Health Services. Purpose. Major Budget Changes. F-12 County of San Joaquin Proposed Budget. Health Care Services Director

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1 Greg Diederich, Health Care Services Director Mental Health & Increase/ Substance Abuse Fund Actual Approved Requested Recommended (Decrease) Expenditures Salaries & Benefits $6,057,625 $7,222,097 $7,549,663 $7,549,663 $327,566 Services & Supplies 8,781,360 9,325,382 13,476,205 13,476,205 4,150,823 Fixed Assets 23,152 51, , , ,850 Total Expenditures $14,862,137 $16,598,629 $21,685,868 $21,685,868 $5,087,239 Expenditure Reimbursements (1,737,121) (1,645,472) (2,125,766) (2,125,766) (480,294) Total Appropriations $13,125,016 $14,953,157 $19,560,102 $19,560,102 $4,606,945 Earned Revenues By Source Fines/Forfeitures/Penalties $210,000 $325,000 $450,000 $450,000 $125,000 Interest/Rents Aid from Other Governments 10,175,028 9,207,432 10,075,854 10,075, ,422 Charges for Services 3,851,285 3,969,550 7,495,298 7,495,298 3,525,748 Miscellaneous Revenues 344, , , , ,775 Operating Transfers In 0 500, , ,000 (250,000) Fund Balance (2,010,034 ) Total Revenues $12,570,741 $14,398,882 $19,005,827 $19,005,827 $4,606,945 Net County Cost $554,275 $554,275 $554,275 $554,275 $0 Allocated Positions Temporary (Full-Time Equivalent) Total Staffing Purpose Although counties are not required by law to provide substance abuse prevention and treatment services, if a county chooses to provide stich services, various State and Federal regulations control its operation. State law mandates a 10% county match of State-provided funds. Federal law mandates that 20% of the Federal funds be spent for prevention, 10% for perinatal services, and 5% for pre and post counseling for injection drug users. Major Budget Changes Salaries & Employee Benefits ~ ($41,994) Negotiated salary and benefits adjustments primarily due to a change in budgeting health insurance premiums from average position costs to actual enrollment. ~ $123,744 ~ $167,613 ~ $58,029 ~ $20,274 Services & Supplies ~ $3,754,563 ~ $172,878 A Substance Abuse (SA) Counselor and Mental Health Outreach Worker added midyear Add a SA Counselor and a Mental Health Clinician. Transfer a SA Counselor from Alcohol/Drug Alternative Program (ADAP). Increase in extra-help. Increase in Methadone maintenance providers and treatment services. Increase in Behavioral Health and Health Care Services Administration F-12

2 ~ $179,770 ~ ($41,861) ~ $82,672 Fixed Assets ~ $310,000 ~ $150,000 ~ $200,000 Expenditure, ~ $325,079 ~ $152,699 Revenues ~ $3,630,127 Increase in operating and supply Decrease in rent and facility-related Cost Allocation Plan adjustment. Residential Reimbursements dorms remodel. Replace modular office. Replace modular group rooms. Increase in reimbursement from Mental (MHS) and Human Services Agency (HSA) for substance abuse counseling and treatment. Reimbursement from Sheriff's Office for Byrne-Justice Assistance Grant (JAG)-related expense. Increase in State Medi-Cal and Federal Drug Medi-Cal revenue. ~ $626,736 Increase III 2011 Realignment funding. ~ $196,489 Increase in State-grant funding. ~ $338,775 Increase in contract outpatient services. ~ ($78,879) Decrease III court-ordered and patient fees. ~ $150,000 Increase III drunk driving fine transfer from Statham Trust. ~ ($250,000) Decrease in Realignment transfer frommhs. Program Discussion The recommended Substance (SAS) budget totals $21,685,868, which is an increase of $5,087,239 from The increase is primarily due to increases in Narcotic Treatment Program (NTP) Drug Medi-Ca1 contrac;:tsand changes to the Substance Use Disorder agreement with the State Department of Health Care Services (DHCS), full-year funding of two positions added midyear , and the addition of three positions in In , the State Budget Act realigned several programs and the revenue to support those programs. As a result, Drug Medi-Cal treatment providers who were reimbursed by the State are now Workload Data Actual Est./Act. Projected ; Prevention Activities Schools Contacted Students Contacted 3,898 4,655 6,854 6,000 7,0'00 Organizations Contacted Individuals Contacted TreatlnentServices Recovery House-Admissions RecovelY House-Client Days 12,438 12,447 14,968 19,008 21,600 Family Ties-Admissions amily Ties-Client Days, 9,093 9,731 9,809 11,556 12,134 Central Intake Referrals 1,560 1,336 1,644 1,780 2,047 Chemical Dependency Counseling Center Intakes ', F-13

3 reimbursed through the County utilizing realigned State sales tax revenue. The recommended budget adds three positions: ~ A SA Counselor ~ A Mental Health Clinician ~ Transfer a SA Counselor from ADAP In , two positions were added midyear for the JAG grant to provide substance use disorder treatment to youth including engagement and support services for the client and family. The position transferred from ADAP will provide services in Recovery House, which will be funded by Substance Abuse Prevention and Treatment (SAPT) block grant. Drug Medi-Cal Organized Delivery System The DHCS proposed an amendment to the California section 1115"Bridge to Reform" Demonstration Waiver. The Drug Medi-Cal Organized Delivery System (DMC-ODS) 1115 demonstration waiver provides a continuum of care modeled after the American Society of Addiction Medicine (ASAM) criteria for substance use disorder treatment services. The waiver will improve the. DMC service delivery system, with more local control and accountability. It will include evidence-based practices in treatment and coordination with other systems including health care. The intent is to demonstrate how organized substance abuse treatment increases the success of beneficiaries while decreasing other health care The DMC-ODS is a benefit for individuals who meet medical necessity criteria and are county residents. This will provide for access with the use of a fee-for-service model. The amendment will include tools and means, for efficiencies to manage Without these tools and means the fee-for-service system currently used exposes most counties to an unacceptable level of financial risk. Narcotic Treatment Programs (NTP) As a result of the 2011 Realignment, counties are now responsible to pay Drug Medi-Cal treatment providers, including utilization monitoring and claims processing, with realigned State sales tax revenue. In , SAS entered into Drug Medi-Cal contracts with providers that were previously managed by the State. Most of the Drug Medi-Cal contracts are with providers of NTPs, the most costly of the Drug Medi-Cal services. The Governor's budget included a State Plan amendment that adjusted the fee-for-service Drug Medi-Cal program to include reimbursement for managing administrative Three substance abuse treatment providers in San Joaquin County provide Drug Medi-Cal funded narcotic treatment services. All three providers have experienced a 50% increase over the level of services projected for The increase in services has resulted from a high number of clients becoming eligible for Medi-Cal benefits under the Affordable Care Act and the State's approval of 175 new NTP slots within the County. The DHCS is responsible for reviewing and approving requests for service increases by Drug Medi-Cal providers. The recommended budget includes an increase of $3.7 million in NTP Drug Medi-Cal contracts of$9.8 million. Residential Treatment The DMC-ODS waiver, if approved, is anticipated to implement in the Central Valley in Phase III of the California implementation. It is unclear if this will occur in Once implemented, this will permit DMC billing at the residential programs to beneficiaries other than pregnant/postpartum and make them operable with no bed capacity limit. The residential programs currently are funded with SAPT block grant. Recovery House and Family Ties receive referrals from Probation, Parole, Child Protective Services, MRS, Cal- WORKs, and self-referral. Recovery House is licensed for men and women. Family Ties is a perinatal program for women and their children. Both residential programs provide treatment and transitional services, and collaborate with other agencies. Family Ties is a six-month program. However, it can be extended up to 60 days based on the clients needs. The DHCS restored the 2014 SAPT block grant award after the sequestration reduction to the Federal Fiscal Year 2013 award. The recommended budget includes $3.2 million in SAPT block grant funding. Outpatient Treatment Programs The Chemical Dependency Counseling Center (CDCC) serves adults, youth, and pregnant or parenting women (perinatal). The CDCC perinatal component has experienced a slight decrease in referrals from Dependency Drug Court and/or Child Protective Services for pregnant substance abusing women. In previous years, these two agencies included a payment agreement with the referral document. Now the majority of clients are responsible for covering the cost of treatment services, possibly through use of Drug Medi-Cal. The screening and assessment process identifies the level of treatment the pregnant woman may need taking into consideration other family dynamics. Some. women are referred to outpatient services but if a more intensive level of treatment is necessary, a referral to residential treatment is given. CDCC is moving towards reinstatement of the Intensive Outpatient Program (lop) at CDCC. This would be a Drug Medi-Cal reimbursable program and would enhance the F-14

4 continuum of care between less intensive outpatient groups and residential treatment. lop was previously provided, but put on hold due to program cutbacks and reduced staffing. The reinstatement of lop is estimated to generate an additional $145,000 in Drug Medi-Cal funding. California Work Opportunity & Responsibility to Kids (CaIWORKs) Program The San Joaquin County CalWORKs Behavioral Wellness Clinic continues to provide substance abuse services to CalWORKs clients who are experiencing symptoms of drug and alcohol abuse, which negatively impact their ability to obtain and retain employment. The SA Counselors provide assessment, testing, educational, and treatment opportunities to this population. The SA Counselors work closely with the clinic's Mental Health Clinicians to provide group therapy. Two Seeking Safety groups continue to be offered to CalWORKs clients who are assessed as able to benefit from this particular group. Developing further opportunities for serving those with co-occurring disorders are a focus in this integrated system of service delivery. The SA Counselors assist HSA Case Managers with home visits and provide assessments and referrals to inpatient and outpatient substance abuse treatment programs. The SA Counselors are out-stationed a few days a week at various El Concilio sites and the Lao Khmu site. In addition, a SA Counselor provides drug testing and referral services for the HSA Dependency Drug Court. Prevention Services Prevention Services offers the following programs and services, which are targeted towards substance abuse prevention and mental health awareness: ~ Alcohol and Kids D01~'t Mix - This communitybased education program is a five session program that provides education about and stresses the importance of not drinking during pregnancy and while raising children. ~ Project Towards No Drug Abuse (TND) - This 12 session interactive classroom-based substance abuse prevention program is designed for senior high school students. Project TND focuses on three factors that predict tobacco, alcohol, and other drug use, violence-related behaviors, and other problem behaviors among youth including motivational factors, skills, and decision-making. ~ Project ALERT - Project ALERT is a substance abuse prevention program designed for seventh and eighth graders. This program is delivered in 14 sessions. The core curriculum stresses motivating nonuse, identifying pressures to use drugs, learning to resist those pressures, practicing resistance skills, a review of the key concepts, inhalant abuse, and smoking cessation. The booster lessons are designed to build on the core curriculum by covering motivating resistance to drugs, practice resisting internal and external pressures to use drugs, and benefits of resisting drugs. Activities, audiovisual materials, handouts, and student homework assignments are part of the curriculum. ~ Too Good for Drugs - This is a school-based prevention program for kindergarten through eighth grade that builds on students resiliency by teaching them how to be socially competent and autonomous problem solvers. ~ Speaker's BureaulHealth Fairs - Prevention Services staff sets up booths at local health fairs and events to provide information to the community on substance abuse prevention, specific drugs and their effects, and mental health awareness. Staff is also available to speak at public engagements and to classes. Presentations can be tailored to meet specific needs and requests of a certain audience. ~ Friday Night Live/Club Live - The San Joaquin Friday Night Live Partnership is made up of 15high school chapters and 11 primary school chapters (sixth through eighth grade) working in partnership with adults. ~ Students in Prevention (SIP) - The SIP program began in 1979 as a peer-to-peer alcohol prevention program. Its main focus is to prevent alcohol use by teenagers. Approximately 50 high school students are employed each year representing 22 high schools. Each SIP student provides a minimum of one monthly classroom presentation in local grammar schools. ~ SIP Transitional Age Youth (STAY) - This project began in 2011 as an extension of the SIP program. The objective was to have college-age young adults serve as peer educators on the topic of substance use prevention and mental health awareness. ~ Yellow Ribbon (YR) - This is a suicide prevention program offered to participating high schools. The STAYteam trains a group of students who provide YR presentations to their campus population. Further, the high schools identify adults on their campuses who serve as extra support when students conduct presentations on their respective campuses. F-15

5 ~ Red Ribboll Celebratioll - San Joaquin County began celebrating Red Ribbon in the 1990s and today prevention staff provides local school districts with support through drug-free activities for youth and their families. School districts are encouraged to purchase drug-free wristbands and promote Red Ribbon activities on their school campuses. Prevention Services offers support by providing guest speakers for school assemblies and arranging for Red Ribbon Week activities. F-16