MENTAL HEALTH SERVICES

INTRODUCTION

Difficult and seemingly deteriorating relations between the clinical staff and management in Santa Barbara County’s Department of Alcohol, Drug & Mental Health Services (ADMHS) were brought to the attention of the 2000-2001 Grand Jury early in its term.

A letter (dated June 1, 2000) from Local 620 of the Service Employees International Union (SEIU), which represents most County service employees, noted that the union had been receiving many complaints from ADMHS employees. A copy of a survey of the Adult Services Clinical Staff of ADMHS, the professionals directly involved with serving mental health clients, accompanied the letter. The survey, which was conducted by the SEIU, appeared to the Grand Jury to have been well designed; the questions were worded positively so that a respondent had to disagree with the question in order to express dissatisfaction. The SEIU survey results indicated significant negative feelings toward management, particularly with regard to commitment to patient care and management-staff communications, and appeared to reveal high levels of stress among members of the staff.1

Notably, neither the letter nor the survey mentioned dissatisfaction with pay or benefits, although there was concern about the availability of professional advancement opportunities. Most importantly, the results of the survey questioned for which "client" the ADMHS services were to be designed.

Initially, the Grand Jury had no interest in intervening in a standard labor-management disagreement, but that did not seem to be the case here. The low morale indicated by the survey prompted the Jury to monitor the situation, because low morale often leads to the loss of highly qualified, experienced professionals who are difficult and expensive to replace.

As the months went on, ADMHS experienced significant attrition in the professional staff, and in April 2001 had a 17.5% vacancy rate. The high turnover of fiscal staff had a debilitating effect on the accuracy and timeliness of ADMHS financial data. In addition, the loss of service staff and the inability to recruit qualified replacements resulted in lost MediCal billing opportunities. This problem, as well as overfilling, has resulted in an accumulated liability of approximately $3.1 million through FY 1999-2000 and a probable significant cost-settlement liability for FY 2000-2001. No funds are currently available for repayment.

Finally, the fact that the bottom-line clients of this agency are vulnerable, mentally ill persons who might be receiving less than ideal care argued for an investigation.

APPROACH

The Grand Jury believed it was important to interview a substantial number of people so that patterns, rather than individual complaints, would be identified. Both staff and management personnel came forward willingly, although in the case of the Adult Services staff, feelings of risk to their employment and reputations often were perceptible. The Grand Jury interviewed 30 ADMHS staff (some more than once), eight members of management, and many community-based (non-profit) care providers of County mental health services. Many letters were reviewed and the Grand Jury attempted to corroborate (confidentially) the information contained in them.

Members of the Grand Jury monitored meetings of the Labor-Management Project Team (first convened October 2000) and some of its subcommittees. Meetings of the Mental Health Commission were also monitored. Additionally, the Little Hoover Commission Report on Mental Health (published November 2000) and other documents were obtained and studied. Visits were made to two County facilities and two community-based organizations that provide care. Because of privacy issues, Mental Health clients were not interviewed.

ADMHS Clinicians

Clinicians are staff workers who deal directly, one-on-one, with the mentally ill in the County’s clinics, psychiatric hospitals, and detention facilities. Many are highly educated and experienced in the mental health field. Some are psychiatrists or have doctoral or master’s degrees in psychology. They are a dedicated lot, having entered the profession as a calling because they care about helping people who are often too sick to help themselves. They know their business and they take it seriously. It is, above all, a people business, one of trying to help people who are often difficult, contrary, even dangerous.

What the Grand Jury heard most when interviewing the clinicians was a sense of frustration about conditions that were impeding their ability to do their jobs properly. Caseloads, especially among the Adult Mental Health Long-Term Teams, are too high to permit enough time with most clients. Offices are shared, making it difficult to offer the privacy needed for patient counseling. Further, the requirement to complete the paperwork necessary to satisfy funding requirements reduces time available for the counseling relationship.

Management was accused, in interview after interview, of not providing leadership, of not listening, of not being available, and even of not caring about the clinicians and the problems they were facing. The Adult Services facilities in Santa Barbara were described as being so decrepit as to be depressing to even upbeat patients. The 50-year-old Psychiatric Health Facility (PHF), which houses up to 16 vulnerable patients and a good-sized staff, was considered by many to be a "sick" building—two resignations were said to have been prompted by its unhealthy, mold-ridden ventilation system. Its water delivery system was also noted to deliver water high in copper salts. Although the PHF was recently evacuated to clean the ventilation system, this may not be fully satisfactory and remains a priority health issue.

Vacant positions have gone unfilled, adding to the general workload. ADMHS vacancies, as of April 2001, were 17.5% of the positions that were budgeted in July 2000. Caseloads were said to be 45 to 50 and even as high as 70 per caseworker, and psychiatrists reported having caseloads of up to 300. (There are estimated to be about 1,600 mentally ill people being served by ADMHS in the County. An additional 4,400 individuals who are substance abusers with or without mental illness are also served each year.)

As previously noted, not one complainant mentioned additional money or benefits. Funding was a concern, however, because funding of ADMHS is especially complicated and funding realities are not widely understood. Staff does not understand (1) who is to be served and by which other organizations within and outside of ADMHS, and (2) what services these other divisions and organizations handle. This leads to a climate in which people are suspicious about where money is being spent if it is not going into the programs with which they deal.

Clinicians were offended by reported management comments such as "You’re lucky to have a job," and "If you can’t take the heat, stay out of the kitchen." What bothered staff was the perception that they were being taken for granted, that management knows full well that they will come through, regardless of conditions, for their clients. They said they could cope with a great deal—budget shortfalls, low staffing levels, lack of facilities and long hours—if only they could get straight, direct, honest answers from management that would simply explain what the problems are and why conditions are not improving.

From the standpoint of the clinicians and other staff, management’s biggest failing seems to be a failure to communicate and to provide the solid leadership essential to supporting beleaguered staff. There were numerous complaints that "They [management] just aren't listening to us," and "We don’t understand what’s going on; why won’t they talk to us?"

The Grand Jury found no evidence that mentally ill people were being ignored or mistreated by ADMHS. There were many complaints about lack of funding, excessive caseloads, and lack of housing for the clients, as well as difficult conditions leading to low morale, anxiety, stress and burn-out among the clinicians. Despite all this, however, the upshot is that ADMHS practitioners are still committed to serving the County’s mentally ill and their families.

ADMHS Management

Managers said they have tried to communicate issues to the workforce, but feel that these attempts have fallen on deaf ears, that clinicians either do not fully appreciate what is conveyed or do not want to understand. Management views clinicians as being too idealistic and of not realizing that there are limits to what can and cannot be done. Some managers implied that workers are not tough enough for the shortcomings of the real world, while management, by contrast, has to make the hard decisions needed to see the Department through.

Of course, the truth is somewhere between. Members of management were cooperative when interviewed by the Grand Jury and did not shirk blame. They were proud of their achievements. Praise also was lavished on the staff, which management described as dedicated and effective. Management did point out, however, that when so many sensitive, well-educated people (about 300 ADMHS staff throughout the County) are involved in providing highly intensive and personal services, there are bound to be differences of opinion about operations and procedures.

The ADMHS Client

If someone is injured or physically ill, an ambulance or physician is called to treat that person. If a person is disheveled, confused, and difficult to talk with, however, he or she may be perceived as a nuisance who should just move on and get a job. Of course, whether that person can actually do anything about his or her condition is questionable. That person may be mentally ill, a substance abuser, or both (referred to as "dually diagnosed."). He or she may be confused and ineffectual, may have limited English language skills, and may have only ADMHS—backed by the will of the public—to offer assistance.

Three different populations are served by ADMHS, the mentally ill, the substance abusers, and the dually diagnosed. ADMHS needs to deliver three distinct therapies. The only other public provider of care, with few State-supported psychiatric hospitals still open, is the jail. Detention has even larger social, if not economic, costs attached to it for the individual, the community, and the taxpayer.

BACKGROUND

In 1998, the then-titled Mental Health Department administration requested and assumed responsibility for the Alcohol and Drug Division of the County’s Public Health Department. This was partially a result of the publication, in 1996, of a Five-Year Strategic Plan for mental health needs of adults in the County, which identified the need to serve dually diagnosed citizens better—individuals with both mental health and substance problems.

Dually diagnosed individuals—fully 50% of the mentally ill who are served by ADMHS (or 3,000 individuals)—were under-served, it was claimed, because, they were neither being assessed nor treated appropriately. Once identified, such individuals need to be treated with an integrated therapy for mental health and substance abuse problems.

The Strategic Plan also outlined a new system of care for the mentally ill adult clients served by ADMHS, based on integration of social and public health services.

A SEARCH survey was conducted at this time that polled the alcohol and drug therapy providers in the County, the community-based (non-profit) organizations that provide the bulk of the County’s substance-abuse therapy. This survey, conducted over three months and published in 1998, sought the opinions of professionals within the County about what they thought was needed in order to integrate the responsibilities of the former Alcohol and Drug Division into the County’s mental health system.

A new Alcohol/Drug Program (ADP) manager was hired in 1998 by the Department (renamed Alcohol, Drug & Mental Health Services, or ADMHS) to serve this dually diagnosed population, in addition to the 1,500 or so individuals who were simple substance abusers, and the approximately 1,500 mentally ill individuals. The new ADP manager was charged with bringing the programs developed through Alcohol/Drug funding to the aid of the County’s dually diagnosed citizens. Despite attempts by the new ADP manager to move toward accomplishing the goals set out in the SEARCH document, little actually has been accomplished. Was ADMHS management unwilling, or was it unable?

The Grand Jury was concerned because a department that is governed by Outcomes Measures in its service design has not seemed to apply performance standards to itself.

The Medical Model

ADMHS senior management is comprised of many of the same individuals who managed the pre-1998 Mental Health Services Department, before the Alcohol and Drug Division was transferred from the Public Health Department. These 20-year-plus management veterans are medical mental health professionals themselves or have been trained by medical mental health professionals. Their experience goes back to the time when mental illness was managed and treated in hospitals. After the passage of Proposition 13, which reduced funds the State received from the property tax, California ended State support of psychiatric hospitals.

Federal and State mandates identify the core mental health patient as an individual with a severe and persistent mental illness such as schizophrenia or a bipolar disorder. These medical conditions require the services of a clinically trained professional. As expressed by its administrators, the goal of ADMHS is to provide necessary medical care in order to stabilize patients by the use of medical means (drug therapy, hospitalization, etc.) and, so, to keep them out of detention or locked mental health facilities.

Such patients may be suicidal or homicidal, a threat to themselves or others. They need help with medication, advice, housing, and hygiene—daily problems easy for most people but often extremely difficult for those outside society’s mainstream. Many are not going to be "cured" with medical means and may well need social service lifetime support, which is not provided by a clinic. Some clients may be seen by caseworkers for years and form therapeutically significant bonds. Others may drift in and out of the system. Frequently, they are individuals who are not well tolerated by society, which often prefers to ignore them.

The medical model works well for a patient with a physical illness. In optimal situations, it can work for patients with medical diagnoses such as "acute schizophrenia with paranoiac anxiety disorder." Diagnosis of a mental illness is delicate and difficult. Medical treatment, however, can follow conventional, published modalities, including drug therapies. The entire therapy is professional medicine, and all treatment must be deemed to be "medically necessary" in order to qualify for funding. The medical model seeks a "cure," however temporary, and, ideally, it effectively and efficiently remedies immediate and acute needs. Unfortunately, this "balkanizes" the care provided to the community to only those individuals who threaten to be in need of expensive hospital care or socially costly jail detention.

The funding system chosen by the County to support this medical system of care model follows a medical service-rate reimbursement plan, and the bulk of the ADMHS mental health funding is currently based on this. The amounts and types of specific medical procedures are budgeted at the beginning of the fiscal year. These are estimates of service-units, negotiated on a "per-unit-of service" rate and accounted for based on a "billing minute" increment. Moneys are funded by the State at the beginning of the fiscal year, and the services inventory is put in a "services reimbursement bank." All clients presenting themselves for services during the year have their care arranged by the service professionals, and accountants draw from this bank and report use back to the State. After year-end, a cost report is prepared by ADMHS to reconcile costs actually incurred for the year with the reimbursements received from MediCal. In a perfect world, these amounts would be the same. However, because reimbursements to the County are based upon an "estimated rate for service" set by the County and the State, money typically changes hands after year-end. The discrepancy between real and estimated service costs, and the number of service-units actually used in the 1998, 1999, and 2000 calendar years, is the source of the current ADMHS operating shortfall.

The service-units estimate prepared at the beginning of the fiscal year relies on the experience and the statistics kept by the Department. Because the medical model slots patients into services that the County has identified at the beginning of a budget cycle, enormous weight is put on how ADMHS administration defines the population to be served. If an error is made in assessing the population to be served or in the types of medical services that will be required, there could be service deliveries that are not reimbursable. Also, if the specified services are not needed or used by the population in a year, the County must reimburse the State for the moneys it has received for those service-units at the beginning of the fiscal year. Last year (FY1998-1999), ADMHS did not use a significant number of services, or used services on ineligible clients, and so incurred a significant reimbursement liability. These reimbursement dollar amounts, or a negotiated percentage of them, must now be returned to the State. A similarly significant reimbursement may be required based on the County’s experience in FY 1999-2000.

The probable two-year shortfall is estimated to be over 15% of the average annual ADMHS budget. The Grand Jury compared these sums to the County’s average annual contribution to ADMHS of $900,000 per year. (The balance of the approximate $35.1 million comes from grants and reimbursements.) The 1998-1999 shortfall is almost four times the County’s contribution to ADMHS. This shortfall, at least partially, will have to be paid from County general funds in the near future. This will also be the case for any subsequent shortfalls. Regrettably, the possibility exists that ADMHS fiscal management may recommend reductions in the mental health services provided by the County as a result of this shortfall.

MISC and the Rehab Model

Two significant ADMHS mental health programs, MISC and the Alcohol/Drug program, are not based on the medical model. MISC (for Multi-agency Integrated System of Care) primarily uses a "rehab" model to serve the County’s children. MISC is discussed later in this section.

The Alcohol/Drug Program within ADMHS is based and funded on a model that is not based on the medical model. County studies, including the SEARCH report, identified a specific group of the mentally ill who were not and are not being best served by medical (clinical) means. These individuals are termed dually diagnosed.

The respondents to the SEIU survey were in Adult (rather than Children’s) Services, and most were on the Long-Term Teams. The Grand Jury heard testimony that suggests that staff believes that ADMHS should provide better client care through an array of social services, housing and links with jobs, in combination with appropriate clinical services, so that the mentally ill can be accommodated and stabilized in the community, thus avoiding the need for acute care services. The implicit goal of these mental health practitioners’ care, rather than a "cure" for their mentally ill patients, is "community integration." This is the essence of the rehab model. Where did they get this idea? From the MISC Children’s Grant, an integrated social services and medical services program based on the rehab system of care, which focuses resources on supporting social services that clients need rather than exclusively on medical services.

MISC is the well-recognized Multi-agency Integrated System of Care, a collaboration of several Santa Barbara social-service and law-enforcement departments (ADMHS, Social Services, Public Health, and Probation), and a number of community-based organizations (CBOs). MISC, and the inter-departmental collaborations it engendered, was responsible for garnering many additional inter-departmental grants for the County.

Targeting at-risk children and their families and administered by ADMHS, the MISC program is in its sixth year. When the original $14 million grant ran out in June 2000, other County Departments and agencies contributed money from their budgets to sustain it, and it is now funded to 97% of its former budget. It is perceived as having great value to the public and fosters valuable cooperation among departments and the CBOs.

Early in its first term, MISC received accolades and awards for its integrated system design and life skills outcomes measurement. Case managers made the care decisions, and quality of life outcomes were measured. The individuals responsible for the design of this innovative program and the associated outcomes measurement design and analysis are no longer with the County.

MISC funding is blended, based in part on the "case-rate" system and, in part, on MediCal reimbursements (the "unit-of-service" system). Each MISC client seen by ADMHS is assigned a fixed dollar amount to be spent as the case manager deems appropriate for non-medical expenses such as food, clothing, shelter, etc. Medical expenses and case management services are reimbursed through MediCal.

The Rehab Model Summarized

The rehab model is based on the Program of Assertive Community Treatment (PACT) from Madison, Wisconsin. PACT was started almost 20 years ago. The California Legislature passed a bipartisan legislative bill, AB3777, in 1989 to create three Integrated Service Agency demonstration projects. These were funded for three years so that these "best practices" models would be available as resources for all California counties. In addition to the partial funding that continues to be provided by the State, the National Mental Health Association (NMHA) and the Federal Substance Abuse Mental Health Services Administration (SAMHSA) now designate these models eligible for Federal funding.

The rehab model is characterized by

  • collaborative case management,

  • case-rate funding, where individuals, not populations, are funded,

  • psychological and social rehabilitation,

  • outcome-oriented quality assurance (Quality of care is measured by assessing practical quality-of-life outcomes such as independent living, work, socializing, avoiding jails and hospitals, etc., rather than the number of units of service that were delivered to each client.),

  • single-point, continuous clinical responsibility: case managers follow their clients in all situations rather than having one group doing maintenance, another doing crisis management, etc.,

  • decentralized policy making: line staff discusses, decides and implements policy decisions for the patient.

Many of the Santa Barbara County ADMHS workers interviewed prefer the rehab model of program organization. This is the system outlined in the Adult Services Five-Year Mental Health Plan, prepared under a previous ADMHS Director in 1997. That this program organization was never undertaken in the Adult Services division of ADMHS may have added to staff frustration. To date, an integrated rehab system has not been pursued by ADMHS administration, despite the published findings of the Five-Year Mental Health Strategic Plan.

While the medical model might be appropriate if the County was forced to fund only mental health crisis management, it is an inadequate modality for treating children, simple substance abusers, or individuals who have been dually diagnosed.

Dually Diagnosed Individuals and the Jails

"The mentally ill patient, by definition, is unable to fulfill his personal and/or civic responsibilities and should not be treated by the justice system, which presumes that a person is given the just consequence for his willful action."

Los Angeles Superior Court Judge Harold Shabo,
in testimony before the Little Hoover Commission

 

Substance abuse problems are evident to law-enforcement, and offenders often end up in jail. For individuals with the dual problem of substance abuse and mental illness, their mental illness often is difficult to identify (diagnose). They frequently end up in jail, are dealt with as simple substance abusers, and are subject to substance abuse offense consequences. Although jail might be an appropriate consequence of substance abuse, it is not an appropriate consequence of mentally ill behavior. Punishment through the justice system does not prevent subsequent manifestations of the patient’s mental illness.

Many substance abusers can and should be treated in the justice system, appropriately in jail, away from contributing influences, with or without (long-term) behavioral modification therapy as one of the tools available to help them. There are substance abuse diversion programs that have treatment modalities and law-enforcement consequences appropriate for the substance offender. Treating pure substance abuse with mental health therapy, however, is inappropriate and serves neither the individual nor the community well. If pursued, it simply burdens the mental health system and wastes money.

Over half the inmates in the Santa Barbara County Jail (Main Jail) have been booked for some type of substance abuse issue. Many of these individuals (more than 50% according to published Federal, State, and Santa Barbara County studies, or over 25% of all booked Main Jail inmates) are or would be dually diagnosed, that is, with mental health as well as substance abuse issues, if accurately assessed. These individuals would benefit from mental health treatment programs, in addition to ancillary substance abuse treatment.

The State recognized this jail population four years ago and funded the Mentally Ill Offender Crime Reduction Program (MIOCRP) to divert the dually diagnosed mentally ill from the jails into community based programs with the goal of stabilizing non-violent offenders in their communities with their families. The program was renamed the Mental Health Treatment Court (MHTC) in 2001. Santa Barbara County was one of 13 counties to receive a four-year grant from the initial funding of this program in 1999.

At the State level, MHTC is still evolving. In Santa Barbara County, MHTC currently funds a post-booking jail diversion program for inmates who elect to participate. These inmates are assigned for 24 months to one of two groups, either into an intensive-support treatment group or into a control group. Both groups are entitled to the full range of professional mental health services at the Adult Mental Health Long-Term clinics at a low (1:15) staff-to-client ratio. In addition to these clinical mental health services, the treatment group receives intense support and social services such as housing, employment, intensive case management, and after-hours crisis support.

Participation is optional once eligibility has been determined by assessment at the Main Jail. The program (whether for the treatment or control group) lasts for 24 months, and once enrolled, an offender may only terminate their participation within the first 30 days. If the offender chooses to terminate their participation, he/she is returned to jail.

In the County, there are currently 77 participants in this jail diversion program, or about half of what was anticipated in the original grant application. Because the grant funds are substantial ($7 million over four years), the lack of participation has been a concern to ADMHS administration as well as to taxpayers. These grant funds serve citizens needs by providing appropriate care at no additional, current County taxpayer expense. The program has an ancillary benefit of reducing the number of inmates at the Main Jail. (See 2000-2001 Grand Jury report, "Detention Facilities and Sheriff’s Department Issues.")

The County recently requested a one-year extension of the four-year grant (due to expire in 2003) but this was denied because of the low level of participation. In light of the recent reimbursement budgetary difficulties, there is an effort within ADMHS to make this program successful.

There is concern that individuals being assessed for the MHTC program by ADMHS staff at the Jail are not fully or properly evaluated for a mental health disorder. The Grand Jury heard repeated criticisms that the assessment process done by ADMHS staff at the Jail did not meet the standards of the evaluations done by the ADMHS Long-Term Teams at the clinics. Long-Term Team clinicians stated that some drug abusers without a primary mental health disorder and exhibiting few permanent psychiatric symptoms were being assigned to their care. Members of the Long-Term Teams expressed concerns that the administration was "trying to get the numbers up," because funding was so critical for ADMHS. In so doing, it has happened that individuals with substance abuse issues only (who, as patients, are appropriately treated by alcohol/drug therapists using non-medical-model therapies) and other individuals with minor depression are accepted into MHTC and, therefore, automatically into the care of the Long-Term Teams. These inaccurately assessed individuals thus receive carte blanche access to intensive professional mental health clinical services unnecessary for their condition for 24 months with no possibility of discharge. The result is an increase in the caseloads of the Long-Term Teams, which have many other clients in addition to the MHTC clients. This makes it more difficult for the case managers to serve other clients adequately and, it was reported, compromises client care, to the staff’s frustration.

The staff believes that senior management knows of their concerns but has prioritized the numbers of clients served over client care and staff concerns.

This diversion program is administered by ADMHS. All assessment is done with ADMHS staff sited at the Main Jail. Once the inmate (client) agrees to participate, the Adult Mental Health Long-Term Team clinicians may not terminate them at any time, even if it is determined that the client does not need psychiatric services. In interviews, this lack of remedy to the improper assessment is the crux of the problem cited by members of the Long-Term Teams.

ADMHS clinicians in the Long-Term Teams have extremely high caseloads, in part due to staffing vacancies. Clients not needing the professional skill of this talented group would ordinarily discharge themselves from care; however, the MHTC clients cannot do so. And, unfortunately, the Long-Term Teams have no authority to discharge these MHTC clients if they no longer need or never needed clinical psychiatric services. This puts additional importance on a proper initial assessment by the ADMHS staff at the Jail.

The Alcohol/Drug Program

Unlike Mental Health Services, the Alcohol/Drug Program (ADP) provides few direct services to County citizens. Despite the $14 million it administers, ADP has only seven employees, but it treats a majority of the clients served by ADMHS, or close to 4,500 individuals.

ADP, with its geographically distributed care centers (Community-Based Organizations, or CBOs), is organized differently than the medical model side of ADMHS, and its programs come with their own funding stream from the State.

CBOs are based in the communities where the clients live in order to stabilize them in their home environment. Behavioral modification of substance abusers takes time, and the outcome measurements must be taken over the therapy period. The community (family, job, mentor support, education) is often important in the design of the therapy. This is why, in other California counties, the therapy often is administered in public health departments rather than being combined with mental health departments.

Prevention is a big part of any approach to substance abuse. Alcohol/Drug therapy and preventive and educational substance-abuse programs in Santa Barbara County are administered through contracts with CBOs. Preliminary evaluations by the County Auditor-Controller of the fiscal status indicate that the Program’s financial position appears sound, despite contractual problems this year and last year that were unrelated to the management of the Alcohol/Drug Program.

The real issue concerning the Alcohol/Drug Program is how well it has been integrated with Mental Health Services, both financially and, especially, in terms of the integration of services to best serve dually diagnosed citizens. This is an administrative challenge that should be met by a full and thoughtful review of the system of care that the ADMHS is expected to provide to the largest group of ADMHS clients.

RECENT DEVELOPMENTS

The beginnings of solutions to some of the problems noted earlier are in place:

SUMMING UP

Over the last 24 months, providing ADMHS services has been done without a clear definition of the client. Providing the wrong services to the wrong people and not identifying the right client, for example, are factors that have severely taxed the resources of clinicians. This has taken its toll in stress and burnout. Workers should not be expected to provide services indefinitely without definition, backup, leadership, support, and resources. Too many of the staff have taken stress leave, and many have left ADMHS to find better working conditions elsewhere—a significant loss to County taxpayers.

The Grand Jury applauds the initiatives of the ADMHS staff and County Administrator’s Office in developing processes whereby many of the issues noted by the Grand Jury earlier this year could be discussed. As a result of those discussions, especially in the Labor-Management and System of Care Project Teams, several important resolutions are in place. This decentralized, rather than hierarchical approach, builds consensus and creates broad ownership of this important service in the County.

ADMHS must yet develop a comprehensive and system-wide approach to its system of care. There must be uniform understanding of what, for whom, and how services will be provided and how they will be funded.

ADMHS is commended for creating the System-of-Care Project Team, an interdisciplinary group that is well suited to research and propose a comprehensive plan that will assure that those who should be served by ADMHS will—within the resources available—receive quality services in a timely manner.

FINDINGS AND RECOMMENDATIONS

Finding 1a: The Grand Jury found that management has failed to

Finding 1b: The beginnings of solutions to these problems are in place:

Finding 1c: The Labor-Management Project Team has accomplished much in the seven months that it has been in existence. This Project Team, in combination with the thoughtful and comprehensive search and research done by the Personnel Department and the County Administrator’s Office, participated in the evaluation and choice of the new ADMHS Director.

Recommendation 1: The Labor-Management Project Team should continue to meet until all processes proposed by the group are underway.

Finding 2: After a lengthy process involving major stake holders including the Labor Management Project Team, the Mental Health Commission, the Advisory Board on Drug and Alcohol Problems, ADMHS management, and the Auditor-Controller’s office, the Department’s restructuring proposal was presented in May 2001 by the Department to the Board of Supervisors. This restructuring should benefit clients by facilitating an integration of service delivery among the ADMHS staff serving adults, children, and alcohol/drug clients. Creating a supervisory level between program managers and their staffs will resolve the presently large span of control being dealt with by the program managers.

Recommendation 2: The restructuring proposed by the Department with input from the Auditor-Controller and the County Administrator is necessary in order to improve ADMHS services in the County. The incoming Director should review and act on the proposal’s key ideas.

Finding 3: Morale is low. People feel stressed and many are unhappy enough to serious consider leaving ADMHS or even the mental health profession. Failures in communication contribute to this stress and unhappiness.

Recommendation 3a: Current and new management must signal that it will listen to staff and do what it takes to improve conditions and boost morale. The leadership capacities and expectations of the managers and executives in the Department should be enhanced. Resources are available from the County Director of Organization Effectiveness to assist ADMHS with these critical tasks. Managers should be held responsible for demonstrating improved leadership practices.

Recommendation 3b: Following the success and example of the Labor-Management Project Team, programs and activities that promote openness should be evaluated and, if believed to have promise, implemented.

Finding 4a: Clinicians and other line staff might fail to understand fully the difficult and complex problems facing management. Unfocused, imprecise complaints about job dissatisfaction are not sufficient to enable busy decision makers to perceive that a real problem might exist. In any case, the lack of specificity is a communication failure.

Finding 4b: The Labor-Management and System of Care Project Teams are appropriate vehicles for error-free and timely dissemination of information throughout this geographically far-flung Department.

Recommendation 4: Staff should take pains to assure that the complaints they voice and the recommendations they make are real, specific, and appropriately directed. Management, in turn, should create a climate that encourages candor and assures that every complaint or recommendation is given attention and follow-up. Staff members should extend a climate of good will to new management and, particularly important, should allow sufficient time for new management to form an agenda to address problems. A climate of patience, openness, and willingness to listen should be demonstrated from the start by staff and management.

Finding 5a: Heavy caseloads were reported and appear to be a major source of staff concern:

Finding 5b: The interdisciplinary System-of-Care Project Team is well suited to research and propose a comprehensive plan that addresses some of the broader issues involved in high case loads. This should help to assure that those served by ADMHS —within the resources available—receive quality services in a timely manner.

Recommendation 5a: Assessments done by ADMHS professionals in the Main Jail for the Mental Health Treatment Court (MHTC) should be aligned with the types of assessments done in the Long-Term Treatment clinics.

Recommendation 5b: The caseload situation, specifically as a result of the MHTC, needs to be assessed by management or, preferably, by the System-of-Care Project Team. Management should recognize that a perceived problem is a real problem. It is not enough to try to prove that the caseload is manageable if many members of the clinical staff are having trouble dealing with their caseloads.

Finding 6: Most clinicians favor a return to the four-person intake team, which was abandoned in favor of the change to a call-in (1-800) client-intake access system in which prospective clients are interviewed and triaged by telephone. A call-in system omits information that would be obtained by seeing the client and noting facial expressions, body language, demeanor, dress, hygiene, stress-level, etc.

Recommendation 6: Management should return to the four-person intake team as a more effective way of assessing clients and distributing work.

Finding 7: Having to share offices impedes clinicians’ counseling efforts and could compromise clinician-client confidentiality.

Recommendation 7: This problem must be resolved by providing private interview areas, if not private offices, that are available for all interviews at all times.

 

Finding 8: Many clients have difficulty finding their way to the centralized mental health facilities.

Recommendation 8: ADMHS should locate some satellite counseling sites in downtown Santa Barbara and Santa Maria that are closer to where clients live.

Finding 9a: Too much paperwork is a universal complaint because clinicians feel that they need to spend more time with their clients.

Finding 9b: Despite all the paperwork, client information is not readily available to assist a clinician in designing urgently needed services.

Recommendation 9a: Redundant data collection should be minimized.

Recommendation 9b: Patient data, respecting all confidentiality laws, should be easily available to those professionals who need to provide urgent client care, and appropriately authorized professionals system-wide should have access to client data both during and outside of regular clinic hours, especially at the Jail.

Finding 10: Reimbursement problems created in the budget might have been avoidable if there had been a way to cross-check service data between Departments prior to submitting the services information to the State, or any other granting agency.

Recommendation 10: ADMHS Management should undertake data sharing with other Departments partnered in client services to assure that the most accurate information is being used to design client services and to create reports.

Finding 11: Staffing vacancies in ADMHS add to the casework overload of the current staff.

Recommendation 11: In addition to staff recruitment, proposals on caseload redistribution developed by the Labor-Management and System of Care Project Teams should be evaluated and, if found to be useful, implemented.

Finding 12a: There has been a lack of management commitment to job training and career advancement for the staff.

Finding 12b: A career path to supervisory positions may be unavailable to most of the staff due to what appears to be a requirement to have supervisory experience in order to qualify for a supervisory position.

Recommendation 12a: Management should encourage staff to advance professionally, increase their knowledge, and keep up-to-date via courses, seminars, workshops, and related activities.

Recommendation 12b: In combination with the restructuring of ADMHS, efforts introduced by the Labor-Management Project Team are valuable toward addressing employee career advancement concerns. These include the evaluation of grades within the clinical classifications and by the addition of working supervisor assignments within the clinics. These efforts should continue to be supported and advanced by management.

Finding 13: No incentives are provided to recruit staff members proficient in needed foreign languages.

Recommendation 13: In view of the ethnic makeup of the communities being served, the recruitment and retention of adequate numbers of clinicians fluent in languages in addition to English should be made a priority.

Finding 14: Many clinicians don’t understand Department funding, funding mechanisms, and funding planning, and are uninformed about the long-term and near-term planning of ADMHS.

Recommendation 14a: New management must find ways to explain ADMHS financing so that it is readily understood. The leadership in the Labor-Management and System-of-Care Project Teams should educate colleagues as the new system of care is designed.

Recommendation 14b: The System of Care Project Team should ensure that all stakeholders have an opportunity to review and comment on their work before final recommendations are made.

Finding 15: Three specific challenges face the new ADMHS Director:

Recommendation 15: The new Director should enlist the support of all employees as well as the Labor-Management and System-of-Care Project Teams in dealing with these important issues.

Finding 16a: ADMHS has contracted with the Auditor-Controller to provide fiscal management services.

Finding 16b: While fiscal matters are important, the mission of ADMHS is the delivery of mental health services within the county.

Recommendation 16a: Complete the work that remains to be done to streamline financial processes for clinical staff and to increase the accuracy of records and billings.

Recommendation 16b: Before any reductions in programs are proposed, the restructuring and streamlining of the Department should be allowed to go into operation and take hold.

Finding 17: The need to upgrade ADMHS facilities, especially the Psychiatric Health Facility (PHF), is one of Santa Barbara County’s most pressing space problems. Recommendation 17: ADMHS facilities need to be evaluated and immediate action taken to recondition or replace existing buildings as necessary.

Finding 18: The public has little knowledge of the work done by ADMHS and how this work benefits the community.

Recommendation 18: The public should be made aware of the efforts of ADMHS via better public relations efforts that take advantage of all media. Publicity could be obtained through efforts to involve civic organizations, social service groups, and philanthropic organizations committed to the best interests of the people of Santa Barbara County.

Finding 19a: Thus far, the Alcohol/Drug services component of ADMHS has been poorly integrated into the Department’s mental health system of care.

Finding 19b: The dually diagnosed comprises the largest single group of clients in ADMHS.

Finding 19c: Based on the SEARCH survey, and managerial and staff interviews, the dually diagnosed is a client group on which more focus should be placed.

Finding 19d: The System-of-Care Project Team is chartered to identify and address the needs of the community and to assess the resources of the Department to design appropriate programs. The assessment will necessarily include the Alcohol Drug Programs.

Recommendation 19a: The expertise of experienced alcohol and drug therapists in the County should be incorporated in the design of a comprehensive system of care. Such a system should particularly address the needs of dually diagnosed individuals.

Recommendation 19b: ADMHS management and the commissions (Mental Health and Drug & Alcohol) must continue to embrace and support the work of the System-of-Care Project Team, and fully commit to implementing its recommendations.

Finding 20: A sustainable system of care cannot be designed and funded without clearly defining the clients who are to be served. Client definition (e.g., dual diagnosed, acute only, preventive services, etc.) is the foundation on which all administrative decisions should be based.

Recommendation 20: The system of care, and the funding to support it, should be consistent with the definition of the client. In order for the system to be sustainable, there must be uniform understanding of who ADMHS is expected to serve, what services will be provided, how those services will be provided, and how those services will be funded.

Finding 21: Comprehensive plans and projects, specifically SEARCH and the Five-Year Plan for Adult Services, took a substantial amount of professional time and energy to create. Leaving them "on the shelf," costs taxpayer money and leads to staff frustration.

Recommendation 21: The County Administrator and the Board of Supervisors should monitor, on a regular basis, specific ADMHS plans and the adherence to and progress of such plans. Some internal ADMHS mechanism, perhaps an evolution of the Labor-Management Project Team, should be involved.

 

AFFECTED AGENCIES

Alcohol, Drug & Mental Health Services
Findings All
Recommendations All

County Administrator
Findings 1b, 1c, 4a, 4b, 9b, 10, 14, 16a, 16b, 19a, 19b, 19c, 19d, 21
Recommendations: 1, 2, 3a, 3b, 5b, 9a, 9b, 10, 11, 12a, 12b, 14a, 14b,15, 16b, 19a, 19b, 20, 21

Board of Supervisors
Findings 1b, 1c, 2, 5b, 6, 7, 8, 9a, 10, 16a through 21
Recommendations 1, 2, 3a, 3b, 6, 7, 8, 9b, 10, 16b, 17, 18, 19b, 20, 21

Auditor-Controller
Findings 10, 16a, 16b
Recommendations 10, 16a, 16b

General Services
Finding 7, 8, 17
Recommendation 7, 8, 17


1 Some of the information from the Survey is set forth in the Appendix to this Report.

 

APPENDIX

The survey discussed in the Introduction to this report was created by the Service Employees’ International Union (SEIU) to poll the Adult Services Clinical Staff of ADMHS. Workers at Lompoc, Santa Maria, and Santa Barbara, and the Psychiatric Health Facility were asked a number of questions about their work environment, paperwork requirements, job satisfaction, burn-out, their future with the Department, whether their job is do-able, opportunities for growth and promotion, etc. Possible answers ranged from Strongly Agree to Strongly Disagree.

Of those polled, 49 individuals, or 59%, of 83 employees responded. (Not all departments or administrative functions were surveyed.) Most who responded disagreed or strongly disagreed that work conditions were acceptable.

To sum up, the survey report noted:

  1. More than 50% of the staff indicated they do not feel there is adequate administrative support in the area of transportation, and 67% do not feel adequately supported in the areas of work environment and paperwork.
  2. Almost 67% disagreed or strongly disagreed that administration is responsive to staff concerns.
  3. Almost 75% disagreed or strongly disagreed that administration makes patient care a priority and supports them in their work.
  4. 82% indicated that they do not feel that administrators understand the clinician’s job or are adequately concerned about clinical workloads.
  5. 60% disagreed or strongly disagreed with the following statements:
  6. "I feel hopeful regarding my future with this agency."

    "I do not feel overwhelmed; my job is do-able."

  7. 63% feel that they could be in danger of "burn-out."
  8. 88% feel concerned about their co-workers level of stress on the job.