Agenda

Return

D. 3

To:	Board of Supervisors
From:	David Twa, County Administrator
Date:	December 11, 2018

Contra

Costa

County

Subject:

UPDATE ON COUNTY PARTICIPATION IN THE STEPPING UP INITIATIVE

APPROVE	OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR	RECOMMENDATION OF BOARD COMMITTEE

Action of Board On: 12/11/2018

APPROVED AS RECOMMENDED

OTHER

Clerks Notes:

VOTE OF SUPERVISORS

AYE:

Candace Andersen, District II Supervisor
Diane Burgis, District III Supervisor
Karen Mitchoff, District IV Supervisor
Federal D. Glover, District V Supervisor

ABSENT:

John Gioia, District I Supervisor

Contact:	Timothy Ewell, (925)335-1036
cc:	Hon. David O. Livingston, Sheriff-Coroner Hon. Diana Becton, District Attorney Robin Lipetzky, Public Defender Todd Billeci, County Probation Officer Anna Roth, Health Services Director Kathy Gallagher, EHS Director

I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown.
ATTESTED: December 11, 2018
David Twa,

BY:	, Deputy

RECOMMENDATION(S):

ACCEPT an update on Contra Costa County's implementation of the Stepping Up Initiative to reduce the number people with mental illnesses in jails.

FISCAL IMPACT:

No fiscal impact.

BACKGROUND:

History of Stepping Up Initiative

BACKGROUND: (CONT'D)

In July 2015, the National Association of Counties (NACo) and partners at the Council of State Governments (CSG) Justice Center and American Psychiatric Association Foundation (APAF) launched Stepping Up, a national initiative to reduce the number of people with mental illnesses in jails and announced a call to action to demonstrate strong county and state leadership and a shared commitment to a multi-step planning process that can achieve concrete results for jails in counties of all sizes. As part of this call to action, county elected officials were asked to pass resolutions and work with other local leaders (e.g., the sheriff, judges, district attorney, treatment providers, and state and local policymakers), people with mental illnesses and their advocates, and other stakeholders to reduce the number of people with mental

illnesses in jails.

Stepping Up participants receive an online resources toolkit to assist with efforts, including a series of webinars, exercises and related distance-learning opportunities; peer-to-peer exchanges; and key resources from initiative partners. The online toolkit includes self-assessment checklists and information to assist counties in identifying how much progress they have already made and a planning template to help county teams develop data-driven strategies that are tailored to local needs.

In support of Stepping Up, NACo, the CSG Justice Center, and the APAF hosted the National Summit on Reducing the Prevalence of Individuals with Mental Illnesses in Jails in Spring 2016 in Washington, D.C.

County Involvement with Stepping Up Initiative

Representation at State Convening

On December 8, 2015 the Board of Supervisors affirmed its commitment of Contra Costa County to reduce the number of people with mental illnesses in our County jails consistent with the goals of the Stepping Up Initiative by adopting Resolution No. 2015/456 (Attachment A), which was sponsored by Supervisor Andersen and Sheriff Livingston.

In January 2017, a Contra Costa team was selected to attend the Californa Stepping up Intiative Summit held in Sacramento. The County was represented by:

Supervisor Candace Andersen
Todd Billeci, County Probation Officer
Robin Lipetzky, Public Defender
Tom Kensok, District Attorney's Office
Captain Chris Simmons, Sheriff's Office (now Assistant Sheriff)
David Seidner, Behavioral Health Division of Health Services Department

Identification of County Programs

One aspect of analyzing the County's interaction with individuals having behavioral health needs is taking inventory of current programs and those planned for expansion. Below is a partial list of programs that the County has identified as being related to the goals of the Stepping Up Initiative:

Current policies, strategies, and programs (partial list)

1. The County Behavioral Healthcare Partnership with Contra Costa Regional Medical Center and Health Centers (BHP) was formed in 2009 as a multi-stakeholder team of senior hospital administrators, doctors and clinicians from the County’s Psychiatric Emergency Services (PES), the Sheriff’s Office (which provides security services for the health centers), mental health consumers, and family members. Chaired by a consumer or consumer ally and staffed by a Patient and Family Advisory Council Coordinator, the goal of the BHP is to ensure that the hospital and psychiatric emergency settings provide effective and holistic services, include family and consumer voice, and reduce seclusion, blame, and shame. Meeting monthly, the BHP has developed a strategic plan and operational protocol to ensure that the Health Centers provide welcoming and accessible care for all mental health consumers and their families.

2. Inter-Agency Electronic Health Record: In 2012, the Health Services Department implemented an electronic health record (EHR) system, ccLink, based on software by Epic; this EHR is connected to both Detention Mental Health staff (DMH, a unit of County Health Services) and the County’s Regional Medical Center, including PES. The system has been refined to include prompts related to housing status, substance use, and other psychosocial factors. With the support of this integrated data system, County Hospital administrators and DMH have developed a shared Treatment Implementation Plan (TIP) and protocol to identify and develop coordinated response and planning for people who frequently cycle among the detention facilities, psychiatric emergency, and hospitals.

3. Homeless Encampment Action Protocol: For the past several years, an interagency partnership (including the Health, Housing and Homeless Services Division of the Health Services Department, the Sheriff’s Office, multiple police departments, and Contra Costa Public Works) has worked to develop a Homeless Encampment Action Protocol. Memorialized in a Memorandum of Understanding signed in 2013, this protocol details a coordinated and supportive response to homeless encampments. According to this protocol, upon any report of a homeless encampment, an officer notifies the Homeless Services Director, who dispatches the Homeless outreach team (CORE) to build connections, protect and store individuals’ personal property, arrange immediate alternative shelter, and provide coordinated connection to ongoing services.

4. Crisis Intervention Training (CIT): With the County’s increasing attention to helping agencies differentiate between criminal behaviors and those that result from mental illness or substance use, under new leadership the County’s longstanding CIT has been enhanced over the past two years. A partnership of the Sheriff’s Office, DMH, and Psychiatric Emergency Services (PES), the CIT is a four-day, 32-hour specialized mental health training, specifically intended to reduce the number of people with mental illness who are either arrested or committed on an involuntary hold, by broadening multi-agency perspectives, deepening technical understanding, and building operational partnerships. Offered twice a year to up to 40 people per session, the CIT is open not only to sworn Sheriff’s Office personnel, but to all other law enforcement agencies in the County as a resource.

5. The George & Cynthia Miller Wellness Center, opened in 2014, is designed to improve access to integrated behavioral and physical health care, especially for people with complex challenges. Located on the campus of the County Regional Medical Center and technologically connected to its data systems, the Wellness Center offers a preventive and more ongoing alternative to County Psychiatric Emergency Services (PES). In addition to offering primary care, pediatrics, group medical visits, and same-day appointments, its behavioral health services include psychiatry, short-term individual and family therapy, outpatient care for substance abuse, support groups, and crisis management and referral into long-term treatment for children and adults. Located just a few miles from the County’s main jail, the Wellness Center is well suited to provide post-release support, an effective intervention that can prevent rapid reincarceration.

6. Laura’s Law Implementation: In February 2015, Contra Costa County adopted Laura’s Law (also known as Assisted Outpatient Treatment, or AOT), the California law that allows the Court to order a small subset of people with serious mental illness to accept treatment and to order the mental health system to provide treatment. Using the Assertive Community Treatment (ACT) model of care, and led by a licensed clinician, the County’s multidisciplinary Care Team manages Laura’s Law referrals. Following a standardized screening, intervention, and investigation protocol, and working with the individual, family, and appropriate professionals, the Care Team undertakes a coordinated response, develops a treatment plan, facilitates voluntary treatment whenever possible, and ensures connection with the proper level and type of care.

7. Mental Health Evaluation Teams (MHET): Established in mid-2015 as a partnership of County Behavioral Health Services and several local police departments, MHET teams are designed to provide targeted support to people whose mental health challenges result in repeated police calls for violent or threatening behavior, or who have been involuntarily hospitalized due to psychiatric crisis. Operating as a pilot in cities located in each region of the County, the MHET teams include both behavioral clinicians and dedicated police officers. Following an incident with either law enforcement or PES, staff can refer cases to their region’s MHET for follow up. The MHET officer and partnering clinician then work with identified individuals, and their families, to identify underlying causes and facilitate connections to appropriate services and supports.

8. At the County’s Adult Detention Facilities, the current intake process includes an initial screening for potential mental health disorders for anyone booked into the jail. Whether an individual self-discloses a mental health issue or the possibility is raised based on observed behavior or a report from a family member or others, any such report triggers an automatic referral to Detention Mental Health. Once a report is made, the person is assessed by DMH clinicians, who may then refer the person to the facility’s psychiatrists, whose diagnosis and treatment protocol will in turn initiate additional decisions, whether they be related to in-custody housing assignment or any other medical treatment decisions. DMH staff chart this medical information into the HIPAA-compliant EHR, which is then accessible to appropriate staff in DMH, PES, and the County hospitals and clinics. In addition, the DMH Supervisor is assigned to shifts both at the detention facilities and at PES, which further facilitates identification of people who are cycling back and forth between the two systems.

9. The County Mental Health Commission has a longstanding mission: To ensure that the County’s Mental Health System delivers services that are effective, efficient, culturally relevant and responsive to the needs and desires of the clients it serves; and to advocate to the Board of Supervisors, the Behavioral Health Division, and the community on behalf of all Contra Costa County residents in need of mental health services. The Commission’s Justice Committee is charged with responsibility for advising County stakeholders regarding issues of criminal justice and mental illness.

10. The Juvenile Justice Commission and the Juvenile Justice Coordinating Council work with the Probation Department, Superior Court and other juvenile justice stakeholders to ensure appropriate services for youth, including those with mental health challenges who interact with the Probation Department.

Current plans to enhance existing policies or services for this population

1. Contra Costa Health Services, in collaboration with the Sheriff’s Office Custody Bureau, has embarked on a process to redesign the health services provided in the jails. Participants include Detention Health, including both medical and mental health components, Behavioral Health, Contra Costa Regional Medical Center and Health Centers, Reentry Health Conductors, additional community service providers as well as inmate-patients. Targeted improvement efforts include:

* Timely access to care
* Care for those with acute/emergent behavioral health issues
* Care for those with urgent medical and/or behavioral health issues
* Care for those with routine medical and/or behavioral health issues
* Medication assessment, prescription, and management
* Specialty Care
* Pre-release and reentry medical care and continuity

2. A new, state-funded, public-private initiative managed by the Behavioral Health Division of Contra Costa County Health Services, CoCo LEAD Plus is intended to break the cycle of criminalization and incarceration for people with mental illness or substance use disorders. CoCo LEAD Plus will implement new arrest-diversion protocols and intensive services for people with behavioral health issues who have been repeatedly arrested by the Antioch Police Department for a broad array of low-level, non-violent charges. CoCo LEAD Plus builds on Seattle’s Law Enforcement Assisted Diversion (LEAD) model, which provides diversion opportunities for people arrested on low-level drug and prostitution charges. CoCo LEAD Plus includes a wider array of misdemeanors and felony “wobblers” in its list of potentially divertible charges. The project combines coordinated diversion protocols with peer-driven outreach and engagement, community-based cognitive behavioral services, community-based restorative justice programing, dedicated transitional housing, subsidized employment, and access to permanent housing for qualified candidates, via Section 8. CoCo LEAD Plus is primarily funded by a three-year, $5,984,000 Prop. 47 grant from the California Board of State and Community Corrections (BSCC). Services began in summer of 2018.

3. Having substantially enhanced the scale and sophistication of the Crisis Intervention Training (CIT), the Sheriff’s Office is working to foster training and adoption of the CIT approaches and practices in all law enforcement agencies countywide. In addition to ensuring that 100% of the Sheriff’s staff are trained to use CIT in all settings (detention, PES, and on patrol), the Sheriff’s Office intends to increase the frequency of the four-day training series available to other law enforcement agencies. CIT was offered to 40 people twice a year, but to better meet the demand, these trainings were increased to three times a year in 2016 and no less than quarterly thereafter.

4. To increase speed of response and maximize utilization for the County’s Emergency Shelters (including specialty shelters), the Health, Housing and Homeless (H3) division of County Health Services has developed an electronic Shelter-Bed Reservation System and coordinated entry, which tracks availability at all County shelters and other services available to vulnerable populations.

5. Coordinated Assessment and Resource (CARE) Center. As one of the main entry points into the coordinated entry system, CARE Centers play a critical role in helping to identify and engage individuals into services. The County has established three CARE centers in collaboration with community-based organizations GRIP and Anka Behavioral Health, who are providing support services to Contra Costa County families who are homeless, including case management, day shelter services, transportation needs, mental health assessment, and crisis intervention.

6. Detention Health is currently examining the process to ensure that returning residents can maintain continuity of care, including medication prescription and management. Currently, some individuals may receive a short course of medication when they are released. Other possibilities that Detention Health is exploring for ensuring medications and continuity of care include Detention Health providers sending prescriptions to a community pharmacy for pick up when the newly released individual returns back to their community, a linkage/referral to a Public Health Nurse case manager through a new program called CommunityConnect, and an appointment in the Health Services Transition Clinic where providers are trained to provide culturally competent and respectful care.

Sequential Intercept Mapping (SIM) Process

Following participation in national and state convenings along with identifying county programs critical to this population over the past three years, the County engaged Policy Research Associates (PRA) to assist with a project to map the path of individuals in our community with behavioral health needs through the local criminal justice system. Sequential Intercept Mapping (SIM) is a model developed to assist in identifying resources in certain points within a service delivery system. The model also highlights gaps in a system, which helps to focus stakeholders attention on issues.

On September 19-20, 2018, PRA facilitated a SIM development workshop, which was attended by 55 representatives, including County employees, stakeholders involved in the county behavioral health delivery system, the local criminal justice system and members of the public. A more comprehensive report, including detailed information about each intercept point, is being finalized by PRA and will be forwarded to the Board of Supervisors at a future date.

Conclusion

Today's report is designed to reintroduce the Stepping Up Inititative to the Board and interested members of the public and to outline efforts undertaken by the County over the last three years to advance the initiative. As described above, the comprehensive SIM report is being finalized by PRA. Staff plans to bring that report to the Board once complete along with recommendations for action based on the contents of the report. Ms. Regina Huerter of PRA, who facilitated the County's SIM development process, will be present to outline that effort. Ms. Huerter's PowerPoint presentation is attached as Attachment B for reference.

CONSEQUENCE OF NEGATIVE ACTION:

This report is informational only.