Shasta Health Assessment and Redesign Collaborative (SHARC) Behavioral Health and Substance Abuse Prevention Committee

Shasta Health Assessment and Redesign Collaborative (SHARC) Behavioral Health and Substance Abuse Prevention Committee Behavioral Health Needs Assessment and Gap Analysis Report May 2015 Prepared By: Health Alliance of Northern California Supported By: Blue Shield of California Foundation

Table of Contents EXECUTIVE SUMMARY... 1 ASSESSING BEHAVIORAL HEALTH CARE NEEDS IN SHASTA COUNTY... 2 Needs Assessment Methods... 2 Section I: Documenting the Health Status of Shasta County... 3 Frontier and Rural Demographics of Shasta County... 3 Population Overview... 3 Leading Health Indicators... 4 Section II: Estimating Need for Mental Health and Substance Use Services... 5 Section III: Review of Existing Infrastructure and Services... 7 Specialty Mental Health Services... 8 Inpatient Psychiatric Care... 8 Medi-Cal Managed Care Utilization... 9 Integrated Primary Care and Mental Health Care Services... 9 Provider Capacity for Behavioral Health Services... 13 Substance Use Services... 13 Community Supports and Resources... 14 Section IV. Behavioral Health Service Gaps and Opportunities for Integration... 14 Community Capacity Assessment Conclusions... 15 Appendix: Shasta County Behavioral Health Community Supports Resources List Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 1

EXECUTIVE SUMMARY The Behavioral Health and Substance Abuse Prevention Committee of the Shasta Health Assessment and Redesign Collaborative (SHARC) is conducting a needs assessment to inform strategies for integrating mental health and substance use services into primary care service delivery in the County. This report aims to document the current health status of the Shasta County communities, assess some elements of the existing behavioral health service delivery infrastructure, and identify existing gaps in service access or capacity. This report is intended to inform discussions of the SHARC Behavioral Health and Substance Abuse Prevention Committee and align project planning with community need. Recent needs assessments conducted in the Northern California region have highlighted some of the key demographic and health factors affecting rural communities such as declining school enrollment and aging of the population. These assessments have also illustrated some of the leading health issues impacting the region. Cancer, chronic disease, and behavioral health conditions contribute to higher mortality rates in the county than compared to rates for California. Deaths resulting from suicide and drug-use are more than twice the state rate. To better understand the behavioral health care needs in the county, this report reviewed prevalence estimates for mental health and substance use disorders. In Shasta County, it is estimated that a total of 26,022 individuals of all ages are in need of mental health services. Of these, an estimated 7,333 adults have serious mental illness (SMI), an estimated 3,194 children and youth have severe emotional disturbance (SED), and an estimated 15,495 individuals have other mental health conditions not considered SMI/SED. In addition, it is estimated that 1,494 adolescents and 14,373 adults are in need of substance use treatment services. Capacity for some components of the health care service delivery system was assessed to better understand where gaps in access to behavioral health care exist. Information collected also helps to identify opportunities for integration of behavioral health services in primary care to maximize the use of resources and increase access to care, particularly for low-income populations in Shasta County. Current substance use treatment service capacity is insufficient to meet the estimated need for services. Interviews with the four federally qualified health centers (FQHCs) and a private primary care provider in the county consistently highlighted this need and identified opportunities for integrating services in the primary care setting. Implementation of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model was identified as an initial opportunity to support these efforts to integrate substance use services in primary care settings. Interviews with primary care providers identified opportunities to further integrate mental health services in primary care. Access to psychiatric consultation would support primary care providers and licensed clinicians with diagnosing mental health conditions and treatment planning, including medication management. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 1

ASSESSING BEHAVIORAL HEALTH CARE NEEDS IN SHASTA COUNTY The Behavioral Health and Substance Abuse Prevention Committee (BHSAPC) of the Shasta Health Assessment and Redesign Collaborative (SHARC) is conducting a needs assessment to inform strategies for integrating mental health and substance use services into primary care service delivery in the County. SHARC identified existing needs assessment data and conducted additional data collection activities to inform this report. This report aims to document the current health status of Shasta County communities, assess some elements of the existing behavioral health service delivery infrastructure, and identifying existing gaps in service access or capacity. This report is intended to inform discussions of the SHARC BHSAPC and align current project planning with community need. Needs Assessment Methods The needs assessment report addresses the following questions: How many people in Shasta County are in need of mental health and substance use services? How many people are currently being served by the system? Where are people accessing care? What are the pathways to care for mental health and substance use services (i.e., referral patterns, ER utilization, hospitalizations, etc.) What is the current capacity of the system to address identified needs? Where are the gaps between estimated need for care and current utilization and/or capacity? What types of integration activities are currently happening? What integration strategies should be considered to address identified needs? The needs assessment included multiple data collection methods to obtain answers to the proposed questions. Previous needs assessments reports were reviewed and relevant data on current health status, estimated need or demand for behavioral health services, and supply of services was included in this report. Key informant interviews were also conducted with primary care rural health clinics, community health centers and private providers to explore current needs, utilization trends, referral patterns, and integration efforts within primary care delivery settings. Additionally, a review of community resources was conducted to identify community supports outside of the health care delivery system. The project needs assessment report is comprised of four sections: Documenting the Health Status of Shasta County Estimating Need for Mental Health and Substance Use Services Review of Existing Infrastructure and Services Behavioral Health Service Gaps and Opportunities for Integration Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 2

Section I: Documenting the Health Status of Shasta County Shasta County is located in far northern California. It is approximately 230 miles north of San Francisco and 160 miles north of Sacramento. The land covers 3,785 miles of widely varied terrain, including rural, semi-rural and urban populations. With only 4% of California s population residing north of Sacramento, our terrain is vast, with few population centers, and thousands of miles of barely inhabited wilderness. The county is primarily rural, with only two percent of the land use urban or suburban. This rural portion of the county is sparsely populated, geographically isolated and mountainous, with severe weather conditions that often make roads impassable. The major portion of the county has a population density of less than seven persons per square mile, and includes two areas designated as medically underserved. The City of Redding, with a population of 89,861, is the county seat and population center (U.S. Census, 2010). Frontier and Rural Demographics of Shasta County Shasta County is often described as a rural county. The current population is 177,223, half of which (50.7% based on the U. S. Census in 2010) lives in the city of Redding with another 20,096 (11%) residents along the I-5 corridor in Anderson and Shasta Lake City. The remaining population is disparately spread throughout the county. The official definition of rural in medical care terms is a Medical Service Study Area (MSSA) with a population density of 250 persons or less per square mile and no incorporated area greater than 50,000 persons. The definition of frontier in MSSA terms is a population density equal or less than 11 persons per mile. All of Shasta County, with the exception of the city of Redding, falls into one of these two definitions. Two Medically Underserved Area s (MUA s) comprise the service area, MUA s 00278 and 07334. All areas of the county are designated as a HPSA (Health Professional Shortage Area), except the City of Redding. Population Overview Figure 1. Map of Shasta County The population of Shasta County is aging and predominantly white. The median age of 42 in 2010 is higher than the statewide median age of 34 and has increased over the last decade from a median of 39 years of age in the 2000 Census (U.S. Census Bureau). Approximately 75% of the population is over the age of 25, as reflected in Figure 1 and in Table 1. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 3

Table 1. Shasta County Population, by Age Group, 2010 Age Group Percent of Population Population 0-4 5.8% 10,268 5-14 12.3% 21,931 15-19 7.0% 12,439 20-24 6.2% 11,003 25-44 22.3% 39,524 45-64 29.4% 52,091 65+ 16.9% 29,967 Total 100% 177,223 Source: U.S. Census Bureau, 2010 Census Figure 2. Shasta County Population by Age Group Source: U.S. Census Bureau, 2010 Census 29% 17% 6% 22% 12% 7% 6% Age 0-4 Age 5-14 Age 15-19 Age 20-24 Age 25-44 Age 45-64 Age 65+ More than three-quarters of the population in Shasta County is white (82.4%), compared to California at 40.1%. Although this represents a clear majority, the white population has declined from 86.4% in 2000. The Hispanic or Latino population at 8.4% is significantly lower than the rate for California (37.6%), but has experienced growth over the past decade, increasing from 5.5% in 2000. Leading Health Indicators Table 2. Population by Race/Ethnicity for Shasta County and California, 2010 Race/ Ethnicity Shasta County California White 82.4% 40.1% Black or African American 0.8% 5.8% American Indian or Alaska Native 2.3% 0.4% Asian 2.4% 12.8% Native Hawaiian / Pacific Islander 0.1% 0.3% Other / More than One 3.5% 2.8% Hispanic or Latino 8.4% 37.6% Source: U.S. Census Bureau, 2010 Census Recent needs assessments conducted in the rural Northern California region have highlighted some of the key demographic and health factors affecting rural communities such as declining school enrollment, which illustrate the out-migration of young, families. These assessments have also illustrated some of the leading health issues impacting the region. Morbidity and Mortality Age-Adjusted Death Rate: The 2014 average adjusted death rate for Shasta County was 860.4 per 100,000, the fifth least favorable County in the state (California Department of Public Health, 2014). Leading Causes of Death: The two leading causes of death were all cancers (182.7) and coronary heart disease (116.9). Chronic lower respiratory disease (70.8), unintentional injuries (60.3), stroke (47.0), and lung cancer (43.3) were the next leading causes of death (California Department of Public Health, 2014). Behavioral Health Causes: Deaths resulting from drug-induced deaths (28.2 per 100,000) and 30 25 20 15 10 5 0 Figure 3. Age-Adjusted Death Rates Per 100,000 (Source: California Health Status Profiles, 2014) 28.2 22.6 24.4 25.2 Suicide Rate 10.1 10.8 Shasta County Siskiyou County (Comparison) California Drug-Induced Death Rate Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 4

suicide (22.6) are significantly higher in Shasta County than for California (10.8 and 10.1, respectively). (California Department of Public Health, 2014). The behavioral health related causes of death in Shasta County illustrate the critical need for increased access to behavioral health care for this rural population. Figure 3 illustrates the significant regional disparity in suicide rate experienced in Shasta County and neighboring Siskiyou County. Broad Determinants of Health Population health outcomes and status are the result of numerous factors, which are referred to as determinants of health. Socio-economic status, educational achievement, and employment rates all factor into population health status. Table 3 identifies some key indicators for the broad determinants of health in Shasta County. Table 3. Broad Determinants of Health, Shasta County and California Determinants of Health Shasta County California Children living in poverty 26% 24% Children eligible for free/reduced 42% 46% price lunch High school graduation rates 88% 81% Percent of high school graduates 42.9% 40.6% attending California public college or university Median household income $44,477 $58,322 Unemployment rate 13.4% 10.5% Population receiving Medicaid i 27.7% 18.61% Sources: County Health Rankings & Roadmaps, 2014; i California Postsecondary Education Commission; ii U.S. Census Bureau, 2008-2010 American Community Survey Health Behaviors In addition to the social determinants of health, individual health behaviors and lifestyle factors also contribute to population health outcomes. Table 4 below describes some of the key health behaviors that impact Shasta County communities. Table 4. Health Behaviors, Shasta County and California Health Behavior Indicators Shasta County California Access to exercise opportunities 74% 91% Physical inactivity 20% 18% Food environment index (lower score 6.8 7.6 indicates lesser access to healthy food) Adult smoking 25% 13% Excessive drinking (5+ drinks/day) 20% 18% Drug poisoning deaths / Drug overdose 27 per 100,000 10 per 100,000 Source: County Health Rankings & Roadmaps, 2014 Section II: Estimating Need for Mental Health and Substance Use Services This section is intended to estimate the current need for mental health and substance use services in Shasta County. Estimates are taken from state and national needs assessments and prevalence estimates and are intended as a tool to support service planning. Detailed mental illness and substance use disorder prevalence estimates were developed by the State Department of Health Care Services as part of the Section 1115 Waiver Behavioral Health Needs Assessment process. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 5

Table 5. Estimates of Need Among Youth for Behavioral Health Services, Shasta County Age Group Number Requiring Mental Health Services (SMI/SED Definition) Number Requiring Substance Use Services 0-5 1,022 0 6-11 1,021 0 12-17 1,151 1,494 Total Youth 3,194 1,494 Poverty Level Below 100% 905 315 100%-199% 777 308 200%-299% 544 282 300%+ 814 496 Undefined 154 94 Source: California Mental Health and Substance Use System Needs Assessment, Final Report: February 2012. These figures provide an estimate of prevalence in Shasta County to help inform service delivery planning efforts. Table 5 provides estimates for the number of youth by age group in need of mental health or substance use services. According to the estimates, approximately 7.7% of youth in Shasta County are in need of mental health services due to a diagnosis of Severe Emotional Disturbance (SED). Approximately 9.86% of youth, aged 12-17, have an Alcohol or Drug Diagnosis and are in need of substance use services. Table 6. Estimates of Need Among Adults for Behavioral Health Services, Shasta County Age Group Number Requiring Mental Health Services (SMI Definition) Number Requiring Substance Use Services 18-20 210 1,518 21-24 537 2,386 25-44 3,311 6,147 45-64 2,725 3,655 65+ 550 667 Total Adults 7,333 14,373 Poverty Level Below 100% 2,629 2,171 100%-199% 3,080 2,175 200-299% 2,413 1,060 300% + 5,458 1,528 Undefined 794 397 Source: California Mental Health and Substance Use System Needs Assessment, Final Report: February 2012. Table 6 identifies prevalence estimates for adults in Shasta County. Approximately 5.25% of adults in the County are in need of mental health services due to a diagnosis of Serious Mental Illness (SMI). Adults between the ages of 25-34 and 35-44 have the highest prevalence of SMI (7.85 and 8.35 respectively) and females have a higher prevalence (6.25 as compared to 4.18 for males). Approximately 9.3% of the adult population is in need of substance use services due to an Alcohol or Drug Diagnosis. Young adults aged 18-20 and 21-24 experience the highest rates (17.53 and 19.28, respectively). This needs assessment report was developed as part of a project that aims to advance the integration of behavioral health services into primary care delivery in Shasta County. As discussed in the previous section, chronic disease and other poor health outcomes exert a powerful influence on the county s population. People who suffer from chronic disease are more likely to also suffer from depression. Major depression is found to co-occur in 11% of patients with diabetes and 31% experienced significant depressive Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 6

symptoms (Katon W, 2008). High rates of chronic disease deaths in Shasta, suggest higher rates of depression. In order to better understand the prevalence of behavioral health issues in the broader population, estimates for mild to moderate conditions were identified. Applying a broader definition to estimate mental health needs that includes individuals with mild to moderate conditions results in about 14.7% of the adult population in need of mental health care, or 26,022 individuals (see Figure 4). Prevalence estimates also include 15,867 individuals in need of substance use services. 40,000 30,000 20,000 10,000 Broad Definition (Non SED/SMI) 26,022 SED 3,194 Youth 1,494 In an effort to better understand the behavioral health care needs of low-income and underserved populations within the County, key interviews were conducted with some of the larger local Medi-Cal providers. Specifically, the four federally qualified health centers (FQHCs) that provide comprehensive primary care and integrated behavioral health care in the region were asked to estimate the proportion of their patient populations in need of mental health care. These anecdotal reports, included in Table 7 below, show some variation based upon each provider and they unique communities they serve. Table 7. Estimated Patient Need for Mental Health Services based on Provider Interviews Primary Care Health Center Estimated % of Patients Needing Mental Health Care i Total Patients Served 2013 ii Hill Country Health and Wellness Center 60-70% 3,708 Mountain Valleys Health Centers (Burney >15% 4,204 Health Center) Shasta Community Health Center N/A 42,736 Shingletown Medical Center 20-30% 2,054 Sources: i Key interviews; ii California Office of Statewide Health Planning and Development, 2013 In addition, a private primary care physician from a group practice, Lassen Medical Group, was interviewed to understand the need for mental health care. Lassen Medical reported that an estimated 50-60% of all adult primary care encounters are thought to have a mental health component. Section III: Review of Existing Infrastructure and Services - Figure 4. Estimated Need of Behavioral Health Services, Shasta County Source: California Mental Health and Substance Use System Needs Assessment, February 2012 This section provides a summary of existing behavioral health care service delivery infrastructure in Shasta County. This overview uses publicly reported data on the County mental health system and SMI 7,333 Mental Health Adults 14,373 Substance Abuse Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 7

interviews with primary care clinics and health centers in Shasta County. To the extent possible, the capacity for mental health and substance use service delivery in these two systems is documented. Specialty Mental Health Services The Shasta County Department of Health and Human Services provides direct mental health care for children and adults with Serious Emotional Disturbance or Serious Mental Illness. An external review of the Shasta County Mental Health Plan assessed service delivery in 2012. This report conducted on behalf of the state by the California External Quality Review Organization (EQRO) utilizes Medi-Cal claims data to assess the quantity of specialty mental health services provided by the County. In 2012, the Shasta County Mental Health Plan served 3,039 individuals. The penetration rate for the Medi-Cal population overall is 7.05%, higher than the statewide average of 5.85% (Table 8 and Figure 5). Table 8. Specialty Mental Health Services Medi-Cal Beneficiary Data, Shasta County, 2012 Element Shasta County Mental Health Plan Statewide Total approved claims $12,222,963 $2,354,984,998 Average number of Medi-Cal 43,126 7,956,900 beneficiaries per month Number of beneficiaries served 3,039 465,331 Penetration rate 7.05% 5.85% Source: California EQRO Report, Shasta County 15% Shasta County Mental Health Plan Penetration Rates, 2009-2012 Source: CA EQRO Report, CY2012 10% 9.27% 7.42% 6.83% 7.05% 5% 0% 6.15% 5.89% 5.78% 5.86% CY09 CY10 CY11 CY12 Shasta County Mental Health Plan Statewide Inpatient Psychiatric Care Restpadd Psychiatric Health Facility (inpatient) offers services to adults, 18 years and older and is the only facility in Shasta County that specifically provides inpatient mental health care. The facility is licensed for 16 beds. The county has additional beds available under contracts with Napa State Hospital; several private non-profit and for-profit psychiatric health facilities; acute care hospitals; and public and private board and care or other residential facilities. The space available is often inadequate to meet the needs of the community as these beds are almost always filled to capacity. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 8

Medi-Cal Managed Care Utilization In 2014, California transitioned the delivery of mental health for individuals with mild to moderate conditions from the significantly underutilized Fee for Service system into Medi-Cal Managed Care. Some initial insight from the first six months of Medi-Cal managed care utilization data, shows a penetration rate among adults of approximately 3.4% with 12% of adult patients categorized at higher utilization (greater than 8 visits per year). Integrated Primary Care and Mental Health Care Services There are four federally qualified health centers (FQHCs) operating in Shasta County that provide comprehensive primary care for county residents, with a priority on populations that are low-income, underserved and uninsured. The county s Medi-Cal program is operated as a County Operated Health System (COHS) and Partnership HealthPlan of California (PHC) serves as the Medi-Cal managed care plan. The primary care provider network includes private medical offices located primary in Redding with a few additional providers spread throughout the county. The FQHCs serve approximately 65% of Medi- Cal beneficiaries. Recognizing the mental health care needs of the patients served, each of the FQHCs has integrated behavioral health care into their service delivery system. In 2013, the four health centers provided 14,292 behavioral health visits. Table 9 below identifies the total number of visits by service type offered by FQHCs in Shasta County. Table 9. FQHC Health Center Visits: Primary Care and Behavioral Health, 2013 Medical Behavioral Health Health Center # of % of # of visits % of total visits total Total Visits Shasta County Hill Country Health & Wellness Center 8,863 44% 3,131 16% 20,007* Mountain Valleys Health Centers 20,537 95% 1,034 5% 21,571 Shasta Community Health Center 102,558 78% 9,333 7% 130,877* Shingletown Medical Center 7,245 90% 794 10% 8,045 Source: California Office of Statewide Planning and Development, 2013 Utilization Data, * Total also includes dental and other services Key interviews were conducted with the four FQHCs and one private medical office to better understand the existing service delivery structures and integration of mental health and substance use services into primary care delivery. Table 10 below provides a brief summary from the interviews with administrators and providers at the four FQHCs. Table 10. FQHC Key Interview Summaries Hill Country Health and Wellness Center (HCHWC) Overview Mental health services are provided in-house with licensed clinical social workers, supportive primary care physicians and support staff. Individual, family and group services are provided. A separate behavioral health unit within the clinic provides the majority of therapeutic and other mental health services. Currently a part time Behavioral Health Consultant (BHC) is embedded within Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 9

Telemedicine Care Coordination Strategies primary care. This allows for better care coordination and warm handoff to the behavioral health unit. Additionally, a Behavioral Health Care Coordinator is available full time to the medical department, assisting with crises, and addressing patients housing, food and other psychosocial stressors, and receiving warm handoffs when the BHC is not available. Substance use treatment is limited to individual sessions with primary care clinicians generally following a dual diagnosis assessment. HCHWC refers to detox services when needed. SBIRT is not yet implemented. HCHWC has an organized pain management program but this is an issue needing additional support. Psychiatry is provided though telemedicine approximately 8 hours/month. Care is coordinated through bi-weekly meetings, and weekly case management reviews. Immediate needs are addressed as they occur. Substance Use Services SMI Populations Limited to individual sessions with primary care clinicians as noted above. Mental health services for SMI patients are served through a contract with Shasta County, which includes the provision of support services such as transportation, food and housing assistance, and employment services. Mountain Valleys Health Centers (MVHC) Overview Telemedicine Care Coordination Strategies SMI Populations Mental health services are provided in-house with a licensed psychologist, a case/care manager, supportive primary care physician(s), and part-time mental health interns. All behavioral health staff are trained or certified in drug and alcohol treatment. Individual therapeutic, family, and health coaching services are provided. Substance use treatment is primarily limited to individual therapeutic services. The clinic makes referrals to out of area residential services as needed. Some SBIRT training has occurred, but the screening is not yet routinely administered. MVHC has a telemedicine contract for psychiatry services, but is looking to expand to have more psychiatry options. MVHC s psychologist travels to one site, Big Valley, regularly, other clinic sites are primarily served through telemedicine. Care is coordinated through bi-directional use of the medical record (progress notes, medication records, treatment recommendations, etc.). In crisis situations, or for warm handoffs, the psychologist or case manager sees the patient to arrange/discuss additional behavioral healthcare. The case manager assists in meeting the social support needs of patients, particularly those involved with behavioral health services. While MVHC is serving some SMI patients for both physical and mental health conditions, there is no contractual relationship with the county specifically for SMI services. A contract with the county supports behavioral Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 10

health services in general, but not specifically for SMI. Shasta Community Health Center (SCHC) Overview Telemedicine Care Coordination Strategies SMI Populations Shingletown Medical Center Overview Telemedicine Care Coordination Strategies Mental Health services are provided in-house with licensed clinicians, psychiatrists, and nursing support staff. It should be noted that primary care physician(s) also support mental health services by prescribing psychotropic medications, and by maintaining and supporting clients after or before a psychiatric consultation. Individual therapeutic, case management and patient education group services are provided. Substance use treatment is very limited. Referrals to residential or detox treatment are performed as needed. SBIRT screenings have not been started. SCHC contracts with two Telepsychiatry providers, Psychiatry Centers at San Diego and Kings View Corporation, for services to children with SED and adults with SMI or medication management needs. Contracts provide for 64 hours per month of psychiatry services. Care is coordinated through the electronic medical record. In crisis situations a room consult can be requested by primary or urgent care for an established patient. Case managers (medical assistants) assist in meeting the support and other needs of clinic patients, particularly those involved with behavioral health services. While SCHC serves SMI patients for both physical and mental health conditions, there is no contractual relationship with the county specifically for SMI services. A contract with the county supports behavioral health services in general, but not specifically for SMI. Mental health services are provided in-house with a licensed clinician and a case/care manager, as well as supportive primary care physician(s). One of the physicians is certified for suboxone administration. Both individual therapeutic and family services are provided. Substance use treatment includes individual therapy, medication assisted treatment (MAT), and suboxone treatment. Referrals to out of area residential or detox treatment are performed as needed. SBIRT screenings were just initiated for new patients, and procedures to implement with established patients are under consideration. The clinic is working on a telemedicine contract for psychiatry services. Care is coordinated through daily huddles between medical and behavioral health staff who review the schedule and discuss patient needs. In crisis situations, or for warm handoffs, the behavioral health clinician is invited Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 11

SMI Populations into an exam room to further support care coordination. The case manager assists in meeting the support needs of clinic patients, particularly those involved with behavioral health services. While SMC serves some SMI patients for both physical and mental health conditions, there is no contractual relationship with the county specifically for SMI services. A contract with the county supports behavioral health services in general, but not specifically for SMI. Table 11 below summarizes the existing integration of mental health and substance use services within a private primary care office setting. Table 11. Private Primary Care Provider Key Interview Summary Lassen Medical Group Overview Telemedicine Care Coordination Strategies SMI Populations There are no dedicated mental health staff or therapeutic services in this setting, however primary care physicians and their support staff treat a variety of mental health conditions. Health coaching occurs within primary care, and therapeutic services are provided through referral. Because there is only one therapeutic provider in the Medi-Cal managed care network in far south Shasta County (Cottonwood), and the provider is not close to the population center, transportation difficulties result in limited therapeutic service delivery. Shasta county children with mental health needs are commonly referred to/from Remi Vista, a community mental health provider serving local schools. Medication management for children often occurs through Shasta County. Some family counseling is provided through County staff or contracted providers. Lassen Medical Group pediatric physician staff estimate that 30% of their patients have a behavioral health problem, with ADHD and other complex behavioral health issues presenting a large challenge to the practice. The clinic is considering hiring a nurse with social work/social services training to assist with therapeutic interventions and referrals to mental health and substance use service providers. Substance use treatment is limited to medication supported outpatient detox services (daily visits with companion support for patient), and referrals to AA, NA, and other community supports. Lassen Medical also makes referrals to residential treatment services as needed. Some SBIRT screening is beginning to occur, but to date is not universal. Lassen Medical does serve SMI adult patients for both physical and mental health conditions. There is no contractual relationship with Shasta County to serve SMI, and this provider has experienced significant difficulty in gaining access to county services for a patient and for coordination of services for shared patients. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 12

Provider Capacity for Integrated Behavioral Health Services Compared to the state as a whole, Shasta County has fewer psychiatrists per 100,000 population (7.9 in Shasta County compared to 16.5 in California). Interviews with the FQHCs also included a review of personnel at the health centers dedicated to behavioral health service delivery. Table 12 below identifies the behavioral health provider types and the Full Time Equivalent (FTE) for providers currently providing care. Table 8. Inventory of Behavioral Health Workforce, FQHCs Provider HCHWC MVHC SCHC SMC Totals Psychiatrist 2.0 FTE 2.0 FTE Psychiatry (telehealth) 2 hrs/wk 16 hrs/wk 18 hrs/wk Behavioral Health 1.0 FTE 1.0 FTE Consultant Psychologist 1.0 FTE 1.0 FTE Psychiatric Nurse <1.0 FTE <1.0 FTE Practitioner Interns (MFT/LCSW) 2.0 FTE LCSW 2.5 FTE 3.0 FTE 1.0 FTE 6.5 FTE Psychiatric Nurse 2.0 FTE 2.0 FTE Case Manager 1.0 FTE 1.0 FTE 3.0 FTE 1.0 FTE 6.0 FTE Care Coordinator 1.0 FTE 1.0 FTE A comparison of primary care providers to behavioral health care providers within the Shasta County FQHC sites provides another look at the capacity for mental health care service delivery in these settings (Table 13). Table 13. Primary Care and Behavioral Health Care Providers, Shasta County FQHCs Health Center Primary Care Behavioral Health Providers (FTE) Providers (FTE) Hill Country Health and Wellness Center 4.91 3.65 Mountain Valleys Health Centers 6.38 0.75 Shasta Community Health Center 36.86 5.77 Shingletown Medical Center 2.44 0.87 Source: California Office of Statewide Planning and Development, 2013; Primary Care Providers include: Physicians, PAs, NPs; Behavioral Health Providers include: Psychiatrists, Clinical Psychologists, LCSW Substance Use Services Shasta County Health and Human Services is a primary provider of substance use treatment services through the Alcohol and Drug Program. The County contracts with three Drug Medi-Cal providers to offer outpatient substance use treatment services. In FY13-14, the Outpatient Alcohol and Drug Programs served 1,039 unique individuals through 1,271 admissions, which was an increase of 28% over the number of admissions in FY10-11. Referrals to Alcohol and Drug Programs come primarily from individuals (54% of referrals in FY 13-14) seeking treatment. Other referral sources include criminal justice (25% in FY13-14), Child Protective Services (15% in FY13-14), and other sources (6%). Health care providers accounted for 1.02% of referrals. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 13

New services have been recently developed to support the treatment needs of the criminal justice population through private providers in a day reporting setting, or through other existing providers. Additionally, a few residential and sober living providers are also available within the Shasta County. Community Supports and Resources Community resources play an important role in providing support to individuals with behavioral health care needs. Health care providers often rely on community resources to help meet the non-health care needs of patients and to connect patients to peers and other trusted sources of comfort and care. A review of community resources related to behavioral health was conducted using the Shasta 2-1-1 online resource database. A resource list of support services, including 12-step programs and faith-based counseling services available in Shasta County is included as an appendix to this report. Section IV. Behavioral Health Service Gaps and Opportunities for Integration The data provided in this report provides an estimate of the current need for behavioral health care services and a partial assessment of the system capacity. The data provided, although not comprehensive, does provide some evidence of the gap in services that exists in the county. The California Health Interview Survey conducted in 2011-2012 reports that among Shasta County adults who self-report a mental health or substance use issue, 61.3% received treatment while the remaining 38.7% reported unmet need. This unmet need is also reflected in the prevalence and system capacity data described in this report. Analysis of interviews with county health care providers identified the following gaps in behavioral health services for patients with mild to severe behavioral health conditions: Behavioral Health Workforce Development: California currently has a major backlog in licensing for LCSW. A more rapid process is needed to get trained professionals into care settings. Behavioral health workforce needs identified include: o Psychiatric nurse practitioner and physician assistants o LCSWs o Case managers Funding: sustainable funding to support service integration into primary care delivery. FQHCs receive PPS payments for the primary care visit. These payments do not independently fund the case management and other support services necessary for integrated behavioral health services. Regional gaps in mental health providers/access: south Shasta County was identified as an area with lack of access to therapeutic mental health services. Increased access to substance use treatment services: all providers interviewed described a need for increased substance use treatment services, either on-site or through referral to community providers. Psychiatric Consultation: to support primary care providers and licensed clinicians with diagnosing mental health conditions and treatment planning, and assisting with medication management, pain management, and neurology. Implementation of SBIRT: Additional SBIRT training and technical assistance is needed to support implementation of this benefit. Capacity to meet the treatment needs of individuals who screen positive on the SBIRT was also identified as an issue. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 14

Data Collection: It is challenging to assess the number of patients with SED/SMI served by the FQHCs and other primary care providers. Additional data collection activities may help to better understand the role of these providers in serving individuals with SED/SMI. Training for clinical providers and support staff: training for providers and support staff was identified as a need by all providers interviewed. Specific training topics identified include: o Pain management o Addiction treatment o Prescribing psychiatric medications for SMI o Managing pediatric behavioral health needs (e.g., ADHD) Community Capacity Assessment Conclusions The Shasta County Health Assessment and Redesign Collaborative will utilize the data and key findings of this report to inform planning for health system redesign activities. Specifically, the information will help to plan strategies to better integrate behavioral health services into primary care service delivery at the federally qualified health centers that are serving the largest numbers of low income patients. This report was produced under the project, Advancing Primary Care and Behavioral Health Integration through Community Collaboration, a grant initiative of the Blue Shield of California Foundation. For more information on these planning activities, please contact the Health Alliance of Northern California at (530) 247-1560. Shasta County Health Assessment and Redesign Collaborative (SHARC) Page 15