San Diego Union-Tribune (Sunday)
COUNTY FOCUSES MORE ATTENTION ON MENTAL HEALTH
Big budget and staffing increases aim to reverse decades of inattention
For the first time, San Diego County is poised to dispatch mobile teams of mental health professionals dedicated to responding to people in crisis instead of sending police officers and sheriff ’s deputies.
It is a long-awaited program that has yet to play out in large numbers, but public health officials nonetheless hope it will help turn a corner in the years-old struggle to improve the government’s handling of mentally ill people.
Earlier this year, the Board of Supervisors sharply increased the number of health care providers in San Diego County’s jails, which have become the repositories of last resort for many people suffering from mental health breakdowns.
Supervisors also created a network of “stabilization units,” where patients in the throes of crisis can speak to experts, stay for up to 23 hours and regain a sense of calm in an environment that is more conducive to recovery than a jail or hospital bed.
The county also plans to expand residential treatment, telemedicine services and outreach efforts to needy people through a health-impact fund. Supervisors have directed millions of dollars in new spending to school-based assessment and counseling programs and to harm-reduction initiatives, or services that promote treatment and well-being over law enforcement and punishment.
The push to tackle so many community mental health needs on multiple fronts reflects the new leadership and priorities of the San Diego County Board of Supervisors, which for the first time in decades is controlled by a majority of Democrats.
“When I ran for the board, I was very critical of the prior board for not investing the funds, committing the resources and making regional behavioral health a priority,” said Nathan Fletcher, who was elected in 2018 and now chairs the body.
“We set about (figuring out) how we could provide a better way,” Fletcher said.
With support from fellow Democrats Nora Vargas and Terra Lawson-remer, who each joined the board last year,
San Diego County is investing in behavioral health on a scale that has never been seen before.
Like most government agencies, the staffing and budget of the Behavioral Health Services office of the county Health and Human Services Agency rose incrementally through the years.
But the investments have grown by hundreds of employees and hundreds of millions of dollars since 2018, when Fletcher claimed his seat on the Board of Supervisors and began making good on his campaign pledge to steer more resources to treatment and services for those in need.
“All of these things really fit together. We’re not just throwing more money at a problem,” said Fletcher, a former combat Marine and relatively new member of the Democratic Party. “We are trying to completely reimagine and rebuild a system, and that takes money.”
This year’s Behavioral Health Services budget exceeds $817 million. That’s an increase of almost $40 million over last year and $105 million in 2019. Ten years ago, the behavioral health budget was $431 million.
At the same time, the county’s mental health workforce has steadily inched upward.
More than 1,110 people now work for Behavioral Health Services, an increase of 100-plus full-time employees over last year and 34 percent higher than the number of positions reflected in the 2012-13 budget year.
Even so, setting money aside to fight what is widely viewed as a crisis in mental health across San Diego County — and much of the country — does not automatically succeed.
Some of the new initiatives take years to implement, and it’s not clear they will all address the community’s unmet mental health needs, which advocates say affect 1 in every 4 families.
At the same time, records show Behavioral Health Services perennially fails to spend all of the money it has been awarded. Last year, the department closed the year with $58 million left over; the year before that, it reported $44 million in unspent funding.
Since the 2012-13 fiscal year, the region’s primary mental health provider has rolled over nearly $250 million — more than $10 million every month over the past decade.
One in 4 adults
Even before the COVID-19 pandemic, calls for mental health services were escalating.
A report by the regional planning agency San Diego Association of Governments, or SANDAG, said the number of mental health calls climbed by 84 percent between 2009 and 2015, from just over 17,000 a year to almost 32,000.
A follow-up study last year found that requests for help continued to rise between 2016 and 2018, when just under 38,000 calls for service were reported. By May 2020, SANDAG said, the region’s mental health providers were receiving an average of 106 calls per day.
“According to the County of San Diego Health and Human Services Agency, around 1 in 4 San Diego County adults face a mental health challenge and 1 in 5 children have some degree of emotional or behavioral difficulties,” the agency reported.
Many families are grateful for the county’s fresh focus on mental health services, and the resources the Board of Supervisors is directing to the issue.
But for some, the programs now being developed may not make the huge impact that county officials hope because they do not address larger concerns that cost even more money or they require changes in state and federal laws.
Laura Steenstra is a volunteer with the San Diego chapter of the National Alliance of Mental Illness, a nonprofit advocacy group that provides resources and counseling to families affected by mental health issues.
Despite the recent initiatives by San Diego County, she said there is a lack of subsidized housing for mentally ill people, and it’s too difficult to qualify — and remain eligible — for benefits that allow people to live independently.
Also, there are lapses in aftercare services once patients are stabilized through treatment and medication, she said.
“Everything seems to be dominated by what insurance will cover,” Steenstra said. “It’s really only a few days of care and then they send the patient off with medication and an IOP (intensive outpatient program).”
But patients often refuse to take their prescriptions, and no one is designated to monitor their progress, she said.
“It’s frustrating for family members when (patients) are not capable of maintaining that care,” Steenstra said. “A lot of loved ones return to homelessness. The definition of what is stable is too broad. It needs to be more clearly defined.”
Sue Caslava of San Marcos is more fortunate than many.
She said her son experienced his first break with reality more than a dozen years ago, when he was in his late teens. One of his conditions is called anosognosia, which is when patients do not think they are sick.
“He didn’t believe there was anything wrong with him,” Caslava said. “He had to be the one to call in (for help) and he wouldn’t call.”
Her son, who is now 32, was in and out of jail before he was diagnosed with schizoaffective disorder and found a successful medication regimen. He also was placed into conservatorship, which means a third party controls his finances, health care and other decisions.
Caslava said most of the families she knows through the National Alliance on Mental Health have no legal say in their loved one’s medical decisions — and she wishes San Diego County supervisors could do something about that.
“We have conservatorship, so we do have a case manager, but 99 percent of the people who are out there are just one slip away,” she said. “If they don’t follow through (with treatment), they are back on the street.
“With some of this new money, maybe San Diego County could give recruitment bonuses and incentives to put some case managers in place.”
Private contractors
The growth in the county’s Behavioral Health Services budget under the newly configured Board of Supervisors has outpaced even the rise in staffing.
Over the past 10 years, mental health spending increased by 90 percent while the number of employees climbed 34 percent.
That means much of the work at Behavioral Health Services is actually performed by private contractors — companies, consultants and nonprofits that deliver direct services to clients or provide expertise to department officials.
San Diego County first became one of the national leaders in privatization in the 1990s, when a different group of newly elected supervisors confronted a seemingly irreversible budget deficit.
The band of conservative Republicans would govern for the next two decades plus, instituting an ethos of “better, faster, cheaper.” The county farmed out everything from solid-waste disposal and telecommunications to family planning and immunizations.
But outsourcing government services is not always seamless.
Contractors are not subject to open-records laws, which can inhibit the public’s ability to monitor taxpayer spending and ferret out conflicts of interest.
Public employees also are needed to oversee private contractors. The level of services may not match what is called for under the agreements, and sometimes government agencies are forced to cancel contracts for nonperformance or waste and demand to be repaid.
Scholars say the privatization of public services has delivered mixed results.
“While the stated rationale for outsourcing in the public sector, as in the private sector, is typically to save money, it is unclear whether, and to what extent, public sector outsourcing reduces expenditure,” said a study from the nonprofit W.E. Upjohn Institute for Employment Research.
“Some studies, in fact, argue that it is more expensive to have private contractors perform government work,” the analysis added.
San Diego County has seen its share of noncompliance by local contractors.
Five years ago, county officials investigating whistleblower accusations against the San Diego nonprofit Mental Health Systems found it improperly sought reimbursements for expenses it had not accrued and diverted millions of dollars to a for-profit company owned by the charity.
Agency officials, who denied any wrongdoing, also were accused of spending $815,000 to rent a $1.2 million building owned by a member of the board of directors.
Mental Health Systems, which operates drug-court, counseling, treatment and other programs for local agencies across California, changed its leadership and agreed to a series of corrective actions.
With annual contracts now worth almost $50 million a year, Mental Health Systems provides even more services to San Diego County than it did in 2016.
More recently, county officials canceled a slew of contracts with the local Volunteers of America chapter after a review found that the charity could not properly account for millions of dollars it had collected for public services.
The county Health and Human Services Agency identified multiple deficiencies and improprieties, including unsubstantiated travel and hotel stays, lax internal controls, overbilling for routine supplies and other questionable practices.
Executives from the national Volunteers of America stepped in earlier this year to take over operations at the San Diego office. The county demanded $67.5 million be repaid to the public treasury but has yet to collect any reimbursement.
“We are still negotiating a mutual agreement on the matter,” county spokesperson Michael Workman said.
Ticketing and jailing
Theresa Bish became an advocate for mentally ill people after her brother was diagnosed with schizophrenia some two decades ago. Like many other patients, Bish’s brother Vincent did not recognize that he needed treatment, and committed suicide in 2003.
Bish’s subsequent work trying to help others got her appointed to the San Diego County Mental Health Advisory Board, where she advised Health and Human Services Agency officials and the Board of Supervisors.
No longer volunteering for the advisory panel, Bish said she supports the new attention mental illness is receiving from current county supervisors. But she worries about what she sees as a persistent lack of oversight and accountability in local government spending.
“Here’s the problem with the money,” she said. “It hasn’t been spent in the most fiscally responsible or effective manner.”
Bish pointed to law enforcement practices of ticketing and jailing those who are mentally ill, especially homeless people, as a huge problem. She said San Diego city and county leaders should work together to develop a 90-day plan to attack homelessness and mental illness, which are inextricably linked.
“Right now we have the money, we have the programs,” she said. “What we don’t have is an analysis of what programs are working and if we overlap on programs.”
Bish also said too many service providers are invested in sustaining the status quo. She suggested the creation of a taxpayer oversight board to examine public spending and make recommendations about increasing its efficiency and accountability.
“These (contractors) need incentives to solve the problem,” she said. “But what we have is a basic gravy train that’s gone on for too long. We still hear people saying they can’t access services for their loved ones, and that’s just criminal.”
Fletcher, the county Board of Supervisors chairman, said it is “heartbreaking and exceedingly frustrating” when contractors do not comply with county rules but he said violators represent a fraction of those who provide services at public expense.
“The overwhelming majority of providers do heroic work in full compliance with all laws and requirements,” he said.
Fletcher, who served two terms in the state Assembly as a Republican before switching parties and winning his current seat, said the initiatives the county has approved in recent months will take time but he is convinced they will help.
“It is not going to change overnight,” he said. “Many of these programs take several years to get into place. There’s a little bit of patience required in letting these pieces fall together.”
In addition to the programs already funded, county officials are planning to partner with UC San Diego to create a “behavioral crisis health hub” — a single place that is regionally located where patients can be stabilized and set up with continuing services.
The county is also planning to establish a “youth hub” in partnership with Rady Children’s Hospital to treat young people with mental health issues.
Both of those facilities are planned to open in 2025.
So far, the new mental health initiatives put forward by the county Board of Supervisors have been fully funded, and the Democratic majority on the panel has committed to the programs for the foreseeable future.
But, like the wholesale changes that took root with Fletcher’s election in 2018, a different crop of elected leaders could shift county priorities once again.