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County ofSan Bernardino

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SAN BERNARDINO COUNTY: DATA NOTEBOOK 2014

FOR CALIFORNIA

MENTAL HEALTH BOARDS AND COMMISSIONS

COMPLETED REPORT

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Date: April 20, 2014

To: Chairpersons and/or Directors

Local Mental Health Boards and Commissions

From: California Mental Health Planning Council

Subject: Instructions for Data Notebook 2014

We ask that this report be prepared by the MH Board or Commission members. You are the most important resources for identifying program strengths and needs in your community.

On the first page , please fill in the requested information for your county websites:

Department of Behavioral Health/ Mental Health Public reports about your county’s MH services.

Please send a copy of the filled-in first page to the Planning Council along with your final report which contains your answers to the questions in the Data Notebook. Please submit your report within 60 days by email to:

[email protected].

Or, you may mail a printed copy of your report to:

Data Notebook Project California Mental Health Planning Council 1501 Capitol Avenue, MS 2706 P.O. Box 997413 Sacramento, CA 95899-7413

Please examine the enclosed information, which will help you discuss the questions in the Data Notebook. We provide examples of recent mental health data for your county. In some figures, the term “MHP” is used to refer to your county’s Mental Health Plan.

Some data comes from APS Healthcare/EQRO, which gave permission to use their figures and tables, prepared for review of each county’s Medi-Cal Specialty Mental Health services. Data in this packet came from the following review cycle:

X Fiscal Year 2013 -- 2014: http://caeqro.com/webx/.ee85675/

Fiscal Year 2012 -- 2013: http://caeqro.com/webx/.ee851c3/

For some questions, you will need to consult your local county Quality Improvement Coordinator, and/or Mental Health Director. If you are not able to address all of the questions, just answer the ones you can.

Thank you for your participation in the Data Notebook Project.

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SAN BERNARDINO COUNTY: DATA NOTEBOOK 2014 FOR CALIFORNIA

MENTAL HEALTH BOARDS AND COMMISSIONS

County Name: San Bernardino Population (2013): 2,076,399

Website for County Department of Mental Health (MH) or Behavioral Health:

http://www.sbcounty.gov/dbh/index.asp

Website for Local County MH Data and Reports:

http://www.sbcounty.gov/dbh/index.asp

Website for local MH Board/Commission Meeting Announcements and Reports:

http://www.sbcounty.gov/dbh/mhcommission/mhcommission.asp#

Specialty MH Data from review Year 2013-2014: http://caeqro.com/webx/.ee85675

Total number of persons receiving Medi-Cal in your county (2012): 631,447

Average number Medi-Cal eligible persons per month: 503,190

Percent of Medi-Cal eligible persons who were:

Children, ages 0-17: 52.0 %

Adults, ages 18-59: 37.5 %

Adults, Ages 60 and Over: 10.5 %

Total persons with SMI1 or SED2 who received Specialty MH services (2012): 27,011

Percent of Specialty MH service recipients who were:

Children 0-17: 43.5 %

Adults 18-59: 51.1 %

Adults 60 and Over: 5.4 **

1 Serious Mental Disorder, term used for adults 18 and older.

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2 Severe Emotional Disorder, term used for children 17 and under.**It’s important to note that the number 27,011 includes only people who are served by DBH that have Medi-Cal. As we go through the report, you will see that the San Bernardino County, Department of Behavioral Health (DBH) serves many more than 27,011 individuals per year.

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INTRODUCTION: Purpose, Goals, and Data Resources

This Data Notebook has been developed for the use by the local mental health (MH) boards and commissions by a yearlong workgroup comprised of members from:

California Mental Health Planning Council (CMHPC) California Association of Local Mental Health Boards and Commissions

(CALMHB/C) APS Healthcare/ EQRO (External Quality Review Organization)

Our plan is for the Data Notebook to meet these goals:

assist local boards to meet their mandates to review the local county mental health systems, identify unmet needs, and recommend improvements.

provide a professional format for submitting reports to their local Board of Supervisors, and/or their county Director of Mental Health Services.

function as an educational tool for local boards, whose members have varying levels of skills, frequent turnover, and need ‘refresher’ training about using data.

help the CMHPC fulfill its mandates to review and report on the public mental health system in California, which also helps provide evidence for advocacy.

Data reporting drives policy, and policy drives funding for programs. But the data must be both recent and available to the public, or else it is not useful. So, the CMHPC will provide examples of local data from current public reports. We focus on two broad areas: (1) evaluation of program performance, and (2) indicators of client outcomes.

We recognize that each county has a unique population, resources, strengths, and needs. Thus, there is no single perfect data source to answer all the important questions one might ask about mental health services. However, the following data resources will help board members answer questions in this Data Notebook:

experience and opinions of the local mental health board members recent reports about county MH programs from APS Healthcare/EQRO data you request from your county QI Coordinator and/or Mental Health Director

(because CMHPC does not have that data, and it’s not in other public reports) client outcomes data provided by California Institute of Mental Health (CiMH) in

their analysis of the most recent Consumer Perception Survey.

Some of our data comes from APS Healthcare/EQRO, which kindly gave permission to use their figures and tables, prepared for review of each county’s Medi-Cal Specialty Mental Health services. Those reviews are at: www.CAEQRO.com. You may find the full-length EQRO reports helpful because they summarize key programs and quality improvement efforts for each county. They also describe strengths, opportunities for improvement, and changes in mental health programs since the last year.

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Understanding changes in local programs can help consumers because of the massive re-organization of mental health services statewide. Some changes have been confusing to clients. The old state Department of Mental Health was eliminated in 2012 and many functions were moved to the Department of Health Care Services. Other changes due to federal health care reform and the Affordable Care Act affect how mental health services are provided, funded, and linked to primary health care or substance use treatment. Also, local counties have adjusted to major challenges.

Remember, this report is about your community, and what you and your stakeholders choose to discuss. Examining the data can indeed “Tell a Human Story.” But quantitative data (numbers) provides only part of the picture, for example:

measures of whether the quality of program services improve over time whether more people from different groups are receiving services how many clients got physical health care or needed substance use treatment.

The other part of the story gives human context to the numbers. Such qualitative data (narrative, descriptions, or stories) tells more of the story, because we can:

describe special programs targeted for outreach to specific groups examine how the programs are actually implementing their goals list concrete steps that are taken to improve services, and tell what is being done to increase client engagement with continued treatment.

We hope this project contributes to ongoing quality improvement (QI) in mental health services. We seek constant improvement in our approach to quality because:

needs change over time, all human endeavors are by nature imperfect, creativity gives rise to new ideas, and we can share examples of successful programs to help other communities.

One question is whether local boards are permitted to provide additional information, besides that requested in this Notebook. We always welcome supplemental reports about successful projects, or which the county administration uses to inform the public. Any additional reports may be attached in an “Appendix,” with the website address (if available). However, we emphasize such extra reports are not required.

Thank you for participating in this project. We hope this Data Notebook serves as a springboard for your discussion about all areas of the mental health system, not just those topics highlighted by our questions.

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TREATING THE WHOLE PERSON:

Integrating Behavioral and Physical Health Care

Studies have shown that individuals with serious mental illness die, on average, 25 years earlier than the general population. This information makes improving the physical health of clients of great importance and should be a goal of county mental health departments along with providing effective and appropriate mental health services. Coordination of care for mental health, substance abuse and physical health is one way of accomplishing the goal.

The California Mental Health Planning Council does not have any data to provide to show how your county’s programs connect clients of mental health services with necessary physical health care. We ask that the local mental health board request information from your county mental health department for any data on numbers (or percent) of total mental health clients who are referred to, or connected with, physical health providers to assess, treat and monitor physical health issues.

If your county has data on numbers or percentages of clients who are also receiving physical health care, please include it in your Data Notebook you submit to the Council.

Check here if your county does not have such data or information.

1) Please describe any efforts in your county to improve the physical health of clients.

County of San Bernardino Response:

The County of San Bernardino Department of Behavioral Health (DBH) provides mental health, substance use disorder (SUD) and prevention services to county residents. In order to maintain a continuum of care, DBH operates, or contracts for the provision of 24-hour inpatient psychiatric care, day treatment, outpatient services, case management, and crisis and referral services.

DBH meets regularly with the Medi-Cal Managed Care Health Plans that provide access to physical and specialty health care services for Medi-Cal and Medicare beneficiaries. These meetings, whose attendees represent a multi-disciplinary cross section of providers, including, medical doctors, therapists, consumers, fiscal, and administration representation, work to identify quality of care, process, implementation, and administrative issues, and collaborate with DBH to find efficient and high quality solutions that increase access to both behavioral and physical health care.

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While physical health is not a primary function of DBH, we work collaboratively with our health plan partners to ensure the successful treatment of our clients in a holistic approach. Since the implementation of the Affordable Care Act in 2010, DBH has undertaken aggressive efforts to improve access to care for both behavioral and physical health care services. DBH works regularly to refine and implement care coordination policies which facilitate exchange of information between physical health care and behavioral health providers to improve the physical health of clients.

In some regions, DBH has co-located behavioral health staff within primary care practices. Certain efforts have been focused on the use of technology and coordination of care through health integration at the policy level to increase the exchange of information between health care providers. A main focus of DBH efforts over the last several years has centered on building strong relationships with the Managed Care Plans that oversee consumers’ access to physical health care in order to strengthen, enhance and facilitate access to health care for all consumers.

To date, DBH has worked on coordination of care and referrals to physical health care for 3,686 DBH consumers enrolled in the Low Income Health Program (LIHP), ArrowCare, which ended in December of 2013. Consumers with Arrowcare for their insurance were provided with 100,665 hours of outpatient behavioral health care during the ArrowCare project period of July 1, 2012 through December 2013. As of January 1, 2014, consumers with ArrowCare for their insurance were transitioned into Medi-Cal, and coordination of care efforts with their new insurance providers under Medi-Cal (IEHP, IEHP Kaiser, Molina and Molina Health Net) are being continued.

Also, DBH is currently working on intensive care coordination and referrals to physical health providers under the California Duals Demonstration project, CalDuals, coordinated by the Department of Health Care Services (DHCS). With a project start date of May 1, 2014, DBH is working with IEHP and Molina to enhance coordination of care efforts with physical health providers for 2,910 DBH consumers who have both Medicare and Medi-Cal insurance.

Additionally, DBH continues to work with the Medi-Cal insurance plans to coordinate care for consumers that have straight Medi-Cal, and are working on a tracking mechanism for referrals and coordination efforts. As each insurance provider has their own tracking mechanism and process, DBH is working with all four plans to standardize tracking and data collection efforts.

As an integral partner in the provision of health care services, DBH is also partnering with the Department of Public Health Community Vital Signs and Healthy Cities Initiatives. These efforts leverage multiple community stakeholder groups to collaborate on overall health and wellness.

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2) How does your county address wellness programs to engage and motivate clients to take charge of improving their physical health?


DBH approaches engagement in wellness throughout the system of care via case management and care coordination services. Consumers identified as having physical health needs have their individual needs addressed through the course of treatment. In addition, DBH deploys a wider variety of strategies to support wellness, including providing access to services in natural community settings and the inclusion of intern programs and teaching institutions in the provision of care. Examples include:

Community-Based Recovery Service Centers: Recovery Center services are available in each region of the county and offer support and wellness to individuals and families recovering from substance use disorders. Services offered include:

o Smoking cessation.o Training/Drug education to increase knowledge of medical aspects of

Substance Use Disorder (SUD), alcohol and drug and the law, family dynamics, and other SUD issues.

o Life Skills to improve daily living such as hygiene, self-care, decision- making, and employment skills.

o Social activities for members in recovery and their families to strengthen social connectedness.

Family Resource Centers: Regional centers that offer an array of services in a natural community setting that can include health and nutrition, stress management, after school activities that build positive skills and socialization, life skills education, and linkage and referral to resources.

Integrated Health Clinics: Integrated health services are provided as part of the Community Wholeness and Enrichment program. Primary health care providers work with mental health and SUD staff to screen, refer, consult, and support primary care providers. Services can include support for stress management, managing chronic disease, or other topics.

Clubhouses: Community clubhouses are programs available throughout the county that offer those living with serious mental illness to access friendship, housing, education, employment, and life skills. Clubhouse members build social skills and have access to preventive health education such as nutritional counseling, healthy food offerings, personal fitness training, preventative testing, stress management and smoking cessation.

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Community Based Services: Holistic Campus Services and Community Education Programs such as the Community Resiliency Model (CRM), which helps individuals develop and teach skills sets for coping and dealing with trauma, identify and utilize community assets by partnering with community members with lived experience and assisting others with accessing resources, support and services.

NEW CLIENTS: One Measure of Access

One way to evaluate the quality of mental health services outreach is to measure how many clients receive services who have never been part of the service system before (“brand new” clients). Another measure is how many clients return for services after a period of time with no services (“new” clients).

The California Mental Health Planning Council is exploring how each county mental health department defines “new” clients, and how a client is labelled when they return for additional services. This information is important in determining whether your county has a “revolving door,” that is, clients who are in and out of mental health services repeatedly. This data is one indicator of the success of your county’s programs in closing cases appropriately and providing adequate discharge planning to clients.

This data is not currently reported by the counties to the state. The Council does not have data to provide to you. This information should be requested from your county mental health department.

Check here if your county does not have this information.

3. How does your county define 'new' client for those individuals who have previously received services, but who have not received services for a while? (e.g., 6 months, 12 months, 2 years?)


A client is defined as being “new,” if they have not had services with DBH before. If they have had services in the system before, they are not considered, “new.” Consumers who have received services and return back after some period of time are considered “returning.”

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4. Please provide any data your county has on the number of 'new' clients last year. And if you have it, how many of those new clients were brand new clients? You may need to ask your county mental health department forthis data.


# new children/youth (0-17 yrs) _5,576_

of these, how many (or %) are ‘brand new’ clients _100%_

# new adults (18-59 yrs) _4,781_


# new older adults (60+ yrs) _332_


Clients New to DBH

Age Groups

New to DBH in FY12/13

0-17 5,576

18-59 4,781

60+ 332

Grand Total 10,689

**Data Source: DBH Data Warehouse

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REDUCING RE-HOSPITALIZATION: Access to Follow-up Care

Sometimes, an individual experiences acute symptoms of mental illness or substance abuse which can result in a brief stay in an acute care hospital. Receiving follow-up services after discharge from a short-term (3-14 day) hospitalization can be critical to preventing a return to the hospital.

The chart below shows the percentage of people discharged in your county who received at least one service within 7 days of discharge. Also shown is the percentage of those same people who were readmitted to the hospital. The chart also shows the same information for receiving services and being readmitted to the hospital within 30 days. Red indicates the numbers for your county and the blue indicates the percentage for the State of California .

San Bernardino County:

**Data Source: APS Healthcare / External Review Quality Organization (EQRO) Report

THERE IS NO QUESTION 5

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6. Looking at the chart, is your county doing better or worse than the state? Discuss why (e.g., your county has programming available that specifically ensures a warm handoff for follow-up services).


DBH has lower engagement rates in outpatient services for individuals recently discharged from the hospital than the state average. However, hospital readmissions are much lower than the state average (almost half). This suggests that readmission rates are low, which indicates that largely, most clients do not get re-hospitalized again.

Because the data in the graph above is for Medi-Cal claims only, it does not include non-Medi-Cal billable services provided to individuals after hospitalization that may assist consumers in accessing Medi-Cal services, such as Mental Health Service Act (MHSA) programs. As such, DBH has identified this as an issue in our ongoing quality improvement efforts and is implementing a performance improvement project through MHSA called the Access, Care and Enhancement (ACE) program to increase engagement in outpatient behavioral health services within seven (7) days upon discharge from an inpatient hospital.

The objectives of the ACE program as it is implemented and improved over time:

Increase capacity in response to the demand for care. Provide shorter waiting times and shorter times between appointments. Provide same day psychiatrist evaluations when clinically appropriate. Provide reduced psychiatrist wait times by expediting opening of cases. Provide scheduled or non-scheduled appointments for inpatient referrals. Provide increased access to individual and group therapy. Provide increased case management services. Facilitate consumer access to additional benefits. Provide access to urgent psychiatric evaluation. Establish development of uniformed screenings and assessment tools. Improve coordination of care and referral within DBH’s system of care. Improve access and better connectivity between referral and care organizations

(such as homeless, primary health care and employment services).

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7. Do you have any suggestions on how your county can improve follow-up and reduce re-hospitalizations?


DBH has several current programs aimed at the reduction of re-hospitalization, which have over time, reduced re-hospitalization rate. With this improvement documented, DBH is now focused on increasing the number of clients who engage in outpatient services within (7) days of discharge from an inpatient psychiatric hospital. This includes educational efforts to ensure consumers are aware of their right to a copy of the aftercare (discharge) plan when discharged from the hospital.

The ACE program has been implemented in the last year, utilizing the Rapid Access Services concept which seeks to improve timeliness of access to DBH outpatient services for clients who are discharged from a hospital. The ACE program will be added to the four (4) major regional clinics, Phoenix Clinic, Upland Community Counseling (UCC), Mesa Counseling Center, and Victor Valley Behavioral Health (VVBH), and would seek to track the increase of client engagement in outpatient services post hospitalization. The ACE program will provide same-day psychiatrist evaluations when clinically appropriate, reduce psychiatrist wait times by expediting opening of cases, allow scheduled or non-scheduled appointments for inpatient referrals to ongoing clinic- based service and for MD appointments following hospitalization, and facilitate consumer access to benefits.

Once fully implemented, a typical consumer encounter in the ACE program would include follow-up with that consumer by a DBH ACE staff within seven (7) days of their discharge from the hospital. This follow-up would include the confirmation of an outpatient appointment that would have been set with a clinic on the day the consumer was discharged from the hospital. The DBH ACE staff would discuss the number and types of medications the consumer was discharged with, ensure they had filled their prescriptions if prescriptions were given, and confirm the consumer’s plans to attend the outpatient appointment as scheduled. The DBH ACE staff would also discuss any barriers for the consumer in getting to the outpatient appointment and try to problem solve these with the consumer to ensure the highest likelihood of consumer attendance at their appointment.

This program is strategically designed to connect consumers to outpatient or other services in an effort to reduce re-hospitalization, and will have data that can be shared in the next report as the program is implemented.

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8. What are the three most significant barriers to service access? Examples:


1. National shortages of culturally and linguistically competent clinical providers including clinicians, psychiatrists and nurses.

2. Geographic challenges.

3. Regulatory barriers that prevent the sharing of client information for care coordination.

ACCESS BY UNSERVED AND UNDER-SERVED COMMUNITIES

One goal of the Mental Health Services Act (MHSA) is to reach unserved and underserved communities, especially communities of color. The MHSA promotes outreach into these communities to engage these communities in services. If individuals and families in these communities are not accessing services, then we may need to explore new ways of reaching them. Or, we may need to change our programs to meet their mental health needs in ways that better complement their culture.

From data the counties report to the state, we can see how many individuals living in your county are eligible for Medi-Cal, and of those individuals, how many received mental health services. Are you serving the Medi-Cal clients who need your services?

Other47,554

Native American 8,625Asian/Pacific Islander 130,560

African- American 174,681

Number of IndividualsCaucasian 677,106

Latino1,021,168

Other2.3%

NativeAmerican 0.4%

Percentage of IndividualsCaucasian

32.9%

Asian/PacificIslander 6.3%

African- American 8.5% Latino49.6%

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Both graphs show the same information, the first has actual counts, the second shows percentages.**Data Source: California Department of Finance (DOF) Demographic Research Unit

San Bernardino County Data: Estimated Total PopulationEstimated Total Population by Race/Ethnicity, Calendar Year 2012

Average Numbers EnrolledCaucasianOther97,68834,861

Native American 1,339

Asian/Pacific Islander 16,985African-American 63,972

Latino288,347

Average Percentages Enrolled

Caucasian19.41%

NativeAmerican 0.27%

Other6.93%


African American 12.71%Latino57.30%

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Both graphs show the same information, the first has actual counts, the second shows percentages.**Data Source: Monthly Medi-Cal Eligibility File, California DHCS

San Bernardino County Data: Medi-Cal BeneficiariesAverage Monthly Medi-Cal Enrollment by Race/Ethnicity, Calendar Year 2012

Number of Individuals ServedOther2,458

Caucasian9,019

NativeAmerican 146

Asian/PacificIslander 616

African American 5,068

Latino9,704

Percentages Served

Caucasian33.39%

NativeAmerican 0.54%

Other9.10%


AfricanAmerican 18.76%

Latino35.93%

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Both graphs show the same information, the first has actual counts, the second shows percentages.**Data Source: DBH Data Warehouse

San Bernardino County Data: Beneficiaries ServedMedi-Cal Beneficiaries Served by Race/Ethnicity, Calendar Year 2012

Number of Individuals ServedOther15,816Caucasian

26,197Native

American 5,935Asian/Pacific Islander 3,032

African American 11,548

Latino57,102

Other13%

Percentages ServedCaucasian 22%

NativeAmerican 5%

Asian/Pacific Islander2%African American 10%

Latino48%

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Both graphs show the same information, the first has actual counts, the second shows percentages.**Data Source: DBH MHSA Integrated Plan

San Bernardino County Data: All Residents Served Through Medi-Cal and MHSA

County Residents Served Through MHP Services by Race/Ethnicity, Calendar Year

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9. Is there a big difference between the race/ethnicity breakdown on the two charts? Do you feel that the group(s) that need services in your county are receiving services?


*Please note that two charts were provided in this section of the report by EQRO. However, the data was incorrect as identified in our last EQRO review in October 2013. EQRO provided updated raw data to DBH in June 2014, and DBH recreated the two graphs, and added six additional graphs for inclusion in this report.

According to these charts, the Caucasian Medi-Cal beneficiary population is being over served and traditionally accessing more case management and outpatient services than crisis services.

The largest Medi-Cal beneficiary group is Latinos, and utilization has increased slightly over the years; however, this population overall continues to have a low utilization rate. Some of the barriers to services include stigma, gaps in culturally and linguistically appropriate services and inadequate transportation. The low utilization rate remains a disparity that is being addressed through the enhancement of existing programs and development of new programs by embedding community and culturally-defined practices into service delivery. In addition to adopting these practices, more strategic outreach and engagement efforts are conducted in Latino communities. These outreach and engagement activities include education on behavioral health topics and ways to navigate the system. These activities are done in an effort to promote awareness, reduce stigma and increase access to care.

According to the preceding charts, there is an overrepresentation of African American beneficiaries served, when compared to the percentage of eligible individuals. African Americans demonstrate higher unmet mental health needs which could result in an increased use of more restrictive levels of care, such as crisis services. In an effort to reduce mental health disparities in this population and also to foster better treatment outcomes, DBH is investing towards more culturally responsive prevention and early intervention activities in an effort to reduce the high use of crisis services by this population. Some of the prevention and early intervention programs include Family Resource Centers, African American Community Health Worker Programs, Resilience Promotion in African American Children’s Services Program, and Holistic Campus activities. DBH is also conducting outreach to the African American faith based community to provide behavioral health education and services. Other activities conducted towards reducing disparities include identifying and using evidence based practices that have been proven to be effective for the African American population.

The Asian/Pacific Islander (API) population is underrepresented, according to before mentioned charts. In API communities, language, stigma, and gaps in culturally and

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linguistically appropriate services are barriers in service accessibility. DBH is making efforts to address this by implementing culture-specific programs that use cultural approaches proven to be effective for the API population. Some of these programs include prevention and early intervention API Pilot Program, Family Resource Centers, Holistic Campus activities, and a new API Community Health Worker program. Since various languages are spoken within the API population, educational brochures and other documents are being developed in various API languages.

The Native American population is a small population in the county. Based on the charts, the Native American population is overrepresented. However, it is important to note that similar to the API population there are regions in the county that have a substantial number of Native Americans that lack access to services. Also, Native Americans tend to be inappropriately served in a traditional treatment setting and that leads to poor treatment outcomes. A holistic approach is needed for individual, family, and community wellness. In an effort to increase access to care and promote better treatment outcomes, DBH partners with various Native American based organizations to provide services that employ culture specific and appropriate services that have been shown to be effective for this population. Examples of these programs include the Native American Resource Center, and the Native American Community Health Worker program.

10. What outreach efforts are being made to reach minority groups in your community?


DBH conducts ongoing outreach and engagement activities to cultural populations to provide information regarding available services and how to access these services. Education is conducted to increase behavioral health awareness, reduce stigma and increase access to care, all in an effort to reduce disparities. DBH currently has a Community Outreach and Engagement office that participates in health fairs throughout the county to provide information on available services. DBH also partners with cultural organizations and coalitions to assist in the development and implementation of new DBH projects and programs.

DBH has a community-driven Cultural Competency Advisory Committee (CCAC) with twelve (12) sub-committees. The CCAC and its sub-committees were instrumental in developing the original Cultural Competence Plan and are involved in all subsequent updates to the plan.

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These advisory groups engage in outreach activities by recruiting members of the community to attend scheduled forums to address the needs of their community and develop strategies to address those needs. This community outreach and engagement approach assists DBH in producing a plan that is community driven, informed and developed. Also, these advisory groups are not only involved in the development of updates to the plan but are also involved in the implementation of the updated plan.

The following are the names of the community-driven CCAC sub-committees/coalitions: Asian/Pacific Islander Awareness Sub-committee, Co-Occurring and Substance Abuse Awareness Committee (COSAC), Disabilities Awareness Subcommittee, African American Awareness Sub-committee, Latino Health Coalition, Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) Awareness Sub-committee, Native American Awareness Committee, Spirituality Awareness Sub-committee, Transitional Age Youth (TAY) Awareness Sub-committee, Veteran’s Awareness Sub-committee and Women’s Awareness Sub-committee.

The CCAC sub-committees partner with community organizations and schools to conduct outreach and education to the community in an effort to increase awareness and promote recovery, wellness and resiliency. DBH also participates in outreach efforts at a systems level with other county departments and county health plans; collaborations include: Drug and Gang Task Force; Coalition Against Sexual Exploitation (CASE); Multi-Disciplinary Task Force; District Attorney’s Bureau of Victims Services; Inland Empire Disabilities Collaborative and San Bernardino County Probation Department.

CCAC acts as a lead in the coordination of the following outreach activities: African American Mental Health Awareness; Native American Heritage Month Pow Wow; Asian Pacific American Mental Health Awareness Day; Juneteenth; TAY College and Career Option Fair; TAY- Reducing Risky Behaviors; Hispanic Heritage Month; and the Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) Awareness Symposium.

DBH also shares information and conducts outreach to various community organizations and committees to provide information on new programs and services, education surrounding mental illness, and various statewide initiatives. DBH utilizes already existing platforms to promote behavioral health outreach and education. For example, DBH has a close partnership with the Mexican Consulate, where outreach collaborations include annual Bi-National Health Week events, Hispanic Heritage Month celebrations and Latino Behavioral Health Week which allows for greater community education on behavioral health issues. DBH’s involvement with the Mexican Consulate Bi-National Health Initiative allows for greater participation and partnership with Latino faith based organizations. The Mexican Consulate participates in regular DBH

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community planning activities such as Mental Health Services Act stakeholder engagement meetings and forums, and the CCAC Latino Health Awareness Committee.

DBH also has a Promotores de Salud/Community Health Worker’s Program (CHW). The CHW Program trains volunteers from the community on behavioral health topics and after these trainings the CHW go out into their communities to educate the public on behavioral health topics in an effort to increase awareness, reduce stigma and increase access to care. The CHW program is designed according to specific cultural populations. The targeted populations include Native American, Asian/Pacific Islander (API), African American and LGBTQ populations.

11. Do you have suggestions for improving outreach to and/or programs for underserved groups?


There is always room for improvement in regards to outreach efforts and programs for underserved populations. DBH uses the Culturally and Linguistically Appropriate Services (CLAS) Standards, various organizational assessment tools, and the Department of Health Care Services’ (DHCS) Cultural Competence Plan Requirement (CCPR) to improve outreach efforts, program planning, and treatment to underserved, unserved and inappropriately served populations. The DHCS-CCPR requires all County Mental Health Plans across the State to develop a Cultural Competence Plan (CCP) that works toward the development of the most culturally and linguistically competent programs and services to meet the needs of the County’s diverse racial, ethnic, and cultural communities in the mental health system of care.

The original CCPR (2002) addressed only Medi-Cal Specialty Mental Health Services, while the revised CCPR (2010) addresses all mental health services and programs throughout the County Mental Health System. The revised CCPR includes the most current resources and standards available in the field of cultural and linguistic competence, and is intended to move toward the reduction of mental health service disparities identified in racial, ethnic, cultural, linguistic, and other unserved/underserved populations. The CCPR addresses eight domains based on the CLAS standards, which include organizational values, polices/ procedures/ governance, planning/ monitoring/ evaluation, communication, human resource development, community and consumer participation, facilitation of a broad service array, and organizational resources.

DBH continually uses the Cultural Competence Plan for the development and improvement of outreach efforts and service delivery programs for unserved, underserved and inappropriately served groups. An example of efforts under this plan include the development of behavioral health programs within already existing

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community health organizations targeted at serving specific underserved and cultural groups. DBH will also be working with community cultural brokers to coordinate ongoing educational forums to increase mental health awareness and provide informational materials in preferred languages spoken in specific communities. Also DBH recently expanded the Community Health Worker (CHW) program to include the Asian/Pacific Islander and Native American populations in addition to the previous target populations of Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ), African Americans and Latinos. The goal of the CHW program is to recruit members of the community and train them on mental health topics so that they can go back to their communities and educate the public on mental health matters in an effort to raise awareness, reduce stigma and increase access to care.

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CLIENT ENGAGEMENT IN SERVICES

One MHSA goal is to connect individuals to services they need to be successful. Clients who stop services too soon may not achieve much improvement, nor is it likely to last. So it is important to measure not only who comes in for treatment, but also how long they stay in services. Here we are considering individuals with high service needs, not someone who just needs a ‘tune-up.’ Although not every individual needs the same amount of services, research shows that when someone with severe mental illness continues to receive services over time, their chances of recovery increase.

Engagement in services, also called ‘retention rate’, is important to review. If individuals come in, receive only one or two services and never come back, it may mean the services were not appropriate, or that the individual did not feel welcome, or some other reason that should be explored. Again, we recognize that some individuals only need minimal services, but here we are looking at those with severe mental illness. Ultimately, the goal is to ensure they are getting needed services and are on the road to recovery. But we would not know that unless we look at how many services individuals received over time.

The chart below shows the number of Medi-Cal beneficiaries in your county who received 1, or 2, or 3, or 4, or 5, or more than15 mental health services during the year. For individuals experiencing severe mental illness, the more engaged they are in services, the greater the chance for lasting improvements in mental health.

12. Do you think your county is doing a good job at keeping clients engaged in services? If yes, how? If not, why?

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According to the data presented in the previous chart, DBH Medi-Cal services retention rates exceed the statewide average in five of the six measures.

We always recognize the opportunity to improve the delivery of services and engage in ongoing quality improvement activities. Currently, DBH uses the following strategies:

Maintaining and developing a comprehensive and progressive continuum of care that allows individuals to be appropriately served in lower levels of care and in the least restrictive environment. Examples include:

o The use of community-based prevention and early intervention services such as those offered at, but not limited to, Family Resource Centers, the Community Wholeness and Enrichment Program, the Student Assistance Program, and the Preschool PEI Program.

o Recovery support services that are available at Clubhouses and Substance Abuse Recovery Centers.

o Utilization of the crisis system of care (Hospital diversion program, Crisis Response Team, and Crisis Walk-In Centers) that allow individuals to have their immediate needs addressed and linked to additional supports.

Providing care coordination services that facilitate access to additional supports such as transportation.

13. For those clients receiving less than 5 services, what is your county doing to follow-up and re-engage those individuals for further mental health services?


For all consumers receiving services, DBH employs several strategies to support follow up care and engagement in services. For those with appointments, daily appointment reminder calls are made, and in some cases, reminder letters sent. Clinical staff also work to engage consumers throughout their course of care by following up when they do not show for appointments and establishing therapeutic rapport. In some cases, case managers or peer and family advocate staff are assigned to provide additional support in engaging clients who need more services.

In other cases, consumers may not need to engage in more services and may wish to access other types of programs that are not Medi-Cal services such as programs provided under Mental Health Services Act (MHSA). These types of services can be viewed as alternative or additional services to Medi-Cal services and support the consumer’s right to self-determination of services that best fit their needs. In Fiscal Year 2012/13, 159,080 consumers accessed MHSA program services including mental health, early intervention, recovery and peer supported specialty services.

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Additionally, to assist individuals in engaging services in both Medi-Cal and MHSA programs, DBH and stakeholders designed and will implement an Innovation project to test the effectiveness of field-based engagement service strategies. The Recovery Based Engagement Support Teams (RBEST) project will test engagement strategies for populations that have not engaged in effectively accessing mental health services and treatment due to various long standing, societal circumstances which impede their ability to successfully live in their communities in a state of recovery and wellness. This includes individuals who are either not active in seeking and receiving necessary psychiatric care, are resistant and known to the public mental health system, as well as those who are not known to the system but known to the community or resources with which they intersect on a daily basis. Lessons learned through the RBEST project will help to inform the department’s practices regarding how to more effectively re-engage clients in care.

14. Looking at the previous chart of who is being served by race/ethnicity in your county, do you have any thoughts or ideas to share regarding your county’s engagement of underserved communities?


DBH is highly committed to serving diverse consumers throughout the continuum of care. Culturally responsive and specific programming has been included in the continuum of care and includes programs such as the Resilience Promotion in African- American Children Program, the Native American Resource Center, and the Promotores de Salud/Community Health Worker programs.

In addition, DBH embeds collaboration with the community into ongoing operations at multiple levels. DBH has a commitment to cultural competence with twelve (12) cultural subcommittees and coalitions that meet monthly, in addition to the Cultural Competency Advisory Committee. Cultural competency is woven into all DBH services, including planning, implementing and evaluating programs.

Inclusion of services provided under these and other MHSA funded programs in the review of County of San Bernardino public mental health system are necessary to properly assess the demographics of those receiving DBH services.

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CLIENT OUTCOMES: Consumer Perception Survey (August 2013)

Ultimately, the reason we provide mental health services is to help individuals manage their mental illness and to lead productive lives. We have selected two questions from the Consumer Perception Survey which capture this intention. One question is geared toward adults of any age, and the other is for children and youth under 18.

Below are the data for responses by clients in your county to these two questions.

For general comparison, statewide reference data for various sized counties are shown in the tables on page 19.

The total numbers of surveys completed for Adults or Children/Youth in your county are shown separately in the tables below, under the heading “Total.”

Q1. Adults. As a direct result of the services I received, I deal more effectively with daily problems.

Strongly Disagree

Disagree Neutral Agree Strongly Agree

Total

Number of Responses

5 21 113 243 195 577

Percent of Responses

0.9 % 3.6 % 19.6 % 42.1 % 33.8 % 100.0 %


*Note: More than 75% of consumers indicated that they either agreed or strongly agreed with Q1, while less than 5% disagreed.

Q2. Children/Youth. As a result of services my child and/or family received, my child is better at handling daily life.

Strongly Disagree

Disagree Neutral Agree Strongly Agree

Total

Number of Responses

11 35 122 322 214 704

Percent of Responses

1.6 % 5.0 % 17.3 % 45.7 % 30.4 % 100.0 %


*Note: Approximately 76% of consumers indicated that they either agreed or strongly agreed with Q2, while less than 7% of consumers disagreed.

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15. Are the data consistent with your perception of the effectiveness of mental health services in your county?


The consumer perception survey results indicated that of those who responded, 76% expressed satisfaction regarding the effectiveness of services. While these results indicate a high percentage of satisfied consumers, as a Behavioral Health Commission we are aware there is still great improvement to be made through the system of care. We understand that these results are not illustrative of community feedback regarding all facets of behavioral health services. However, these results are reflective of consumer perception regarding many of the programs being administered by the Department of Behavioral Health.

Consumers routinely express high levels of satisfaction with the effectiveness of Clubhouse and recovery based outpatient services, but request improvements in other areas such as inpatient psychiatric hospital services.

As a routine practice, DBH administers consumer surveys to obtain consumer feedback on critical issues. The 2013 DBH Supplemental Health Survey asks consumers about follow-up appointments after hospitalization. Results showed a need to continue improving coordination of outpatient care following inpatient hospitalization. The ACE program was developed in response to many of the barriers that consumers reported are important to them (appointment reminders, follow-up calls, assistance with scheduling, transportation, etc.), and focuses on increasing consumer engagement in outpatient behavioral health services following hospitalization.

As a Commission working with a department that has a continuous quality management focus, we are continually examining the effectiveness of the system of care and regularly work with DBH staff to identify areas for ongoing improvement.

16. Do you have any recommendations for improving effectiveness of services?


Recently DBH established a System-wide Program Evaluation and Outcomes Committee with the objective to develop a system-wide framework for program goals and outcomes. Committee membership includes a variety of DBH programs and community-based organizations. The Committee has developed a matrix of goals and associated key outcomes. The goals are derived from legislation, regulations, and Department of Health Care Services (DHCS) Information Notices and the key outcomes are operationalized ways of measuring progress toward the goals at regular intervals.

DBH has provided initial training on how goals and outcomes are to be integrated into all programs to create a systematic way to measure program performance and identify

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opportunities for improvement. Training and support will continue as the program improvement process evolves.

Additional recommendations for improvement include:

Provide mental health screening and assessments in “trusted” community locations where the underserved and unserved already congregate such as faith- based institutions.

Promote mental health and SUD awareness and training to primary care providers.

Incorporate culturally effective treatment and approaches in service delivery. Build partnerships and increase coordination and communication between other

providers, for example primary care providers and other county departments. Ensure access to transportation so that consumers are motivated to keep their

appointments. Continue to work closely with our Medi-Cal Managed Care Plan partners to

coordinate care between both behavioral and physical health care services, including the exchange of appropriate, allowable health care information.

Continue to engage in consumer and provider education regarding insurance plans, benefit packages and types of health care services available in the County of San Bernardino.

Enhance education to family members, consumers and providers about the importance of person/family centered care planning so that beneficiaries and their families are effective partners in health care decisions.

17. Many counties experience very low numbers of surveys completed. Do you have suggestions to increase the response rate?


While DBH received 3,500 survey responses this year, improvements to surveys could be made. Suggestions include reducing the survey to one page, or at most two pages. Many consumers are discouraged by multi-page forms that require a great deal of time and attention to complete.

Additionally, consumers report a disconnection between the survey and “real life” in regards to the services they receive at the clinics. San Bernardino County, with consumer input, would be willing to work on a redesign of the survey with DHCS, if the state is so inclined. The ultimate goal would be to provide a clear and reasonable explanation (in terms that consumers can quickly understand) about how their contribution could potentially impact and improve the services that they or other consumers receive.

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18. Lastly, but perhaps most important overall, with respect to delivery of services, do you have suggestions regarding any of the following:


It is important to note that service planning to address gaps in service and unmet needs is a layered process. DBH utilize data analysis and mapping techniques that assist the department in identifying where service needs exist in the county visually. Specifically, the department reviews stakeholder feedback and applicable regulations as well as overlays county demographics, levels of poverty, available behavioral health providers, current Medi-Cal eligible populations, and the geographic distribution of consumers served on several versions of geomaps of each section of the county. These maps assist the county and its stakeholders in program expansion and utilize technology to easily display and identify unmet needs, distribution of services and identify areas which need expansion. The following answers are derived using those maps which are available upon request.

a. Specific unmet needs or gaps in services

DBH utilizes its research and evaluation division to evaluate service needs in the community. The process includes mapping out current resources, identifying the number of people served in specific regions, determining who will need services in what areas, determining what types of services are needed, and evaluating if enough services are available by service type. Over the next several years, DBH will be focusing on enhancing culturally competent services in three areas, individual and group therapy, case management and psychiatry.

b. Improvements to, or better coordination of, existing services

Under the implementation of the Affordable Care Act, DBH has worked diligently with our Managed Care and other health partners to better coordinate existing behavioral health services. Efforts over the next several years will include a focus on interdisciplinary coordination for treatment teams within programs/clinics, improvement of coordination between programs, and improvement of coordination between Medi-Cal Managed Care Plans and DBH (HMO to HMO). DBH continues to expand stigma reduction efforts and suicide prevention education through targeted program improvement efforts and community partner collaboration.

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c. New programs that need to be implemented to serve individuals in your county

In implementing the Affordable Care Act, DBH is planning for the expansion of services, over time, to accommodate the increased number of Medi-Cal beneficiaries that will need to access specialty mental health care (Tier III). Additional program planning will be done in the areas of transitional care (inpatient to outpatient), as well as for programs that utilize culturally competent, community-defined, best practices and evidence based practices in all levels of care.

<END>

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REFERENCE DATA: for general comparison with your county MHP results

County Mental Health Plan Size: Categories are based upon DHCS definitions by county population.

o Small‐Rural MHPs = Alpine, Amador, Calaveras, Colusa, Del Norte, Glenn, Inyo, Lassen, Mariposa,Modoc, Mono, Plumas, Siskiyou, Trinity

o Small MHPs = El Dorado, Humboldt, Imperial, Kings, Lake, Madera, Mendocino, Napa, Nevada, San Benito, Shasta, Sutter/Yuba, Tehama, Tuolumne

o Medium MHPs = Butte, Marin, Merced, Monterey, Placer/Sierra, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Yolo

o Large MHPs = Alameda, Contra Costa, Fresno, Kern, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Santa Clara, Ventura

o Los Angeles’ statistics are excluded from size comparisons, but are included in statewide data.

Total Values (in Tables above) = include all statewide data received by CiMH for these survey items.

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References / Data Sources

African American Health Institute (AAHI) of San Bernardino, (2012). Pathways into the Black Population for Eliminating Mental Health Disparities: California Reducing Disparities Project, African American Population Report

American Community Survey 2007-2011 File, United States Census Bureau, http://www.census.gov/acs/www/data_documentation/2011_release/

APS Healthcare/External Quality Review Organization (EQRO) Report, Fiscal Year 2013-2014, http://caeqro.com/webx/.ee85ae6

ArrowCare Report, December 20, 2013, Department of Behavioral Health California Department of Finance, Demographic Research Unit, E-5 Population and

Housing Estimates for Cities, Counties and the State, January 1, 2011- 2014, http://www.dof.ca.gov/research/demographic/reports/estimates/e-5/2011- 20/view.php

California Reducing Disparities Project, California Department of Public Health, http://www.cdph.ca.gov/programs/Pages/Old%20- %20CaliforniaReducingDisparitiesProject.aspx

Community-Defined Solutions for Latino Mental Health Care Disparities: California Reducing Disparities Project, Latino Strategic Planning Workgroup Population Report, 2012, UC Davis Center for Reducing Health Disparities, http://www.ucdmc.ucdavis.edu/newsroom/pdf/latino_disparities.pdf

Dashboard Report, Fiscal Year 2012-213, Department of Behavioral Health Data Warehouse, Research & Evaluation Unit, Department of Behavioral Health

In Our Own Words: Asian Pacific Islander (API) Population Report, California Reducing Disparities Project, California Department of Public Health, http://crdp.pacificclinics.org/files/resource/2013/04/Report.pdf

Mental Health: Culture, Race, and Ethnicity - A Supplement to Mental Health: A Report of the Surgeon General, 2001, Office of the Surgeon General (US), http://www.consumerstar.org/resources/pdf/surgeongeneralsreport2001.pdf

Mental Health: Culture, Race, and Ethnicity (2001) - A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999)

MHSA Integrated Plan Fiscal Years 2014/2015-2016-2017, Department of Behavioral Health, http://www.sbcounty.gov/dbh/mhsa/mhsa.asp#

Monthly Medi-Cal Eligibility File, California Department of Healthcare Services Native American Health Center Inc. (2012) Native Vision: A Focus on Improving

Behavioral Health Wellness for California Native Americans: California Reducing Disparities Project, Native American Strategic Planning Workgroup Report

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Native Vision: A Focus on Improving Behavioral Health Wellness for California Native Americans, California Reducing Disparities Project, California Department of Public Health, http://issuu.com/nativeamericanhealthcenter/docs/native_vision_report

Pathways into the Black Population for Eliminating Mental Health Disparities, California Reducing Disparities Project, California Department of Public Health, http://www.cdph.ca.gov/programs/Documents/African_Am_CRDP_Pop_Rept_FI NAL2012.pdf

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REMINDER:

Thank you for your participation in completing your Data Notebook report.

Please feel free to provide feedback or recommendations you may have to improve this project for the following year. We welcome your input.

Please submit your Data Notebook report by email to:

[email protected]

Or, you may submit a printed copy by postal mail to:

Data Notebook Project California Mental Health Planning Council 1501 Capitol Avenue, MS 2706 P.O. Box 997413 Sacramento, CA 95899-7413

For information, you may contact either email address above, or telephone:

(916) 449-5249, or

(916) 323-4501

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Tab 4

County of San Bernardino Behavioral Health Commission

Data Notebook 2014August 7, 2014

References/Data Sources

African American Health Institute (AAHI) of San Bernardino, (2012). Pathways into the Black Population for Eliminating Mental Health Disparities: California Reducing Disparities Project, African American Population Report

American Community Survey 2007-2011 File, United States CensusBureau, http://www.census.gov/acs/www/data_documentation/2011_release/

APS Healthcare/External Quality Review Organization (EQRO) Report, Fiscal Year 2013-2014, http://caeqro.com/webx/.ee85ae6

ArrowCare Report, December 20, 2013, Department of Behavioral Health

California Department of Finance, Demographic Research Unit, E-5 Population andHousing Estimates for Cities, Counties and the State, January 1, 2011-2014, http://www.dof.ca.gov/research/demographic/reports/estimates/e-5/2011- 20/view.php

California Reducing Disparities Project, California Department of Public Health, http://www.cdph.ca.gov/programs/Pages/Old%20- %20CaliforniaReducingDisparitiesProject.aspx

Community-Defined Solutions for Latino Mental Health Care Disparities: California Reducing Disparities Project, Latino Strategic Planning Workgroup Population Report, 2012, UC Davis Center for Reducing HealthDisparities, http://www.ucdmc.ucdavis.edu/newsroom/pdf/latino_disparities.pdf

Dashboard Report, Fiscal Year 2012-213, Department of Behavioral Health

Data Warehouse, Research & Evaluation Unit, Department of Behavioral Health

In Our Own Words: Asian Pacific Islander (API) Population Report, California Reducing Disparities Project, California Department of PublicHealth, http://crdp.pacificclinics.org/files/resource/2013/04/Report.pdf

Mental Health: Culture, Race, and Ethnicity - A Supplement to Mental Health: A Report of the Surgeon General, 2001, Office of the Surgeon General(US), http://www.consumerstar.org/resources/pdf/surgeongeneralsreport2001.pdf

Mental Health: Culture, Race, and Ethnicity (2001) - A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999)

MHSA Integrated Plan Fiscal Years 2014/2015-2016-2017, Department of Behavioral Health, http://www.sbcounty.gov/dbh/mhsa/mhsa.asp#

Monthly Medi-Cal Eligibility File, California Department of Healthcare Services

Native American Health Center Inc. (2012) Native Vision: A Focus on Improving Behavioral Health Wellness for California Native Americans: California Reducing Disparities Project, Native American Strategic Planning Workgroup Report

Native Vision: A Focus on Improving Behavioral Health Wellness for California Native Americans, California Reducing Disparities Project, California Department of PublicHealth, http://issuu.com/nativeamericanhealthcenter/docs/native_vision_report

Pathways into the Black Population for Eliminating Mental Health Disparities, California Reducing Disparities Project, California Department of PublicHealth, http://www.cdph.ca.gov/programs/Documents/African_Am_CRDP_Pop_ Rept_FINAL2012.pdf

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