Mental Health Services Department Budget Unit 4120 Department Head: James Waterman, Appointed

Mental Health Services Department Budget Unit 4120 Department Head: James Waterman, Appointed SUMMARY OF EXPENDITURES AND REVENUES APPROPRIATIONS: Contingencies Salaries and Benefits Services and Supplies Other Charges Fixed Assets Other Financing Uses TOTAL NET EXPENDITURES REVENUES: Use of Money/Property Intergovernmental Charges for Services Miscellaneous Other Financing Sources County Contribution Mental Health Program Realignment Mental Health Services Act TOTAL NET REVENUES FY 2007-08 Actual FY 2008-09 FY 2009-10 Approved Budget Estimated Actual Department Requested CAO Recommended Incr/(Decr) From Budget $0 $5,131,690 $0 $0 $0 ($5,131,690) 45,628,443 45,355,875 43,832,169 45,682,802 45,364,250 8,375 36,290,920 43,805,822 39,119,789 40,560,854 40,560,854 (3,244,968) 7,126,683 6,883,585 11,026,012 11,105,876 11,105,876 4,222,291 143,913 46,553 0 0 0 (46,553) 176,000 224,000 0 0 0 (224,000) $89,365,959 $101,447,525 $93,977,970 $97,349,532 $97,030,980 ($4,416,545) $314,361 $300,000 $300,000 $250,000 $250,000 ($50,000) 62,312,747 20,881,938 19,630,484 19,079,998 19,079,998 (1,801,940) 39,392,518 34,103,058 33,610,246 36,670,035 36,670,035 2,566,977 78,456 294,800 233,400 279,175 279,175 (15,625) 19,853 771,125 771,125 771,125 771,125 0 24,879,582 23,338,873 22,171,929 22,171,929 (2,707,653) 13,569,715 16,471,153 14,671,916 14,671,916 1,102,201 $102,117,935 $94,800,218 $94,355,281 $93,894,178 $93,894,178 ($906,040) MENTAL HEALTH NET FUND ($12,751,976) $6,647,307 ($377,311) $3,455,354 $3,136,802 ($3,510,505) NET GENERAL FUND COST $771,125 $771,125 $771,125 $771,125 $771,125 $0 Authorized Positions: Full Time Part Time Total Positions Funded Positions: Full Time Part Time Total Positions 630 634 634 634 514 (120) 11 11 12 12 12 0 641 645 646 646 526 (120) 481 480 480 480 480 0 11 11 11 11 11 0 492 491 491 491 491 0 OPERATIONAL SUMMARY Mission: Fundamental Functions & Responsibilities: Working together toward hope, recovery and independence. Countywide managed care specialty mental health provider for Medi-Cal beneficiaries Safety net provider for uninsured, seriously mentally ill individuals County of Kern 2009-10 Recommended Budget 176

PROGRAM DISCUSSION The Mental Health Services Department is facing a number of challenges including eroding funding, and developing programs related to the Mental Health Services Act. At the highest priority is to maintain capacity to meet the demand for involuntary treatment and referral (5150) evaluations. Throughout Kern County, persons who are gravely disabled (unable to meet their basic personal needs for food, clothing, or shelter) due to a mental illness or pose a danger to themselves or others due to a mental illness are detained involuntarily by peace officers or designated persons approved by the Board of Supervisors. Until October 2007, Kern Medical Center was the only facility designated for 72-hour evaluation and treatment of adults and minors, age 16 and over, in the County. Individuals arriving at the facility pursuant to Welfare and Institutions Code Section 5150 have been evaluated at the Emergency Psychiatric Assessment Center (E PAC) to determine if they are appropriate for admission for 72-hour treatment and evaluation. In February 2009, the Mary K. Shell Psychiatric Evaluation Center Crisis Stabilization Unit (PEC -CSU) opened, which eliminated a significant liability for Kern Medical Center and provided the department greater volition in the placement and treatment of individuals in the community who are most at risk to endanger themselves or others. Since its opening, the demand for this evaluation center has exceeded expectation, providing services at a rate of 375 in its first month. The recommended budget requires the reduction in provider contracts. A significant portion of the operating funds for mental health programs are provided through State Mental Health Program Realignment funding. The amount of realignment funds for mental health programs for FY 2009-10 includes a $22.1 million allocation. This is a decrease of $2.7 million from the amount budgeted in FY 2008-09 due to lower sales tax and vehicle license fee revenue. There is a $4.2 million increase to other charges for psychiatric provider contracts due to a reduction in psychiatric inpatient beds at Kern Medical Center. The Mental Health Services Department focuses its efforts to ensure access to high quality mental health services throughout the County. Implementation of the Mental Health Services Act has had a significant positive effect on these efforts. In November 2004, the voters approved Proposition 63. This legislation, which came to be known as the Mental Health Services Act (MHSA) established a new dedicated funding source designed to assist county mental health departments in developing, expanding and delivering innovative and integrated services for children, adults, and older adults. MHSA funded programs are augmenting the role of Kern County Mental Health by providing consumer-driven services to previously underserved populations. POSITIONS DISCUSSION The recommended budget includes the deletion of 120 vacant positions: one Deputy Mental Health Director for Administrative Services position, at an annual savings of $178,000, ten Office Services Technician positions, at annual savings of $661,000, five Office Services Assistant positions, at an annual savings of $323,000, one full time Program Specialist position, at an annual savings of $88,000, five Fiscal Support Supervisor positions, at an annual salary savings of $405,000, three Senior Office Services Specialist positions, at an annual savings of $210,000, three Office Services Specialist positions, at an annual savings of $195,000, two Substance Abuse Specialist positions, at annual savings of $144,000, five Mental Health Nurse positions, at an annual savings of $546,250, six Clinical Psychologist positions, at an annual savings of $739,000, two Accountant positions, at an annual savings of $160,000, two Pre-licensed Vocational Nurse positions, at an annual savings of $124,000, two Pre-licensed Mental Health Technician positions, at an annual savings of $104,000, ten Staff Nurse positions, at annual savings of $1.0 million, one Department Analyst II position, at an annual savings of $79,000, three Administrative Coordinator positions, at an annual savings of $263,000, one Mental Health Managed Care Administrator position, for an annual savings of $107,000, fifteen Mental Health Therapist positions, at an annual savings of $854,000, 32 Mental Health Recovery Specialist positions, at an annual savings of $2.4 million, one Mental Health Planning Analyst position, at an annual salary savings of $83,000, five Mental Health Recovery Specialist Aide positions, at an annual savings of $400,000, one Fiscal Support Specialist position, at an annual savings of $75,000, one Fiscal Support Supervisor position, at an annual savings of $82,000, one Occupational Therapy Technician position, at an annual savings of $55,000, and two Psychiatrist positions, at an annual savings of $548,000. DIRECTOR S DISCUSSION County of Kern 2009-10 Recommended Budget 177

As the State s lawmakers grapple with economic uncertainties and indecision about dealing with California s budget calamity, each pronouncement coming from Sacramento strikes another blow to Kern s ability to manage its mental health obligations. Initially expecting relatively budget neutral effects of State spending for mental health and substance abuse treatment, Kern County Mental Health now expects that significant elements of the department s funding will disappear. Nearly 10 percent of mental health revenue and almost a third of substance abuse revenue is slated for elimination. Specific funding streams partially or wholly at risk includes EPSDT, Managed Care, Healthy Families, CalWORKs, SACPA, and MediCal. As a community-based outpatient treatment system of care whose purpose is the diversion of its individuals served from hospitalization to less costly treatment modes and, ultimately, recovery from their illnesses, these funding cuts are devastating to the Department and to the County. Faced with FY 2008-09 s dramatic cost increases in the crisis and inpatient arenas coupled with overall reduced revenue streams, the constant change brought about by that year s staff reductions and concomitant caseload increases, the constriction of outlying area clinics, and insufficient support staff, the department approaches FY 2009-10 with trepidation. The grim reality of likely revenue shortfalls from State program cuts demands that the department downsize more quickly than attrition allows. The historic and traditional front line preventative defense of outpatient services from inpatient hospitalization is shifting from a community based prevention and recovery model to a centralized, reactive, and costly emergency-oriented inpatient model. The challenges for Kern County Mental Health are formidable. Increasing demand for inpatient and emergency services has required redirection of resources away from the community-based treatment model created by the department over the past decade; recent Countywide increases in staff costs coupled with nearly $7 million proposed State and federal revenue reductions have necessitated departmental constriction, restructuring, and consolidation. Department management in concert with the stakeholder s community is addressing these challenges with downsizing plans, site consolidations and eliminations, program reductions, and staff redeployment. Adult Services: Outpatient resources have been reduced and in some cases eliminated, potentially heightening the risk that inpatient use may be exacerbated. System redesign efforts are being pursued to help mitigate such potentiality. Community-based teams have been consolidated to reduce supervision demands and eliminate office space needs. Access to services for uninsured adults will be more challenging. Less seriously mentally ill adults will be diverted from the treatment system into community resources. Children s Services: Some constriction has occurred on Children s teams but overall they are less dramatically impacted than are adult teams due to categorical funding that is available for children s services. Crisis Services: Additional funding has been channeled into inpatient services including the creation of a contracted psychiatric health facility, and a peer-based crisis residential unit is being planned as a collaborative effort between the department and community homeless shelters. Summary: Out of necessity, we will change the way we serve mentally ill individuals. This represents a difficult but necessary realignment of our system to accommodate the current climate of social services reductions. GOALS AND PERFORMANCE MEASURES Performance Measure # 1: Percent change in the number of days of psychiatric hospitalization of individuals in their first year of mental health treatment compared to the year prior to treatment. FY 2005-2006 FY 2006-2007 FY 2007-2008 FY 2008-09 FY 2008-09 Mid-Year Results FY 2009-2010 75% reduction 70% reduction 77% reduction 75% reduction 77% reduction 77% reduction This indicator measures the reduction of days of hospitalization comparing the year prior to AB 2034 (currently MHSA AT&T) treatment to the first year of treatment. This indicator demonstrates the effectiveness of treatment in reducing psychiatric crises and subsequent reductions in use of high cost services. County of Kern 2009-10 Recommended Budget 178

We are exceeding our proposed goal. The program providing these services are funded by the Mental Health Services Act (MHSA). Performance Measure # 2 Percent change in the number of days of incarceration of individuals in their first year of mental health treatment compared to the year prior to treatment. Mid-year Results 74% reduction 70% reduction 77% reduction 75% reduction 71% reduction 75% reduction This indicator measures the reduction of days of incarceration compared with the year prior to treatment. This indicator demonstrates the effectiveness of treatment in reducing psychiatric crises and subsequent reductions in use of high cost services. The department continues to compare favorably with historical State averages on this measure (75%). Teams providing these services are funded by the Mental Health Services Act (MHSA). Performance Measure # 3 Percent change in the number of days of homelessness of individuals in their first year of mental health treatment compared to the year prior to treatment. Mid-year Results 88% reduction 70% reduction 87% reduction 75% reduction 77% reduction 77% reduction This indicator measures the reduction of days of homelessness compared with the year prior to treatment. This indicator demonstrates the effectiveness of treatment in reducing psychiatric crises and subsequent increase of days when individuals have a stable place to live and are not homeless or at risk of homelessness. The department continues to compare favorably with historical State averages on this measure (73%-88%). We are meeting our proposed goal. Teams providing these services are funded by the Mental Health Services Act (MHSA). Performance Measure # 4 Percentage of children in foster care who receive mental health services. FY 2005-2006 FY 2006-2007 FY 2007-2008 Mid-year Results FY 2009-2010 32% 31% 31% 35% 35% 40% This indicator measures the percentage of children age (0-18) in foster care who receive mental health services from the department as compared to Statewide. Foster care children are at extremely high risk for criminal justice involvement, educational under-performance, increased substance use or other serious life crises if they do not receive mental health services when the need is identified. Large county average rate is 48%. State average rate is 50%. Kern County needs to continue its improvement in the rate at County of Kern 2009-10 Recommended Budget 179

which we see foster kids. Services for foster children are funded with State and federal funds (Medi-Cal). Performance Measure # 5 Percent difference between levels of mental health service to Hispanic Medi-Cal beneficiaries and Caucasion Medi-Cal beneficiaries, as measured by dollar amounts in Medi-Cal claims. FY 2005-2006 FY 2006-2007 FY 2007-2008 Mid Year Results FY 2009-2010 $2,625 in claims per person per $3,366 for Hispanic vs. Within 10% of Within 10% of Within 6% of Within 5% of year for Hispanic vs. $4,666 for White (77.8% difference) $4638 for White (37.8% difference) This indicator measures whether two ethnic groups receive comparable levels of service, based on MediCal paid claims. Once a person is in the system, do they get the same amount of services? As an indicator of cultural competence and equity, it is expected that different ethnic groups would receive relatively comparable services. This measure focuses on services to the Latino community, which is historically underserved in Kern County. The department has focused on percentages of different ethnic groups who get into the system in the past. This is a new focus, namely what happens to those who do get into treatment. This is a vital measure. This measure focuses only on MediCal beneficiaries. The services are therefore funded with State and federal funds. Performance Measure # 6: Percentage of adult mental health individuals served who are satisfied or very satisfied with Kern County s services. Mid Year Results 92% 85% 92% >88% 88% >88% This indicator measures the percent of Kern County adult Mental Health beneficiaries who are satisfied or very satisfied on a statewide customer satisfaction survey. This indicator demonstrates satisfaction with treatment services. The department continues to compare favorably with historical State averages on this measure (88%) All adult services are funded with an array of revenues: State and federal Medi-Cal, State categorical and discretionary, grants, private insurance, and patient fees. County of Kern 2009-10 Recommended Budget 180

Performance Measure # 7: Percentage of youth mental health individuals served who are satisfied or very satisfied with the County s services. Mid-year Results 86% 70% 80% 80% 82% >78% This indicator measures the percent of Kern County youth Mental Health beneficiaries who are satisfied or very satisfied on a statewide customer satisfaction survey. This indicator demonstrates satisfaction with treatment services. The department has historically been lower than the State average (74% to 86%), but has made improvements on this measure. This year s measure exceeds the current State average (78%) for the first time. All youth services are funded with an array of revenues: State and federal Medi-Cal, State EPSDT, categorical and discretionary, grants, private insurance, and patient fees. Performance Measure # 8: Percentage of families of youth receiving mental health services who are satisfied or very satisfied with the County s services. Actual Mid Year Results Results 87% 85% 85% 85% 89% >86% This indicator measures the percent of Kern County Mental Health families of youth who are receiving services and who are satisfied or very satisfied on a statewide customer satisfaction survey. This indicator demonstrates satisfaction with treatment services. Satisfaction scores of family members whose youth are receiving services continue to remain high, and compare favorably with State averages (73%-86%). All youth services are funded with an array of revenues: State and federal Medi-Cal, State EPSDT, categorical and discretionary, grants, private insurance, and patient fees. County of Kern 2009-10 Recommended Budget 181