No fiscal impact.

History of Stepping Up Initiative  
  
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 the 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 California Stepping up Initiative Summit held in Sacramento. Representatives from the Board of Supervisors, Probation, Public Defender, District Attorney, Sheriff’s Office and Behavioral Health participated in the event.  
  
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.  
  
2019 Pursuit of Fund Opportunities  
  
Since the last update to the Board in December 2018, the County has pursued or is in the process of pursuing several grants that are consistent with the principles of Stepping Up, including promoting early intervention and diversion from incarceration. Below is a listing of specific funding opportunities of note:  
  
AB 1810/SB 215 Mental Health Diversion: AB 1810 authorized an expansion of pre-trial diversion programs for individuals with certain mental disorders alleged to have committed a misdemeanor or felony offense. Subsequently, SB 215 was signed into law to address a number of concerns related to the new jail diversion program for people experiencing mental illness created by AB 1810 (Chapter 34, Statutes of 2018). Specifically, the bill excludes certain violent offenses from the diversion program (including murder and sex offenses) and preserves victim restitution.  
  
The Legislature included $100 million in new funding statewide for counties to implement AB 1810 locally. This funding is split into two phases: $91.5 million in phase 1 funding targeting 15 “high utilizer” counties, which is defined as the counties that refer the most inmates declared Incompetent to Stand Trail (IST) to the California Department of State Hospitals for services and $8.5 million in phase 2 funding for all remaining counties. Contra Costa is a Phase 1 county.  
  
Phase 1 counties are eligible for a direct allocation of funding from the state, which requires the county to enter into a contract with the Department of State Hospitals. The contract would require reporting of certain data to be made on a regular basis and funding is targeting the felony IST population. The funding requires a 20% match from large counties, including Contra Costa.  
  
The County Administrator’s Office has been facilitating discussions with the Superior Court, District Attorney and Public Defender Offices and the Health Services Department-Behavioral Health division to develop a program to serve this population using the new state funding. Staff anticipates a final plan will be forwarded to the Board for consideration in June 2019. The state has determined the Contra Costa share of funding is approximately $3,114,100 over 3 years. This will result in the County only being able to serve a small amount of individuals; however, it creates an opportunity to establish an important mental health diversion program that is consistent with the principles of Stepping Up and the ability to tether future funding sources together to scale the program. Total Grant Request: $3,114,100. 3 Years. 80% State, 20% County Match.  
  
Proposition 47: On March 12, 2019, the Board authorized submission of a Proposition 47 grant to the California Board of State and Community Corrections. The County has designed an innovative, trauma-informed, culturally competent, diversion program for people arrested in Contra Costa County who have schizophrenia, schizoaffective disorder, or bipolar disorder alone or with a co-occurring substance use issue whose behavioral health condition played a significant role in the commission of a crime and are at risk for being declared incompetent to stand trial. "CoCo FACT" proposes to divert 75 clients for the 3-year grant period. The proposed program was developed with assistance of a Local Advisory Committee (LAC) of residents, stakeholders and community based organizations that met regularly to develop the program.   
  
CoCo FACT includes an evidence-based intervention that is centered on Forensic Assertive Community Treatment (FACT) paired with housing, vocational supports, trauma reduction, and restorative justice components to help address individual and structural barriers that contribute to recidivism among those with involvement in the criminal justice system to decrease recidivism; promote recovery; and ensure community safety, stability, and healing. This project will be transformative for the County and its citizens, resulting in reduced recidivism and healing for both victims and offenders, replacing ineffective and costly practices that fail to address the actual factors contributing to the perpetration of the crime.   
  
This grant would complement the previously described allocation of AB 1810 dollars, which, similarly, targets individuals within the local justice system with mental health needs that would benefit from diversion. Braiding both funding sources ensures that the County's focus is scaling up services to this population in a coordinated manner with the same goals and objectives. Total Grant Request: Up to $6,000,000. 3.75 Years. 100% State  
  
JAG Grant – Holistic Intervention Partnership (HIP): The HIP program is sponsored by the Public Defender's Office and will establish an innovative holistic defense system that focuses on early intervention at the time of police contact in misdemeanor cases. A public-private partnership between the Public Defender’s Office, multiple County agencies and community-based partners, HIP will provide multi-disciplinary case management and navigation services to indigent individuals to ensure timely and coordinated access to a client-centered array of housing, behavioral health, transportation and legal services at the critical time of initial law enforcement contact. Over the proposed three year program, HIP will reduce system burden and improve criminal justice outcomes in misdemeanor cases in all three regions of the County. Total Grant Request: $3,136,875. 3 Years. 100% Federal (via State)  
  
BSCC Youth Reinvestment Grant: The Youth Reinvestment Grant is sponsored by the District Attorney’s Office. Over a four year term, this program proposes to divert an estimated 150 serious pre-charge juvenile cases from the juvenile justice system into a community-based restorative justice diversion program. By the end of the program, youth participating in the program will understand the impact of the harm and will have taken accountability for their actions. After successful completion of the program, the District Attorney’s Office will close the case without charges filed. Total Grant Request: $1,100,000. 4 Years. 90% State, 10% In-Kind Match.  
  
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 comprehensive report, including detailed information about each intercept point, was assembled by PRA for review by the County in January 2019. The Office of Reentry and Justice requested comments from stakeholders and included comments, edits and factual corrections to the document. The draft final report was sent to public safety and health and human services Department Heads that compose the Stepping Up Steering Committee on March 8^th and the Committee met to review and discuss the report on March 14^th.  
  
The Steering Committee reviewed the draft final report and acknowledged its strengths and weaknesses. The report includes information provided as part of the September 2018 convenings with the observations of the specific stakeholders in attendance. This was a critical part of developing the SIM map - an illustration of the County’s criminal justice system and the different intercepts within the system. The report does not include a comprehensive review of the County’s criminal justice system, but it is important to note that such a review was not within the scope of this project. The Report is included in this report as Attachment B and the SIM Map is included as Attachment C.  
  
SIM Report Recommendations:  
  
The SIM Report includes several recommendations for review by the County. The Stepping Up Steering Committee reviewed the recommendations and made several important observations: 1) the recommendations ranged from very general to very nuanced; 2) several of the recommendations are already being implemented by the County in varying degrees; and 3) the recommendations can be rolled into three core focus areas: Diversion, Transition Planning, and Data Collection/Analysis.  
  
Below is a listing of each recommendation and information regarding current County initiatives related to each:  
  
1. Establish an “Uber” Committee and process that allows for shared leadership, responsibility, coordination and oversight of justice system and behavioral health innovation and reform.  
  
The County has developed a comprehensive system to review health and justice policies and initiatives throughout the County. This includes convening the Community Corrections Partnership, Racial Justice Oversight Body and Mental Health Commission. It is important to note that the Mental Health Commission has a Justice Systems sub-committee that concentrates specifically on issues related to the justice system and the Community Corrections Partnership has created the Community Advisory Board composed of community stakeholders that provide critical advice to the CCP on issues within its purview.  
  
The Committees identified above are advisory to the Board of Supervisors and report periodically to the full Board, the Public Protection and/or the Family and Human Services committees. This allows for an important flow of information to Board to advise on policy and service delivery issues.  
  
2. Establish standardized metrics and data sharing across county agencies to improve data-informed decision-making.  
  
Office of Reentry and Justice (ORJ): The ORJ has worked to establish standardized metrics and data sharing in multiple ways: the development of an AB 109 Annual Report and quarterly reporting requirements; the development and administration of a Salesforce-based Reentry Services database (“SAFE”); the commission of reports on the status of our data systems and recommendations for a cloud-hosted relational data warehouse (“Reentry Data Management in Contra Costa: Analysis and Recommendations,” from Tetra Tech and “Data Capacity Assessment and Infrastructure Recommendations” from Resource Development Associates dated April 2014); staff support of a Data and Evaluation Committee (DEC), a Quality Assurance Committee (QAC), and the Community Advisory Board’s Data subcommittee; the hiring of a Research and Evaluation Manager (REM) in August 2018; and the development of an Intern position to support the REM.  
  
Public Defender’s Office: The Public Defender Mental Health Unit is working to establish an improved client tracking system in order to identify and highlight gaps in the system of care. The Office has found that many Public Defender clients experiencing Mental Health challenges are referred to the Mental Health unit repeatedly through different avenues.   
  
Individuals may be referred to the Mental Health Unit, over a period of time, through each of the following avenues: 1) conservatorship proceedings, Assisted Outpatient Treatment (AOT), and competency proceedings in a criminal case, such as Incompentant to Stand Trial (IST).  
  
The ability to track and monitor the various mental health services that Public Defender clients are receiving is essential to advocating for improved and coordinated service provision for these individuals.   
  
Health Services Department: The Health Services Department and Sheriff’s Office have established a real time data sharing interface for basic demographics as two-thirds of the arrestees have been previously seen by Health Services. This allows Health Services to automatically locate an inmate’s patient chart in its Electronic Health Record rather than creating a new patient record.  
  
The Health Services and Employment and Human Services (EHSD) departments have signed a Data Sharing MOU to exchange information about shared clients including basic demographic, benefits, etc. data so that Health Services Case Managers can assist their clients in signing up for programs that they may be eligible for or ensure they continue to be enrolled in existing programs. For example, EHSD provides dates for clients that are coming up for Medi-Cal redetermination in next 60 days. This allows Health Services to follow up and assist these shared clients to complete the redetermination process and allowing for the continuation of Medi-Cal benefits, if still eligible.  
  
3. Increase countywide deflection and diversion strategies. Explore the need for a 24-hour crisis stabilization and triage center and a mental health – first responder co-responder strategy.  
  
Public Defender’s Office: The Public Defender's Office continues to expand mental health diversion services to include more robust community-based treatment options for mentally ill individuals who may qualify for diversion. This includes planned staffing related AB 1810 programming and, if successful, the Holistic Intervention Partnership discussed preveiously.   
  
The Office continues to be a partner in streamlining the Mental Health Diversion process in order to ensure increased collaboration and additional participation from both county agency and community-based service providers, including expansion Law Enforcement Assisted Diversion (LEAD) efforts. This builds on the collaborative work of CoCo LEAD Plus, which allows for law enforcement agencies to divert individuals directly from the time of law enforcement contact or arrest by connecting them with behavioral health treatment and other essential social services.  
  
Health Services Department: The Health Services Department-Behavioral Health division launched an Adult Mobile Crisis Response Team (MCRT) in July 2018 which is staffed Monday - Friday 7:00am -11:30pm and Saturday and Sunday 8:30am -5:00pm for in field responses to calls for mental health crisis. The goal is to de-escalate situations, prevent the need to place individuals on a “5150” hold and provide up to 30 days of services for stabilization and/or linkage to services. The MCRT is also trained in Psychological First Aid and provides support to communities impacted by traumatic events.  
  
Similarly, the Behavioral Health division has funded Seneca, a community based organization, to provide a Children's Mobile Response Team (MRT) in January 2018 which is staffed Monday - Friday 7:00 am - 11:00 pm and Saturday and Sunday 11:00 am - 9:00 pm. This allows MRT to be more responsive at peak crisis times, including before and during school hours and late into the evening on weeknights. The MRT program is deploying teams in strategically located sites throughout the county to minimize the response time for in-person support. During off hours, the MRT has a telephone line that is accessible to the community to provide support and consultation around the clock.  
  
The Contra Costa Health Services Behavioral Health Mental Health Evaluation Team (MHET) is a co-responding team paired with local police departments. Each region of the county has a host police department with an assigned MHET police officer while the surrounding police departments each have a MHET Liaison officer. Referrals come from the MHET officers for individuals who have had multiple police contacts due to mental health reasons and multiple Psychiatric Emergency Services (PES) visits. Clinicians initially respond with an officer to assess the situation. Once it is determined to be safe, the clinician will provide services for up to 60 days to stabilize the situation and link individuals to services to prevent further police contacts and/or PES visits.   
  
Contra Costa Behavioral Health also partners on CoCoLEAD Plus - a Law Enforcement Assisted Diversion program in coordination with the Antioch Police Department (APD). Individuals contacted by APD for misdemeanor eligible offenses are offered diversion. A community based organization, HealthRIGHT360, is contracted to offer extensive community services while Behavioral Health addresses mental health and/or substance abuse issues. In addition, Behavioral Health sponsored the County’s application for funding from the Proposition 47 grant to establish a Forensic Assertive Community Treatment (FACT) program. As described previously, FACT is designed for individuals who are granted diversion by the court and require a more intense level of services. The FACT program will offer housing as part of the ACT model treatment. In addition, a less intense level of treatment in the community for individuals who will benefit from this level in included as part of the program as well.  
  
4. Further incorporate the use of peers and peer support and recovery across intercepts.  
  
The County provides and will continue to provide for positive peer interactions as a key to treatment and maintaining a sober living environment. A sober living environment means safe, clean, residential environments that promote individual recovery through positive peer group interactions among house residents and staff. Sober living housing is alcohol and drug-free and allows residents to continue to develop their individual recovery plans and to become self-supporting. The residential environment must co-exist in a respectful, lawful, and non-threatening manner with residential communities in the County.  
  
The County funds a variety of positive peer support opportunities through AB 109, Behavioral Health and Alcohol and Other Drug services funding. In addition, individuals that have been previously incarcerated participate in programs within the adult detention facilities, including the Jail to Community transition planning program funded by AB 109.  
  
5. Identify “familiar face” high utilizer populations to help manage costs, reduce unnecessary utilization of services while increasing individual stabilization. Develop “high-utilizer” strategies.  
  
Public Defender’s Office: The Public Defender's Office is working to improve communication with Detention Mental Health division of the Health Services Department to assist with early discharge planning and to improve the continuum of care for mentally ill individuals who are released from custody. This includes evaluating whether individuals who are released have a follow up appointment in place at an outpatient mental health treatment facility prior to release and are provided with prescribed mental health medication upon release.   
  
The Public Defender is also working to increase staff presence at Mental Health Evaluation Team (MHET) meetings to increase collaboration across the county through participation in case conferencing, expanded opportunities for diversion and increased identification of high utilizers.   
  
Health Services Department: The Health Services Department’s CommunityConnect program developed and implemented a predictive risk model to identify high utilizing Medi-Cal residents within the County. The model uses historical data from the department’s Data Warehouse to predict future inappropriate hospital, medical emergency or psychiatric emergency department utilization. Historical data includes demographic, social factors (homelessness, detention history, etc.), behavioral health and medical diagnoses and utilization (Emergency Room/Psychiatric Emergency Services visits, Ambulance, etc.). The CommunityConnect program uses this data to enroll the highest utilizers in social case management services, including assignment of a case manager that is matched based on historical need and providing supportive wrap-around services that will increase stabilization, reduce utilization of unnecessary services and reduce costs.  
  
Alcohol and Other Drugs Services (AODS): AODS receives funding from AB109 to conduct face-to-face screenings in jail and provide placement in treatment upon release. Combined with case management services, AODS targets AB 109 referred clients with a long Substance Use Disorder (SUD) history, acute intoxication and/or withdrawal potential, recidivism, and Opioid Use Disorder (OUD). Case management is provided with the goal of extending periods of sobriety, creating readiness for treatment, and developing positive social and family networks to assist with recovery. AODS is cognizant that timely access to SUD treatment is paramount in reducing unnecessary utilization of other costly health and social services, preventing incarceration and increasing stabilization of individuals.  
  
6. Implement a comprehensive substance use disorder strategy: Population identification and treatment resources in the jail and community.  
  
Alcohol and Other Drug Services (AODS): On July 1, 2017, Contra Costa became the 5^th county in the State that opted into the Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver. The DMC-ODS is a pilot project authorized originally under California’s Section 1115 Bridge to Reform Demonstration Waiver and continued in the Medi-Cal 2020 Waiver. This pilot program allows counties to expand the type and capacity of services for Medi-Cal eligible Contra Costa residents with a Substance Use Disorder (SUD). Articulated in the County Implementation Plan, county residents with SUD can access a full continuum of treatment options available, which includes: Withdrawal Management, Outpatient, Intensive Outpatient, Residential, Case Management, Recovery Support Services, Medication Assisted Treatment and Recovery Residences. As a result of the implementation of the Waiver, the County provides a comprehensive array of services, which is modeled after the American Society of Addiction Medicine (ASAM) criteria.  
  
In addition to counseling services, some patients may need to take medication to support their recovery process through Medication Assisted Treatment (MAT). Methadone as well as Buprenorphine helps individuals with Opioid Use Disorders (OUD), which includes Heroin and prescription drug abuse. Additionally, MAT makes available other medications to help reduce cravings for alcohol such as Acamprosate and Disulfiram.  
  
Residents seeking access to treatment contact the Behavioral Health Access Line for a screening to determine placement in the most appropriate level of care and appointments to the treatment of their choice. In collaboration with the Sheriff’s Office, a speed dial number was established in 2017, to allow inmates in adult detention facilities to call the Access Line. To support the volume of calls from jail, a Substance Abuse Counselor has been designated exclusively to serve this population in preparation for their release date. Likewise, a Substance Abuse Counselor is available to the Superior Court to conduct face-to-face screenings and provide results/placement in real time to the courts. To ensure coordination, the number of calls, screenings and referrals is reported to the Superior Court and the Sheriff’s Office on quarterly basis.  
  
While comprehensive SUD treatment services are not currently available in the jail and DMC-ODS funding is not an option for that service, Contra Costa is actively involved in a Medication Assisted Treatment (MAT) Collaborative through the California Department of Health Care Services (DHCS) as an addition to the collective response of Health Services Department to the Opioid Epidemic in the county.   
  
Through the MAT Collaborative, the Detention Health division of the Health Services Department along with Behavioral Health-Alcohol and Other Drugs Services (AODS) have partnered to provide a more organized way to deliver certain medication to inmates while in custody and upon release. The MAT Collaborative has brought much needed training resources to staff in the jail to guide efforts intended to eliminate service gaps. Likewise, through the MAT Collaborative, the County has been able to seek funding for two additional Substance Abuse Counselor positions who will soon join the medical team in the detention facilities. The responsibilities of the each counselor will include supporting treatment in jail and ensuring seamless transition planning from jail to the community.  
  
7. Examine the need for pretrial interventions to reduce failure to appear of individuals who are booked and released.  
  
Public Defender’s Office. The Public Defender's Office is working to expand the existing Pretrial Services Program (PTS) to include screening for additional types of charges. The PTS program currently screens those who are eligible, based on certain qualifying charges, for release on supervised release pretrial. Screening criteria should be expanded so that additional individuals may be screened for potential supervised release pretrial.   
  
In addition, expansion of the Misdemeanor Early Representation Program (EarlyRep) to all law enforcement agencies countywide would failures to appear in misdemeanor cases and expand early connection with community-based services.  
  
Currently, the EarlyRep pilot program is a partnership between the Public Defender’s Office and some, but not all, of the Law Enforcement Agencies (LEA) within the county. The Public Defender EarlyRep team is currently working with individuals cited by Antioch, Richmond and Martinez police departments as well as the California Highway Patrol. The Office is working to further expand EarlyRep to provide early legal services to individuals who are cited by any of the LEAs countywide.   
  
Finally, the Office is working to expand the use of the UpTrust text message court date reminder system, currently used as a tool in the EarlyRep and PTS programs only, to all individuals with pending court dates countywide in order to reduce failure to appear at scheduled court dates.   
  
8. Improve Pre and Post-arrest diversion opportunities for incompetent to stand trial populations.  
  
As described in further detail above, the county has pursued a number of funding opportunities to build out diversion programs for juvenile and adult populations, including AB 1810 and Proposition 47 funds specifically to enhance mental health diversion within the County.  
  
9. Review and address problem-solving court criteria to align with national best practice standards.  
  
The County works cooperatively with the Superior Court on problem-solving court issues, including the Veteran’s Treatment Court. In California, the Superior Court is a function of the state and although the County can provide comments and input, ultimately, the Court decides how to organize and implement judicial calendars.  
  
10. Increase equity and access to services regardless of AB 109 funding.  
  
In 2015, by direction of the Public Protection Committee, a workgroup of County staff and representatives of AB 109-funded community-based organizations met on 6 occasions to develop recommendations for reentry service expansion beyond the AB 109 population. A prioritization policy was developed to ensure that the AB 109 population would have access to services. The reentry service providers’ “available capacity” could be provided to returning residents whose qualifying event was being charged with or convicted of a felony offense in the following order:  
  
Priority Status Groups  
1. AB 109 Sentence  
2. Formal Felony Probation  
3. Released from a Correctional Facility in the Past Three Years  
4. Pretrial population  
5. Informal Felony Probation  
6. Specialty Courts  
7. Parole  
  
Access to services for all returning residents is provided through the Reentry Success Center, based in Richmond, and the Central-East Reentry Network, provided by HealthRight 360. Due to the limitations of resources, the housing services have the least amount of “available capacity” to non- AB 109 populations; however, they are not formally excluded from service provision. Reentry services for those whose charge or conviction was a misdemeanor offense are provided through Clean Slate functions of the Public Defender’s Office and may be expanding through grant funding.  
  
11. Improve jail-based services and transition planning to reduce recidivism and improve health and other outcomes for detained or jailed individuals.  
  
Sheriff’s Office: The Sheriff’s Office has a Jail-to-Community program funded by AB109 with Men & Women of Purpose and Reach Fellowship serving male and female inmates within adult detention facilities. Both organizations provide weekly group meetings, mentoring, and additional service referrals for people throughout the three detention facilities.  
  
In addition, the Sheriff’s Office has a significant partnership with the Contra Costa County Office of Education to provide services to inmates, including:

• A fully accredited adult school serves approximately 2,200 students each year throughout the three detention facilities.
• The Pre-Release Planning Pilot has served approximately 175 participants since launching in 2017. Approximately 80% of those enrolled in the program complete the process and exit custody with a transition plan in hand.
• Coordination among CBO's coming into the detention facilities to see participants has greatly improved, thus increasing the likelihood for continued engagement post-release and reduced recidivism.
• Health, Housing, & Homeless (H3) meets with potential clients pre-release in preparation for post-release shelter placement.
• Partnering with the Reentry Success Center as the first point of contact for recently released individuals has increased post-release service connection.
• A second Transition Specialist was hired in 2018 to serve a greater number of people in preparation of successful reentry into the community.
• Enhancements to SAFE have vastly improved jail-based services coordination between providers.

• Train staff of intervention and sanction grids, which should be aligned with long term offender change.
• Train staff how to structure appointments to target criminogenic need areas.
• Provide offenders with programming that targets their antisocial cognition and skills.

The Board will not have accepted the update on the Stepping Up Initiative, received the SIM report or affirmed the three focus areas outlined in the Recommendation section.