCS would need to give you more details on the background on that.

Department of Finance, you said round one through four has gone out, five has gone out. Where's round six of the funding? So we still have funding in this pot for the last round for CYBH?

We do still have funding for round six. I would have to get back to you on the specifics of whether we've released the RFAs or anything like that, but I could get back to you if you'd like.

Do you have a response? I don't know if you have an addition. I've been trying to get this whole year an understanding of what's left in this initiative.

Good morning, Chair. Yes. Round six has not yet gone out. We've been working with the third party administrator, the California Institute for Behavioral Health Solutions. Sorry, Autumn Boylan with DHCS--I didn't say that part--to design this strategy for round six, which will be focused on community defined evidence practices, specifically in partnership with Medi-Cal managed care plans, commercial plans, and community-based organizations to promote the adoption of community defined evidence strategies with communities locally and funded through our health plans. So there is still funding available for that. About 30 million dollars was allocated for that round, and the funding has not yet been--the RFA has not yet been issued.

Okay, thank you. And then, Toby, I'm sorry. I usually like to call you by your title, so I don't--

No, please. Toby.

So you said a report is due to a student on CYBH. Is it going to talk about the efficacy of each program with each grantee or what will we be seeing in that report?

So, to clarify, we are not--so there are multiple reporting requirements within CYBHI. We have a small sliver of that, and the Mental Health Student Services Act predates CYBHI, but it was incorporated in because there were significant additional resources dedicated to the School Mental Health Strategy as part of CYBHI. It dwarfed the original 300 million dollars that the Commission received to support school-based mental health. So we have--just to be clear--we are not reporting on everything that the Administration is doing in terms of CYBHI.

We do have some reports. I'm sorry, I do not know the date that it is due. And we have some other oversight reports due to you around full service partnerships and we are preparing other information for you. For example, we are in the process of developing a strategic plan to identify the challenges we have in the State of California in ensuring that people who develop psychosis have access to evidence-based care in an early manner.

And as part of that one, we're working with some partners to do the economic impact analysis of what it would cost to get from what we believe is about a ten percent access rate today to a targeted 90 percent access rate with some very significant early evidence that it would actually cost us less to improve access to care through those strategies.

Senator Roth.

Thank you, Madam Chair. You know, I was chairing Sub One when we did the Mental Health Student Services Act. We wanted a bunch more money, we wound up with 50, and then later others took it to new heights. Where do we go then to get a report on how this is is all coming together if you only have a piece of it?

I mean, the goal was--and part of this came about, I think, because when I would ask school superintendents if they were on the local Mental Health Services Board, most of them who came before us in Budget Subcommittee Number One had never heard of it, and they certainly didn't have a seat at the table and had never received any resources from the county or anywhere else. No fault of anybody's, because, you know, out of sight, out of mind.

The goal was to put them all at the table and see if we could direct some resources through the county to the school districts to provide an appropriate level of service at the school district and then referral to mild to moderate to severe, wherever the students needed to go.

How do we--where do I go to find out how successful the program has been? Are the school districts reporting through their stovepipe? Are the counties reporting? Maybe my licensed clinical social worker, colleagues who know this subject much better than I know, but I don't know. So is that a fair question to you?

It is a fair question to me, and, you know, I cannot speak for the Administration in terms of the broader impact of CYBHI, and I would certainly, you know, want to defer to Finance or the LAO or the Administration on that. I can, you know, what I can share is that it's absolutely the right question, right, that the way in which the Mental Health Student Services Act was implemented, particularly in recognition of the pandemic, was to really facilitate those partnerships, Senator Roth, that you talked about, right?

And so, as the Commission put these dollars out--and it was not a lot of money. It was two and a half million to small counties, four million to medium size, and a whopping six million to large counties like Los Angeles. It was not a lot of money.

And so our primary focus, our goal, was to facilitate collaboration between LEAs, county behavioral health departments, and County Offices of Education, which meant that each applicant had the right to sort of design their strategy that was appropriate for their community. It wasn't one-size-fits-all. The uniformity that we were looking for was collaboration, but what they collaborated on, there was tremendous variation in terms of bringing clinical care into a school, doing training for teachers, focusing on suicide or suicide prevention. So lots of variation.

Now, we're at this stage where we believe the right thing to do is to begin to build off of the base of collaboration that is now very robust. There's lots of very positive stories about strong working relationships between these institutions that have not always coordinated or communicated, often for very good reasons, and begin to push the system to be more consistent in terms of standards of care and strategies so that we can begin to guide over the long-term the scaling of effective interventions in all of the domains that our local partners have recognized are important, which includes teacher training, suicide prevention, workplace mental health for school staff, right, as well as access to clinical care for students' youth empowerment strategies.

There's a lot of work to be done in order to do that. One of the conversations we've been having with the Administration is how can we actually sustain leadership on school mental health over time, recognizing that CYBHI is a sunsetted program with one-time funding? Very good use of one-time funding, but it's one-time funding.

And so I would say the train is moving, to use your example, and we have a lot of work to do to actually make sure it's heading in the direction that helps us learn from the experiences that we've funded so far to shape opportunities for sustainable funding for the local partners, do this in a way that allows us to scale effective practices, and includes the ability to research and understand where it's working and where it's not so that we aren't simply replicating disparities across the state as has come up in some of the conversations today.

Well, we seem to be, fortunately, moving in a direction of multiagency coordination of effort in areas such as this, which then, of course, facilitates appropriate reporting and accountability when we're not moving in a stovepipe way, but instead across the board with a common set of goals and objectives. Hopefully we will see some coordinated reporting. It's a shame the program is sunsetting.

Hopefully we can, when the money becomes available again, we can fire it back up, but it's ever more important than to have coordination across agencies and departments. So we maximize the money that is available in the system to provide the most to those who need it the most. So that's all I have to say, but thank you for your efforts. Thank you, Madam Chair.

Thank you.

Senator, I would just add to that, that as the state thinks about the clear and consistent reporting on behavioral health expenditures, one of the questions is, are we including the resources that are coming through the LEAs to support those goals, recognizing that we should not and cannot separate out the opportunities for behavioral health support through our LEAs from the core program.

It doesn't mean that county behavioral health departments are responsible for that, but we need to think more holistically about the universe of funding and how we leverage it, and so I think there's a lot of work to do with DHCS and the Administration, both on the revenue reporting side as well as the outcome and accountability side, recognizing that preventing school failure continues to be recognized as a core goal of the BHSA.

Well, it's my understanding, anecdotally, that one of the issues that we raised in the way back--I mean, I've been here for a long time--was that perhaps we should, our Medi-Cal plans, county plans, should be more involved on the school district sites for a whole variety of reasons, both as navigators and to get people enrolled who, families enrolled who would not otherwise be enrolled, and my understanding is, at least in some counties, that's happening, and that effort needs to be included in the measurement as well because that's a service that would otherwise have to be funded by someone else.

Agreed.

Officially moving on to Issue Number Two in the reappropriation.

Thank you, Madam Chair, Members. The Commission receives funding through the Mental Health Wellness Act. It's 20 million dollars a year, and those funds are administered by the Commission under the guidelines of that act that says it is to prevent--support prevention, early intervention, or response to crisis. We did an analysis of where we had been investing through the lens of the lifespan and recognized that we were deficient in the very young ages and for older adults.

And so, in partnership with the California Department of Aging, we prioritized funds to support these two interventions that target the needs of older adults, again, based on guidance from the Department of Aging. One of our counties that received funding through a competitive procurement has recently notified us that they will not be able to use the fund, so there's one million dollars left over. It is outside of the window that would allow us to reappropriate it.

And so our ask is to allow us to reappropriate that to bolster the funding that we have provided to the other partners just to extend the impact. These are early intervention programs that are designed to support older adults to stay in their home and to, you know, live independently. They're just key programs that, ideally, we'd like to be able to scale.

But right now, they're dependent on these type of grant funding, and so they ask us to reappropriate those dollars so we can reinvest them into the programs that are currently in place. There will be no delay in making that happen because the way we wrote the procurement is that unallocated funds would be redistributed to the existing grant recipients. And I would note that there were no applicants who were not funded, and so it's not--so the money would not be taken away from anybody. It's money that was voluntarily relinquished.

Okay. Well, any additional comment on this item?

Will Owens with the LAO. We have not raised concerns with this proposal.

Nate Williams, Department of Finance. Nothing to add.

We're going to hold the item open. Thank you so much for joining us today.

Thank you. Appreciate it.

Now moving into the Department of Health Care Services.

New faces.

Would you like us to jump in with issue one? Yes.

Introduce yourself please.

Yes. Good. It's time to say good afternoon. I'm Paula Wilhelm. I'm the Interim Deputy Director for Behavioral Health at the Department of Healthcare Services, and we have been asked to provide a brief overview of significant program changes related to our specialty mental health and our drug MediCal and drug MediCal organized delivery system programs for current fiscal year and coming fiscal year.

So, as you all are aware, there's a lot going on in behavioral health to choose from and highlight, and I'm going to focus my remarks on a couple of our core multi-year behavioral health initiatives. So the California Advancing and Innovating MediCal initiative, or CalAIM, began back in calendar year 2022, and the Department continues to phase in those policy changes over time.

DHCS is also currently seeking approval from our federal partners at the Centers for Medicare and Medicaid Services for the behavioral health community-based organized networks of care and treatment demonstration, also known as BH Connect. And if approved, some components of BH Connect may be implemented beginning in January 2025. So I'll provide just a few updates on CalAIM and then preview the BH connect policies that we propose to implement beginning in 2025.

As you may be aware, our core CalAIM behavioral health initiatives are meant to improve access to whole-person behavioral healthcare and improve quality outcomes, and we wanted to achieve this in part by reducing administrative complexity across our specialty behavioral health delivery systems.

So the Department continues to monitor and support implementation of some of the key policy changes from the past few years, including updates to the criteria for accessing our specialty mental health and substance use disorder treatment services, implementation of standardized screening and transition tools for MediCal members who are seeking behavioral health services, updates to our clinical documentation policies, behavioral health payment reform a new model to pay our county behavioral health plans, the no wrong door policy, which is meant to ensure that MediCal members can access timely and appropriate mental health services regardless of the delivery system in which they first seek care.

So, in addition to those ongoing initiatives in the current fiscal year, the Department, in close partnership with county behavioral health plans and our community-based behavioral health providers, have also focused on expanding MediCal peer support services and our recovery incentives program, implementing mobile crisis response services. So to date, 51 out of 58 counties have opted to cover MediCal peer support services, and more than 1800 MediCal peer support specialists have now been certified to work in California.

Turning to our recovery incentives program, we have 19 of our drug MediCal organized delivery system counties that are now able to offer contingency management, which is an evidence-based treatment for individuals with substance use disorder. As you may be aware, we are proud of this program. California was the first state in the nation to receive federal approval to cover contingency management in Medicaid through an 1115 Medicaid waiver authority.

And so at this point, we're about a year into program implementation and 88% of our MediCal members live in one of those counties that has at least one contingency management provider in operation. So also, all 58 counties are now required to implement MediCal mobile crisis services by the end of the fiscal year.

So 46 counties were required to implement by December 31 of 2023 and the 12 remaining counties, smaller rural counties that we gave a little more runway to to work out reimbursement models are required to implement by June 30 of 2024. So looking ahead to the coming fiscal year, DHCS has made significant progress in planning and designing our BH Connect initiative.

On October 20 of last year, we completed a major milestone by submitting our application to CMS for the components of BH Connect that we need to implement through another Medicaid section 1115 demonstration waiver. BH Connect is really designed to complement and build on the array of behavioral health investments that are underway right now.

Our goal, sort of across behavioral health programs and initiatives, is really to strengthen and expand the full continuum of community-based behavioral health services that are available to our MediCal members with significant behavioral health needs, and we also are striving to improve access, health equity, and quality of care. So before I close, I will touch on a few of the initiatives that are included in BH Connect.

First, we propose to implement MediCal coverage for several new evidence-based therapies for individuals with significant behavioral health needs, and these include assertive community treatment, coordinated specialty care for first-episode psychosis, clubhouse model services, supported employment, and transitional rent. DHCS will support implementation of these services, in part by establishing centers of excellence so technical assistance hubs to support counties and providers with training and implementation so that they can implement the efficiency evidence-based practices with high fidelity.

And we are also proposing to offer incentive funds to county behavioral health plans for implementing and scaling the new evidence-based practices and then ultimately demonstrating improvements in health outcomes for the members who are accessing these services. As mentioned earlier in the agenda today, we are also seeking expenditure authority for a behavioral health workforce initiative, which will administer in partnership with the Department of Healthcare Access and Information, or HCAI.

We're seeking to support both long and short term investments in the workforce, and probably don't need to tell anybody that these investments are sorely needed in order to lift up the new services we're proposing to cover, help realize the promise of the Behavioral Health Transformation Initiative, etcetera. We cannot do that without a robust and representative behavioral health workforce. BH Connect also includes several components intended to support outcomes for children and youth in the child welfare system who also have behavioral health needs.

So a couple of programs we're excited to move forward with include activity funds, which would be available to pay for activities and supports that promote social and emotional well-being and support children who have experienced physical and mental health effects from trauma.

Who will be able to administer that funding? Is it coming out of schools or how would a child be eligible for that?

Great question. So that's one of the pieces that we are seeking federal approval on now, and we've talked about whether it would be DHCS or Department of Social Services administering directly, but that is to be determined. And then was also going to mention the cross-sector incentive program, and that would be incentive program to facilitate collaboration and drive improved outcomes across agencies that serve the child welfare-involved population.

So these would be incentive funds available to county behavioral health plans working in concert with our MediCal managed care plans and our child welfare agencies, so available to all three entities. And finally, I'll mention that BH Connect also includes an option for county behavioral health plans to receive Medicaid reimbursement for services provided during short-term stays in facilities that have been designated as institutions for mental disease.

But this is only available if the county agrees to cover that full array of new evidence-based therapies and to reinvest any dollars generated through the demonstration into community-based behavioral health services while meeting new accountability requirements. So again, we are negotiating the terms of this program with our federal partners right now. We hope to obtain approval by the end of the calendar year and then would be able to begin rolling out the components in 2025. So I will close there, but happy to take questions.

I wanted to talk about the mobile crisis services we got approved for a five-year period. Are we looking ahead post 2027? I mean, you know, a lot of stakeholders love this ability to be able to get this federal match for mobile crisis. I don't know if it's too early to start having those conversations. I feel like it's never, but just want to get further insight on that.

Yes, so we have added mobile crisis services as a MediCal benefit. So we envision that continuing to be available after the period when the enhanced federal match is available.

And what's, I mean, what's the success rate? And do we see these at every single county? I don't think maybe every single county has it. But at what point will we start getting feedback on this program?

And when you answer that, also, is there standardization between counties and mobile crisis teams? So I think they look different in different places.

Yeah, those are great questions. So right now, we have 31 counties that have fully implemented the benefit in a manner that is compliant with our guidance. And so that includes, you know, being able to cover the county's whole geography, being able to have the service available. 24/7. And then we have 15 counties that are continuing to work to be able to implement in the way that is required to get the enhanced federal match.

So in those 15 counties, they may have some mobile crisis capacity, and they may be responding as they're able to, but they're not all the way to meeting the requirements for the enhanced federal match. And then the remaining final 12 counties have until June 30 to implement.

And then to the standardization. Are they all?

Yeah, so we have a pretty extensive guidance on what we expect mobile crisis response to look like and some of the requirements they have to meet, and that includes timely response and the way that folks are able to have a number to call in and the 24/7 access requirement. So I think we have both a really strong framework in our guidance, and we've been providing a lot of dedicated TA on this topic. So the benefit is standardized.

There will, of course, need to be some local variation and innovation just to account for different geographies, et cetera.

And is this a mixture of both just mental health? Is it all just mental health response teams? Is it also paramedicine response teams?

Yeah. So there is a large array of different professionals that are able to participate on the team in order to, again meet the requirements to attain federal reimbursement. And so paramedics are one of the approved types of professionals.

Ryan, any additional comment from LAO?

Nothing to add, but available for questions.

Nate. Nate, is it?

Nate Williams, Department of Finance. Nothing to add.

Great, we're going to move on to issue number two, narcotic treatment program licensing trust fund.

All right, so to provide a brief overview of this particular proposal, the Department is requesting expenditure authority of 500,000 for budget year and ongoing. And this is for the narcotic treatment program, or NTP Licensing Trust Fund. And this request is really to enable the Department to expend all the available funds that we have collected from our NTP licensing fees. So we use the fund revenue to support our oversight and compliance monitoring for all of the licensed ntps.

But our existing law does not grant the ongoing expenditure authority that we need to access the whole fund, including 10% reserve. And so when we do experience those shortfalls between what we need to spend and the existing expenditure authority, we have to seek General Fund relief. So the purpose of this request is really, we are asking for an amount that we believe will support our licensing oversight operations on an ongoing basis. We don't anticipate needing to increase the fees or ask for more.

We've been looking carefully at our budgets and think we will be able to operate within this amount. So we just need the authority.

For how long? You'll be able to operate under this for 500,000 for how long?

We don't have. We haven't identified a year at which this will not be enough at this point. Like this is. Yeah.

Brian, any additional comment?

We have no concerns with this proposal.

Nate?

Nothing further to add.

Thank you. Holding the item open. Moving on to issue number three, Behavioral Health Bridge Housing Program funding shift.

All right, so due to lower than projected Mental Health Services Act revenues, the budget proposes to shift 265 million from our mental health services funds that were appropriated in the 2023 Budget act to the General Fund in 2024 to 25. This shift will actually not have an effect on the timeline for distributing bridge housing funds pending budget approval.

We have a current round of bridge housing funds that just closed in the beginning of April that was 265 million available through competitive applications to county behavioral health agencies. We would plan to make those award announcements from that 265 million in July 2024, and so that would coincide with the coming fiscal year and the availability of the delayed funds.

There's also a proposal to delay 235 million in General Fund originally planned for the budget year 2025-26 and in that event, we would release the next round of bridge housing on a similar timeline in 2025.

We think that the proposed delays are reasonable in light of the budget condition and that the funding shift is reasonable in light of revised lower estimated revenues into the Mental Health Services Fund.

Thank you.

Nate Williams, Department of Finance. Nothing further to add.

Okay, I'm going to hold the item open. Moving on to issue number four, Children and Youth Behavioral Health Initiative fee schedule TBL.

Good afternoon, Chair and Members. Thank you so much for having us here to talk about this proposal. To start with a brief overview of the proposal, the 2023 Budget Act included $10 million for the Department of Healthcare Services to establish a statewide third-party administrator for the CYBHL fee schedule program. In the fall of 2023, the Department issued a request for information and selected a vendor.

We've partnered with Carelon Behavioral Health to serve in that capacity, and we've been working with Carelon Behavioral Health and the county offices of education, local education agencies, and health plans to stand up the infrastructure that's necessary for the TPA to be able to serve in that statewide capacity to serve both the health plans and the local education agencies.

Is this the third party that you mentioned earlier for the last one?

No, that was a different third-party administrator for the evidence-based practice grants. This is specifically to serve the health plans and the LEAs as an intermediary for administering the fee schedule program specifically.

I'll talk a little bit more about what their role is, but the idea is to centralize the health plan oversight functions into a single statewide infrastructure or entity so that all of the local education agencies that participate in the fee schedule program will go through one single, centralized statewide entity rather than managing relationships with each individual health plan separately.

And specifically, the third-party administrator in this role will support both the health plans and the LEAs by streamlining the oversight and significantly reducing the administrative functions that would otherwise fall to each health plan to separately administer.

Without this infrastructure ongoing, the participating local education agencies, California community colleges, California State University, and University of California systems would be required to coordinate benefits for all students receiving CYBHI schedule services, figure out which plan is responsible for coverage, submit claims to the health plans, and be subject to different oversight processes of each plan.

A significant majority of the local education agencies and nearly all of the colleges and universities lack any prior experience with billing health plans for student health services, and nor do they have the necessary billing infrastructure and data systems to manage direct claiming processes with the volume of plans that we have in California. And as a reminder, the CYBHI fee schedule program is a multi-peer obligation.

So it's the MediCal managed care plans, the commercial health plans or health care service plans regulated by the Department of Managed Healthcare and Disability insurers that are regulated by the California Department of Insurance are all obligated under existing state law to reimburse school-linked providers for the provision of outpatient mental health and substance use disorder services provided to a student in a school linked setting.

What we've learned in the last two years as we've been working with the LEAs, County Offices of Education and Health plans, is that this is a supremely complicated initiative to stand up. And as Executive Director Ewing was speaking about earlier, with the foundation of the Mental Health Student Services Act, as well as with the Student Behavioral Health Incentive program, we've started to initiate programs that build the relationships between the health plans, the counties, the LEAs, and the county offices of education.

But these are newer relationships that didn't previously exist. And the administrative function of the third party administrator is really to support both the health plans by taking on some of those responsibilities that otherwise they would each separately have to administer, but also to really support and facilitate the participation of the local education agencies so that they only have one oversight entity to navigate and partner with, rather than 100 oversight entities across the state through all of these different payer systems.

This will, you know, this came about through our stakeholder engagement process. It came up through our work group and a recommendation specifically from our County Office of Education and LEA partners that, you know, having a statewide infrastructure would really support and enable their participation in these types of programs. We've been working with the first cohort of LEAs. We launched this program in January of 2024.

47 local education agencies across 25 counties, including all of the county offices of education, have been working closely with us, Caroline Behavioral Health, and all of the health plan payers to kind of normalize all of these operational procedures, implement all of the necessary data sharing agreements, and set up the infrastructure that's needed.

And so this proposal is really meant to support the ongoing infrastructure since we had the initial pilot funding for the first two years of the program, the idea behind the fee is that we would use that fee by charging a small, reasonable fee to the health plan payers, since the TPA will take on those functions on their behalf and continue to Fund this contract into the long term to support the successful implementation of this program.

Thank you so much.

We've not raised concerns with this proposal.

Nate Williams, Department of Finance, nothing further ahead.

Senator Eggman?

Yeah, I would just say, so we feel like it's going to work? I mean, because when we first started working on this, the school said we can't, we can't do the billing. And the plans were like, whoa, what are we doing here? So we feel like through this process, we've been able to come up with this entity that's going to do the right we report to, this is all going to work out?

We're very confident that this is the best path forward. This first year of implementation of the fee schedule program is really about learning. So we've implemented a pretty intensive learning collaborative model for the first cohort that again started in January. We put out the applications for the second cohort and had 98 local education agencies apply to be a part of the second cohort. We've been meeting in nearly bi-weekly sessions with all of the implementing partners to work through all of the operational complexities.

Like I said, this is new for the LEAs. This is very new for the California community colleges, who we've been also working with closely, as well as the UC and CSU systems. And so we really think that without this type of infrastructure, it would not be feasible for many of our LAA partners or college and university systems to participate in this billing opportunity.

And really, this is a sustainable, long-term, permanent source of funding to sustain school-based mental health and outpatient SUd services in schools by holding the plans accountable. And so this, you know, it's not, it's not easy. It does make it easier, though, and it reduces the administrative complexity significantly by having all of this go through one entity. So even though they have to have a data sharing agreement, they have to have, you know, data exchange, they have to upload their claims data into this system.

Without this infrastructure, they would have to do that for every plan that is a pair within the system. And if you think about a county like Los Angeles, that's many, many plans that each LEA would have to navigate separately.

And it's great that we've got this part of it worked out, but how are we measuring success for the actual program?

Yeah. So, and to answer some of the comments that you were raising with Toby Ewing earlier today, the California Health and Human Services Agency is leading the evaluation work for the Children and Youth Behavioral Health Initiative broadly. They've contracted with Mathematica to conduct an independent evaluation of all 20 work streams of the children and youth Behavioral Health Initiative, including the fee schedule program.

And the five departments that are working with the California Health and Human Services Agency to implement the CYBHI work streams are working very closely with Mathematica, including our Department.

So, thinking about this strategy, if we focus on school-based services and the investments that we've made with the Mental Health Student Services Act, with the Student Behavioral Health Incentive program, or SBHIP, with the Cal Hope SEL program, around social and emotional learning, the well being and mindfulness grants, and now this fee schedule, this is really foundational in building out a strategy for supporting schools who are the ones who are seeing our kids more frequently than their parents are in some cases.

So we're working with Mathematica on a results-based accountability framework that will include specific reporting and dashboard reporting so that we can say how many kids are getting services through these, through these programs. On,

When would that be live?

Well, so the program's just getting off the ground for the fee schedule program, for example. But we would start to implement the dashboard on a quarterly basis.

Once we have data that we can populate, and probably starting in early 2025, we'll have data that we can start to populate in that space. But we'd be looking at a variety of metrics, including not just utilization, but utilization by payers. So we'll know which kids are getting services based on coverage requirements. We'll also know who's getting care, you know, in terms of the student population, how they're being provided services, and what types of services are being delivered to students in a school-linked setting.

So we've included a broad array of services in the fee schedule program, including a wide array of psychoeducation services, treatment services, screening and assessment, and care coordination, so that we're really supporting what schools are already doing and providing.

And that also, that data stream goes to Toby as well. Right. Because if we're going to be measuring or accounting for all the money that goes into mental health in every county now.

So, I mean, the dashboard and the evaluation will be publicly reported. But yes, we do work with mental health or the Behavioral Health Services Accountability Commission. And like I said, I think what we're trying to think about is the strategy behind all of the school-based services investments and how we can show all of these partnerships, which, you know, the MHSSA and SBHIP are foundational.

The wellbeing and mindfulness grants are focusing on really that primary prevention focus around well being, mindfulness wellness centers and schools, and then the fee schedule layers on top of all of that to provide a sustainable source of ongoing funding provided by the health plans for their enrolled members to the schools directly. So that's not all coming through the state to fund in the long term.

Thank you so much. We're going to hold the item open.

Thank you.

Thank you for joining us today. Moving on to Department of State Hospitals.

Brief. I'll keep it really brief. Good afternoon. Chair and Member, Stephanie Clendenin, Director for the Department of State Hospitals. The Department of State Hospitals manages the California State hospital system. DSH's mission is to provide evaluation and treatment in a safe and responsible manner by leading innovation and excellence across the continuum of care and settings. We operate the five state hospitals located throughout California. A conditional release program, which is a system of community based services that's operated in partnership with county behavioral health departments and private providers.

And this is designed to transition patients back into the community following a forensic commitment to DSH. And we also have partnerships with county behavioral health programs, private providers and county sheriffs to provide community based restoration diversion opportunities. Jail based treatment programs for individuals committed to the Department as incompetent to stand trial. The individuals that are served by our system are mandated for mental health treatment by either the criminal or civil court judge or the board of parole hearings.

And the majority of the individuals we serve are either forensic commitments they have either committed or have been accused of committing crimes linked to their mental illness. And then we also serve individuals who are conserved through the civil courts under the Lanterman-Petris-Short act. The department's proposed budget for fiscal year 24-25 totals 3.4 billion, which is a decrease of 85.3 million.

And with 12 new proposed positions in budget year, the Department is projecting the census of 8163 by the end of the fiscal year 9267 across its programs by the end of fiscal year 202425. And that increase is primarily related to expanding capacity for the treatment of incompetent disdain trial individuals, primarily through the expansion of community based restoration and diversion with some small increases in capacity and census planned at our state hospitals and JBCTs. Happy to take any questions and just to say congratulations on that.

I know this has been a big issue, but how many people have been on that list and being innovative and going down to the jail level and not waiting for everyone to get. I think it's just. It's certainly short in the list. Thank you.

I had. Well, it's related, but I wanted to know about individuals who are in regular prisons who are diagnosed IDD and I'm trying to figure out maybe it's. I know it's a different Department and this. Is there a. Maybe there's an assumption that perhaps an individual who has an intellectual developmental disability at minimum is incompetent to stand trial. Wouldn't that alone divert that individual to go not to a regular prison, but to a state hospital?

Good question. So as it relates to individuals with IDD, there is a separate structure within the statute for incompetent to stand trial. So the statute that relates to the state hospitals primarily is related to individuals with serious mental illness. But there is a structure and a statutory construct for individuals with IDD and that then is tied to the Department Developmental Services. However, some individuals can be referred to the Department.

Okay, and then how are our diversion programs going? Are we seeing a little success? I know there is a big shift, right. I just want to know if we have any early data on how many were able to divert away.

Good question. I not sure I have the diversion statistics with me, but we have. Let me see, see what I have in my little packet. But we have currently the. As far as diversion is concerned, we had the pilot program and then we in the IST solutions that has been funded to make those programs permanent and to expand them. As far as it relates to the pilot program, we're still within the pilot program and just finishing up the pilot program.

I think we have 29 counties that are participating in diversion. And that pilot program was proposed to Fund up to, I think it was 700 or 800. Looking back to my crew back there, they're not coming to save me today. But it was several hundred individuals to be diverted through the pilot program and that is largely coming to completion. We do have within our budget estimate binder a report on the outcomes to date, but I don't have those handy at my hand.

But it's a pilot, so it's going to end?

It is going to end, but we've already been funded for the ongoing program. So the IST solutions included funding for us to expand community based restoration and diversion and also included funding for us to expand and to provide actually infrastructure funding to provide up to 5000 beds. Because one of the challenges that we found within, within the pilot program was actually the ability to find housing for individuals so that we are not competing with the housing stock that already exists.

The IST solutions provides funding for us to be able to expand housing with a focus on felony isTs.

At what point do we have in the Department an internal timeline to look at how carecorps is going to impact the capacity at our state hospitals? Do we have something that internally we're looking like this has really impacted or deterred a lot of people from coming into state hospitals?

Yeah, good question. The care court is designed to really serve the individuals that we see largely that are coming into the Department as incompetent to stand trial, individuals that are experiencing homelessness and have serious mental illness. That'll take time for us to really be able to see the impacts, but it is largely the design to treat the individuals that we had been seeing over the recent years at the increase in referrals to the Department.

And maybe I missed this. I apologize. I see the numbers are all five hospitals. Our capacity. Would you say this is a good amount that we have or. It looks like, it appears that the ratio to person to staff seems pretty good, but I don't know what I'm comparing it to. Can you tell me more about how would you describe your capacity levels and your ratios to staff to individual in there?

So a couple of things I can touch on. First of all, we have over 6000 inpatient beds in this system and overall institutionalization is not what we want for our Californians with serious mental illness. However, we do have, like I said, 6000 beds.

I would say if you asked me that question several years ago, I would have said we didn't have enough because we were, had these very large waitlists and we were really struggling to provide services today through the expansion, with the expansion of our capacity outside of our state hospital walls, through our community based restoration and diversion programs, the partnerships with our sheriffs and their jails and our county behavioral health providers, through the community based restoration and diversion programs, as well as private providers, because we are also contracting for services in community inpatient facilities as well.

We have a very robust now continuum of care for individuals to kind of meet the needs that they have at varying different levels across our system. So as far as capacity, we're doing fairly well now and we still have funding to build out those 5000 beds for community based restoration and diversion. So quite a bit of capacity that we have available to us, but not all of it now, is within the state hospital system.

And then I would say with respect to your question about like staffing and the staff to patient ratios, so we have established staff to patient ratios for our clinical providers and our nursing staff as it relates to the level of care that an individual has within our system.

So, you know, our acute programs generally run around the one to 15 where our ICF programs are running about one to, I think it's 25 to 30 in, depending on the type of commitment for our, for our hospital programs. And then nursing has their own ratios.

We recently, and I think in the next item, we're going to touch a little bit on this, but we did recently go through a mission based review project with the Department of Finance, and that relooked at our ratios to really take a look at if we had enough allocation of staffing to meet the patient's needs based on the changing population that we had over the recent years. And so that did make adjustments to our ratios as it relates to the services that we provide for the patients.

Thank you so much. My last question is related to. I'm trying to choose the correct word because I wouldn't say success rate for the IC part, but if you could share a little bit more of.

Trying to find a different word, how long perhaps it takes for us at the state hospital to then allow that person to be competent to stand trial and go continue in their procedure. How often are we getting to a point, or is there points where we say, hey, this person really cannot. And what's the ratio there? Is it more we're able to bring them back to competency or not?

Yeah, all good questions. And so the lengths of stay are going to depend on the program that they're in. So within the state hospitals, generally our length of stay runs around about the 150 days ish mark. That is generally. Let me back up. So the state hospitals, it runs around 150 days. Our jail based competency treatment programs run less than that.

That's because generally we are identifying for placement in those programs individuals that are likely to restore faster and individuals that have the higher needs to come into the state hospitals. In our community based restoration programs, those are going to be much longer. Those are designed to be community based treatment for a longer period of time and then connection to ongoing treatment after they're restored.

So ultimately, those times are going to really depend on the program, the individual's mental health needs and kind of what services they're going into. There's also severity of criminal offense as well. That doesn't necessarily play into. Well, it does, yes. It doesn't play into their restoration, but it will play into their maximum commitment time. Right. So if somebody.

So the maximum commitment for an individual who is committed to the Department is two years, but if the equivalency of the time that they would get for their charges was less than that, then they could have a Shorter term with us. So it's up to a maximum of two years. And then generally we restore a high rate. I think it's about 95% of individuals get restored. There are some individuals that just reach maximum commitment.

We were still continuing to work on them, but they did reach their maximum commitment time with us, and they may have restored, we don't know, but they did reach the maximum commitment. And then there are few individuals that we do return to the courts as with no substantial likelihood that we will be able to restore them.

Okay, thank you. Will, any further comment on the. Well, nevermind, it's informational. Never mind. Okay, thank you. We're gonna move on to issue number two. Program in caseload updates.

Good afternoon, chair and Committee Members. Brent Houser, Chief Deputy Director of Operations for the Department of State Hospitals, before speaking to issue number two, just wanted to go back to issue number one on the question of how many individuals were diverted. Apologies, Director. Better late than never. But they did come to say over 1500 individuals that have been diverted since the program, and obviously that's increasing with all the recent investments.

Thank you so much for that.

All right, going back to issue number two, there are six program case load and updates listed in the agenda. I'll cover most of those and then transition it over to the Director to speak to the incompetent stand trial solutions. More specifically, beginning with the DSH metropolitan increased secure bed capacity project, DSH is reflecting a one time savings of 9.6 million General Fund in the current year.

This project was originally associated with a capital outlay project in 2016 to build security, fencing and infrastructure around an existing building so that we could add capacity and utilize that building to serve forensic patients. The project continues to experience delays into activation with the remaining two units out of five to serve incompetent stand trial patients with a 10 month delay, which is yielding the $9.6 million of savings associated with personal services for the next caseload. Adjustment.

Adjustment this is specific to the mission based review initiatives specific to direct care, nursing and treatment team. In the Governor's Budget, the Department is reflecting a savings of 50.6 million in the current year. As the Director mentioned in issue one, several years ago, DSH initiated a partnership with the Department of Finance to evaluate our staffing practices workload across the state hospitals and reviewed 24 hours care, nursing services and treatment planning and delivery.

As a result of this process, proposed staffing methodologies were adopted and implemented in position requests, yet led to additional positions across nursing and treatment team classifications that have been authorized and phased in over a multi year period. The savings are reported in the current year as a result to delays in hiring those newly authorized positions and challenges experienced in filling those positions for the patient driven operating expenses and equipment.

Update DSH is requesting $10.8 million General Fund and ongoing to support increases in patient driven support costs within the DSH system. This is specific to increases in costs for utilities, pharmaceuticals and foodstuffs. The Budget act of 2019 adopted a methodology to provide funding for these patient related items based on updated census figures as well as an updated per cost per patient. The request is as a result of increases due to inflation for essential patient related basic activities and a projected census increase.

My last update before handing it over to the Director is on the conditional release program for non sexually violent predators. DSH assumes a one time savings of $599,000 in the current year as a result of delayed admissions in one of our Northern California statewide transitional residential programs.

Within the conditional release program, savings are attributed to temporary pausing admissions to allow for further development of that program, but we have since resumed admissions for that particular program, and I'll hand it over to the Director to speak to the updates on incompetent trial solutions.

With respect to the IST solutions, we are reporting a savings of 58,573,000 in the current year, and these savings are related to our jail based competency treatment programs, community inpatient facilities, and early access and stabilization services. The Department is also requesting two positions. This is just position authority only to support efforts related to the growth cap implementation.

By way of background, over the past decade, the Department of State hospitals has experienced significant growth in the number of individuals found incompetent to stand trial and felony charges and referred to the Department for competency restoration. With year over year growth in IST referrals that are outpacing the department's ability to create sufficient additional capacity. Until recently, despite our efforts to expand treatment capacity, IST referrals outpaced our 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 the necessary infection control measures that we had to implement at the stage hospitals during the first two years of the pandemic, the wait list and wait times increased significantly. And then, as a result of the 2015 lawsuit by ACLU regarding the time that IST defendants were waiting in jail to be transferred to the department's treatment programs, the court ordered the Department to initiate substantive 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 toward meeting the final 28 day deadline last fall. Recognizing the impacts of the pandemic on the Department. The court reset the deadlines and we are now to achieve the 28 days by March 1 of 2025.

2025 and interim benchmarks have been set for 60 days by March 1 of this year, 45 days on July 1 of this year, and 33 days by November of this year. The 2022 Budget act included .

Did we make the 60 day?

We did, we did. We did. So we just recently provided a report to the report to the court on our progress and the report reflected that the average time to initiating treatment for ists in February 2024 was just 12 days and we had 98% of individuals who received treatment within 60 days and 90% were receiving treatment in under 28 days as of that February update.

So, as it relates to IST solutions, it encompasses a suite of programs and strategies that the Department has implemented to expand the continuum of care for ists and provide timely access to services, and to provide just an update on the four IST solutions that we are projecting savings or have a request for the budget the first was the early access and stabilization services, which is being implemented in the jails.

Under this program, IST individuals receive stabilization and treatment services in the earliest point possible in jail while we work to coordinate placement to the least restrictive treatment setting available within our IST continuum. As of the Governor's Budget, we had implemented ease programs in 44 counties and despite the rapid implementation of this program, there are still several large counties programs that are anticipated to be implemented in the future. Thus, there is a one time estimated savings of about $20 million in the current year for this program.

Next, we have been expanding jail-based competency treatment programs to provide additional short-term treatment capacity. There are currently 424 JBCT beds across 24 counties and we are reporting a net savings of 8.6 million in 23-24 for this program as a result of updated timelines associated with finalizing contracts for new and expanding JBCT programs.

And then we are utilizing community inpatient facilities, as I mentioned previously, and this is to provide restoration of competency and stabilization services and as of the Governor's Budget, we had contracted with five community facilities for a total of 183 beds and they are located in Anaheim, Bakersfield, Los Angeles, Sacramento, and Yuba City.

We have also executed a construction contract with Crestwood Behavioral Health for the activation of a 36 to 40 bed MHRC located in Fresno county, but due to the lengthy negotiation process required to secure additional contracts, we are currently projecting a one time current year savings of 30 million for the community patient Facilities program. And then lastly, we are also implementing the felony IST growth CAP program.

This program aims to address the increasing referrals to the Department by establishing a baseline number of IST determinations for counties based on the 21-22 rates and assessing a penalty in the county if the county exceeds the referral level by a certain threshold. Last year, 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 2022 to 23 and the final IST data with the counties is in process of being reconciled and based on the 22-23 referrals, or potentially 11 counties that may be issued penalties ranging from $34,500 to 13.6 million for exceeding their baseline referral levels. And we're requesting position authority only for two positions to support the significant data needs to operate operationalize the felony IST growth cap program that was not contemplated during the initial development of the original IST budget solution. And that concludes our updates with respect to the estimate. So we're happy to take any questions.

Deputy Director. Is that?

Chief Deputy Director.

I'm sorry. Sorry. I gotta get it right. Chief, for ConRap, the program you mentioned, you said that you started accepting people already to your Northern California STRTP facility capacity 20. Is it filled now? Because I don't know if you have those numbers.

I don't have those numbers readily available, but that's something we could follow up.

Do you know when you started transferring people to that location?

I do not have those details. We can follow up with your staff on that.

Thank you. I was just asking because I'm wondering if there was a backlog. Because that savings was from a backlog. We were waiting for that further construction that I think is.

Yeah, the savings isn't related to a backlog. The savings was related to. The beds weren't filled. So. And the. Because we had deposit admissions with respect to that program due to some staffing challenges. And so we did resume admissions. Don't have the current census, but we also are planning to provide an update in May revision as well.

Senator.

Thank you, Madam Chair. Madam Director, maybe you could refresh my recollection a little bit. I apologize. I didn't do my homework on this particular subject, but I seem to recall some concern from district attorneys in inland Southern California about the cap and the way the ists were counted. Am I having a mind failure?

There was definitely concerns raised around the growth cap, and we spent quite a bit of time last summer and early fall with the counties working through the growth cap methodology and revise the growth cap methodology and that substantially reduced down the level of the penalties that is going to be potentially sent to the counties. But there were definitely concerns as it relates to the growth cap.

But those, have been, those have been mitigated.

I would say that we definitely worked with our county partners to address concerns with how the growth cap penalty has been, like I said, calculated and developed. But I would say that counties still are not happy about the growth cap penalty. So I would say there's still concerns about the growth cap existing and still require for, you know, is there other adjustments we can make to the, to how we are calculating the penalty?

But overall, I would say that they're quite a bit less than what they were earlier.

Well, I didn't receive any calls in advance of this hearing, but maybe I'll get them afterward and then we can have a conversation. But I appreciate your response.

Thank you, Madam Chair, Department of Finance. Any additional comment?

Joseph Donaldson, Department of Finance no additional comments.

Thank you, LAO. Any additional comment?

Will Owens LAO. Nothing further to add.

Okay, we're going to hold the item open. Move on to issue number three, infectious disease prevention.

Good afternoon. Brent Houser, Chief Deputy Director of Operations again, I'm also joined by my colleague, Medical Director Doctor Katherine Warburton, to speak to issue number three. Specific to this agenda item, the department's requesting 25.9 million and 24-25 and 7.7 million and ongoing for expenditures related to infection control measures to continue to protect DSH patients and staff.

Additionally, DSH requests permanent funding and position authority for 10 limited term public health nurse positions in 2425 and ongoing to ensure compliance with public health related guidelines and regulations. During the onset of the COVID-19 pandemic, DSH implemented a response plan across its system and adjusted this plan on an ongoing basis.

Although the California State of emergency ended in February of 2023 and the federal State of Emergency in May of 2023, we still do have an ongoing responsibility and requirements to protect the health and safety of our staff and patients from aerosol transmissible diseases based on the changes in operations made by DSH in accordance with oversight entities such as the CDC, CDPH, Cal, OSHA, and local public health guidance, we have continued to support infection control measures post pandemic emergency, which is included but is not limited to the Administration of vaccine and education, continued provision of PPE isolation and quarantine guidelines continued sanitation protocols and testing protocols when necessary.

Our request is lower than prior years, primarily due to the ongoing changes in reduction in requirements by CDC and CDPH over time, as well as changes in the severity of the virus which has resulted in less outside hospitalizations, the number of isolation units we need and we no longer need to utilize admission observation units. That concludes testimony on issue number three. And Doctor Warburton and I are happy to answer any questions on this item.

Thank you, Doctor. Chief. Thank you, Will, any additional comment?.

Will Owens LAO, we haven't raised concerns with this proposal. No additional comments.

All right, we're going to hold the item open. We're going to move on to issue number four, IST solutions for trailer bill language.

Is it on?. Hi. Good afternoon, Chair Members. Chris Edens, Chief Deputy Director of Program Services at the Department of State Hospitals. I'll be handling issue four, the IST Trailer Bill. The Department of State Hospitals proposes trailer Bill related to incompetent to stand trial solutions. The trailer Bill addresses issues that will help improve program efficiencies in the management of the IST waitlist and utilization of treatment program beds.

The proposed changes will do several things, including clarifying the Department of State hospital's records access to reduce admission barriers. Establish a wait list management process for ISt individuals referred to the Department but who are not available for admission because they are not currently in the sheriff's custody. Clarify when IST individuals who have regained competency can remain at the Department when it is needed to maintain their competency.

Establish authority for the court to address the issue of involuntary medications for individuals that remain at DSH for purposes of maintaining their competency. This would be under Penal Code 1372, subsection E, extend DSH authority to Bill for individuals restored to competency who remain in state hospital treatment beds after 10 days to other DSH funded programs. Programs allow DSH to assist discharging patients with obtaining California ID cards to support successful transitions to the community.

And lastly, the proposed TBL would update the data reporting timeline for county operated DSH funded diversion programs from quarterly to monthly submissions. Happy to take any questions.

Yes, could we talk about the clarity on removing from the IC waitlist of the individual is out of the county's sheriff's custody. Does that mean we just lost this individual?

No, no. Some of the individuals that are ist on felony charges just may be released from jail, out on their own recognizance or maybe have been eligible for bail. And so they're out of the sheriff's custody.

So they're accounted for, they're just not, no longer. Okay.

Yeah.

And then what is the clarity regarding the circumstances under which an individual restored a competency can remain a DHS for the purpose of maintaining competency?

So penal code 1372, subsection e is when we've restored the individual to competency. But our doctors have determined that we need to provide ongoing treatment to ensure that individual will maintain competency until their sort of proceedings commence and they, and that they sort of make it through the trial process. And so we may make a recommendation to the courts to retain that individual to maintain their competency.

The law as it stands is not clear as to the point in which we were to advise the court that the person may no longer need to be in a state hospital level of treatment to maintain their competency. So this is really clarifying that process. It is also clarifying when a court can opine on extension or renewal of an involuntary medication order.

And then my final question is regarding the IST work group and then the bed capacity strategy, not just our state, but community bed capacity and so forth. An update on that and how that's going.

Oh, yeah. So the Director talked a little bit about our diversion pilot program. Currently we've got about 29 counties that are operating. We've diverted over 1500. That's actually data as of June of last year. In terms of permanent programs, we've currently transitioned one of our pilot programs, La County to permanent program. That is, we in last summer had executed a contract with La County for over about a four to five year period. We will be expanding that program to over 1300 beds in terms.

Are those the sub acute beds in the communities?

No, those are, well, it's a combination of beds. Mostly they're residential, residential unlocked, secured residential settings. There are some sub acute beds that are within the LA contract as well as some acute beds. They have sort of a full continuum of care in La County with most of those being residential programs.

So work is still continuing. We're still working with counties to build those subacute bed capacity and so forth.

Right. We're in the earlier stages for the community programs. Really our first order of business was focusing on the wait list and the short term solutions, and that was primarily our jail based programs.

Any additional comment?

No additional comment. Thank you.

Okay, we're going to hold the item open and move on to our last issue, issue number five on the central utility plan replacement at the metropolitan location.

Good afternoon. Sean Hammer, Deputy Director of Administrative Services, Department of State Hospitals, here to present issue five, the DSH Metropolitan Central Utility plant replacement. The Department of State Hospitals requests 50.5 million in public building construction funds for the construction phase of the metropolitan central Utility plant replacement project.

This project will replace the existing central utility plant located at DSH Metro that currently supplies steam for hot water and central heating, as well as chilled water and air conditioning to 32 patient housing and administrative buildings, DSH retained an architecture and engineering firm to determine the best alternative for replacement of the aging and obsolete central utility plant. Specifically, what was identified was a centralized option, and this project will include replacement of chillers, boilers, and pumps.

The replacement of piping and installation of water lines throughout the project will improve the overall infrastructure, move the facility away from steam generation, and transition to hot water boilers via a commercial duty system with low emission equipment, and it will also allow for maximum efficiency. This concludes my testimony, but happy to answer any questions.

I plan to visit this site soon, so I hope I see all those. I'll update when I go. I guess.

I mean, it's 50 million. Like, how bad do we need it now? I mean, it's.

Well, the original pipes that are there were put in in 1915, and the last time the system was updated is 1988. So we lose about 20% to steam leaks. 20% of the energy efficiency.

And this is coming out of. Not the General Fund, right?