Measure O Annual Update

There is a Dec 10^th Report to the Board of Supervisors from the Department of Health Services titled ” Measure O Update for Fiscal Year 2023-2024” which updates them on the progress of Measure O, our sales tax-funded Behavioral Health and Homeless Community Solutions Initiative.

Executive Summary: The Sonoma County Board of Supervisors requested an update on Measure O during the June 2024 Budget hearings. This update covers fiscal year 2023-2024 expenditures by category; estimated fund balance for fiscal year 2024-2025 and fiscal year 2025-2026; and provides a review of outcomes and numbers served from last fiscal year. Additionally, staff will highlight Measure O successes and discuss the approach for current and future Measure O funding.

Discussion: In November 2020 Sonoma County voters passed Measure O to provide essential funding for mental health and homeless services with 68.07% of the vote. Measure O, a one-quarter cent sales tax, was estimated to generate over $25 million each year for ten years to help protect essential mental health and homelessness services.

The Measure O Sales Tax Ordinance identified five categories of services to be funded with the revenue: 1) Behavioral Health Facilities, 2) Emergency Psychiatric and Crisis Services, 3) Mental Health and Substance Use Disorder Outpatient Services, 4) Homeless Behavioral Health and Care Coordination, and 5) Transitional and Permanent Supportive Housing. The Measure O Expenditure Plan designates a set percentage of funding for each category.

On December 7, 2021, the Board of Supervisors established a Citizen’s Oversight Committee to monitor the implementation of Measure O. The Citizen’s Oversight reviews expenditures for alignment with the intent of the Measure and does not make or recommend funding decisions.

On October 23, 2024, the committee voted to confirm that the Measure O expenditures for Fiscal Year 2023-2024 met the intent of the measure. This past fiscal year was the 3rd full year of Measure O funding. Tax revenues for the year again exceeded the initial projections made when voters considered Measure O. Tax receipts totaled $32 million as opposed to the initially projected $24 million (total revenues including interest and unrealized gains was $34.2 million) The surplus has provided capacity to pursue expanded opportunities within the established categories to support our community.

For Fiscal Year 2023-2024, below are the Measure O funds used/spent by category: · Behavioral Health Facilities: $7,055,539 · Emergency Psychiatric & Crisis Services: $12,425,458 · Mental Health & Substance Use Disorder Outpatient Services: $1,275,496 · Behavioral Health Homeless & Care Coordination: $7,842,652 · Transitional & Permanent Supportive Housing: $3,345,616 The total projected Measure O revenue for FY 2024-2025 is $32,865,501.

In FY 24/25 a total of $66.2M of Measure O resources are available for programming, financed with $33.3 in fund balance and $32.9M of total revenues. The approved FY24-25 budget includes $37.5 million in expenditures for Measure O. The Department will be seeking $10.2 in additional appropriation in FY 2024-2025 Q4. Given the total planned expenditures of $47,739,541 for FY 2024-25 budget, the ending fund balance in June is projected to be $18,478,541.

Details of the various expenses by categories with additional information can be found in Attachment A Presentation.

The Mobile Support Team and Crisis Assessment Prevention and Education described below highlight recent updates from the Measure O-funded Mobile Support Team (MST) and Crisis Assessment Prevention & Education (CAPE).

· In December 2022, California Department of Health Care Services (DHCS) established a new Medi-Cal benefit providing 24/7/365 community-based mobile crisis intervention services to those experiencing a behavioral health crisis. On April 16, 2024, county staff launched Sonoma County’s 24/7 call center and a revamped Mobile Support Team (MST) to meet this need. The MST is partnering with SAFE (which serves Petaluma, Rohnert Park, Cotati and Sonoma State University) and inRESPONSE (which serves Santa Rosa)) to provide countywide coverage. The Sonoma County 24/7 call center and revamped MST is available to all Sonoma County residents regardless of insurance status. An additional $5M in Measure O funds are being held for contingencies from potential MST expansion based on future county and Regional Model City needs. The actual draw on the fund balance will be recalculated based on Federal Financial Participation action receipts from the Medi-Cal program.

· Crisis Assessment Prevention & Education (CAPE). CAPE provides school-based behavioral health support and interventions to schools in Sonoma County. Four mental health teams are strategically located across the county. CAPE is reinstituting in-person response to students experiencing behavioral health crisis and linking students to substance use disorder treatment services for to youth and young adults.. The program is active and expanding, providing services such as: direct linkage to County Behavioral Health services and navigating other health insurance to connect to treatment; substance use and suicide prevention and early intervention – educational presentations and campaigns, linkage, and referral; and peer support and groups. In the 2024-2025 school year , CAPE will be partnering with these schools: Analy High School and Laguna High School in West County; and Sonoma Valley High School, Creekside High School, Adele Harrison Middle School, Alta Mira Middle School, and Hanna Boys Center in the Sonoma Valley.

Successful Outcomes from Measure O

The Psychiatric Health Facility (PHF) has continued to operate at its full capacity of 16 beds, serving over 150 individuals annually due to Measure O funding.

The Crisis Stabilization Unit (CSU) served nearly 1,000 individuals and was also able to continue operations at full capacity due to Measure O until the current temporary closure due to facility issues. The Mobile Support Team has expanded into a Regional Collaboration that utilizes exciting new approaches to crisis response.

Measure O has also laid the groundwork for new programs launching this year, including CAPE, additional support for the Valley of the Moon Short Term Residential Treatment facility, and the expansion of Medi-Cal drug service.

This year also saw the finalization of incorporating Homelessness Services into DHS with Measure O providing 100% of funding for the Homeless Encampment Assistance and Resource Team (HEART) and Solving Obstacles for Unsheltered Lives (SOUL) programs, and a significant amount of funding ($4.2M) for George’s Hideaway. The George’s Hideaway project is a Permanent Supportive Housing (PSH) Project Homekey site near Guerneville. Measure O funds were used to support site renovation (including planning, water/sewer, and demolition work) under oversight of the Community Development Commission (CDC). This site will provide supportive care including therapy, substance use disorder care, benefit navigation, job training and life skills.

Also, in September of this fiscal year, the funds allowed for the release of the Measure O: Behavioral Health & Homelessness Community Solutions Notice of Funding Availability (NOFA) in the amount of $5.6 million, including $4.2 of Measure O funding and $1.4 million in Homeless Housing, Assistance and Prevention (HHAP) funding. The NOFA is open to applications from interested parties, community partners and any other local government agencies. The NOFA covers multiple program areas within each Measure O category with a specific focus on areas of identified need including on service navigation, staffing shortages, education/training and upstream approaches, peer support, individual and family counseling, and cultural competence. Additionally, the HHAP portion of the NOFA prioritizes permanent supportive housing, rapid rehousing, emergency shelter (congregate and non-congregate), street outreach, capital expenses for permanent supportive housing or enhancing existing emergency shelter projects for privacy, and lastly, operating subsidies for permanent supportive housing and rapid rehousing.

To determine priorities and opportunities for strategic application of Measure O funding in the future, department leadership plans to conduct a detailed budget and program analysis and identify areas where Measure O funding could be used and where other funding sources could be leveraged. The goal is to separate annual, recurring commitments from the projects where funding could be shifted as they mature and/or become self-sustaining.

The remaining Measure O funding would be a mix of unallocated fund balance and expected revenues. Staff plans to release a recurring Notice of Funding Availability (NOFA) for which Community Based Organizations and local government partners could apply. Through an open application process, a Community Advisory Panel will be selected to help review NOFA proposals and make recommendations to the Board for final approval. Staff will present the outlines of this proposal to the Board for further guidance and direction at the Board meeting.

https://sonoma-county.legistar.com/LegislationDetail.aspx?ID=7040199&GUID=50628097-0FF6-49E5-AB44-8607A01F14CB

Pretrial Transitional Housing and Case Management Agreement

Recommended Action:

A) Authorize the Chief Probation Officer to execute a professional services agreement with Interfaith Shelter Network, Inc. (IFSN) for the initial term December 1, 2024, through November 30, 2027, in the amount of $2,105,870, and to execute up to two one-year renewal options for a maximum five-year agreement value of $3,691,122 in addition to amendments that do not exceed $50,000 per year or otherwise substantively change agreement.

B) Authorize the Chief Probation officer to retroactively amend the current agreement expiring 11/30/24 with Interfaith Shelter Network by $135,000 for a maximum five-year value of $2,235,000.

Executive Summary:

The Probation Department requests Board approval to execute a professional services agreement with IFSN to provide services for individuals on pretrial release who are homeless and have mental illness or co-occurring mental illness and substance abuse disorder. Such individuals pose difficult challenges to the courts because while the crimes for which individuals are charged might not warrant incarceration while awaiting trial, their mental health and living conditions increase their likelihood of committing new crimes, failing to appear in court, causing harm to themselves, or being victimized in the community. To reduce these risks, courts may require such individuals to remain incarcerated until adjudication. The continuing services proposed under this agreement provide the courts a viable alternative to incarceration whereby individuals on pretrial release can remain safely in the community and receive supportive housing and intensive case management. Overall program goals are to reduce unnecessary incarceration and associated costs, provide treatment and services to improve outcomes of justice system-involved individuals, and increase public safety.

Additionally, the Probation Department requests a retroactive increase of $135,000, bringing the 5-year maximum agreement value to $2,235,000. When the contract was originally prepared in 2019, inflation was estimated to be 3 percent per year. However, the CA Consumer Price Index for All Urban Consumers has averaged 4 percent per year for the past 5 years. In addition, rent, utility, insurance, and living wage increases have contributed to the increase. These updated costs have been programmed into the agreements and contracts within the Community Corrections Partnership’s FY 24-25 budget.

The Sonoma County Community Corrections Partnership (CCP) and Measure O allocate funding for this program and have approved the FY 24-25 expenses. Future funding will depend upon continued CCP approval and Measure O funding.

Discussion:

Background

In 2016, the U.S. Department of Justice released a competitive grant for the Justice and Mental Health Collaboration Program (JMHCP). Sonoma County was awarded $250,000 for a three-year project to improve public safety and serve individuals with co-occurring mental illness and substance abuse disorder who encounter the justice system. This grant continued through September 30, 2020 and was expanded upon in 2018 with an additional $750,000 award.

In FY 21-22, upon exhaustion of JMHCP funds, Probation requested partial year funding from the CCP to continue housing and case management for mentally ill individuals on pretrial release. In FY 22-23, CCP funding was expanded to cover the full year and combined with Health Services allocation of Measure O funds for case management. The CCP and Measure O have continued to fund pretrial housing and case management, and the CCP has allocated funding for this program as part of FY 24-25 expenses. Future funding will depend upon continued CCP and Measure O approval.

Request for Proposals

The Probation Department issued a Request for Proposals (RFP) announcement in August 2024, which was distributed to 714 suppliers as well as 2,200 notifications to subscribers on Purchasing’s RFP posting list. The RFP sought proposals from organizations that could provide eight or more supportive housing beds along with case management services to individuals with mental illness on pretrial release. Additionally, the RFP requested an array of supportive services to help individuals on pretrial release stabilize their lives, such as permanent housing assistance, enrollment in health care, and job search assistance. Finally, the RFP required that the successful organization develop a quality assurance and outcome reporting plan to ensure high service standards and to help stakeholders determine program performance.

Sonoma County received proposals from IFSN and Committee on the Shelterless (COTS). A panel of representatives from the Probation Department and the Department of Health Services rated the proposals using clear criteria such as qualifications and experience, staffing, program services, and cost of service.

While both IFSN and COTS presented viable programs, the panel rated IFSN more highly based on the alignment of program services offered with the County’s needs, the ability to provide uninterrupted services, and the cost to provide services. Additionally, the COTS proposal included community-based case management only, while IFSN offers transitional housing, case management for house occupants, as well as community-based case management.

Based on its proposal review, the panel recommends awarding supportive housing and case management services to IFSN.

Program and Scope Overview

Housing: The program will provide an eight-bed housing facility, which has averaged 91 percent occupancy for the last 12 months, and support individuals with mental illness or co-occurring mental illness and substance abuse disorder maintain stability on pretrial release and achieve better outcomes. Desired outcomes include participants not committing new offenses, making their court appearances, and complying with court orders, and, post-adjudication, being better prepared to live successfully in the community. The broader goals are to enhance public safety, rehabilitate individuals in the criminal justice system, and reduce unnecessary incarceration.

Case Management: A case manager working outside the jail will support participants during the pretrial process, including accompanying them to court. This case manager will work closely with a case manager in the jail to ensure that information regarding participant needs is included in the planning process, and that those selected for the program benefit from a warm handoff and avoid service gaps. Additionally, a case manager will work on site at the supportive house to help participants connect with stabilization services, obtain medication, address health issues, and other related activities.

Quality Assurance: IFSN will collaborate with the Probation Department to develop and implement quality assurance and data collection plans to ensure high-quality program implementation and allow the Probation Department to evaluate program performance.

Conclusion

This program intends to promote public safety, improve outcomes, and reduce costs for justice-system-involved individuals with mental illness. Commonly, this population ineffectively-and expensively-accesses multiple community services, including police and fire first responders, hospital emergency departments, mental health crisis services, and jails. Most treatment is short-term and non-rehabilitative, resulting in repeated cycles through these services. By providing stable housing, intensive case management, and 24-hour monitoring, this program intends to break the cycle.

Behavioral Health Services Staffing Allocation Request to BOS on Dec 3rd

Recommended Action:

A) Adopt a personnel resolution amending the Department Allocation List of the Department of Health Services, adding 2.0 full-time equivalent Behavioral Health Clinician positions and 1.0 full-time equivalent Senior Client Support Specialist, effective December 3, 2024.

B) Adopt a Resolution authorizing budgetary adjustments to the fiscal year 2024-2025 adopted budget, increasing appropriations in the Department of Health Services by $468,207 to reflect revenue and expenditures associated with the requested position allocations.

(4/5th Vote Required)

Executive Summary:

As part of our response the California Department of Health Care Services’ Corrective Action Plan, Department of Health Services (DHS) management requests the addition of 2.0 full-time equivalent (FTE) Behavioral Health Clinician position allocations for the Behavioral Health Adult Access Team (not to be confused with ACCESS – Accessing Coordinated Care and Empowering Self Sufficiency – which is a separate program of the same name located in the Homelessness Services Division). These positions will provide Behavioral Health Assessments, case-management, and referrals for clients requesting services through the Access Team.

Additionally, the Youth and Family Services section of the Behavioral Health division within DHS is requesting approval from the Board to add 1.0 FTE Senior Client Support Specialist (SCSS) to staff the mandated Child and Family Team Meetings for youth who qualify for Intensive Care Coordination and Intensive Home-Based Services. These positions will leverage Medi-Cal Federal Financial Participation and Medi-Cal Administrative Activities, with approximately 50% matching funds provided by the Mental Health Services Act (MHSA).

Discussion:

Access Team – 2.0 FTE Behavioral Health Clinicians

The Behavioral Health Adult Access Team under the Adult Services unit is the first contact for clients requesting mental health services and are responsible for providing initial assessment and case-management services for clients requesting services with Behavioral Health. Access team assessors determine the level of need for mental health services, provide assessment, linkage, and information and referral for mental health services for children, youth, and adults. Clients qualify for different levels of care based upon these assessments.

The California Department of Health Care Services (DHCS) requires that the initial service appointment for new clients be offered within 10 business days of request. The current volume of requests has exceeded the existing capacity of the assessors and is resulting in timeliness issues, with some requestors waiting 6 weeks for their initial assessment. DHCS issued a Corrective Action Plan (CAP) on 4/26/23 regarding this issue during DHS’ last annual network certification; but despite adding additional 1.5 FTE of case-management coverage on the team in the Spring of 2024, the volume continues to exceed assessor capacity. DHCS issued a new CAP finding on 10/7/24, identifying timeliness to services as the leading issue.

Additionally, DHS has been approved to implement the Drug Medi-Cal Organized Delivery System (DMC-ODS) waiver starting in December. Based upon feedback from other bay-area counties, DHS anticipates an initial 50% increase in request volume that will taper off within the first quarter to an average of an ongoing 25% increase in request volume. Currently there are 5.0 Assessor FTEs on the Access Team, and 2.0 Senior Client Support Specialist FTE (to perform case-management). Each Assessor FTE can handle 20 new Assessments per month, plus a 30-member ongoing caseload. The current volume of inquiries is 200 per month, with 75% resulting in Assessment; and is anticipated to increase to an ongoing 175-200 Assessments needed per month after DMC-ODS. As such, DHS is requesting the addition of 2.0 FTE Behavioral Health Clinicians to improve the current wait time concerns, as well as in anticipation of the ongoing increase resulting from DMC-ODS.

This request is also responsive to the programmatic changes necessitated by the California Advancing and Innovating Medi-Cal (CalAIM) directives and the expansion of Substance Use Disorder Services through DMC-ODS.

Behavioral Health Clinicians perform duties which include, but are not limited to, the following: conduct comprehensive assessments to diagnose mental health conditions; develop treatment plans to authorize and guide specialty mental health services; provide emergency interventions in the field; provide a variety of case management and therapeutic support services to clients; may provide transportation, placement assistance, advocacy, and skills coaching for activities of daily living and other client support services; collaborate with other client-serving agencies to ensure the most supportive environment for each client; and perform related duties as required.

Youth and Family Services – 1.0 FTE Senior Client Support Specialist

Child and Family Teams (CFTs) within the Youth and Family Services section of the Behavioral Health division within DHS bring together loved ones and experts to support the child in reaching their potential and are dedicated to helping the family thrive. CFTs draw on a child’s and family’s strengths, experiences, knowledge, and network of support to create a plan for the safety, stability, and well-being of the children and family. The CFT process is intended to be inclusive of multiple formal support systems a family may need, as well as the informal, community, and natural supports that surround a family. CFTs are a required service for foster youth meeting the Katie A subclass, and for children who screen as qualifying for Intensive Care Coordination and Intensive Home-Based Services. These children are the higher needs children serviced by our system, many of whom are involved in multiple systems such as Behavioral Health, Child Welfare, or Juvenile Probation.

DHS is currently on a 2021 Corrective Action Plan with DHCS because the division is not facilitating any Child and Family Team Meetings for youth who qualify for Intensive Care Coordination and Intensive Home-Based Services.

These services are mandated by DHCS as part of the Mental Health Plan, and provide required and mandated Early and Periodic Screening, Diagnostic and Treatment services to youth. DHS has never had staff to provide this requirement. Youth and Family Services will need to provide approximately 1,600 CFTs per year. 1.0 FTE SCSS can provide approximately 350 CFTs per year.

There are not currently any staff available to provide these required and mandated services. Adding this 1.0 FTE SCSS will bring the total SCSS allocated to Youth and Family Services to 2.0 FTE (the second FTE is an underfill using an existing position) and will enable Youth and Family Services to begin providing the required services to children, including foster youth and youth on our Full Service Partnerships; the Family Advocacy, Stabilization and Support Team; and Transitional Age Youth. These 2.0 FTE SCSS will be able to provide close to half the required CFTs. DHS is planning to request addition staff next fiscal year to address the shortfall.