MHSA Community Service and Supports Program Requirements

1. California Institute For Mental Health California Department of Mental Health Mental Health Services Act Community Services and SupportsThree-year Program and Expenditure Plan Requirements In partnership with

2. Goal of Today’s Presentation • Clarify the final “MHSA Community Service and Supports Three-Year Program and Expenditure Plan Requirements” • Respond to initial questions

3. Agenda • Purpose and Summary Information • Part I: County/Community Public Planning Process and Plan Review Process • Section I: Planning Process • Section II: Plan Review • Part II: Program and Expenditure Plan Requirements • Overview • Section I: Identifying Community Issues • Section II: Analyzing the Mental Health Needs in the Community • Questions and Answers • Break • Section III: Identifying Full Service Partnerships • Section IV: Identifying Strategies • Section V: Assessing Capacity • Questions and Answers • Section VI: Developing Work Plans, Timeframes and Budgets

4. Today’s Presenters • Carol Hood – Deputy Director, Systems of Care • Mike Oprendek – MHSA Team Member • Tina Wooton – MHSA Team Member • Silvia Rodriguez-Sánchez– MHSA Team Member • Dee Lemonds – Chief Adult and Older Adult Program Policy • Dave Neilsen- Chief of Children/ Family Policy • Mike Geiss – DMH Consultant

5. Purpose of Document • Document is intended to • Specify requirements and priorities for county funding requests for services for people with serious mental illness and severe emotional disturbance • Move toward system transformation envisioned by MHSA • Produce meaningful and measurable outcomes statewide • Support local priorities within the above parameters

6. Stakeholder Process • Requirements developed with input from an extensive stakeholder process • 15 statewide meetings with approximately 2100 participants • 12 statewide conference calls with approximately 900 participants • Over 1300 e-mails • Over 200 written letters • Over 700 constituency groups

7. Five Fundamental Concepts for Plans The following concepts must be embedded throughout the county responses. • Community collaboration • Cultural competence • Client/family driven mental health system for older adults, adults and transition age youth and family driven system of care for children and youth • Wellness focus, which includes the concepts of recovery and resilience. • Integrated service experiences for clients and their families throughout their interactions with the mental health system

8. Three Types of Funding • Full partnership service funds • Funds to provide all necessary services and supports for designated populations that will be served in the first three years 2. System development funds • Funds to improve services and infrastructure for the identified initial full service populations and for other clients 3. Outreach and engagement funds • Funds for outreach and engagement of those populations that are unserved.

9. Requirements Are Intended to Initiate Significant Changes Including: • Increases in the level of participation and involvement of clients and families in all aspects of the public mental health system • Increases in client and family operated services • Outreach to and expansion of services to client populations in order to eliminate ethnic disparities and expand access to unserved and underserved • Increases in the array of community service options for individuals diagnosed with serious mental illness and children/youth diagnosed with serious emotional disorders, and their families, that will allow them to avoid unnecessary institutionalization and out-of-home placements

10. Part I: County/Community Public Planning Process and Plan Review Process(See Part I, Page 9.) • Section I: Planning Process • Counties that received unconditional plan approval do not have to provide as much detail about their process, but must briefly describe their actual planning process

11. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Page 9.) • Section I: Planning Process • Counties that received conditional approval have to provide more detail about their actual planning process • Letters with specific issues went to each county with conditions

12. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Page 9.) • Section I: Planning Process • Same factors required as in initial planning funding request • Meaningful involvement of clients and families as full partners • Comprehensive and representative planning process • Clear designation of overall responsibility for planning process • Training provided to ensure full participation of stakeholders.

13. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Page 9.) • Section I: Planning Process • Counties may resubmit parts of their plan to eliminate the conditions in advance

14. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Section II, Page 12.) Section II: Plan Review • Provide a description of the process to ensure that the draft plan was circulated to representatives of stakeholder interests and any interested party who requested it. • Provide documentation of the public hearing by the mental health board or commission.

15. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Section II, Page 12.) • Section II: Plan Review 3) Provide the summary and analysis of any substantive recommendations for revisions 4) Provide a description of any substantive change made to the plan circulated for public comment

16. Part I: County/Community Public Planning Process and Plan Review Process (See Part I, Section II, Page 12.) • Section II: Plan Review • A county’s Program and Expenditure Plan will not be reviewed for funding until the county has successfully carried out a complete and adequate planning process as approved by the State Department of Mental Health, has completed the required local review and public hearing, and has met the previously stated requirements.

17. Part II: Program and Expenditure Plan Requirements (See Part II, Page 12.) • Identification of specific populations to be served through the MHSA—Community Services and Supports: • Services for Children and Youth • Provided to children and young adults with severe mental illness as defined in the W&I Code 5878.2 • Those minors under the age of 18 who meet the criteria set forth in subdivision (a) of 5600.3—seriously emotionally disturbed children or adolescents • Provided to children up through age 21 for those who meet the special education eligibility requirements under Government Code Chapter 26.5, Section 7570 • Some transition age youth may also be served under W&I Code, Section 5865.1.

18. Part II: Program and Expenditure Plan Requirements (See Part II, Page 13.) • Identification of specific populations to be served through the MHSA—Community Services and Supports: • Services for Adults Older Adults • Services will be available to adults and seniors with severe illnesses who meet the eligibility criteria in the W&I Code Section 5600.3(b)—adults and older adults who have serious mental disorder and (c)—adults and older adults who require or are at risk of requiring acute psychiatric inpatient care, residential treatment, or outpatient crisis intervention because of a mental disorder with symptoms of psychosis, suicidality, or violence. • Some transition age youth may also be served under these provisions.

19. Part II: Program and Expenditure Plan Requirements (See Part II, Page 13.) • Document follows logic model that links: • Community issues resulting from untreated mental illness and a lack of services and supports • Mental health needs within the community • The identification of specific populations to be fully served based upon the issues and needs identified • The strategies and activities to be implemented and • The desired outcomes to be achieved.

20. Part II: Program and Expenditure Plan Requirements (See Part II, Page 13.) • In addition to a focus on community issues and outcomes, the MHSA also emphasizes the importance of measuring outcomes achieved by specific individuals and families, including but not limited to: • Hope • Personal empowerment • Respect • Social connections • Independent living for adults and safe living with families for children/youth • Self-responsibility • Self determination • Self esteem for clients and families

21. DMH Envisions an Ongoing Process(See Part II, Page 13.) • Along with other individual and system level outcomes, these individual value-driven outcomes will be incorporated within the outcome measurement system to be developed and implemented under the MHSA • Ongoing process of identifying community issues and unmet needs, focusing upon specific individuals and populations in need based upon these identified issues, developing and implementing state of the art service and support strategies and assessing outcomes

22. DMH Envisions an Ongoing Process (See Part II, Page 13.) • All of these outcome reviews are meant to ensure that counties are providing the highest level of quality care possible in the most efficient and effective ways • Ongoing quality improvement process, data and feedback on the individual, community and system levels are used to refine and improve services and supports • Plans for addressing individual quality of care issues are a part of this ongoing process.

23. DMH Envisions an Ongoing Process Identified community issues and unmet needs Highest quality of care possible In the most efficient and effective ways Assessing outcomes State of the art services and strategies

24. Part II: Program And Expenditure Plan Requirements (See Part II, Page 13.) The plan document submitted must follow the format and structure included in the following sections: Section I:Identifying Community Issues Related to Mental Illness and Resulting from Lack of Community Services and Supports Section II: Analyzing Mental Health Needs in the Community Section III: Identifying Initial Populations for Full Service Partnerships Section IV: Identifying Programs and Strategies Section V: Assessing Capacity Section VI: Developing Workplans with Timeframes and Budgets/Staffing

25. Part II: Program And Expenditure Plan Requirements • Overall Format • “Direction” in highlighted box provides background information on what is being requested and state priorities • “Response” specifies questions which must be addressed by counties in their plan submissions.

26. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • The “Directions” section spells out the community issues related to untreated mental illness identified in the MHSA • For adults, older adults and some transition age youth - homelessness, frequent hospitalizations, frequent emergency medical care, inability to work, inability to manage independence, isolation, involuntary care, institutionalization and incarceration.

27. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • The “Directions” section spells out the community issues related to untreated mental illness as identified in the MHSA. For adults, older adults and some transition age youth – • homelessness, • frequent hospitalizations, • frequent emergency medical care, • inability to work or be independent, • isolation, • involuntary care, • institutionalization and incarceration (MHSA, Section 2: Findings and Declarations). CSS Requirements beginning Page 14

28. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • The “Directions” section spells out the community issues related to untreated mental illness as identified in the MHSA for children, youth and some transition age youth – • inability to be in a mainstream school environment, • school failure, • hospitalization, • peer and family problems, • out-of-home placement, and • involvement in the child welfare and juvenile justice systems

29. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • Counties and stakeholders are asked to examine these issues and others in the context of their communities and identify which of these community issues and concerns they will focus on in their initial three-year program and expenditure plan. Issues should be identified and discussed by age groups

30. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • Describe the factors or criteria used to inform a county’s choices about which populations or groups of individuals will be a focus of MHSA services over the next three years. • Describe the racial ethnic and gender disparities related to the identified issues

31. Part II: Program and Expenditure Plan Req. Section I: Identifying Community Issues • If, through the planning process, a county decides to focus on an issue or issues not specifically described in the MHSA, the Program and Expenditure Plan must describe why these issues are more significant for their community and how the issues are consistent with the purpose and intent of the MHSA • If a county does not believe that providing expanded MHSA services for each age group in the initial three years is feasible, the county must provide an explanation about why it is not feasible.

32. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community(See Section II, Page 15.) • Counties must provide an assessment of the mental health needs of county residents and residents of American Indian rancherias or reservations within county boundaries, including adults, older adults and transition age youth with serious mental illness and children/youth who may have or have been diagnosed with serious emotional disorders. • Document provides a definition of unserved, underserved/inappropriately served and fully served with examples in each category

33. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 16.) • Although counties may also elect to provide some new or expanded services to underserved individuals already receiving some services in their system, DMH expects counties to identify unserved individuals and their families in the priority populations for MHSA funding.

34. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 17.) • Counties are not going to be required to provide detailed estimates of the numbers of individuals in their total population who may need mental health services, but are currently unserved • Using available local data, counties must assess in general terms the needs of unserved populations of individuals with the kinds of age and situational characteristics identified in the MHSA

35. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 17.) • Particular attention should be paid to identifying and analyzing ethnic disparities. Some populations such as native Americans may be underrepresented in the data. • Counties must identify and analyze in detail their current utilization data in terms of numbers of clients and family members who need MHSA programs and services and are already being served

36. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 17.) • Assessments should consider the following service needs of: • Gay, lesbian, bisexual, and transgender individuals • Race ethnicity • Gender and primary language • Individuals with co-occurring disorders • Hearing or visual impairments • Other physical disabilities and medical conditions such as HIV/AIDS

37. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 17.) The DMH’s expectation is that counties will identify the number of persons, by age group, race ethnicity, gender and primary language, that may be underserved, including individuals that some might define as inappropriately served such as: An older adult with frequent emergency room visits who has not had a comprehensive medical, mental health and social assessment An adult living in an IMD or a Board and Care facility because of the lack of supported housing services

38. Part II: Program and Expenditure Plan Req. Section II: Analyzing Mental Health Needs in the Community (See Section II, Page 17.) The DMH’s expectation is that counties will identify the number of persons, by age group, race ethnicity, gender and primary language, that may be underserved, including individuals that some might define as inappropriately served such as: (Cont.) A transitional age youth who does not have a comprehensive plan for transitioning out of foster care, or A child/youth living in an out-of-home placement or involved in the juvenile justice system due to lack of or access to appropriate community based services

39. Part II: Program and Expenditure Plan Req. Section II: Analyzing MH Needs (See Section II, Page 18.) Responses: Four Questions • Using the information from population data for the county and any available estimates of unserved populations, provide a narrative analysis of the unserved populations in your county by age group. Specific attention should be paid to racial ethnic disparities. • Using the format provided in Chart A, indicate the estimated total number of persons needing MHSA mental health services who are already receiving services, including those currently fully served and those underserved/ inappropriately served, by age group, race ethnicity, and gender. Also provide the total county and poverty population by age group and race ethnicity. (Transition Age Youth may be shown in a separate category or as part of Children and Youth or Adults.)

40. Part II: Program and Expenditure Plan Req. Section II: Analyzing MH Needs – Four Questions (See Section II, Page 18.)   3. Provide a narrative discussion/analysis of the ethnic disparities in the fully served, underserved and inappropriately served populations in your county by age group as identified in Chart A, “Service Utilization by Race / Ethnicity”, on page 19. Include any available information about their age and situational characteristics as well as race ethnicity, gender, primary language, sexual orientation, and special needs. 4. Identify objectives related to the need for, and the provision of, culturally and linguistically competent services based on the population assessment, the county’s threshold languages and the disparities or discrepancies in access and service delivery that will be addressed in this Plan.

41. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • The goal is for counties to begin moving toward “full service partnerships” for all persons served • Counties are encouraged to start “small and smart” and expect that program capacity will evolve over time • Counties must specify the numbers of individuals they will serve in this manner, by age group, within the first three years of MHSA funding, with priority given to un-served populations (See Section III, Page 20.)

42. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • Overall, counties must dedicate the majority of their funding for full service partnerships over the three-year period. (Some expenditures in System Development and Outreach and Engagement programs may count toward this requirement which does not apply to small counties until the third year.) (See Section VI, Page 39.)

43. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships Initial populations for Full Service Partnerships must be consistent with issues of public concern and the MHSA – and give priority to persons previously unserved. Specific populations by age include: • Children and Youth between the ages of 0 and 18, or Special Education Pupils up to age 21, with serious emotional disorders and their families – who are not currently being served. (see Section III, Page 20 and 21.)_

44. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships Un-served Children and Youth (continued) • Generally this will be youth and their families who are uninsured, under-insured and/or youth not eligible for Medi-Cal due to being detained in the juvenile justice system • It could also include homeless youth, youth in foster care placed out-of county, youth with multiple foster care placements, or children and youth who are so underserved they are at risk of homelessness or out-of-home placement (see Section III, Page 21.)

45. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • Transition Age Youth (TAY) – between 16 and 25, with serious emotional disorders – currently unserved or underserved who are homeless or at imminent risk of homelessness or are aging out of child and youth mental health, child welfare and/or juvenile justice systems, and youth involved in the criminal justice system or at risk ofinvoluntary hospitalization or institutionalization. Transition age youth who have experienced a first episode of major mental illness are also included. (see Section III, Page 21.)

46. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • Adults with serious mental illness – including adults with a co-occurring substance abuse disorder and/or health condition – who are either: Not currently served – and meet one or more of the following criteria: • Homeless • At risk of homelessness – such as youth aging out of foster care or persons coming out of jail • Involved in criminal justice system (including adults with child protection issues) • Frequent users of hospital and emergency rooms (see Section III, Page 21.)

47. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships Or so underserved that they are at risk of: • Homelessness – such as personsliving in institutions or nursing homes • Criminal justice involvement • Institutionalization Transition age older adults (often between 55 and 59) who are aging out of the adult mental health system and may be at risk for any of the conditions cited above are also included. (See Section III, Page 21.)

48. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • Older Adults 60 years and older with serious mental illness – including older adults with co-occurring substance abuse disorders and/or other health conditions – who are either: • not currently being served and: • Have a reduction in personal or community functioning • Are homeless or at risk of homelessness, institutionalization, nursing home care, hospitalization and emergency room services. (See Section III, Pages 21 and 22.)

49. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships Or are so underserved that: • they are at risk for any conditions previously cited are also included. • Transition age older adults (often between 55 and 59) may be included with the older adult population when appropriate. (See Section III, Page 22.)

50. Part II: Program and Expenditure Plan Req. Section III: Identifying Initial Populations for Full Service Partnerships • Full service partnerships must include: • Provision of all necessary and desired appropriate services and supports to assist in achieving the goals identified in the individual’s plan • Individualized service plan that is person/child centered (See Section III, Page 22.)