Assembly Select Committee on Native American Affairs

Hi there. Good afternoon. The joint assembly health and select committee on Native American affairs oversight hearing on AB 988, outcomes review and suicide prevention and intervention in the California Indian communities, will commence now. I first want to just welcome to the joint oversight hearing of the assembly, you all to the Assembly Health Committee and the select committee on Native American affairs.

Today's hearing will cover two subjects, the outcomes review of AB 988 of twenty twenty two by Assembly member Bauer Kehan and suicide prevention and intervention in California's first people's communities.

Mental health crisis intervention is a crucial piece of an effective and complete continuum of care, And it's not just about having a place to call, but having someone available to help and providing a person in crisis with a place to go. Over the last several years, California has embarked on a behavioral health transformation through CalAIM, proposition one, CareCourt, mobile crisis expansion, BH Connect, the children and youth behavioral health initiative, and much more.

988 implementation is a key piece of that overall puzzle because it was intended to provide for a community based alternative to law enforcement when responding to a mental health crisis. Any emergency. Introducing and passing bills is a core part of our legislature's responsibilities, but we must also make sure we're tracking how legislation is being implemented and the impact it is having on the lives of California.

This year, the speaker is implementing the outcomes review process to do just that. Today, we will hear perspectives from call centers and providers about how 988 is working on the ground and hear from key state agencies on their roles and progress on implementation. Fundamentally, our interest through the process will be to identify whether the state is on track to meet the promise and vision of a robust, responsive, and effective crisis intervention system. And if not, how we might need to adjust to get there.

After the outcomes review portion of the hearing, we will also hear from our tribal leaders, mental health providers, and the Department of Public Health specifically on the issue of suicide prevention and intervention in suicide prevention and intervention in the California Indian communities.

Across decades of research, American Indian and Alaska native populations have consistently experienced the highest suicide rates of any racial or ethnic group with disparities particularly pronounced among adolescents and young adults. In California, home to the largest native population in the country, native youth ages 10 to 25 experienced the highest suicide rate from 2016 to 2021 according to the State Department of Public Health. The final panel will bring more light to this issue and provide an opportunity to explore solutions to address this long standing tragic disparity.

With that, I would like to turn it over to chair Ramos who is going to offer some introductory comments. And before that, my deepest apologies, was hoping to open our session with a native prayer.

Thank you so much, madam chair. We'll go ahead and sing a traditional song. We share that song because of the stuff that we're gonna be going through as Indian people and all people that issues that we're gonna be discussing here today. That song is traditional song from our territory from San Bernardino County Serrano people. You have it in Serrano.

Thank you, Chair Ramos. Any additional comments?

Thank you, madam chair, and, for agreeing to do this, joint committee. Nearly six years ago during COVID pandemic in 2020, we authored, AB 2112, which established a statewide office of suicide prevention within the Department of Public Health. Before, during, and after the pandemic, suicide and suicide ideation rates among Native Americans have been disproportionately higher than other demographics at nearly double the national average.

Native youth ages 10 to 25 experienced the highest suicide rate from 2016 to 2021, according to the State Department of Public Health. Despite making up the smallest ethnic demographic in California and the nation, today's discussion will demonstrate Native Americans' communities are not alone in this crisis.

Therefore, solutions must come from a concerted and inclusive effort so we can all take a step closer toward prevention and solutions. AB 2112 took the first step in addressing suicide by creating a statewide office of suicide prevention within the Department of Public Health. Their task was to help us spot trends, share research, and especially to aid in preventing suicide among the most vulnerable populations. When we discuss the mental health of Native American people and the crisis of suicide, invisibility is a huge problem.

Past history and still today, many in Indian country feel isolated.

That resources don't adequately reach California's first people. As a state, we must create opportunities for tribal voices to tell us their truth and their needs. We must provide tribal communities and urban areas adequate resources to ensure the tribes are actually receiving the funds and assistance they need as was supported by AB 988. And ensuring relevant departments and agencies are genuinely engaging with tribal communities, their members, and including their needs as budget and outreach priorities in the state of California.

Today, in a further panel, we will hear from members of tribal communities who live and work on the front lines of this crisis and those that work with them.

Today's tribal panelists will add a voice that many times is overlooked. I wanna thank you, chair Banta, for agreeing to have this joint hearing so that California's first people, their voices are being heard today. Thank you.

Thank you, Chair Ramos. We will now move to our outcomes review for AB 988 and offer the chance for our colleague, Assemblymember Bauer Kehan, who's been leading on this effort for many years, who is joining us today and is the original author of this legislation to make any opening comments.

Thank you, madam chair. And I wanna start by thanking you and the committee for your partnership on this, and the speaker for this outcomes review process.

For those of us that have been around for a minute, this is so critical to actually achieving the goals we set out to achieve when we passed legislation, and it is such an honor to do this alongside our colleague, chair Ramos because he was, many people probably don't know this, the first and most prominent coauthor on AB 988 because he was, even then, incredibly focused on, suicidality for California's first people and ensuring we saved as many lives as possible.

So as one of my partners in this legislation, I'm proud to be here with you today as well. I often say that if AB 988 was the only bill I passed in my time here, it would be enough because saving lives honestly is if we save one life in this job, I feel like we have achieved so much.

And, I truly believe that AB 988 has already saved lives, but will continue to save lives. It was passed during a time of extraordinary budget surplus, and it was a fee bill. And nobody thought it was possible because why would we pass a fee bill when we had this huge budget? And we did it through incredible bipartisan partnerships.

It passed both houses with bipartisan supermajorities because every conversation I had with a colleague, and I talked to every single one of my colleagues, they had a story of a loved one who was here on this planet because of somebody who stepped in, in a moment of crisis, or a loved one who didn't and who was no longer with us and whose life was cut short by suicide.

So they understood the importance of California setting up an incredibly robust crisis, continuum crisis care continuum, which started with the 988 call centers and went well beyond the mobile crisis that is envisioned in this bill, but that this was a beginning piece of this puzzle. And just recently, in the last month, the Journal of American Medicine published a study that since the federal passage of nine the 988 legislation, forty four hundred youth have been saved from suicide as a result of the 988 system.

Forty four hundred children that are alive today because of the 988 system. I said one was enough, but forty four hundred. And honestly, I after this outcomes review process, which is culminating honestly in today, and I think I wanna point out that this process can be more than a single hearing as a in preparation for this hearing, we visited one of the 988 call centers.

We had many calls to hear what was happening, and we can do better, which just means we can save more lives. I remember where I was when I got the call the governor had signed, and I remember where Miles Hall's mom was when I called her and told her that we'd sign this bill into law. And Miles Hall was the namesake for this bill because it came to me through a mother who had lost her son. He was in a schizophrenic crisis.

Law enforcement was called.

He was the only person to call when you needed help. And law enforcement showed up. He had a gardening utensil in his hand, and he was shot dead on the spot. And I knew when she told me that story that for people like Miles, we could do better, and we had to do better. And so we set out to ensure that there wasn't just a place to call, as the chair said, but someone to show up.

And so AB 988 funded two things. It funds the 988 call centers, but it also funds the mobile crisis response. If the mobile crisis response is dispatched through the 988 call centers, which is an important point. And so the vision of this bill was that when someone was in crisis, they would call 988. They would have the support of incredibly trained call center operators.

I've had the opportunity of sitting with many of these operators, and I wanna give them a shout out today because it is hard work to sit on those phone lines and to support people, but they do it because they are just loving humans that want to save people in a moment of crisis. And that the vast majority of people would be served by the call centers, but there would be some who needed more.

And that instead of sending law enforcement, we would have in every county in California twenty four seven mobile crisis response teams to show up and provide a health care instead of a law enforcement response. As I started to look at I was a part of the 988 work group, so I have been a part of overseeing this rollout. Hot tip to my colleagues, you can write yourself into the bill.

I actually didn't name myself, but then when they were picking the legislator, it was sort of, I got chosen. And, and so I've been watching this process, come to fruition, and it has been amazing to see that now every single county has mobile crisis. It is not rolled out as in the way that I think I would have wanted, and there's a couple things that I see that I don't think achieves the goals of the vast number of legislators who supported this bill.

One thing we put in the bill was interoperability. So it was key to us that if you didn't know 988 was there and you called 911 with a mental health crisis, 911 could put you over to 988, and you could get the services we envisioned.

Also, if you called 988 and you were truly having a moment where you need an ambulance, you were having a health care crisis, for example, the 988 call centers could send you over. Interoperability is not live today. So despite the fact that this bill went into law, it turns out we maybe had did not have a shared definition of interoperability, but I think it's an critical piece of making this system work.

The mobile crisis response teams, like I said, every Single County, as I've been told, has mobile crisis teams. They are not being dispatched through the 988 center at all anywhere, as I understand it, which means ninety day funds cannot go to those mobile crisis teams.

So let's get that in order because we're gonna need those mobile crisis funds. And we also want those operators to have that tool at their disposal. The tech system that was built to allow for this is live in one call center. I went to that call center. I saw it live in action, and it's pretty phenomenal, but it needs to be in every single call center in California.

And currently on the budget proposal from January is a cut to the mandatory mobile crisis funding, which would really cut into the vision of this bill, so that needs to be a part of the conversation. And then lastly, you know, we have because of the vision of calls to the behavioral health crisis continuum, we have different agencies doing different pieces of this, and that's not a bad thing.

Different agencies have different expertise, but we need to make sure and I think one of the things that will come up today is, are those agencies working together in a way that fully, fulfills this vision? Is there too much bureaucracy stopping the funding from going to where it needs to go? Are call centers able to staff up the way we need to staff up?

988 has resulted in a massive increase in calls to call centers. Do we have the people power to actually serve the people that are calling? And so all of this hopefully will be part of what we review today and part of the cleanup that happens in the wake of this review process. But I wanna say that I think there's urgency. The mental health crisis is not waning.

Anyone who lives in the world of teens as I do know, our youth need us, our adults need us, and we need to get this right because we are saving a lot of lives, but, honestly, we could be saving more. And so let's do everything we can. And with that, I wanna thank the panelists for being here and showing up. They didn't have to, but they did, and for all the work they do.

You know, none of this we pass a law, and then it takes massive amounts of people and, agency staff and the governor staff to make sure that it it actually becomes a reality.

And I have had the privilege of watching that over the last few years, and I wanna thank them not only for that work, but also for being here to have this conversation. So thank you, madam chair.

Thank you. Are there other members of the committee who would like to offer any opening comments? Assemblymember doctor Patel.

As a new legislator, walking into this process midway, it is my great honor to sit alongside these wonderful colleagues. Thank you, madam chair and mister chair, for convening this committee together, this hearing together. I'm also the chair of the youth mental health select committee, for youth mental health and treatment access. So understanding where the barriers are and the roadblocks are is critically important to me in the work that I'm doing and the approach that we take.

I certainly believe in the efficiencies that we can create.

And if interoperability is a challenge, if we're identifying these challenges, I'm looking forward to hearing how we get towards the solutions that we need. So thank you very much for including me in this hearing today.

Thank you. We are honored to be joined by a number of panelists today as we move to our, stakeholder and call center perspectives, the first panel, who are sharing their information and perspectives with us. For the first panel, please come forward. We request that each of the panelists stick to their allotted time of five minutes each so we can hear from everyone and have time for some dialogue.

We plan to provide time for member questions after each panel, and we will allow public comments after panels two and three.

With that, I'd like to invite up our first panel where we will hear from stakeholder and call center perspectives on 988 implementation. I'd ask each panelist to introduce themselves with their name, title, and organization. We are joined by Tara Gamboa Eastman, Jonathan Porteous, Nargis Zahori Dillon, and Genevieve Valentine. With that, we can have the first panelist present if assembly member Hadwick doesn't have any opening comments. Okay.

Thank you.

Good afternoon, Chair Bonta, Chair Ramos, and members. Tar Gamboe Eastman, director of government affairs for the Steinberg Institute. We were proud to be one of the lead cosponsors of AB 988. I also want to thank the speaker and the committees for undertaking this outcomes review process. This hearing is such an important opportunity to evaluate whether implementation is actually delivering on legislative intent.

With that, the vision for AB 988 was clear. 988 was supposed to become a true alternative to 911 for people experiencing behavioral health crises, a system where Californians would have someone to call, someone to come, and somewhere to go. Unfortunately, nearly four years after the passage of AB 988, California is still far from that vision. To understand where implementation has faltered, we can follow the three same pillars. First, someone to call.

California's 988 call center network is still operating far below what was envisioned in AB 988 as a result of systemic underfunding. For example, California's in state answer rate for phone calls is approximately 85%, but for text and chat, answer rates remain dramatically lower, around 42%. Text and chat are often the preferred entry point for young people, LGBTQ plus individuals, and individuals who are scared to make a phone call. But the disparity between calls and text and chat reflects a larger implementation problem.

California has continued to fund 988 based largely on historical call center capacity instead of how people are actually accessing crisis services today.

Just last week, DHCS stated that its funding methodology largely looks backwards at prior call volume and prior funding levels. The result is predictable. Call centers are being asked to adapt to rapidly changing demand without the resources needed to modernize and expand their services, and the consequences are visible in the data. Since the passage of AB 988, to California call centers have closed, in part because they did not have the financial support necessary to support successful transition to the expanded 988 model.

At a time when we should be expanding capacity, California is instead losing it.

Second, someone to come. AB 988 was never intended to stop at a phone call. The promise was that when appropriate, 988 could dispatch behavioral health response instead of law enforcement. But years after AB 988 was signed, there has still been no meaningful statewide integration between nine eighty eight and mobile crisis teams.

AB 988 explicitly allows for the 988 surcharge to fund mobile crisis teams connected to the 988 system, yet none of that funding has gone towards mobile crisis teams.

At the same time, the Administration is proposing to make the statewide Medi Cal mobile crisis benefit optional for counties. If that proposal moves forward, California will fall even farther away from the core vision of AB 988 than we are today. Third, somewhere to go. Without integrated mobile crisis response, we cannot meaningfully talk about crisis stabilization, diversion from emergency rooms, or reducing incarceration. And finally, interoperability.

One of the most important goals of AB 988 was reducing unnecessary law enforcement involvement in behavioral health crises. Yet today, there is still no meaningful statewide diversion infrastructure between 911 and 988. In most cases, transfers still rely on dispatchers manually calling one another. That is not transformation, but the same system we had before AB 988 passed. Meanwhile, local communities are proving that better models are possible.

The San Ramon Valley Fire District modified its local 911 scripting to identify behavioral health crises and transfer appropriate calls to 988. They have reported reductions in hospitalization, incarceration, alongside improved access to care. The innovation is happening locally, but it should be led by the state. At this point, stakeholders are left asking a very difficult question. How has California fallen so far behind on progress of a federally mandated program with dedicated funding, broad stakeholder support, and overwhelming public need.

From the outside, it appears there have been critical errors in prioritization, governance, budgeting, and implementation strategy. My hope is that after today's hearing, we'll have the answers to move forward and deliver on the behavioral health crisis response system that California was promised. Thank you.

Thank you.

Good afternoon, chairs, members, and colleagues. I'm doctor Jonathan Porteous. I'm the CEO of WellSpace Health, which is a community based health system here in the region. I'm also a licensed clinical psychologist and have led WellSpace's suicide prevention work for decades. It's a lot of nights.

WellSpace Health has operated a suicide prevention line since 1953. We are an original lifeline with the National Suicide Prevention line. We founded a founding member of the Crisis Center for National 988 Suicide and Crisis Lifeline, and we're a founding member of the 988, the consortium representing our 11 nationally accredited 988 crisis centers. We provide 988 talk, text, and chat response in 30 of California's 58 counties and a statewide backup.

We respond to a number of local and state crisis lines, including local 911 diversion partnerships and crisis lines provided to the California state legislature staff statewide.

In 2025, my organization managed more than one hundred thousand 988 crisis encounters. And I'll say this very clearly, only 5% of those calls led to us engaging outside support for mobile crisis or emergency responders. Given the length, breadth, and clinical expertise of my team, I'm pleased to be here and will be direct with my comments about the implementation of AB 988. First, thank you. A heartfelt thanks for adopting 988 and and delivering it to us.

For the first time in history, we have a long term funded strategy capable of meeting both the scale and intensity of need, but there's a both and in here. While the volumes of calls, texts, and chat have increased exponentially, our initial baseline funding hasn't scaled as anticipated and has remained level at best. At the same time, the Lifeline's primary revenue stream was reduced drastically without consulting us. We are the experts in this work.

So I'm terribly grateful for you for helping us establish the stunning evidence based lifeline, and I'm disappointed to share that 988 barely got started and is already underfunded, and that's unnecessary.

The governor's proposed 32,000,000 in 98 crisis center funding, and we're asking for a 105,000,000. That is our expert opinion as a state crisis centers. The organization's actually doing the work. But here's another problem. The people who do the work are not included in the conversation.

We've begged, we're pushed back, granted token seats on committees. Behind our backs, we've been told by officials that they've said we're unsophisticated. We're not capable of navigating complex funding methodologies. We're referred to as vendors with self serving demands. It's all incredibly offensive.

We launched and operated these programs decades before anyone took notice. For my organization, it was 1953. For decades, our crisis centers in California operate one of the most successful suicide prevention programs in the nation without state support. In most cases, we ran at a financial loss keeping the programs alive so we could keep our communities alive. It's our sincerest hope that we'll be embraced as partners or at least as experts.

We should be both. Outside of our direct funding, there's been a kind of bad trend in people blurring the lines between 988 mobile crisis and access lines. 988 is a system of crisis centers responding to calls, text, and chat. We resolve 95% of all encounters virtually with no need to dispatch in person responders. We're at the front end of the crisis continuum at intercept zero.

Responding to 988 calls, chats, and texts is the earliest intervention of all early interventions. Mobile crisis response is in a different category. And remember, within 988 maybe 988 mobile crisis is funded secondarily to 988. Recognizing the importance of expertise in addressing those 95% of crisis episodes and then creating appropriate throughput for the 5% of crisis episodes warranting a mobile crisis response. 988 prevention, prevents crises from escalating into costly higher level care.

988 is operated statewide by 11 crisis centers using one nationally recognized evidence based clinical protocol and represented by 988 California. Mobile crisis response, however, is operated statewide in 58 different ways in 58 counties. Let's be clear, mobile crisis response and case management are not 988. They're sequential early intervention services with 988 the earliest at intercept zero. Access lines in each county actually, they offer 56 different behavioral health information referral systems in 58 counties.

My organization answers the access line for YOLO and San Joaquin Counties within our crisis communications hub, allowing us to seamlessly integrate them within our 988 response system. But in the other 28 counties we serve, we struggle to connect people to services through access lines. And, again, due to the relation between 988 and access lines, people conflate the two. With tightening budgets, let's not forget why we prioritize AB 988 funding the way we did.

Nine eight eight crisis centers are intercept zero, the earliest of interventions, the front door to crisis care.

They resolve almost all crisis encounters without additional response. They offer pennies on the dollar investment compared to in person response. They're wise, proven, and should be fully funded. We're big supporters of mobile crisis teams and know they're an integral part of crisis response. A lot of people are waiting for me to say this.

I continue to heavily recommend the state adopt the federal certified Community Behavioral Health Clinic, CCBHC model. It's kind of a travesty that we haven't. It is an 85% federal match for mobile crisis response. 85¢ on the dollar, federal match. It has additional billions in federal matching dollars.

The other states are pacing forward who have adopted the CCBHC, and that includes New York and Texas. And when do they ever talk to each other? I'll end by saying thank you. The legislature made the right decision and created the proper framework for a vibrant and impactful system, And I've highlighted flaws in the implementation, which I was invited here to do, and I'm here to answer any questions you might have. Thank you.

Thank you. Please go ahead.

Good afternoon, chairs Bonta and Ramos, assembly member Bauer Kehan, and members of the committee. My name is Narja Sohori Dillon, and I'm the president of 988 California, the crisis center consortium. I'm also the executive director of crisis support services of Alameda County, which is the 988 center located in Oakland.

We're here today for an outcomes review of AB 988, and I want to use this opportunity to highlight some of the accomplishments of our system and also some of the areas where California's 988 system is not delivering on its promise. The five year plan's first goal is to build public trust and awareness.

It's working. Comparing January 2025 to January 2026, the incoming call volume to California's 988 centers increased by over 37%, and the incoming text and chat volume increased by over 26%. The reliance is life saving. As assembly member Balor Kayehan stated, there was a JAMA study published last month that found that 988 is associated with an 11% drop in youth suicide deaths.

To put that in context, over the last twelve months, the California 988 centers have responded to over 600,000 contacts.

We use the word contacts to include all calls, texts, and chats combined. However, that's not meeting the state goals of a 90% in state answer rate. As Tara said, the text and chat answer rate is below 40% right now. There's a human impact when we talk about that answer rate. When a California teen in crisis texts us and is routed to an out of state backup center, the counselor lacks the localized emergency response knowledge outlined by AB 988.

They don't know our mobile crisis teams or our tribal resources. This is a safety gap that increases the likelihood of a traumatic law enforcement intervention, the exact outcome AB 988 was written to prevent. Increasing the number of contacts answers is answered is simple. It comes down to increasing the number of staff available to respond. The legislative analysis notes a $73,000,000 gap between the governor's 32,000,000 proposal for local assistant and the consortium's $105,000,000 need.

I want to be clear, our number is based on rigorous bottoms up methodology that the centers conducted in February. Our calculations are not arbitrary. We use the perspective capacity model that accounts for meeting existing demand plus growth and compliance with follow-up requirements. Follow-up refers to outbound calls made to those disclosing suicidal or homicidal thoughts in the last twenty four hours. It's a proven life saving intervention, and not all California centers currently have the capacity to meet the federal standard.

The $2,000,000 increase in local assistant proposed by DHCS has been referred to as A Budget request that would maintain the current system. The problem with the current system is that it's not meeting the goal set federally or statewide nor is it delivering all that 988 has promised. Beyond the immediate staffing crisis, we must look at the AB 988, 5 year implementation plan. While the plan outlines a strategic blueprint, there's a massive chasm between the state's goals and its investment.

Goal a focuses on public awareness.

The state is launching massive media campaigns to drive people to 988, but awareness without capacity is a dangerous bait and switch. If we successfully build trust and increase our call volume but don't have the staffing to meet the need, we will lose our most important tool in suicide prevention, the trust of those in need. Goal D, focuses on integration. The plan requires nine eight eight centers to be air traffic controllers for mobile crisis team and stabilization beds. This integration is high acuity work.

It requires sophisticated interoperability and more time for contact. You cannot add dispatching duties to a counselor's plate without funding. We must also address the 5 year plan's goal to divert mental health calls from 911 to 988. This goal is also central to AB 988. According to research from Stanford Law School and the Gartner Center, between twenty one and thirty eight percent of all 911 calls are related to mental health or substance use.

In California, where 911 handles roughly 28,000,000 calls annually, even a modest 1% diversion rate would generate an additional 250,000 calls to 988 network. That is an overnight 50% increase to our call volume. The 5 year plan envisions 988 centers acting as the primary dispatch for non law enforcement response, yet the state is proposing a funding level that can't even sustain our existing call volume.

We can't ask 988 to be the state's primary 911 diversion engine while simultaneously cutting the surcharge and providing a budget that ignores the increase in demand, let alone the massive influx of complex high acuity calls that diversion will create. Lastly, the staff report correctly highlights a confusing governance between DHCS and Cal OES.

The move to decrease the 988 surcharge from 8¢ to 5¢ in 2026 during a time of a historical surge in demand is counterintuitive and does not get us any closer to the goals outlined in the 5 year implementation plan. Since 988 surcharge went into effect, more than half the funds have been allocated to Cal OES despite ongoing underspending. Meanwhile, the centers doing the twenty four seven work don't have the resources to meet the demand for our services.

The surcharge put in place by AB 988 gives our state the opportunity to create a responsive 988 system. We urge this oversight committee to ensure that our 988 system has the resources needed so that when Californians reach out for help, they know they will get the timely, compassionate care they were promised.

Moving forward, we hope you all can require that funding levels and surcharge be determined by clinical demand and KPIs, which are managed by DHCS. Many of the California centers have been part of the lifeline for over 20 years. We support the state's 5 year implementation plan, but we can't achieve a comprehensive continuum of care if we're not at the table as partners. Thank you for your leadership and for ensuring that the promise of a B988 is a reality for every Californian.

Thank you. And our last panelist.

Good afternoon, Chair Bonta Ramos, members of the Assembly Health Subcommittee, and Select Committee on Native American Affairs. My name is Genevieve Valentine, and I'm San Joaquin County's health care services director. Thank you for the opportunity to speak about San Joaquin County's implementation of our mobile crisis medical benefit, our integration of 988 within our system, and the lessons we have learned building a broader behavioral health crisis continuum.

San Joaquin County was intentional as we built a behavioral health crisis system that was designed to meet individuals where they are, to reduce unnecessary emergency department utilization, support our law enforcement partners as appropriate, and to provide compassionate intervention in the least restrictive setting possible. Implementing 988 systems and our new mobile crisis benefit allowed San Joaquin County to analyze our own system and to address gaps that we saw.

Rather than relying on a one size fits all model, we built three distinct mobile crisis response teams to provide the right care at the right time in the right setting.

Our community crisis response team responds alongside law enforcement and high acuity incidents. Our provides outreach and engagement, follow-up care, coordination, and stabilization after an immediate crisis. A critical part of our implementation has been the integration of our local 988 call center. San Joaquin County has worked closely with our 988 representatives to establish referral pathways into our local mobile crisis system.

Today, 988 routinely connects callers needing in person behavioral health support directly to our specific mobile crisis line through a true warm handoff process, allowing information to transfer seamlessly between the 988 crisis counselor and our field based responders.

Our local 988 provider, WealthSpace, also now operates through this process our behavioral health access line. This is allowing us to have a full continuum of care from triage call, coordination to crisis response, outpatient referrals, and substance abuse residential treatment assessments. This dual role allows for real time documentation and direct referrals and has significantly improved clinical handoffs. Building this system has required extensive coordination and communication and outreach.

In the last year, we conducted more than 36 in person stakeholder meetings and implemented broad public education campaigns to ensure our residents understood how to access 988, how to access our mobile crisis system, the difference between the two systems, and how to use us rather than calling 911.

One key lesson in this implementation is our ongoing communication community needs evolve. This approach is already showing results. We now respond to approximately 250 mobile crisis field calls each month, which is an increase by 40% prior to rollout. And most of these calls result in a community based intervention. Only 14 last quarter ended in an involuntary psych hold.

In fact, though, over 40% were private insurance and non medical beneficiaries. The mobile crisis medical benefit and 988 has fundamentally shifted crisis response within our system. Where behavioral health crisis is once defaulted to 911, emergency departments, or even incarceration, we now have more effective, compassionate alternatives. These programs are reducing strain on our first responders and are improving outcome measures for families and individuals in crisis.

San Joaquin County has been lucky enough to receive over $200,000,000 in B CHIP funding to develop our future SJB Well campus.

This campus will expand crisis stabilization, treatment capacity, and substance abuse residential and outpatient treatment for adolescents and adults. These investments will directly support our 988 system and our mobile crisis services by ensuring individuals who are stabilized in the field have appropriate ongoing care. As we have continued to navigate our continuum, San Joaquin County remains committed to continuous quality improvement and innovation. One example is our work to integrate nurse navigation into our local 911 EMS system later on this year.

Our goal is to provide our community with further treatment, improved triage, and to connect individuals to the appropriate health service as appropriate.

In closing, San Joaquin County believes the combination of 988, the mobile crisis medical benefit, and B CHIP investments will transform behavioral health care in our state. These efforts are creating a more coordinated, client centered, community focused program focused on prevention, stabilization, treatment, and recovery. We're just now beginning to see the real impact of this improved coordination, the increased diversion from hospitals and jails, and we do have better access to care. So maintaining this continuum is critical as these programs continue to demonstrate long term positive outcomes.

I would like to thank you for allowing us to share our experiences, and I welcome any and all question.

Thank you. We can bring it back to the panel now for any questions or comments. We'll start with Assemblymember Bauer Kehind, and we will go from there.

Okay. Thank you, madam chair. Thank you all. That was super interesting and helpful. I will start with you, doctor Portia.

Am I pronouncing your last name? Okay. So one of the things I've heard is exactly what you're saying, and doctor Dylan, I heard this news so both of you can answer this, is that we're not adequately meeting the need of the call centers because of the way the budget process is working around this.

And you write letters, and then they get considered, and maybe you get your funding, and then maybe the number goes up, and it all happens sort of in this what doesn't feel like a very scientific mechanism. Although, maybe the number in your letter is scientific.

I have no idea. I don't get to see the behind the scenes of what goes into your letters. And so one of the things I've wondered is should there be a more mechanical way of figuring that out? Is there some formula we should be following to figure out how much call centers should be getting? The call centers are all different.

You serve more counties than other call centers. Their volume is different. Contra Costa, I imagine, is smaller than WellSpace. They only serve one county. And so do you either of you have thoughts on how we could do it in a much more scientific way, if you will?

So I can speak to kind of how we did the February projection that we worked on. And what we did is we worked on current call volume as well as projected growth. We took the percentage of individuals who would respond yes to a follow-up. So percentage of those who qualified and then a sub percentage who are likely to consent yes to account for the follow-up volume.

And there is also matters when you think about call center staffing, we call it shrinkage, which is a counselor who's on the line is not able to pick up Right.

Like, is not on the phone 100% of the time. There is required trainings that they have to go through. There is sick time to account for, and there are a number of national formulas actually that already exist that are for call center staffing. And the way they work is they work based on average length of contact. So staffing will look very different for calls versus text and chat, because a text and chat is about forty five minutes on average.

Right? So they use average length of contacts. You can tell it how long note writing takes between contacts, and you can tell it kind of how often people call out sick. You can put all of these inputs, and it will actually give you a pretty accurate estimate. Like, my center has a staff member whose entire job is staffing projections in order to ensure that we're using our resources to the best of our ability.

So I actually don't think we have to create one. We could maybe use one that already exists or maybe be inspired by some of the ones that exist. But the methodology used last year was April multiplied by 13 for a thirteen month contract.

Got it. Thank you. And I think I wanna point out something really important, which is, since we're only responding to 40% of texts, which is mostly our youth, as you mentioned, and our LGBTQ plus community, and I wanna give a huge shout out to, I assume it was, Ms. Welch behind you, but I don't know who. When the Federal Government got rid of press three here in California, we trained our call center operators to manage that in a culturally competent way.

When you get routed out of state, that's not true. And so there are real life consequences to not being supported here in California. And so to know that 60% of texts are getting routed out of state is is seriously concerning. So thank you.

That accounts for, like, a significant piece of why our projection is so high is because it accounts for us responding to all the incoming texts and chats.

Yeah. And as California has put a lot into the youth behavioral space, and we know that's how they connect in. So, anyone who talks to teens know they don't pick up the phone. And then, mister Porteous, you talked about the access line issue, which somebody was talking to me today about this, and I said, is that 211? 311? I mean, to your point, I can't even keep straight what all of these numbers are for.

But I didn't understand. I understood the problem statement you were saying. What is your suggestion? Like, how do we start to get our arms around that? Oh, maybe that's for whoever wants to address that.

I think you have a very good example of how to do it.

Oh, it's through San Joaquin. Okay.

This this coordinated approach. When we are allowed to make the placement into the continuum of care from the 988 system, we are then able to go around every other obstacle and go straight into care. So we had a chap recently who ended up in a detox facility. I bumped into him. He was leaving Sacramento County and was talking about how good his treatment was.

He had called in from an outside county, I think it was San Joaquin, suicidal, was worried about keeping his job. He was using substances. We were able to refer him straight into a detox facility Into a residential rehab. Two months later, he was going home back to his job.

So your suggestion is that we would route, basically, everyone and with proper funding, I heard what you said, with proper funding, route everyone through the 988 system?

My suggestion is that we would coordinate county access lines into the crisis center that is responsible for that county as it's amplified by this party.

Do you wanna will you explain a little bit, like, mechanically how that works? Do they call 211 or do they all call 988?

So through the chair to our assembly member. Sorry. I wanna make sure I stay proper protocol. So our system's actually done very different. So we don't use 211 to get into our behavioral health access line.

So we have a 1800 number for our county. We have another phone number, 468-8866, if anyone needs it. But what ends up happening is the access line actually gets routed to our local to WellSpace. WellSpace gets to answer those calls. They get to triage.

They do the ASAM exams. They do the triage for whatever service is necessary. If they need to link them over to the 988 piece of their services, they can or vice versa. So there allows for really good streamline coordination. Now, not every county's mechanisms are the same as San Joaquin County, so I don't wanna speak on any of their behalfs.

But I can say for us, this absolutely works knowing that we do a lot of partnerships with other WellSpace counties that have their 988 system. So we have the ability to know other resources for individuals that might be calling our county but has an amount of help from another county. And so it does allow for a larger system, but it also allows for county staff to do the real necessary clinical treatment on the ground and not be on the phone.

And so it allows for the phone triages to be done by those who do it better than we do from a county perspective and allow us to do the field based service delivery.

And then you said the WellSpace actually does your dispatch of mobile crisis when they get a call where they think mobile crisis is needed. Is that true?

Slight correction.

Okay. Please.

It's not direct dispatch. What it is, is they have a direct line to who dispatches. That way, in case there was something else that we were missing or we had other questions, oftentimes, we know some of our residents that our 988 crisis counselors may not know, where we can actually bring in another family resource and so forth. But it is a direct 988 hand off to our mobile crisis phone number, which is 468-2222, which is very important, though.

And I can tell you in the last quarter, approximately 5% of those from our 988 call center actually was deployed out in the field for a mobile crisis response.

Got it. I'll have to come visit WellSpace. Thank you. My last question was, you mentioned CCBHC. You lost me there, and it sounded like something I should know about.

Will you elaborate?

I manage a network of federally qualified health centers Okay. As part of my organization. The CCBHC is a behavioral health version of that. So the CCBHC is a certified community behavioral health clinic. It is managed through grants from SAMHSA, the Substance Abuse Mental Health Service Administration.

That is the regulatory body certifies just like HRSA certifies an FQHC. And those are then mental health delivery systems with a heavy emphasis on crisis mobile crisis and crisis response. Most states have adopted it, have grown out their mobile crisis teams with that. It allows a certain flexibility for local communities, and you see the same expansion in behavioral health programs as you've seen with health care, with federally qualified health centers where it just is this incredible partnership with the community.

And then you get an if you get certified by the Federal Government, you get an 85% match?

The state gets an 85¢ percent match on those funds. So it's a billing to Medicaid, but it's billed to the state Medi Cal system, and the state gets an 85¢ on the dollar match from the feds for the mobile crisis work. And there are different.

We're currently getting 85% without the certification, But the when that current match goes away, this would be another avenue to get the match? Okay. I'm getting a nod head yes now I'm following. Thank you.

Thanks.

That was it. Thank you, madam chair.

Thank you. Any others with any questions? Ramos?

Thank you, madam chair, and thank you to the panelists. We heard a lot of information that's there. We talked about the federal aspect and adopting those types of standards here in the state, but we also heard about local impact and how that's having a success story. And looking at the calls, I believe it was doctor Jonathan part of his chief executive officer, talked about a 100,000 calls. Was that right?

Yes, sir. Calls, chats, and texts. So with that, was there a way or mechanism to identify if any of those calls were from tribal communities or California Indian people in rural communities or urban areas?

If that is disclosed, we can. We can also geolocate, but that's used for a crisis. But that is definitely something and we've established partnerships as much as we can given our geographic reach of 30 counties with with the Native American communities.

How is that outreach to the Native American communities being conducted?

We've historically, when the funding has been available, had a a Native American coordinator for tribal relations. And that way, we can kind of try and create that traffic control level communications with handoffs to to tribal entities. Unfortunately, that funding comes and goes.

Funding specifically for tribal communities or funding for specific suicide prevention in the state of California?

Funding for the suicide prevention and the the handoff to the tribal entities. So we would like to work seamlessly with local tribal communities and have that ability to refer into services locally and be in the hands of a culturally competent provider. And that that's where we have had challenges with funding.

So do you think it takes specific funding outreach to tribal communities in order to build that relationship, or is that already included in the basis of funding from the state of California?

Well, currently, there is a 988 tribal task force that is in its final year, and they have SAMHSA funding For specific outreach to tribal communities. I know because our center is part of it because Alameda County has a large urban Indian population. So the that funding, which is ending, was specific to doing outreach in communities, and there was specific tools that were developed in partnership with tribes as a way to ensure that the languaging use is actually different.

It talks about put down, like, a heavy load. The images the imagery is different.

There was a PSA that was created. The grant lead is the Riverside San Bernardino Indian Health. Ritsubishi, I don't really know what it stands for all the way, but they are the grant lead. So there is a group that has been focused on this work, in the last three years through federal funding. Tara, were you gonna say something?

Yeah. I was just gonna add in terms of the $9.08 8 fee, the way we've kind of structured it is everything has to originate from the nine eight eight point. So if if a tribe had a contract with an existing call center, they would be eligible for those funds, Or if they operated their own, call center or mobile crisis teams, the tribes would be eligible for funds under the nine eight eight surcharge under existing law.

And is, the the tribal communities the only community that has to have specific funding in order for outreach to happen with other outreaches and other demographics in the state?

No. I think this might be a better question for some of our state partners later. There's been a large discussion in terms of the outreach and communication strategy for September, getting the timing right, partnering with the Office of Suicide Prevention. There's also interactions with, the prevention dollars from the Behavioral Health Services Act, which might be included for September, and, I don't have the latest on the communication strategy. But if you do, Nargis.

Yeah. I was gonna say, I think counties tend to fund a lot of population specific. I know I have a grant through Alameda County for a Spanish language outreach person who does specifically work to get individuals from monolingual Spanish to reach out to 988. So there are some other populations depending on your locality that might have specific funding, if they're deemed to be underutilizing.

Well, thank you. And and we'd also did hear that there's different ways that are being, tackled through the different counties. I think 56 different ways, and there's no universal approach, but yet we heard a success story from San Joaquin. Can you elaborate a little bit more on that?

Yes. With the mobile crisis response, there are are essentially each county has its own version of mobile crisis response. With the call the access lines, each county is responsible for an access line into behavioral health services. The majority of counties just do their own, but a couple of counties, notably San Joaquin County, have have decided to work with the 988 call center and make that integrated so that they can be bidirectional referral from 988 into services and vice versa?

And, obviously, you heard just how well that's going.

Chairman, I will say it absolutely works within our county. We we have a much better streamlined system of care now. We don't have the greatest staffing ratios for for transparency. People don't wanna live in Stockton. And so we really have to rely on our partners and our resources to collectively provide the best wrap around services.

So when we have to look at our system wide, we know that we have to partner appropriately. And it just made sense for us as we were evaluating nine eight eight mobile crisis that access to care being all in one call center model made sense for us.

Thank you. And you also mentioned there's 36 in person meetings. Correct?

That is that is correct, chairman. What we ended up doing was we did 36 in person community outreach meetings. We have five major cities in San Joaquin County, so each city had different meetings. We reached out to our health plans. Michelle Garibaldi, who is our chief mental health clinician who oversees this program, happens to be in the audience if anyone wants to get additional information after the hearing about how we did it on the ground.

But we did a lot of work with our local health plans. We also did work with all of our major law enforcement partners because we really wanted them to also refer directly to 988 instead of passing out cards to other services. So our local law enforcement partners understand the value of 988. We also started going to our EMS local system, meetings so that our emergency ambulance responders knew the difference between mobile crisis, 988, and the different services delivery.

So we tried really hard to look at it from an integrated health perspective.

I can answer for you, which you did not ask yet. Approximately 1% of our mobile crisis responses are for our Native American population.

Well, thank you for that and bringing that that that data forward. And in your 36 in person meetings, was there a tribal component, tribal voice involved in in in that also?

I really appreciate that question because actually, there is a member of, the tribal community on our behavioral health advisory board. So she brings a great voice to the tribal, conversation and then links us to the appropriate partners. We don't have any, local tribal territories within our county. However, we do a lot of work with Mariposa County and some of our other county partners.

And it's important to continue to raise that that voice because there's just a large population of Native Americans in the state of California that live within our urban and rural communities that many times are misclassified for the resources that come forward. But also when they're reaching out for for assistance, right, that sometimes it gets pushed back to Indian health or or some of these other components when if we're talking about suicide prevention in the state of California that truly includes California's first people.

And and the reason I'm asking these questions is because we wanna make sure there's not a a block. Right? If someone is calling in, regardless of where they're from, they're getting the resources.

They're getting the resources they need at that time. That's why we're asking these questions. Also, wanted to sitting on the San Bernardino County Board of Supervisors work with Department of Behavioral Health and in those areas, we talked about adopting federal standards. We talked about 56 different ways that counties are doing it, but we also heard success stories of being able to adapt and meet the needs quicker than, I guess, maybe the state can do at at the local level.

Can you elaborate a little bit more on that?

I guess from the from the the wide lens perspective and then the the Micros perspective from counties. And does it all work together, I guess? If

I may, the flexibility that comes with a certified community behavioral health clinic, I think is part of that. And it allows a community to to to lift up behavioral health services that that are truly just driven by the community. So they're driven from the community versus by some other funding stream and others determining what is needed.

So what we've seen if the best corollary really is the federally qualified health centers, where historically, Medicaid funds came to the state and were dispersed through counties in a in a in a fair way. But but but there was sort of a clunky process where local quote clinics got the money ultimately and there was this whole process through the counties.

Federally qualified health centers can build around the county straight to the state, and that allows them to build and scale their programs much more rapidly. My organization scaled a 3,000 patient clinic in 2009 to a 130,000 patients now. That's and that's what we're seeing with CCBHCs in other states. They're just they're just building the systems. Great need.

And to elaborate on that, local government has the ability to get a little creative, and I am very blessed. I will say that I am the health care services director who previously was the behavioral health director. And so under health care services in our county, I actually oversee correctional health, behavioral health, public health, our FQHC look alike, EMS, veteran services, a few others. I have the largest department in the county, but that allows us to be fully integrated within a health system.

Not every county has the ability to do that.

And so as we look from an integrated system, we know where to braid, not blend funding. And so we have to get really creative so that we're not getting ourselves into trouble. But it definitely is a huge push from the local government's perspective of how we should model health care at large.

Thank you. Thank you so much. Thank you, madam chair.

Assemblymember Bauer Kean, you had a clarifying question? Yeah.

I just wanted to say that much has been said about the 56 different county models, and that was the intent. I mean, if you think about California's counties, they are so different. You can't imagine an urban county looking like a rural county.

And so the idea was unlike the call centers, which are federally mandated and are all following very strict guidelines so you can handle many counties at once, we really wanted to give the counties the ability to do what we heard San Joaquin County did, and that was to meet the needs of their local residents in the way they could best do so, and that would look different in LA than in San Joaquin. And so I think that this is actually a success story.

And so the 56 different models can be a good thing, not necessarily a bad thing. And I think you're giving an example

of where it's really worked. Assemblymember Patel.

Thank you for your thoughtful presentations. It's got my gears turning for sure. A couple questions. One is around, the staffing and the ability to staff. Is this, kind of a burnout workforce development issue, or is it really because of the unpredictability of funding funding streams, like the current situation where we're looking at a cut?

Yeah. So the staffing, like, yes, there is burnout, but I would say that the from receiving funds to being able to have people on the line and picking up contacts, there is a lag time that often results in for example, like, we've gotten last minute allocations. I can't start billing tomorrow. Right? The staff have to be trained.

All the centers are accredited, so there's about a hundred hour training that anyone has to go through before they can pick up a crisis contact. So there is lag time between funding allocation and expenditures catching up. However, I we don't have a shortage of applicants, honestly. There are a number of California, like, workforce development initiatives that we are taking advantage of.

I know in Alameda County, we're working with, local community health workers, for example, to have placements from our community colleges and things like that that really allow for building the a mental health workforce that's not reliant on a post secondary degree.

So those have been those have been helpful to us in the September era having multiple pathways to the mental health field. So it's not a for me, like, if you were to allocate additional funds to me, it would take me about four to five months before I can use it. So if there is ever information that, like, oh, some of the centers have underspent, it's because from allocation to expenditure, it's not instantaneous. But it's not a matter of people not wanting these jobs.

Thank you for highlighting that. That's an important point. I think we see that in other systems as well where the money is allocated and it takes a takes just a minute to kinda get things rolling and get it going before those, allocations are spent. It doesn't mean that it's not needed or useful or, isn't, you know, required to do the work that you're doing. Another question on the CCBHs.

I don't know much about them, but I now upon learning more about them, I feel like this should almost be embedded in every a FQHC for an integrated health and well-being kind of system. How many CCBHs do we have in California? I'm from San Diego County, by the way.

Yeah. San Isidro Health has a CCBHC in San Diego County. There are, I think, 13, maybe 15. Yeah. And certified by SAMHSA.

Because the state doesn't doesn't use hasn't adopted this model, we each get $1,000,000 as a grant from the feds every year to run our CCBHC. So we we can do a $1,000,000 worth of services essentially through that. So we don't have the opportunity sort of to to to gear it up. When when that opportunity has happened, if you look at the other states that have done it or just look at the SAMHSA website on CCBHCs, it's it's pretty spectacular.

And these are funds that have been appropriated pretty heavily by by both sides.

So Josh Hawley was the one who just most recently increased those funds for CCBHC. We do have innovation that's happening more than most states. I I can't not say thank you to miss Walsh for the work she's done, and BH Connect is coming online. So I think we have we have innovation. It's it's the ability to scale it.

It's the ability to to actually build these systems where you will see huge returns. Because for all those lives saved, you save a lot of other costs.

What I'd just like to add that I think we're we are incredibly innovative, and I agree miss Welch is leading the way. Oftentimes, when the counties are not getting reimbursement from the private insurance perspective. And so just with our mobile crisis itself, knowing that over 40% of our calls last quarter were private insurance, and there is no parity. And so oftentimes, we're we're providing the good service. We're providing what's necessary, but we're not keeping the the bills paid by those reimbursements.

Yeah. We've encountered that with the CYBHI as well. Yes. So thank you for that. You're welcome.

Madam chair.

Thank you. And I just wanted to kind of hit on some of the areas of concern related to the implementation strategy that was raised by miss Gamboa Eastman earlier on and I think referenced with WealthSpace as well. And so if you were to kind of narrow down some of the challenges related to the interoperability components related to nine one one and nine eight eight, I think that there it would be helpful to better understand that.

And then, the secondary piece around the continuum of service between, the hand the warm handoff that is, sensitive to, geography so that there are actual resources available, between the 980 call or the 911 call depending on how it comes in, and then connection to the mobile crisis center. Can you, from each of your perspectives, kinda walk walk us through where the breakdowns are with that?

Yeah. I think to take interoperability first. I think the first and most fundamental has been in the technology component. OES was tasked with getting technology for September and 09/11 interoperability in AB 988. To Assemblymember Bauer Kehans' point, we did see that technology go into place in one call center as a pilot.

My understanding is that there's been a number of challenges at OES that have resulted in the delayed timeline and also narrow scope, partially staffing changes that have delayed things. It sounds like there's been, delays from the Federal Government as well that are out of our control. But I think maybe more concerning because if if it was only a Federal Government, delay, you know, that is outside of our control, but I think the answers from OES have been that, it's going to be very hard to scale.

We need to wait for NextGen nine eleven which is years away. There's concerns that we're choosing the same provider that was, chosen for NextGen nine eleven which we are no longer using anymore, and then once we get the technology in place, my understanding is that there's no expectation that OES will require the call centers to use it, and, from my perspective, I'm I'm concerned that we're investing a lot in the technology that will won't ultimately be used.

So I think that's that's kind of the OES concern. Maybe I'll stop there and see if others have any on that and then go to the second point.

If I may yeah. I mean, part of the the the original question about funding decisions, there was sort of a whimsical decision to change the tax and and and pay the call centers less. And that, I believe, largely was based on how much funding was not being needed in the current quest for an interoperable system. It didn't reflect what we need running the crisis centers. The promise of that interoperable system, we love it.

There's actually gonna be an interim cost for most of us as we try and build bring our systems forward. We're all working with creaky systems that we were waiting for that system. So there'll be an interim cost. So even that would would reflect part of our our our need for funding. The warm hand off, they need they need to just be more sort of more structure.

I understand the need for local difference and and 58 counties to do their own thing. Absolutely. And there are cultural considerations within that. But the the the ability to to create an air traffic control system where a nine eight eight center is handing off to dispatch or handing off to to mobile crisis directly. It's not Harabedian.

And that's part of what we can't do in the absence of funding. We have hybrid versions. The sheriff of Sacramento County who will will tell you that because of our back line between our crisis center and nine one one, their number of officer involved shootings went from 24 to three in one year. So so and what we're doing, I think I've heard others say this differently, we're bringing people into other systems. Thank you.

Yeah. On the warm handoff, I was gonna kind of echo the system that you mentioned. That's how we do it in Alameda County as well is we we forward to a 10 digit number. We create kind of, I don't know, old school interoperability. We have speed dial, and we program in our mobile crisis teams.

And one of the challenges that poses to the kinda 988 vision is the ability to, like, pull reports, for example, on how many 988 calls transferred to mobile crisis and then how many of them got a response because the systems aren't talking to each other. We're basically forwarding a phone call because we have assessed that they need that response, and we have that partnership with our mobile crisis partners. So in the opening assembly member, you mentioned the mobile crisis 988 relationships.

The relationships exist, but they're actually not quantifiable through technology because we're all using our own thing. Like, my my team literally presses a button and forwards to the CAT team.

We're the overnight dispatch for the CAT team in Alameda County. We're doing the work, but it's not being captured through the 988 system because the way to do it is through kind of Jerry rigging the phone systems.

Did you what, Rene?

It would also mean us modifying some of our electronic health records. And so it's not just the streamlining of the warm handoffs with phone calls and so forth. It's who has access to electronic health records and making sure that HIPAA and confidentiality is also in play and how do we put firewalls in between certain things. And so it's multilayered, but it is absolutely one of the biggest challenges is from a technological perspective and the ability to pay for those technological advances.

On the second question, love all of that feedback. From a state perspective, I think as a sponsor, I was anticipating the nine eighty eight advisory committee to work out some of these technical issues and then come up with the protocols for how in different county settings across urban and rural, we could do the integration of mobile crisis teams and the warm handoff in a way that takes into account the local needs.

And stakeholder processes are incredibly complex, but I think the ultimate result of the nine eight eight five year implementation plan was incredibly high level and got too far ahead of where the system really is. We anticipated, you know, a a future state of what this program should be, but didn't break down the basics of how do we get the call centers funded, how do we do 988911 integration, and mobile crisis team connection.

And I think that's been one of the the challenges over the last few years is having really, technical state leadership on how to get this done.

Yeah. And I just wanted to add because we did go and see the one call center this technology has been deployed, and the saddest part of this whole story is that exactly what you were looking for exists, and nobody has it. And so I think that is an incredible failure of leadership at the state that we paid for this technology to be created. It is the same technology being used on the nine one one next gen system.

Literally, this call center has a big red button where they can press and take them into the other system.

It is then all logged through the system exactly in the way you describe. It it it has been built. We have paid for it to be built, and you don't have it. And so I do think that piece of interoperability, you know and they say they think they've complied with the legal definition because you can pick up your other phone and call them, which obviously was available prior to me putting into law.

It had to be inoperable, so I don't know why they could think that's what I meant.

But I do it it just is frustrating to me because everything you described exists, and we need to get into the hands of call centers.

I think the other question that I wanted to raise was really well, one, I'm looking at the you mentioned governance structure. Right? I'm looking at this very complex diagram with four different agencies, CDPH, MSAA, DHCS, DMHCL having their own particular, you know, role. We have Cal OES.

I think what I hear you saying in several different iterations is that we essentially costed out the the need for how much we needed to be able to really have a comprehensive continuum of service based only on one very small piece of it, which was the technology component then kind of, you know, firewall the rest of it.

So can you help us walk through the fact that, you know, assembly member Bauer Kean is sitting on these work groups? You all are sitting on these work groups. There's a very complex governance structure. And then at the end of the day, a major decision about funding or the the the rate was set without any ability to really understand the comprehensive nature of the system. Where where is the I don't wanna use the word failure.

Like, kind of like the where where where where was the where was the friction that caused us to kind of miss that?

Yeah. I mean, I think it's hard to tell from an outsider's perspective, which I think is the frustration that doctor Porteous brought up in his talking points that as stakeholders as stakeholders and as partners in the nine eight eight system, it has not been a super transparent window into how these decisions are made and why we've ended up with such a complicated system that isn't delivering results. I think, from an outsider's perspective, the departments and state agencies seem to be very committed to working together.

Part of the breakdown to me appears to be different definitions of what the September crisis system is and a lack of shared agreement, which was part of what we would hope we were hoping would be addressed in the 09/1985 year plan that it there would be kind of this common definition that I don't think ever really surfaced. I think part of it also is cultural.

I mean, you're dealing, with departments with very different populations of focus, very different mandates who come at it from very different perspectives, and building a shared vocabulary appears to have been quite challenging. But I think, you know, part of my hope for the second panel is that we'll get a better understanding into how these departments and state entities are working together and how they can work better together with the right resources.

I think if there is a breakdown in statute or in funding that would facilitate, better state governance, that would be helpful to us to be able to course correct.

May I add something? I think running a 247 crisis line is a unique service delivery model, and it's a service delivery model that the state has not been in the business of providing in the past. As a result, maybe the degree of consultation that we ask for at times might seem, like, too much to some of our partners, but some of it is because none of the people who are in charge of California's nine eight eight system have ever run a crisis center.

And so when I found out on the Internet that the surcharge was reduced, no one even, like, sent us a note. So I sure wasn't part of any conversations.

That disconnect that that's the moment where it was the most highlighted, was, okay. The this like, we we are nowhere near this decision making framework. And, unfortunately, because this is a new service to the state, but it's not a new service to us, we wish that we could be, like, partners in the discussion.

I understand that, like, I don't get a vote, but I do think it would have been helpful to have conversations about things like staffing models and projection projected growth before I found out on a state website that the surcharge was reduced by 3¢, which was also something that, like, I didn't even think was possible. I thought 8 was the floor.

And last response, and we do have two other panels, I think, that will be very helpful, and I see some members coming forward for that. So please go ahead and respond, doctor Porteous, and then

I just wanna make sure we clarify because we're making a public record here. That was a budget change proposal. The fee has not been reduced. So it was a proposal. It

has been

Oh, it has been reduced.

Okay. Yes.

Wow. I just had a moment. Sorry. Wow. And then not.

So one of the one of the experiences I had with this whole implementation was a very energetic OES, very energetic departments. People really sort of hungering to to work together. We don't represent there are 450 PSAPs in California. There are four hundred and fifty nine one one centers. There are eleven nine eight eight centers.

We don't represent that kind of huge massive people who come into meetings. We don't have this history of building a system since the seventies, I think, when they started working on nine nine one one. It's not it's not a lack of professionalism on our part. It is a system that has never integrated what we do. And we see that with our colleagues across the country.

And we're we're we're small but mighty because we're keeping it very very sort of streamlined with 11 crisis centers. And and we would rather not proliferate to 450, frankly.

Well, thank you so much to all of the panelists. Very robust conversation. And and I know that we will be able to dive a little bit more deeply into some of these issues with our second panel. I wanna thank you all for your presentation. As we move into the second panel, we which will be on state implementation and financing, I'd like to invite up to the table Stephanie Welch, Ivan, Barwaj, Steve Yarborough, and Michelle Jody Cabrera.

As with the first panel, please introduce yourself with your name, title, and organization.

Okay. Good afternoon, Chair Bonta, Chair Ramos, Assemblymember Bauer-Kahan, and other members here today. Thank you very much. My name is Stephanie Welch. I'm the Deputy Secretary of Behavioral Health for our Health and Human Services Agency, and we're going to go through a few slides very quickly because I know that we have lots of interest in this topic and lots of questions.

I really just want to recognize the individuals, who are just on the panel, and other individuals that you're going to hear today. The people who are in the trenches doing the work are the people who, we here at state service, want to serve and support.

And, I am deeply appreciative for how much they have taught us over the last many years, on on what is a fairly complex, issue, but it has really been, a privilege for our agency, housing 12 departments, five offices, and having a responsibility to lay liaison with our other state agencies and departments to have the responsibility of putting together the five-year 988 implementation plan.

And, in particular, our role in that is specifically to focus on coordination, to support accountability and transparency, and something that's very important to our agency and to our secretary, which is to be dedicated to community engagement. So, as some of the other individuals have spoken of, it was, by design, that we wanted to build out our crisis care continuum in concert with the overall investments from the state, during this administration in partnership with the legislature.

So, building out a high quality crisis care continuum, was part of the vision of behavioral health transformation to make sure that all Californians, regardless of payer and regardless of where you live, would have access to quality crisis services. The 988 five year implementation plan was submitted just over a year ago in January 2025. At that time and in the current budget year, we have about $30,000,000 that goes to funding and supporting the crisis centers.

To my point around community engagement, that was a critical part of this year long process of putting together the plan. That was incredibly important to us.

This slide lifts up that there were seven public meetings of our public advisory committee, which you have heard about, 21 public meetings with our seven work groups. Those are all of our subject matter expert work groups, and 13 focus groups. And I did really wanna lift up that we worked with Native American communities to host three Native American focus groups.

Those took place in person on tribally owned lands, and it was incredible to have an additional elected tribal officials to join us and attend us in those focus groups. And so appreciate and look forward to the rest of the agenda today on that topic.

As was mentioned, and I'm gonna get to I'm gonna actually skip ahead because you mentioned this incredibly complicated diagram. This really is part important to us in terms of state governance structure. And we went through an effort during the five-year planning process to really clearly identify the various different roles of the of of the different state entities. So, and I'm gonna walk through some of the accomplishments of each of our departments in just a moment.

But, within Health and Human Services, we house our public health department, which is the lead on public messaging.

We also house our Emergency Medical Services Authority, which has a critical role in clinical triage standards and supports our EMS system locally. Of course, our Department of Healthcare Services, which is our state Medicaid entity, and our Department of Managed Care, which regulates our insurance individuals with commercial and other payers, insurance. Excuse me. What I wanted to emphasize in this complicated slide is that there are areas of overlap. There are areas in which, there are responsibilities that both part both of our departments have to work together.

For example, some of the issues around clinical, quality services, and triage, we have expertise from our EMSA department, but also the expertise of our Department of Health Care Services. We also, through our DMHC, have to work with the California Department of Insurance, which is an entity outside of our agency, also overseeing, and regulating, insurance.

So, that is why it was important for us to put together, that particular slide, but also, continue to nurture those relationships and have the capacity to make sure that we are connecting on those topics. So, as mentioned before, and I certainly I wanna I appreciate all of the nice words about me, but that's because you see me. There is an ocean and an army of dedicated public servants that I work with.

And most notably here in the audience today, Doctor Anh Thu Bui, who is our 988 Project Director. She is a psychiatrist, and she brings a lot of clinical leadership as well as compassion, to leading our 988 efforts. She also was, instrumental in helping us very quickly within a matter of a few weeks engage with the Trevor Project to ensure that we were able to, utilize and repurpose some existing services immediately, in order to provide this level of training.

So, at this point, we've conducted over 80 interactive virtual ninety minute trainings, and we've trained over 500 voluntary attendees from our eleven nine eight eight centers. So, I just wanna thank the partnership with the call centers because they really showed up, and they supported their staff to participate in this training.

We have also moved on to recording some video trainings, so that we may be able to make this training available to other individuals in the future. So, we look forward to that continued partnership and the the incredible relationship we have with the Trevor Project. That is one of the things that we have done here at agency over the last several months, since we have submitted the report.

Really wanted to lift up, well, I'm sure my colleague here from the Department of Health Care Services will talk about a lot of specific things. I really wanted to, underscore our responsibility around ensuring that people who are covered by commercial insurance are being served by the system, but also the system that is serving them is getting reimbursed.

And so one of the things that DHCS has been working on is they have a Medi-Cal mobile crisis training assistance center. And the breakthrough series that they've been working on, specifically, right now, one of the really tactile things that they're working on is supporting and looking at how to secure commercial insurance payments for those who receive mobile crisis services. So, right now, they have 15 counties participating in that activity.

Next next up, wanted to share that the DMHC is also working on improving commercial health plan insurance reimbursement for crisis services. And so, while a number of things have happened, I do wanna lift up that they have made progress in terms of identifying and analyzing over 1,200 different denied or underpaid claims.

Basically, we wanna study why why is this happening: is this a contractual problem that we could address, is it simply noncompliance, etcetera? So really wanted to appreciate the partnership we have with the counties. They supplied us with the denied claims that we could analyze and the department is developing TT - trading and technical assistance to continue to support, making sure that the billing and claiming process is working efficiently.

I think I'd have to note on this that that we're excited about the initial progress, but I would be remiss if I didn't say there's a lot of work to do in this space. And lastly, our Emergency Medical Services Authority operates the really operates in the inner intersection of the 911 system, EMS, and hospitals, and has been working with us since the beginning on our 988 work.

They are really responsible for coordinating the partnership between 911 and 988 to ensure that individuals experiencing crisis are receiving appropriate emergency medical services and transportation to care. I think at a very high level, and I appreciated, the example coming from San Joaquin County, while there is a deep belief, at our department as part of this administration, that we want to build a non-law enforcement response to crisis, most certainly. But in many in many instances, behavioral health crisis is complex.

Somebody may be under the influence. There are medical issues that might be at hand. And so, we really need to comprehensively examine the various different people who might be appropriate to provide that type of crisis response. And it has been, very enduring to get to know the the many individuals across California who are working in our EMS system, who are deeply dedicated to addressing behavioral health crisis. And I'm almost done here.

And I think, lastly, and I know you're gonna hear a little bit more about this later when our Department of Public Health has an opportunity to present to you all, but it was really important for us to also make sure it was clear in our plan that the California Department of Public Health should be the entity that is responsible for leading the charge on September, messaging, and wanted to lift up that, in our published priorities for the first three years of funding for the Behavioral Health Services Act that will be administered by the California Department of Education, that while they'll be doing a campaign around 988 aware - excuse me, 988 awareness, they're also going to be working on a trusted messenger campaign.

To your very point earlier, I think it was the person from Alameda County who mentioned how important it is to build trust, but also just to educate the community as to where they should be calling and for what reason. But what we're really excited about is to partner with the crisis centers to make sure that we support them directly with resources to continue to do this work.

So, really making the link to make sure that our 11 crisis centers, as well as other important trusted messengers, have resources to support the the the nine eighty eight public education efforts. And so, with that, that is my update on the things that our departments have been doing, and I look forward to answering any questions.

Thank you so much.

Assemblymembers Harabedian and Patel, Chairs Bonta and Ramos, and members of the committee, I'd like to thank you for offering the opportunity to provide an update on the Department of Health Care Services 988 suicide and crisis lifeline implementation efforts. My name is Ivan Bharadwaj. I am Chief of the Medi-Cal Behavioral Health Policy Division at the California Department of Health Care Services. In addition to 988, my team and I oversee the policy components of the medical specialty behavioral health plans.

And before I get started, I wanted to acknowledge that I represent a small team of people at DHCS who are deeply passionate about 988 and the promise that it offers.

They work tirelessly day in and day out, including nights and weekends to support this critical program, and it would not be what it is without their efforts. So, today, I'll briefly cover where DHCS fits into the state's 988 system and our specific responsibilities, provide an overview of implementation progress, highlight key activities, summarize current funding, and provide a forward looking update on our proposed trailer bill language and budget change proposal to strengthen and sustain California's 988 crisis network.

The Miles Hall Lifeline and Suicide Prevention Act requires the California Office of Emergency Services, or Cal OES, to verify the technology that supports transfers between ninety day crisis centers and nine one one public safety answering points is available. Additionally, the act established California's 988 State Suicide and Behavioral Health Crisis Services Fund which are supported by surcharge fees and directed the California Health and Human Services Agency to develop a five year implementation plan for a comprehensive ninety day crisis system. Much of this was covered earlier.

Within this framework, DHCS administers and supports California's 988 crisis center network. This includes overseeing statewide implementation of the 988 line, conducting monitoring and operational oversight, engaging stakeholders, and advancing key 988 policy priorities. In 2024, DHCS engaged advocates for human potential or AHP, as its administrative entity for the 988 network. Through the structure, DHCS contracts with HP, which in turn subcontracts with and funds the 988 crisis centers.

As the administrative entity, AHP also provides training and technical assistance and other administrative support to the 988 crisis centers.

With that background in mind, I'd like to dive into how DHCS monitors performance across California's 988 network. We monitor 988 crisis centers through key performance indicators required under the national 988 lifeline network agreement, including the proportion of contacts answered, speed to answer rates, and rollover rates to the national backup network. These requirements are also outlined in our subcontracts with our 988 crisis centers. DHCS also reviews monthly 988 crisis center data to identify areas where additional support may be needed.

When performance gaps are identified, we work with our administrative entity, again, AHP, who contracts directly with the 988 crisis centers to provide targeted training and technical assistance to help 988 crisis centers meet their performance goals.

Our March 2026 performance data demonstrates the impact of California's investments and oversight of the statewide 988 crisis center network. In total, California's 988 crisis centers received more than 74,000 contacts, a roughly 130% increase in monthly contact volume since 988 launched in July 2022. Looking at performance over the past twelve months from April 2025 through March 2026, California's average in state answer rates were 87% for calls, 33% for chats, and 35% for text.

As context, SAMHSA's expectation is that answer rates for all contact types exceed 90%. While these results leave room for improvement, California's current performance is comparable to or in some cases better than rates for 988 systems in similarly sized states.

In March 2026, California had the highest number of routed calls in the nation, with call volumes at least 50% higher than those in Texas or Florida, which are the next two most populous states. And we at at this time, we also maintained answer rates that were more than 10% higher than these states. I do wanna note that all contacts not answered in California are routed to and answered by out of state backup centers, ensuring that every contact receives a response.

In addition to performance monitoring, I also wanna highlight several key implementation efforts with a focus on our 988 awareness campaign and training and technical assistance. The ETS through our administrative entity provides comprehensive training and technical assistance to help 988 crisis centers better serve high risk groups such as youth, tribal communities, LGBTQ plus individuals, older adults, and people with substance use needs.

Stakeholder input and monthly demographic data guide priorities and ensure training response to emerging needs in the crisis system. Technical assistance and training are provided through webinars, office hours, coaching calls, quarterly meetings with 988 crisis centers, and individualized support. As part of this work, HP meets with 988 crisis centers to identify their specific training and technical assistance needs and provide tailored support. We also monitor and use KPIs to help inform the TTA provided and ensure centers receive the specific assistance that they need.

Also wanna highlight the state's effort following the federal decision to end the national press three option in July 2025.

As Miss Welch mentioned, immediately after this decision was rendered, CalHHS initiated efforts to partner with the Trevor Project to provide LGBTQ plus competency trainings, including a four part equitable care series, for California's 988 crisis counselors. DHCS, for our part, actively partnered with CalHHS by helping promote and reinforce the Trevor Project's training.

This included distributing training announcements to all 988 crisis centers, highlighting the sessions during the statewide 988 center meetings, and providing ongoing feedback to CalHHS to help ensure strong engagement and participation across the network. To strengthen coordinated care, DHCS also partnered with 988 crisis centers to create a statewide referral resource directory, that's accessible to all vanity crisis center counselors.

The directory includes more than 2,500 vetted resources such as mobile crisis teams, stabilization programs, substance use treatment, basic needs support, and other community based services.

Counselors can search by geography, language service type, insurance status, and special population needs. These functions aim to provide seamless connections to appropriate resources for for help seekers in our communities. Relatedly, I want to acknowledge that, there was a substantial effort, that 988 crisis centers invested in regularly updating the referral resource directory.

Maintaining accurate current and local resource information can be administratively burdensome, and we deeply appreciate the time and attention centers dedicate to making the directory a reliable and effective tool for supporting help seekers contacting 988. This is on top of all of the regular efforts in supporting the 98 network including, of course, working with 988 help seekers directly.

Their efforts here cannot be underestimated nor underrepresented. To increase awareness of 988, DHCS also launched a statewide multilingual, billboard campaign funded by SAMHSA and consistent with the Governor's Executive Order addressing mental health among men and boys. The campaign included messaging tailored to youth and young adults and was available in English, Vietnamese, Chinese, Spanish, and other languages.

In partnership with the DHCS Office of Tribal Affairs and the California Consortium for Urban Indian Health, DHCS also developed a Tribal 988 campaign featuring artwork by Tribal artist Monica Zavala. The campaign resulted in nearly 1,000 billboards that generated more than 320,000,000 impressions.

You may have seen a few of them. I regularly drove past a a Spanish language one on 16th and T. DHCS continues to prioritize collaboration with tribes in urban Indian communities, by expanding culturally responsive crisis care, offering specialized Tribal led training for crisis center staff and supporting outreach efforts such as the Tribal 988 billboard campaign. These efforts strengthen access to Tribal and Urban Indian resources within California's nine and eight system and support culturally grounded crisis response across the state.

Looking ahead, I wanna briefly outline the proposed trailer bill language that will guide the future structure of the 988 system in alignment with the five year implementation plan.

The 988 TBL authorizes DHCS to establish a new statewide designation process for California 988 crisis centers. It would define what qualifies as a designated 988 center, describe what is meant by a mobile crisis team, and clarify how funds from the 988 suicide and behavioral health crisis services fund will be allocated. The 988 center designation process proposed in the TBL will be established no sooner than 10/01/2027.

The designation framework in the TBL outlines eligibility criteria, application and review procedures, and the duration of the approval process. The primary goal of the proposed designation process is to create a pathway, to add new 988 centers while specifying standards that all active centers must meet to receive 988 funding.

All existing California 988 centers must obtain DHCS designation approval by 12/31/2029 and DHCS looks forward to supporting and collaborating with existing centers, counties, and other stakeholders on this effort. The statewide standards that DHS will develop if the TBL is enacted are meant to ensure service quality at designated 988 centers by addressing staffing requirements, training, clinical and triage protocols, performance measures, counselor service expectations, and process and the processes for oversight and monitoring of designated 988 centers.

Critically, current 988 centers will continue receiving fund, funds from the 988 fund until 12/31/2029. After that date, only centers that have obtained DHCS designation approval will receive funding from the 988 Fund. Lastly, beginning 01/01/2029 excuse me, 2028, DHCS will be required to publish on its website a list of all 988 centers, a list of all 988 centers that have obtained designation, and any corrective action plan, suspensions, or revocations issued.

Next, I'd like to briefly walk through our current funding that supports California's 988 operations and system development. For the beginning of fiscal year 26'-27', that is from July 2026 through September 2026, DHCS has approximately $5,500,000 of Samsung 988 grant and community mental health services block grant funds allocated for crisis center operations. Between this current fiscal year and the next fiscal year, that's over $10,000,000 in mental health block grant funding that will go towards centers.

And as context, we specifically directed funding from the block grant to supplement available funds for 988 crisis centers. Now looking at the governor's proposed budget for fiscal year 26'-2'7, DHS is expected to receive about 67,300,000 from the 988 fund.

This is the broad pot of money that essentially supports the full range of 988 crisis system needs. Of this total, about $28,200,000 is earmarked for Medi-Cal mobile crisis services that are dispatched through ninety day consistent with the language in the ninety day statute that permits use of 988 funds for mobile crisis encounters that originate through 988 contacts. The remaining portion is part of a broader fiscal year 26'-27' Governor's Budget Proposal.

Specifically, DHS has submitted a budget change proposal or BCP requesting which I'm happy to further detail now. To complete the work outlined in the 988 TBL that I just discussed, particularly standing up the designation process and to address growing operational demands of the 988 system, DHCS submitted a BCP requesting additional staffing and contract resources.

The BCP requests funding from the AB 988 fund to manage the increasingly complex and growing workload associated with DHCS's 988 administration responsibilities, including support of the 988 designation process outlined in the TBL, as I noted. Our request includes the following, $19,400,000 in addition to the existing $12,500,000 in ongoing authority to support 988 crisis center operations in fiscal year 26'-27' through 29'-30'.

$3,000,000 annually to support a contract for the 988 administrative entity, AHP, in fiscal year 26'-27' and ongoing. $2,000,000 annually to support a contract for a program certification consultant in fiscal year 26'-27' through 29'-30'. And $1,400,000 in fiscal year 26'-27' and $1,300,000 in fiscal year 27'-28' and ongoing for eight permanent positions.

Thank you. I'm gonna probably stop you there because this is an oversight hearing, and that sounded a little bit what we might express if we were in a budget hearing and and you are overtime. So...

Thank you.

Thank you.

Good afternoon. I'm Steve Yarbrough, Deputy Director of Public Safety Communications at Cal OES. Chair Bonta, Chair Ramos, committee members, Assembly Member Bauer-Kahan, thank you for the opportunity to provide updates on California's 988 system and the progress we've made in strengthening our statewide crisis response network.

California has made substantial progress, as you've heard, in building a modern statewide 988 system that connects people in crisis to immediate help and strengthens the bridge between behavioral health and emergency response.

Over the past two years, we've moved from concept and planning to implementation, deploying core technology, strengthening operational readiness, establishing statewide governance structures that guide the system's long-term development, and aligning the system with our partners.

California's 988 system is grounded in a strong partnership between Cal OES and our state-level colleagues. Concerning 911 and 988 interoperability, as it stands right now, all 911 public safety answering points in the State of California have the capability to transfer calls to 988 centers. Well, similarly, all 988 centers have the capability to transfer calls to 911 centers or among other 988 centers.

So, as a result, baseline interoperability consistent with the statutory requirement has been achieved through that system. Cal OES has taken additional steps to validate this capability. In 2024, interoperability between 988 and 911 networks was successfully verified in the Cal OES laboratory through controlled test calls.

In 2025, this interoperability was further demonstrated operationally through successful live transfers between the Buckelew 988 crisis center and 911 PSAPs. Together, these efforts confirm that both the technical capability and the functional interoperability required under statute has been established with ongoing work focused on strengthening consistency and operational protocols across those systems.

Major accomplishments--we have network infrastructure that's been deployed to all of the 11 lifeline crisis centers. This includes server racks, network ingress points, and secure cloud connectivity points.

This creates the foundation that allows calls to move between 988 and 911 when necessary. A new call handling platform from the NGA--is the vendor who provided that--has been validated in the lab and is currently being tested in a live environment at the Buckelew call center under an ongoing project. The Buckelew call center is successfully able to receive calls and texts while validating interoperability with 911.

In terms of next steps and milestones, Cal OES continues to have active engagement with the Substance Abuse and Mental Health Services Administration to establish an agreement to route traffic from the national text chat line to California's 988 platform. As we continue to work to document this in a memorandum of understanding, SAMHSA has granted California provisional approval to move forward with full deployment of the statewide 988 platform across all California crisis call centers, a major step in achieving a seamless unified system for voice, text, and chat.

California has now built the backbone of a modern resilient 988 system, one that is technologically sound, operationally coordinated, and designed for long-term statewide scalability. This includes the full network, advanced routing technology, and unified call handling platform and a governance structure that guides long-term growth, strategic development, and aligned partnerships.

Cal OES develops and maintains the statewide technology and ensures the system can interact safely and reliably with 911, safeguarding critical points of connection between the two systems. Our state-level partners oversee the operations of the crisis centers themselves, including staffing, training, contracts, and clinical components.

Together, these roles keep the technical and operational pillars aligned but appropriately scoped. The progress made so far reflects a coordinated effort across state partners, call centers, and national stakeholders, and positions California to deliver a stronger, faster, more connected crisis response system for every resident. We greatly appreciate the committee's attention to this work and welcome the continued dialogue. I'm happy to answer any questions the committee may have.

Thank you. Ms. Cabrera.

Good afternoon, Madam Chair Bonta and Chair Ramos, and Happy Mental Health Awareness Month to all the members of the committee. My name is Michelle Doty Cabrera. I'm the Executive Director of the County Behavioral Health Directors Association, and we represent the county behavioral health directors for all 58 counties as well as our two city mental health authorities. Our members lead the public behavioral health crisis response system in California through a combination of required and discretionary services.

All 58 counties operate as individual Medi-Cal Prepaid Inpatient Health Plans subject to the same federal managed care final rule and parity requirements and responsible for the delivery of timely access to medically necessary services for Medi-Cal beneficiaries.

In addition, every county is required to have a 24/7 access line pursuant to federal and state law under contract with DHCS as Medi-Cal plans. These access lines are designed to connect Medi-Cal beneficiaries with services, including behavioral health crisis services. Following the passage of ARPA, California established a new mandatory statewide 24/7 community-based mobile crisis response benefit under Medi-Cal. I cannot underscore enough how big of a feat rolling this out has been.

The state invested 210 million in infrastructure and start up costs for the mobile crisis benefit as the first round of BHCIP, and I want to acknowledge and thank the Assembly and Assembly Member Bauer-Kahan's leadership in coordinating a letter with 37 other members of the Legislature to oppose the proposal in the January Budget to repeal funding at the state level for that benefit.

In addition, counties have had to invest substantially in building out the network of statewide 24/7 mobile crisis care. The reality is that a crisis is not the time to ask about whether someone is insured and how, and so what has started out as a Medi-Cal benefit really does serve the whole community.

Thanks to the Budget Bill, again, passed to support the 988 vision, private insurance plans are technically required to reimburse counties for our mobile crisis services and other behavioral health crisis services without the need for prior authorization.

In fact, and in reality, few do, and when they do, it is at a deeply discounted rate. One county behavioral health agency built the private insurance company for an $800 encounter for crisis and received $11 back. It did not even cover the cost of the time for the staff to send the bill into the insurance company.

CBHDA has worked with our member counties and with state regulators at DMHC to ensure that health plans are understanding the parameters of the law and to try to get better compliance with the intent of the law as noted in your background paper. But, certainly, as mentioned by Deputy Secretary Welch, gaps remain, and we still have a lot of progress to make.

In addition, there is currently no mechanism for county behavioral health agencies to tap into the 988 fees to pay for mobile crisis services as allowed for in the law, and I very much appreciate the intent of DHCS in their budget proposal to attempt to start that process, although, again, how we would do that remains a lot to be understood, especially since we're not yet at the point where we're fully funding the call center activities, which CBHDA very much supports, again, aligned with the intent of AB 988.

To the extent that resources are available and consistent with state law, counties are able to or historically have been able to, at their discretion, invest in a number of other behavioral health crisis suicide prevention intervention strategies, and many of these were historically funded under the Mental Health Services Act, or MHSA.

They include things like peer-run warm lines, suicide prevention campaigns, programs and services to reach underserved communities, including immigrant communities, LGBTQ communities, family supports like NAMI, respite services, wellness centers, et cetera.

Prior to Medi-Cal mobile crisis, the primary avenue that we had to know when someone was in crisis and needed our immediate help was actually through 911 and law enforcement, and so we have a long history of embedded clinicians within 911 dispatch centers or doing law enforcement training and co-response teams. That was all prior to the mobile crisis benefit. Counties have also helped in the build out of the 988 call center network.

In the early days, specifically, we funded the Spanish language lines, which were mentioned by Nargis and are now the pillar for the national 988 network. Two of our 11 call centers in California are run by counties, one in Santa Clara and one in Kern, and of course, these do have integrated 988 mobile crisis services. In fact, in Santa Clara, they have a number of different mobile crisis teams available through 988, including one that guarantees no law enforcement response.

Other counties like San Diego, Sacramento, Los Angeles, and of course, San Joaquin have proactively contracted with their 988 call centers where possible to integrate their 24/7 access line with their mobile crisis teams. All of these, again, have to meet the federal and state standards and requirements for their Medi-Cal access line services, so I wanna just put a pin in that.

The progress that our state has made to try to reach the initial vision of 988 of offering someone to call, someone to come, and somewhere to go was very ambitious and not entirely baked into the federal law. But we knew from the onset that building out a distinct behavioral health specific network of crisis response would take time and investment.

And the structures that support us all today are wobbly at best, as we're hearing in this hearing. CBHDA supports the concept of designation for call centers, for example, to improve coordination and then align expectations across the state for the role of our 988 call centers.

For example, in 2023, when the Suicide Prevention of Yolo County ceased their operations as one of the state's 988 call centers, it came as a surprise to the largely suburban and rural counties that they served. There was no notification to those counties of this planned closure even though those counties were funders of their 988 services at the time.

When a couple of those counties who were left without their former 988 provider reached out to the state to find out if they could become a 988 call center, they were diverted back to one of California's call centers and told that they would not be able to apply to be designated.

This is just one example of why we think that additional state oversight is necessary. There needs to be better coordination at the state level to ensure that linkage to the county behavioral health crisis response system. And I know I'm over time, so I'll just wrap it up and say thank you so much for hearing our comments, and I'm happy to take any questions.

Thank you so much, and we will now bring it back to the panel for any questions or comments. Assembly Member Bauer-Kahan. Mr. Ramos, go ahead.

Well, thank you, Madam Chair, and thank you, Assembly Member Bauer-Kahan. Just wanted to touch base on the infrastructure for treatment at the local level and statewide. Is there still a need for the infrastructure of those that are calling 988, whether at the county or statewide, to be able to have placement for services?

Thank you for this question, Chair Ramos. I wanna say, in terms of the bricks and mortar infrastructure, I don't know that any place in the world has done as much as California, and I say that quite literally. That is not-- I'm not being-- it's not a hyperbole. I think between the initial rounds of BHCIP, which were funded with one-time revenues, and then the Bond BHCIP under Proposition 1, the $6 billion worth of investment at once in treatment facilities is probably unparalleled anywhere else.

I did a little bit of research to figure that out. But the buildings and then the services that go inside of them, two separate things, right? It's like winning a car in the lotto. Who's gonna pay for the insurance and the maintenance and the gas that you need to keep that car up and running?

And that's where we see real significant gaps in funding, both at the federal level as well as the state level. Behavioral health services are certainly nowhere near funded appropriately. There are gaps everywhere, and especially we see these in crisis services, for example. A crisis stabilization unit can only be funded up to 24 hours. After that, no more funding.

It just drops off. If you need an inpatient or residential bed, even for drug and alcohol treatment, we had to get a waiver from the federal government to allow for those services to be paid for in a facility larger than 16 beds. And in a state as populous as California, those requirements at the federal level that we do small, tiny little providers makes it really difficult to have the capacity that we need to serve all Californians.

So I would say, we kind of do this fits and starts thing in behavioral health. We fund things through grants like the CCBHCs and then sort of imagine that they'll be sustained in the long run, and it's not a whole-- 100% there, right? And so we've got work to do, but we're certainly making good progress along the way.

Well, thank you for that, and sitting on the San Bernardino County Board of Supervisors looking at crisis stabilization centers, but also the mobile reaction team that's there, went from short-term and trying to get to a point to where it's long-term services for those that are out there. And so we continue to look at the infrastructural needs that are there. I also wanna thank the Deputy Secretary, Welch, for reaching out to tribal communities. You mentioned that in your opening.

Can you elaborate a little bit more on that outreach? Did it prove beneficial, and what were the outcomes after those hearings or those outreaches?

Yeah. It absolutely was beneficial, and Chairman Robert Smith from the Pala Band of Mission-- Pala Band of Mission Indians--did I say that correctly? I apologize--is actually one of our Advisory Committee members and has presented several times at our Advisory Committee.

The direct result of some of that work was a recommendation to pursue a Press 4 option for Californians from Native American communities, and so, certainly, we know that that is something being discussed. There's-- you have been a champion for that issue. I look forward to staying and hearing some of the comments from the panel after us.

So in our implementation plan, we have lifted it up as something that we definitely should explore, as something that the community here in California is asking for, and so we should deliberate. And that is-- I would be remiss if I didn't also mention that, here in California, there is a large constituency that also is advocating for California to pursue a Press 3 option that would be a direct line to support LGBTQ plus youth.

And so, these are things that in our five-year implementation plan, as it was the will of our Advisory Committee, we definitely identified as things that the state should continue to explore.

Well, thank you for that and thank you for reaching out to the Chairman from Pala. He's been a long time advocate to make sure that things and resources are reaching Indian Country in the State of California. I also wanna talk to Ivan, I believe, or Steve, Steve Yarbrough. With the different Gen X-- the 911 system Next Generation, is that-- you mentioned that it is actually up and able to identify 988 calls, right?

And so are we taking into account that Next system to be able to be compatible with all the work that we're doing? And we're hearing the providers and all those working on the 988 system. Is it gonna have that infrastructural capability to adapt to these in the separate numbers that we're talking about?

Yes. I thank you for that question. So the ability to, you know, press #3 or #4 or any of those, you know, groups would happen upstream of the California system. So in other words, when somebody dials 988, it goes to the federal call center, and that's the point at which the #3 or #4 option historically has been pushed.

So since that's been discontinued at the federal level, at least in the #3 option, then there are ways from a technology standpoint that we could adapt the system here to be able to have that option to designate a #3 or #4 once it lands at the California level. So, yeah, there is-- I think I'm aware of a piece of legislation that's currently being considered that might do that very thing, and so in looking at that and what it would take to adapt our system, we're definitely planning for the potential need to outfit all of the call centers with that technology.

Well, thank you for that, and you're aware that in our other role that we did have a hearing on the topic of the Generation 911 and a series of discussion took place there. I'm just concerned that we're having the right voices at the table to ensure that that integration can take place.

So putting that out there for the outreach to happen to make sure that the voices that are on the front lines are actually being heard with the integration moving forward. I also did wanna bring forward to Ivan; you mentioned in a series of costs and those things that you were mentioning, but you also talked about resources, resources that are out there in the State of California. Do you know, or is there any inclination to have a resource established on a tribal reservation?

I think if you're considering a kind of a tribal Press 4 option--

No. I'm talking about the actual centers, resources that you were talking about in the State of California, different communities that we're talking about throughout the State of California. Is there an inclination to have one of those centers, if not more than one, within the tribal communities on those grounds itself?

So I think we're having those exploratory conversations. We see the 988 designation process that's proposed in the trailer bill language as a pathway, a potential pathway for bringing additional 988 crisis centers online, and that would include tribal-led crisis centers.

And I will say that this is building upon the work that we did in spring 2023 where we hosted two 988 tribal summits in partnership with your office and Didi Hirsch, you know, kind of to better understand what culturally competent care would look like and also really understand what the parameters of a tribal Press 4 option would look like or tribal-led 988 crisis centers.

Thank you for that, and I believe that was held at the Morongo Indian Reservation down in Southern California, and that was sometime back. And so I think we're at to a point now to where we're seeing the crisis and we're having this joint hearing because the crisis and the data still within Indian Country-- the data still shows that there's an uptick. So how are we gonna start to be able to bring some resolve to that?

And I think having some of these centers directly on tribal lands is important to have also and making sure that there's protocol for the 988 system to make sure there's designated for tribal components and their voices are actually being heard and entwined in the discussion moving forward--not exploratory, but actually having them at the table.

Certainly looking forward to those discussions and putting it out there and and looking forward to hear from the tribal leaders in the next panel on how that-- if there is that outreach going on and how better the departments can be in moving forward within the tribal community itself.

Certainly wanna make sure that mobile crises that are going on within the counties-- serving on the County Board of Supervisors, tribal communities are part of our overall responsibility to make sure that those crisis, mobile crisis doesn't stop at a tribal reservation, that they actually continue to move and the outreach is there.

We heard about billboards. You did mention that billboards and having tribal communities and having different outreach in that component of it. I think we're moving in the right direction, but I think there's still a lot of work that needs to be done. Mobile crisis continues to be an issue that we wanna make sure that those respond to the tribal communities on reservations and tribal communities that are within our rural and urban settings.

And so I just wanna make sure that we know that the counties are doing a lot of the legwork, but also the responsibility to tribal communities still does reside also with the County Board of Supervisors in the State of California. Thank you, Madam Chair.

Thank you, Madam Chair. I don't actually think I have a question on interoperability because when I entered the workforce in 1999, I could transfer a call by pressing a button and then press a phone number transferring it, which is what OES claims interoperability is, and I think that is a far cry from what we envisioned. I appreciate that you have built out, and I saw, as you mentioned, at Buckelew--and thank you for helping arrange that--true interoperability, but that's at one call center.

And so I don't-- like, that was a wonderful speech you gave, but we heard the panel before of people who are actually taking those calls say it's not happened. So I just-- I'm not gonna ask a question, but I think the point has been well-made that we have to achieve it, and honestly, I think that I will look to change the definition so that you can no longer claim to be in compliance because I don't think you're in compliance.

And I also-- so I did wanna touch, Ivan, on the point you are making about how creating a second level of bureaucracy-- so currently, in order to be a 988 call center, as the point has been made, for those that don't know, you have to go through a federal certification process and get certified by the federal government and become a 988 call center. You are making the claim that putting a second level of certification and bureaucracy at the state level will lead to more call centers?

Because I appreciate what my colleague said, and I actually think it's a brilliant idea to have Native American call centers, but I can't imagine a world where more bureaucracy leads to more call centers. So I give it to you. How does that help?

Thank you. I don't think of it as bureaucracy. I think of it as establishing certain standards and protocols to be able to ensure that the organizations that we bring online are qualified to provide 988 crisis center services. And so, the TBL outlines a lot of the kind of general broad requirements. We know in working with our federal partners that they ultimately defer to the states on which organizations become part of the network.

I think our responsibility is to ensure that we have high-quality services that are being provided by the 988 crisis centers, and the way to do that is to administer the process directly and ensure that the-- that we're setting out the requirements and we're vetting them directly and that we're reviewing all components of the services that they'll be providing in order to ensure that we're delivering on that quality care.

So your system would be in lieu of the federal certification?

No, it would be in addition to.

Okay. Right. That-- sorry. I thought that second time you said that if we did it locally-- so I just wanna make sure we were clear. Okay. Let's get to the fee question. The reason I thought the fee hadn't been approved is because I'd seen BCPs--and they were mentioned here today--that would raise the funding, which would, I think, ultimately lead to a raise in the fee, and I didn't realize. But, yes, it automatically goes. I knew that, which is a good thing in some ways.

But so, one of the things that happened that caused the fee to go down was, I believe, it was over $40 million that was being sat on, if you will, that had not been appropriated. So can we talk about that? Why, when we're sitting here listening to the inability for call centers to answer over 60%, it sounds like, of texts and chats, are we not getting those dollars out the door?

So, yeah, glad to have the conversation around that, and you're right. Every year, if we take into account the amount of funding that remains in the fund when we're determining the rate necessary to fully fund what has been appropriated through the Budget Act.

And so when we do that, we start with the, you know, the Budget Act and what it says and then reduce our funding need by the balance in the account and come up with a surcharge to then calculate the need or calculate the rate necessary to fully fund what's appropriated, and so when we're doing that, the money is sitting in the account because it may have been appropriated to one of the departments or agencies and not used for the purpose it was appropriated for.

So in that case, it can't then be redirected to another program, you know, because the rules of, you know, funding state programs don't allow me as the fund administrator to decide where to send that money. It was appropriated for a specific purpose. If it's not used for that purpose, I can't then choose another purpose to send that money to.

Got it. And the 40 million was for technology. Was it--

That's correct.

That's correct. And so that was the vision to get--all of those wonderful people to sit together last panel--that system that I saw, so, yeah. And I do think-- I appreciate personally that we aren't just collecting fees from California to have them sit in an account. So that's an upside to this process, but at the same time, we need to be fully funding.

So it was mentioned prior, the way the call center funds are being decided today is both on past call volume, right? That's my understanding. And they can't increase call volume if they don't have the operators to do so. So I am sort of sitting in a place where, like, how do we ever get to more of a response rate when we're funding them on how they responded in the past and then they can't hire, and then we're continuing to only respond to 35 to 40% of texts?

So do you have a suggestion, and I put this to both of you--Ivan, you might be a good person to answer this--for how we should be doing a better job of calculating sort of a forward-looking need of call centers to get them to the 90% that all of you want?

And I wanna say, you know, I've had the privilege of partnering with, I think, every one of you, and I know that each of you is fully committed to this system and you wanna save the lives in the same way we do. So I just-- I'm trying to figure out how we can make a better system to make that happen.

Now I'll lead off, and then I'll turn it over to Ivan. So the way, you know, the the Cal OES role in the funding part of this works is we kind of start at the end of everything. We take as inputs what is already determined upstream from us and then calculate. So for us, it's just a math problem, and it has to do with the number of service lines that come from the carriers, telephone carriers, and then whatever's in the final Budget Act. And so when it comes to the decisions based on call volume and so forth-- and I think I'll defer to our colleagues here at at Health Care Services.

So I'm gonna give you a very honest answer. I think that--

You love honesty.

Yes. So I think that, you know, in talking with the 988 crisis centers themselves and on what are the challenges--and some of that came up today--a lot of it is, like, they're being funded on an annual basis.

Yep.

So, you know, just administering any organization, hiring one person when you don't know what the funding looks like the next year is challenging, right? You don't know if you're gonna be able to keep that person on staff. And so, you know, what we're working on is to, one, develop a volume, a contact volume-based model where we can predict where contact volume really will be and building off of a lot of the work that the consortium has done and the crisis centers have individually done.

But I think in an ideal state, we wanna be able to create a funding roadmap where we're looking not just annually, we're looking three years, five years. What does it look like for each crisis center so that they can hire not just that one person and be concerned--hey, am I gonna have this person on staff next year? But it's about, hey, I can hire these 50 people and I know that they're gonna be staffing this center for the next five years. And so that ultimately, I think, will be what changes our ability to meet KPIs consistently across the board across all modalities.

I think that's phenomenal, and I think that, you know, speaking for myself, you know, I think the Legislature would like to partner with you in a future where that's possible because I think it will make our call centers and the system work better. The last question I have is on mobile crisis. So I heard, I think, you, Ivan, say that you have a BCP that would put 20 million into mobile crisis as we mentioned earlier, and I think Michelle mentioned this.

In order for that to be paid for out of the 988 fee, those have to be dispatched through the 988 call centers. I'm hearing that there is some dispatching happening, but to date, we haven't seen, I think, any funds go to mobile crisis out of the 988 fee, but I might be wrong. You can correct me if I'm wrong there.

So I guess I'm trying to figure out how do we get to the future that was originally envisioned for the 988 system where we have the 988 call centers dispatching the mobile crisis teams that's paid for in a myriad of ways, whether it be parity, which I love. Thank you all for working on it. I know that's an incredibly hard problem to solve. You know, obviously, Medi-Cal match and the fee, as the bill anticipated. But how do we get to mobile crisis being a reality out of our call centers?

One quick point of clarification. The federal law, which you're, of course, familiar with, says that the fee at the federal level can be used to respond to any behavioral health services that are in response to a 988 call. So it does not have to be directly dispatched, but it does need to be tied back to that 988 call.

And we can do that, and we could do it today, as I mentioned, with all of those call centers that are directly connecting people over to the mobile crisis teams. Even if it's a speed dial, as long as that's tracked, it's eligible under this law.

I think we do get into some complexities with the way that California's law was written in that it says that any services that are reimbursable under insurance, whether it's Medi-Cal private insurance, cannot-- are not eligible for the fee. Now, of course, unfortunately, the number of uninsured individuals in California will go up likely due to HR 1 next year, and so there will be additional gaps that do not exist today that we could potentially tap into the fee for.

But what I was saying is that OES has not-- DHCS has not yet engaged the communities of individuals who could tap into these funds to ask about how we can start to track those callers from 988 through to those mobile crisis services so that we can create that linkage from a financing perspective. This is not easy because it hasn't been done before. The 911 system in a lot of ways is infinitely simpler than what we're talking about with 988.

It's a mix of public and private. It's a whole new delivery system unique and specific outside of 911, and so there's inherent complexity, and we can figure it out, but we haven't yet gotten to the table altogether to have those conversations, let alone put it into a policy, which is why I was saying there's not yet a mechanism. No mobile crisis teams could ask for money because there's no way for us to ask for money for mobile crisis today.

I just wanna acknowledge that this is a topic that has been talked about quite a bit in our 988 Advisory Committee, and I think I failed to mention that we reestablished our 988 Advisory Committee so that we could complete our required annual progress report to you by December of this year. This is one of the topics that has been discussed, and I hope you see here, like, a commitment, like, we're kinda, like, ready to roll up our sleeves and talk about it.

It's complex, but just wanted to reiterate that, at agency, we're eager to have this conversation and start thinking about what this would look like and to do it-- as you know, it's a five year plan. We're one year into the plan. It's time for us to get to this particular topic.

Did you have anything to add, Ivan?

I would just say selfishly, we-- like, when I said we have a small team working on 988, that's true for mobile crisis as well. The resources that are contemplated in our budget change proposal would really go a long way to helping stand up that mechanism that Michelle was mentioning.

We really need-- we need to be able to create that, like, technical mechanism to be able to identify where 988 can dispatch a mobile crisis team and it results in a mobile crisis encounter and we can ultimately be able to tap into those funds.

Well, I think the answer is sitting at Buckelew, I guess, was my experience at Buckelew, so I-- let's get that system out because, again, it was a direct connect to the mobile crisis teams to the extent that they could, and the system appeared to be tracking all of that as it does all the calls, right? These-- that's what these tech systems do.

And so, I guess my vision of this was always what I was hearing from WellSpace and San Joaquin that a call would come in, that it would be, again, whether-- I guess maybe dispatch wasn't the right word. But the 988 call center would be the one to say-- because, like, we heard, and this was the data we had heard actually prior to passage of AB 988, was that 85, 90, 95% of calls could be handled by the call centers with their expertise.

And so it would reduce the demand on our mobile crisis teams and allow them to really handle the most acute cases, which is a win for everybody, and then they would know with their expertise when to dispatch. And, again, maybe dispatch isn't the right word, but when to get a mobile crisis response team on the ground, and then that would be where the fee would step in and pay for what is left to your point, Ms. Cabrera, about private pay and Medi-Cal and all of that, but fill the gaps in that mobile crisis.

And given what the governor has proposed in the cutting of the mobile crisis benefit, you know, we really need to be focused on how we're gonna pay for these services because they are saving lives, and I know everybody here knows that. And so I really-- I appreciate and I wanna say-- I know. I found Antu. It was a little bit of a, where is she? But she is back there in the back row, and she has been truly an amazing steward of the plan and of the work.

And for anybody who, you know, has questions about where we are meeting specific communities of Californians, she has been there to shepherd that process in a way that really, I believe, will meet every diverse Californian where they are more authentically than I ever could have dreamt up when we drafted that process.

So, you know, I know that the effort is there, but now, you know, all these years in, I really wanna see it come to fruition, and the technology is a really critical piece of it that we need to get out. With that, thank you, Ms. Chair-- Madam.

Thank you. And for the sake of just making sure that we have an opportunity to move on to the next panel, I will just offer comments, and there will not be any rhetorical questions. I think one of the things that I am very interested in making sure that we're focused on is the fact that the promise of integrating the 988 opportunity with the continuum of services and specifically the mobile crisis centers.

So it strikes me as kind of-- we are in a bit of a pickle where we are putting forward or have received from the Administration a cut to those mobile crisis centers, which, by the way, everybody should know are extremely popular with the Legislature, in the Assembly in particular. I think there's three letters on it.

One letter has over 30 signatures. The others are not far behind, I think, because people recognize the incredible value of that, of the mobile crisis centers and the alternative to policing and the culturally concordant resource that that brings to our communities on the one hand.

But we are also attenuating our ability to potentially fund those from a sustainability perspective when we are not connecting them to the 988 call centers and giving the 988 call centers the ability to actually make those connections with the mobile crisis centers, deploy directly the authority to be able to do that.

So I think that-- I'm very excited that you all are going to be making this a centerpiece of your next series of conversations, and I do think that we have the ability to ensure sustainable funding for 988 as well as the mobile crisis centers if we are able to make sure that we have the braiding of services that I know that you all will focus in on.

So I'm thankful that that work will move forward, and finally, I will say that I wanna thank our deputy secretary for taking the time to kind of lay out the very complex nature of this work to date. We need to recognize that you are in year one of a five-year implementation plan around a very complex thing, and it's a great opportunity that we actually have so many state agencies willing to come to the table to be able to create some streamlining and recognize the interconnectedness of that work.

And I think we're hearing from our, you know, our partners on the ground at the county level and with our other-- our providers that we need to make sure that that continues to be something that happens, the integration continues to be something that happens through the implementation phase.

So I know that work will happen. I think we have identified some very specific concerns that we've been able to dive into as it relates to this piece of our puzzle, and I am heartened that we are on the way and that there has been, from my perspective, incredible receptivity to some of the suggestions and points of inquiry that we've made through this oversight panel.

And with that, I wanna thank you all for being here, and we will now move on to our third panel. We will reserve public comment for the-- for after our third panel just for the sake of time and making sure that people are able to get to where they need to be. So with that, we are now gonna move on to the second subject of this hearing.

As I mentioned at the start, this panel will focus specifically on suicide prevention and intervention in California's first nation communities. The historical mistreatment, forced displacement, and oppression of native peoples has long been a long-term, multigenerational impacts. Considering and highlighting this historical context, it is critical to understand the higher rates of suicide in our communities.

As such, we can only do this if we hear from them directly, and I want to make sure that we have an opportunity to know that at this panel, we will have Joe James, Chairman of the Yurok Tribe, Erica Pinto, Chairwoman of the Jamul Indian Village of California, Virginia Hedrick, Chief Executive Officer of the California Rural Indian Health Board, Mike Duncan, Director and Founder of Native Dads Network, Shari Sinwelski, Vice President of the Crisis Care Didi Hirsch Mental Health Services, Ashley Mills, Assistant Deputy Director Center for Healthy Communities, California Department of Public Health as a part of that.

Stephanie Weldon will not be participating in this panel due to an emergency. And with that, I would like to turn it over to my co-chair, Assembly Member Ramos.

Well, thank you, Madam Chair, and certainly I wanna thank the presenters here today to shed light on these. And you've heard the panels prior to you, so if there is some comment as far as the outreach to the tribal communities and where there is a need, where it's happening, where there's success stories, I believe this body would like to hear that. But go ahead.

Thank you so much. We will move forward with our first panelist on the list, which I believe is our Chairman, Joe James.

There we go. There you go. Time and opportunity. My name is Joe James, chairman of the Yurok tribe. The tribe is located up there in Northern California about five hours, six hours north here in Humboldt and Donor County.

I'm grateful this opportunity. I'll, I'll be short and brief and, and to the point. It is a serious matter. It's been a tough winter. It's been a tough spring for our community up there at Yurok with our brothers and sisters.

As I sit here today with a with a with a heavy heart, when you look at stats and statistics, we lost a 20 year old native gentleman in our community. And I'll I'll just keep it at that because I, I wanna be mindful and respectful of the famine and still raw, but it is related to what we're talking about today. 20 years old. I want I wanna back up.

In 2002 in 2016, there were seven suicides over a span of eighteen months, and the Yurok tribe declared a state of emergency.

We have a a number of suicide walks to bring the community together. At the end of the month, we'll have we have another suicide walk. In in light of this emergency, in light of the number of of deaths and suicides and, and, and youth and murders. You know, during that time, we declared that state of emergency. There's a lot to happen in between time, but for for for shortness of time, we received a a a B chip grant for a youth behavioral health health facility.

But I just wanted to provide back in 2016, we're reactionary. We wanna be prevent preventive. That's the, unfortunately, the framework, that got us here to now, to have that facility for our youth for 10 to 25 to create a safe space to have those clinical medical treatments and provide that social, behavior health. And again, it's a, so I, I wanted to provide that. We're very isolated and very rural.

Everything is an hour and a half to two hours in the life of Yurok and living on the Klamath River, and that's fine. You know, that's that's where we live, in a beautiful area that's surrounded by the river and the forest. But what comes with that is you're rural and isolated and away from things. Again, so we're very proud and supportive of our partnerships. We have done great work here in a short period of time with the state and our partners.

I heard the discussions throughout here today. The inclusions of tribes, a 100% need to be included as as as partners, as resources, as funding, or in the trenches as a tribal chairman. I hear people's families, I hear people's calls, in real time, just like our operators that mentioned before us. And again, we're doing everything we can to combat this crisis with our youth. But with the data that that was that was said here today, I won't repeat, it is spot on.

I just provided that what happened unfortunately yesterday. And again, as I, I'm glad here to come down to speak on this matter. And again, looking forward to providing resources, any way we could do to help. What again is we do have a story, willing to share. We can with that, in shortness this time, I do wanna be brief and, and to the point.

Resources, funding, partnership is critical for us. Whether it's awareness, prevention, reaction, mobile systems, resources, those are things that we fully support and wanna advocate and continue to to work with you. On behalf of that, Joe James, your arch tribe. Thank you.

Thank you, Chairman James. We'll move now to Chairwoman Pinto.

Hello.

My name is Erica Pinto. I am the tribal chairwoman for my tribe, the Hamul Indian Village of California. We're located in the southernmost tip of California, exactly opposite of the rocks. Well, thank you, first of all, for allowing me to provide comments. Thank you, madam chair, Chair Ramos, and honorable members of the Assembly Health Committee, the Native American Affairs Committee.

So I'm honored to be here before you today to provide remarks on behalf of my people, our neighboring tribal communities, and the many native families throughout California who who continue to carry the burden of historical trauma, loss, and unmet health needs. I guarantee you, all of our tribal communities have been impacted by a loss of life. Matter of fact, I can think of a childhood friend, Dean Rosales, about six years ago who committed suicide, a good friend of the family. It was devastating for us all.

I also appear before you today as someone deeply committed to achieving high quality health care for California native communities.

For many years, I have worked alongside other tribal leaders, health professionals, and community advocates throughout the state and with Southern California Southern Indian Health Council and other regional and federal efforts focused on improving access to culturally grounded health care for our native people. The work has continually reinforced my belief that for our people, mental health care cannot be separated from cultural identity, community, and healing. Today, I wanna speak plainly about the crisis facing our communities.

Native youth in California experienced some of the highest suicide rates in the state as was mentioned. Despite native people representing one of the smallest demographic populations, behind every statistic is a son, a daughter, a parent, a family member whose absence leaves permanent damage in the community.

For tribal communities, suicide prevention is simply not a behavioral health issue. It's connected to generational generations of historical trauma, forced assimilation, family separation, boarding school policies, violence, substance use disorders, poverty, discrimination, and the erosion of culture and language. Many native people continue to experience profound barriers to accessing health care, particularly in rural and underserved areas. At the same time, our communities have shown resilience in the face of these hardships. California tribal nations possess strong traditions of healing, ceremony, and community.

When our people have access to culturally competent health services, language revitalization, traditional healing practices, and strong community networks, our lives are saved. That is why continued implementation of AB 988 must include tribal communities in meaningful and sustained ways. I appreciate the efforts that have already begun through tribal listening sessions, nine eight eight tribal summits, and engagement between state agencies, crisis centers, and tribal organizations. Those conversations have helped identify critical recommendations directly from native communities.

However, I was as was stated earlier, more work can be done to continue to improve outcomes for our communities by investing more deeply in prevention.

Real prevention begins with healthy families, strong schools, safe communities, youth programs, mentoring, economic opportunity, and health services that are available before things reach a breaking point. At Hamul Indian Village, I am the director of our program, the Acorns to Oaks program, which focuses on culture and tradition and education and health. In Indian country, prevention also means restoring identity and belonging.

The Southern Indian Health Council and many tribal organizations throughout California continue working every day to provide integrated care that addresses physical and mental health, substance use treatment, prevention services, and community wellness. Despite this work, tribal health systems remain underfunded and stretched thin.

We need stronger partnerships with the state, sustainable investments in tribal behavioral infrastructure, working development that supports native counselors, peer specialists, community health representatives, and behavioral health professionals. We need flexibility that allows tribes to design programs rooted in our traditions and community needs. Youth engagement also remains extremely important. I've seen firsthand how reconnecting young people to culture can change lives. When native youth know who they are, where they're from, and that their lives matter to their community, hope becomes stronger.

Native youth should not only be the recipients of services, but should help shape those services. Young people better understand the challenges facing their generation than anyone else. California should continue creating opportunities for native youth leadership in suicide prevention planning, peer support programs, and behavioral health initiatives. I do remain hopeful that we can achieve better outcomes because I have seen our communities come together to support one another.

With leaders, health professionals, advocates, elders, youth demanding change, California has a real opportunity to become a national leader in building a crisis response and suicide prevention system that respects tribal sovereignty, centers, native voices, honors culturally grounded healing.

The health of tribal communities is not separate from health of California. Tribal communities deserve systems that treat natives with dignity, respect, and urgency. When native communities are healthy, resilient, and supported, our entire state is stronger.

I'll leave you with this.

I'm not one that wants to achieve failure. But one thing I am happy that I failed at is an attempted suicide in my teens. So I am here because I failed at that. But everywhere else, I want to see successes for our people. Thank you again for this opportunity to testify today and for your attention to this important issue.

I look forward to continuing to work in partnership with the legislature, state agencies, tribal nations, community organizations to protect the health and future of our people across California. Thank you.

Thank you. We can now hear from Virginia Hedrick.

Virginia Hedrick. I'm the CEO of the California Rural Indian Health Board. We work on behalf of 21 tribal health programs who deliver care to American Indian patients throughout every corner of California and work on behalf of 76 tribes. It should be noted given that our organization has no formal relationships with any nine eight eight service providers. Good afternoon, chair Bonta, chair Ramos, and members of the Assembly Health Committee and Select Committee on Native American Affairs.

Thank you for convening this important hearing and for the opportunity to speak today on suicide prevention and behavioral health equity in California tribal communities. Last week, many of us stood together during mur missing murdered indigenous peoples week here at the Capitol, honoring families, survivors, advocates, and tribal leaders working to bring visibility and justice to native communities impacted by violence. Those gatherings were a reminder that these issues are not separate. Suicide prevention, substance use, violence, MMIP, and the loss of native youth are all connected.

They're connected to generations of systemic harm, underinvestment, invisibility, and policies that disrupt tribal families, communities, and our traditional systems of care.

California must also continue to acknowledge the truth of its own history. In 1851, California's first governor waged a war of extermination on California Indians. Those actions matter because the impacts of those policies did not disappear with history. Native communities continue to carry the trauma of violence, displacement, family separation, cultural suppression, and exclusion. We see those impacts today in disproportionate rates of suicide, mental distress, substance abuse, and violence.

And I wanna say something personally. I've lost too many friends to suicide from childhood on up. And no matter how many people you lose, it never gets easier. It compounds. Every loss stays with you, and I refuse to ever let that feel normal.

Aside from my professional titles, the one that is most important to me is mom. I'm raising five native children in the capital city of of California. And as hard as it is to admit, we've had our own battles with suicide ideation. Healing for our family has come through therapy, ceremony, and community. Four out of five of those children danced in front of the capital last week.

And it was much for their own healing as it was for the community. That's why culturally grounded behavioral health care matters so deeply. Accessing care through community based events at Indian health programs has been essential. Today, American Indian and Alaska native communities continue to experience some of the highest behavioral health disparities in California.

According to the UCLA Center for Health Policy Research, more than one in three American Indian and Alaska natives adults in California experienced moderate or serious psychological distress in the past year, and sixty one percent of those individuals had not seen a medical provider.

Native youth aged 15 to 24 continue to experience the highest suicide death rate of any racial or ethnic group in California, and these statistics should be unacceptable to each and every one of us. These disparities are compounded by poverty, geographic isolation, transportation barriers, provider shortages, and a lack of culturally responsive care. Despite these needs, tribal communities continue to face barriers accessing prevention and behavioral health funding through broader state and local systems. Tribal health programs are best positioned to design culturally responsive approaches for our own people.

That's why I'm asking this legislature to establish a permanent tribal set aside for all behavioral and prevention funding, never lower than 5%.

And I wanna be clear. This shouldn't be seen as a kind gesture. Not this is not charity. This is an obligation California has to its first people. If California is serious about equity, healing, and accountability, then tribal communities must receive dedicated protected funding that cannot disappear when budgets tighten or priorities shift.

The state should also commit meaningful dollars towards creating a dedicated tribal nine eight eight here in California, similar to what other states already have and are building. California is currently funding a native warm line founded under my direction when I was with the California Consortium for Urban Indian Health Entitled Red Line, but that warm line cannot fill the gaps in an emergency behavioral health crisis response.

Native people in crisis deserve access to culturally grounded crisis intervention from people who understand our communities, our histories, and our lived experience. It has to be noted that tribal communities already possess the leadership, cultural knowledge, and proven pro proven programs to do this work effectively. Through the California Rural Indian Health Board's Healing Our Own People project, tribal communities across California are implementing suicide prevention, intervention, postvention, youth resiliency, and culturally grounded healing programs, serving more than 64,000 native patients statewide.

What tribal communities need now is equitable access to prevention resources, sustained investment, and true partnership with the state. If the state is serious about healing, then tribal sovereignty and tribal self determination must be part of that solution.

Thank you. We'll move now to Mike Duncan.

Not new yet. Mike Duncan, Chu, Wintun, Maidu, Wailaki, Western Banchoshone. Good afternoon, Madam Chairman, Bonta and Chairman Ramos and the health committee. My name is Michael Duncan. I'm the executive director of Native Dads Network.

I'm also an enrolled member at the Round Valley Indian tribes. I'm Wintu, Maidu, Wai'leki on my father's side and a Western Band Shoshone Timoke on my mother's side. I work throughout the state of California and tribal communities supporting fathers, families, youth, using healing center programs focused on wellness prevention and cultural connections since 2009. Our work extends now out about surrounding states, of Oregon, Washington, Arizona, Nevada, Alaska, and Hawaii. A native dads network I'm sorry.

Here locally in Sacramento as a tribal men's wellness program. It has grown into developing to servicing the whole entire family. You know, our program is really, is very unique. You know, it was a it was it was used to, really develop the and strengthen the importance of fatherhood. In that work, we we've engrown and, and started our own youth program.

It's called it's called Impact. And Impact is a acronym. It stands for indigenous mentors protecting ancestral, cultural, tribal traditions, youth leadership program out of the Prop 64 elevate youth funding. We developed this program to break cycles of intergenerational trauma, and we, we use it to address the current substance use issue within Indian country and the suicide epidemic in tribal with tribal youth.

Currently, today, we are a statewide organization that works with tribes and tribal agencies in rural and urban areas to, provide a cultural and a clinical based need that's for programming and, and for programming in each in each community.

In our work, we do develop the understanding and how diverse each rural and urban community is and how complicated and at layered it is to develop an effective program. Today, I want to speak about something that affects nearly every native family in some way, that suicide among tribal people here in California. I'm here today as a father, grandfather, a community member. I'm here for my relatives, our children, our parents, our veterans, our young people, and our friends.

Native American communities communities continue to experience some of the highest suicide rates in the nation, especially among native youth.

In California, in many native, tribal communities face limited access to mental health care, living poverty, addiction, the cycle of intergenerational trauma, isolation, and unresolved grief. These challenges didn't appear overnight. They're connected to generations of boarding school, forced relocation, loss of language, loss of cultures, and policies that separated native people from their identity, family, and community. Historical trauma is real. Many of our native families were taught silence instead of healing.

Many of our men were taught to hide emotions instead of talking about grief, depression, or hopelessness. Despite the improved policies in our health systems that have created that have been created with good intentions, we're still losing our people at an alarming rate. I want to say I'm truly thankful for all their hard work that was created before us, but it's not enough. We need culture change within our families, communities, our governments, and our health care systems to see real change.

But I also want to say this clearly, native people are not broken.

We are resilient people, and we will be heard. So some of the things that we look, you know, with our work that's we're a statewide organization and that we, we go to communities when we're called.

We see that, with that being said, some of the areas that we wanna be addressed, you know, are communities that are not receiving fund a significant significant funding to address the needs for tribal communities to support long term programming, including funds to increase resources, and networking opportunities for tribes and organizations, and cultural ordinance trainings for allies that are that want, to support, organizations and, and tribal communities. We have become a crisis response organization.

Like a lot of us here, you know, we get the calls at 02:00, 03:00, you know, in the morning or in first thing in the morning from grandparents or parents and family.

But we're we're just one organization, and we're very small. So a lot of those calls don't get we don't we're not able to get to. So we we need resources put into what I heard a lot today about the mobile crisis trainings for our tribal communities. We also have to recognize that substance abuse and suicide is a trauma response. It goes hand in hand with with broken systems.

The system that we that's being created is a one size fit all model that doesn't work for tribal communities. Funding needs to be invested to each community that to share, find solutions that fit that specific community. We should look into a statewide board of tribal leaders to address the needs of each tribal community and collect data that reflects each community. We need to utilize local grass, fund and utilize local grassroots organizations, community, tribal, or nonprofits to assist in community needs.

Our communities are have survived because of culture, ceremony, family, and connection.

One of the strongest protective factors against suicide is cultural identity. When our youth know who they are, where they come from, and that they belong, they become stronger. When they hear their songs, learn their traditions, sit with elders, they feel connected to community. Our hope grows. We also need systems that distribute funds to truly understand our people, our native people.

Mental health services must be culturally grounded and culturally driven. Healing, for native community should include ceremony, elders, traditional teachings, language, and land based healing alongside clinical support. Our ancestors survived unmanageable hardships so that we could be here today. That means every native life carries value, responsibility, and a sacred purpose. Our ether does not statistics, but they are the future carriers of our songs, language, and ceremonies, and nations.

I have hope today. And again, today, you know, it's again, it's about continued partnership with each one of you today. Thank you for your time. Hope.

Thank you. We'll move now to Shari Sinwalski.

Hello, madam chair, assembly member Ramos, and committee. I'm Shari Cygnalski with Didi Hearst Mental Health Services in Los Angeles, the largest nine eight eight center in California. My esteemed colleagues earlier in the earlier panel have already demonstrated why nine eight eight is a key component to the state's crisis care continuum and suicide prevention efforts. Since its launch, the nine eight eight suicide and crisis lifeline has been seen strong and accelerated growth, reflecting both increased awareness and urgent need.

This rapid growth tells us that more individuals are seeking support earlier and more often, which is a positive sign.

I'm grateful to be invited to speak about the issue of Indian suicide prevention, especially given that I do not identify as a member of this community. I have not had the lived experience that so many of my colleagues on this panel have talked about, and I don't fully understand or know how to provide the beautiful, ceremonies of healing and support that happen in these communities. Yet I stand here as an ally with my colleagues.

Suicide prevention with native communities is an urgent public health priority that demands culturally grounded community led solutions. Effective prevention must go beyond traditional clinical approaches and invest in approaches that recognize cultural identity, traditions, language, and tribal sovereignty in health care delivery.

They must support strengths within native peoples, such as strong family and community connectedness and resiliency. Recognize perfected I'm sorry. Recognize protected factors against suicide. The 988 suicide and crisis lifeline is a critical component of suicide prevention efforts in native communities because it expands immediate accessible support while offering opportunities to better align crisis response with cultural needs.

For many native individuals living in rural or underserved areas with behavioral health services are limited, 988 provides a free 24/7 connection to train counselors who can deescalate deescalate crises and link individuals to local resources.

However, for 988 to truly meet the needs of native people, native individuals must, one, know that these nine eight eight services exist, and two, trust that that it's a service that's culturally relevant for them in their lives. Just like any other person in suicidal crisis, native people want and need to be understood and have their stories heard. A significant amount of work has been underway, both nationally and in California, to adapt nine eight eight for native communities and increase trust, awareness, and use.

These efforts focus on making nine eight eight culturally relevant, tribal led, and better connected to native serving systems of care. California has prioritized including native voices in nine eight eight planning through two regional nine eight eight tribal summits to encourage tribal engagement in system design and implementation.

SAMHSA launched the nine eight eight tribal response grants to fund tribal nations and native organizations to strengthen their nine eight eight collaborations. In California, these grants have led to the creation of a California nine eight eight tribal task response task force whose work has included developing tribal outreach and awareness materials and cultural cultural competency training for nine eight eight counselors.

Longstanding data limitations make it difficult to know the true impact of these efforts as nine eight eight systems prioritize immediate support, not demographic data collection with individuals in crisis. Thus, utilization reports may be missing complete data on the use of nine eight eight amongst certain populations, such as tribal communities. However, current reports indicate a relatively low number of native people utilizing the 988 service in California.

A specialized service such as the Native and Strong program in the state of Washington that provides a more customized options for individuals who press 4 after dialing 988 may be a worthy consideration in California.

In the short term, it would route native callers who who press 4 to 988 counselors that would know that the call is from a native community member, helping them to have a greater understanding into the needs of the person in crisis and to potentially connect to them to tribal health systems where appropriate. It would show members of the community that there is a service that's established just for them.

It would also allow for stronger stronger data collection as we would know individuals that were using the service. Down the road, in the longer term, a press 4 option could allow, native native members seeking 988 services to be routed to centers within tribal, communities, or on tribes.

There is a suicide crisis for native communities in California. Suicide prevention is most effective when it builds on strengths, not just risks. Evidence consistently shows that a sense of belonging is a significant protector protective factor against suicide. Otherwise stated, culture is prevention. Strengthening identity, relationships, and community connection is one of the most powerful ways to save lives and promote long term well-being.

Thank you.

Thank you. And we will move on to our final panelist, Ashley Mills.

Thank you, chairs and members of the committee, for inviting the California Department of Public Health to provide an update on the Office of Suicide Prevention. My name is Ashley Mills. I oversee the Office of Suicide Prevention within our injury and violence prevention branch at the department. The Office of Suicide Prevention, established under chair Ramos Assembly Bill twenty one twelve, provides technical assistance, conducts statewide assessments, shares data, convenes partners, and focuses on populations at highest risk for suicide, including native youth.

Consistent with Assembly Bill twenty one twelve, the office implements suicide prevention efforts that are aligned with Striving for Zero, California's strategic suicide prevention plan.

This plan describes strategies along the prevention continuum where we have evidence of effectiveness from prevention infrastructure to promoting connectedness and belonging to crisis prevention and postvention or supports following a suicide. California's native communities have long faced disproportionate and tragic impacts from suicide. Today, I'll highlight current Office of Suicide Prevention activities and outline some next steps supported by the Behavioral Health Services Act population based prevention program, which launches very soon in the next fiscal year.

Our goal is always a comprehensive stigma reducing evidence informed approach, grounded in community expertise and experience. We've heard a lot of data points today.

I wanted to to raise one more. From 2017 to 2024, native youth under the age of 25 had the highest rate of suicide of all age groups. Rates were 2.4 times higher for males and 3.1 times higher for females compared to statewide youth. Since 2023, the Office of Suicide Prevention has participated in monthly tribal information sharing meetings hosted by CalHHS and the department's Office of Health Equity, as well as California Native American Day at the state capitol.

These engagements help the office share native focused opportunities, such as the native youth suicide prevention request for application, which we released earlier, and provides updates on native youth data, promote suicide prevention resources, including nine eighty eight, but also those of our Never a Bother campaign, which I'll talk a little bit more about in a little bit, and some safe storage guidance.

Our Office of Suicide Prevention also hosts quarterly communities of practice webinars. Recent topics have included veterans suicide prevention messaging and suicide prevention for boys and men, both highly relevant to native communities given high military service rates among California's veterans and elevated suicide rates among native boys.

Unfortunately, my colleague, Stephanie Weldon, our CDPH deputy director of the Office of Health Equity and the department's tribal liaison had an urgent personal matter come up today, and isn't able to be here to provide a background on our tribal consultation engagement work. But on her behalf, I would like to share that CDPH is committed to building and advancing our relationships with tribes in our mutual goal of improving health disparities among American Indians.

Through our office of health equity, there is ongoing and active engagement with tribes, Indian health programs, and urban Indian health on a variety of topics.

Our department's partnership with tribes through the tribal health equity advisory group brings Native American tribal and Indian health program representatives, perspectives, expertise, and input directly into the department's policies, practices, and programs, including those under our Office of Suicide Prevention. The department is committed to transparent collaboration to strengthen trust and supports better health outcomes for California's Native American communities and to address the behavioral health needs of tribal citizens.

Earlier this year, the Office of Suicide Prevention awarded 1,400,000 to three tribal entities, the Native Youth Suicide Prevention Grant Program, which will be used to support suicide and self harm prevention efforts among California's native youth through the age of 25 for a three year grant period. Funded at 160,000 for grantee per year, these projects will advance evidence informed youth suicide prevention efforts through culturally anchored strategies that reflect the values, practices, histories, trauma, lived experiences, and unique political status of native and tribal communities.

As stated in Striving for Zero, the strategic plan for suicide prevention, lethal means safety strategies are one of the best empirically supported methods of preventing suicide.

The office continues to distribute lock boxes to promote safe storage of firearms and medications along with safe and secure storage of firearm materials like flyers and stickers, promoting 988 suicide and crisis lifeline and other supports. Since 2024, 40 tribal entities have requested and received lock boxes, and this year, the office is distributing an additional 1,605 cable locks and 2,655 lock boxes to 22 tribal entities. Our communication strategies include cocreating public media campaigns and engaged trusted messengers.

Trusted messengers help bridge communication gaps, foster understanding, and improve the impact of public health messages, especially in communities facing disparities. By building trust, these messengers increase the likelihood that health information is heard, accepted, and acted upon.

In March 2024, the office launched Never a Bother under the Children and Youth Behavioral Health Initiative. It's a youth suicide prevention campaign that included native youth as a priority population. Nine tribal entity grantees co created campaign materials, served as trusted messengers, and implemented evidence based suicide prevention activities that reinforced campaign messages and supported youth locally. Grantees adapted the Never Bother materials to reflect their culture and their community, and these resources remain available on our campaign website.

Building from this model model, we're developing two new behavioral health services act population based prevention program campaigns.

One will focus on adult and older adult suicide and self harm prevention, aiming to reduce stigma, improve public education, and support social norms change. Another will increase awareness and trust in nine eight eight and other crisis services, and we will be aligned with the California Health and Human Services, nine eight eight crisis system strategic blueprint. Both efforts will fund community based organizations and tribes to tailor and share messages and will provide support for nine eighty crisis centers, which act as trusted immediate sources of compassionate help.

Together, these efforts aim to reduce barriers to care, increase access to culturally responsive support for communities that may be mistrustful or unaware of available services and supports. The department's Behavioral Health Services Act population based prevention program will also continue the CalHOPE Warm Line and Red Line, which offer preventative non crisis emotional support, often from peers with lived experience to reduce loneliness and help prevent crises.