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MHSA Issue Resolution Process and Complaint

Last updated on September 4, 2020

Following the guidance of the May 26, 2020 San Diego County MHSA Issue Resolution Process (p217-218) I filed the following complaint as a consumer of BHS services:

September 2, 2020

TO: Dr. Luke Bergmann

FR: Jerry Hall, BHS Services Consumer

RE: MHSA Issue Resolution Complaint

I am writing this complaint as an individual consumer of San Diego County Behavioral Health Services (BHS). Although I serve on the San Diego County Behavioral Health Advisory Board (BHAB) I do not represent that group with any publicly available claim or statement within.

The core of this complaint centers on the fact that our BHAB is not functioning as was seemingly intended by California Legislators through various legislation including Proposition 63 (2004) and AB1352 (2019) referenced below.

There is a sustained dysfunction that can be broken into three categories:

  1. California Mental Health Services Act (MHSA) state law.
  2. BHAB as a body understanding and asserting its role, performing their responsibilities, and delivering results.
  3. The dynamics between BHAB and BHS and how the latter intentionally or unintentionally thwarts BHAB’s work.

One of the most prominent responsibilities mentioned throughout the legislation is BHAB’s duty to ensure meaningful stakeholder engagement. The Welfare and Institutions Code (WIC) states in part that such advisory boards are responsible for many elements outlined below.

A. Ensuring Meaningfully Engagement with Stakeholders

5602.4(a) Review and approve the procedures used to ensure citizen and professional involvement at all stages of the planning process. Involvement shall include individuals with lived experience of mental illness or substance use disorders and their families, community members, advocacy organizations, and mental health professionals. It shall also include other professionals that interact with individuals living with mental illnesses or substance use disorders on a daily basis, such as education, emergency services, employment, health care, housing, law enforcement, local business owners, social services, seniors, transportation, and veterans.

BHS recently instituted its own Community Engagement Workgroup which meets periodically. This group does not acknowledge or recognize the need to document the procedures BHS will use to ensure such citizen and other stakeholder involvement.

In a section below, you’ll find that BHS includes a blurb about it’s process in it’s MHSA 3-Year Plan but, that does not satisfy providing BHAB any detail as to the specific plan, including objectives, challenges, opportunities, strategies or tactics. As such, BHAB has no ability to participate in working with BHS to create and approve such a plan and procedures.

Further, this workgroup includes several BHAB members participating, including this author, and even though this issue has been repeatedly brought to the table it is not acknowledged nor operationalized by BHS staff.

B. Community Forums

Each year, the BHAB and BHS leaders meet at an Annual Retreat to review the previous year and develop its goals for the following calendar year. At that meeting, I personally asked well-informed and senior BHS staff when the traditionally scheduled Fall-season Community Forums were taking place so that we might participate in shaping how they were conducted. The response was effectively that nothing had been planned. In fact, I later learned that BHS had already signed a contract with a provider to conduct such forums a few weeks before that retreat.

These forums took place in early 2020. They were highly structured and some stakeholders were ‘meaningfully engaged’. Some concerns include:

  1. BHS created a highly structured forum itinerary that included:
    1. A general statement at at least two of the forum openings was made that there were three topics that would not be discussed at the forum including homelessness, criminal justice, or transportation. It is puzzling to think a behavioral health agency holding annual forums would parse out the arguably top two most important social issues of the day, including criminal justice and homelessness issues.
    2. Another concern is that BHS provided only a single one-minute for participants to provide feedback on Innovation (INN) programs presented in a less than one-minute summary by the moderator. This is entirely counter-intuitive and seems more likely an exercise to allow BHS to tick a box indicating they got stakeholder feedback.
  2. Once those forums were concluded a report was submitted by the provider in March 2020. The first opportunity BHAB was given to view the document was September 1st, the same day as the general public, a full five months later.

    Why would BHS refuse to allow the supposed integral partner BHAB, dedicated to ensure stakeholder engagement, review this report for over five full months? How much valuable insight could we have gained, after going out into the community to confirm and learn, and return with more informed feedback to both BHS and the Supervisors?
  3. All forums were attended by employees of current BHS providers and civilians. The concern is that this arrangement allows for skewed results. For instance, existing staff understand budget and political realities and likely contribute within those boundaries. Whereas behavioral health consumers and their families would participate in a much more organic manner and give highly intuitive feedback. Of course, this isn’t to suggest provider’s staff wouldn’t provide valuable feedback if they attended as consumers.

    Also, there seemed to be a limited range of stakeholders that participated; the vast majority were either providers, consumers, or family members. As it turns out, in reading the Community Engagement report of March 2020, less than 10% of participants identified as either consumers or family members (including duplications with each other and other categories). We missed the opportunity to have not only far more consumers and family members, but also a wide range of subject matter experts, such as those described above, that could have provided highly valuable contributions.

C. MHSA 3-Year Plan

BHS is required to submit an MHSA 3-Year Plan to the Mental Health Services Oversight and Accountability Commission (MHSOAC) detailing it’s plans for the upcoming three-year period. They are also required to send an annual update which traditionally includes reporting outcomes and adjustments to the 3-Year plan. The advisory BHAB is supposed to ensure this plan is developed with local stakeholders as outlined above. However, it has been unable to do so because BHS traditionally keeps BHAB in the dark throughout the plan- and content-development process. Each year, the first time BHAB sees this MHSA 3-Year Plan draft is the same day it is released to the public. This is typically at or immediately before a monthly BHAB meeting.

Drafts of the plan and County general budget are typically released before the new fiscal year, along with a 30-day period being opened for public comment, revision, and final vote.

This year, the FY2020-2021 budget has already been approved and voted upon by Supervisors, before BHAB had any opportunity to review the plan drafts, obtain any community feedback, and have an opportunity to make their contributions to the BHS and Supervisors.

We were told, because of the Covid-19 crisis, the plan development would be delayed. However, we weren’t told it would be released without any chance to effect any changes to the final budget. We were to get the plan draft at the August BHAB meeting but, at the last minute we were told it wouldn’t be released for yet another month.

For this fiscal year, the plan was posted online August 31st and will be announced at the September BHAB on September 3rd. This signifies the beginning of the 30-day window for public comment, culminating with a public meeting at the same BHAB meeting October 1, 2020.

My concern is that BHAB has had little opportunity to ping the community in an organized manner without any idea of what the plan was for the next three years, and without any resources allocated to do that work. Other large counties were able to submit their 3-Year Plan drafts on time. With a significant amount of resources at its disposal, much of the report being already ready due to it being a largely boilerplate construction, there is little reason why BHS has an all-or-none approach to engaging BHAB in its release.

D. Voting Member Supervisor with Zero Attendance

Of the 21 Members of BHAB, one includes a voting-Member seat filled by a County Supervisor. The designated Supervisor has yet to attend a single meeting since they were appointed January 2019, and re-appointed in January 2020. Although they have sent a staffer to many of the meetings, that staffer does not sit with the BHAB Members, does not stay in the room for the entire meeting, does not participate in any dialog in any regular fashion, and cannot vote.

This isn’t an optional role. Unfortunately, this Supervisor has simply chosen to not participate.

E. Year-long BHAB and BHS Collaboration

Throughout the year, BHAB is responsible for reviewing and submitting comments for reports, inspecting facilities, and addressing any behavioral health related issue it chooses.

They have yet to systemize any of these processes as BHS does not choose to collaborate with BHAB to create a calendar, discuss milestones, and develop content. For reports, we are oftentimes offered opportunities to submit contributions and that in and of itself can be challenging as many BHAB members themselves choose not to participate. The BHAB does review drafts of these documents and typically votes in their approval.

It is a rare event for BHAB to visit facilities or address behavioral health related issues other than those discussed at our monthly general meetings. That said, this seems to have become the status quo as BHS does not make any effort in my opinion to invite such collaboration.

F. Community Program Planning (CPP)

Part of the MHSA law allows for BHS to utilize up to 5% of its annual MHSA revenue received in the Community Program Planning (CPP). This current fiscal year, this limit would be close to $10 million. To date, San Diego County has yet to allocate a single dollar from the MHSA revenues towards the CPP. They have said that any funds used for various elements of the CPP were taken from BHS general administrative funds and that more dollars would therefore remain in programming.

The concern is that the MHSA was designed to ensure stakeholder engagement, that there would be a citizen’s advisory board to ensure its mission was being achieved, and that there would be funding for the latter to ensure its objectives were met. That is not happening in San Diego County. Having a clear budget developed by BHAB must be an essential component of its annual planning and budgeting process.

G. BHAB Advising Supervisors

The intent and design of the BHAB is to give recommendations and advice to the Board of Supervisors. That is not being done in any systematic way. We are working through the Building a Better BHAB Workgroup, which I chair, to create such systems. However, here too a dynamic exists where, without BHAB’s mandate being clear and well understood, Supervisors miss the opportunity to capitalize on community-stakeholders feedback, buy-in, and ultimately may not hear of any concerns or complaints.

H. Issue Resolution Process

This complaint process, the Mental Health Services Act (MHSA) Issue Resolution Process was revised on October 29, 2018, and again on May 26, 2020 to clarify how MHS would handle complaints from stakeholders in regards to MHSA-related issues, including the ones in this letter.

One stage of that process is to report to BHAB on a quarterly basis, any such submissions. To date I do not recall, nor can I locate a single report in my meeting archives, a single report ever being provided to BHAB. If there have been complaints since that time, BHAB should be provided accurate information on those complaints, not in the least pertinent details so that we can contribute to the process as Members.

I. BHAB, BHS, and County Leadership Dynamics

Another overarching concern is that only some of BHAB members are stepping up to begin picking up the duties and responsibilities required in state law. However, the dynamics between BHS and BHAB are effectively sustaining the status quo and quelling participation.

We can all read the law, we can all interpret it one way or the other, but the consistent denial of BHS to step up and support the incessant pleas to develop such a process must end.

That brings me to my greatest concern. That is, having served on both the Alcohol and Other Drug Advisory Board and now the integrated Behavioral Health Advisory Board under two different directors for around eight years now, it seems clear that there is pressure from other entities that oversee the BHS department – be they other county departments, leadership, or the Supervisors themselves

Again, without clarity it is difficult for BHAB to do its job as a mandated Advisory Board with so many sustained barriers.

J. Consultants Engaged but, Not with BHAB

Supervisors and BHS made a significant agreement with a contractor to assess behavioral health issues within the county. The primary focus has been those with the criminal justice system. BHAB and the Public Consulting Group were suddenly told we were ‘partners’ and that BHS and BHAB were now somehow collaborating on behavioral health-related issues within the criminal justice system.

The consultant has been generating work and results all along but, BHAB has not been engaged other than a very cursory manner, with any of the work or reporting from the contractor.

To create such a relationship, engage such a significantly funded consultant, and then to completely marginalize BHAB from any meaningful participation, is entirely inappropriate and seems to be the county ignoring state WIC law.

K. Excess Funds

From 2016-2019 I initiated many conversations at BHAB meetings in regards to how BHS had been sitting on over $145 million dollars in Excess Funds. BHS staff continually downplayed the existence of the funds, the importance of spending them (technically, they were subject to Reversion but, had not been), nor one iota of collaboration between BHS and BHAB as to how those funds would be spent – other than their bringing multi-million dollar expenditures to the BHAB without clearly defining the use of these Excess Funds, and obtaining a vote of approval for recommendations to the Supervisors.

It is still unclear what remaining funds exist, and BHS insists they have all been appropriated to various programs without our clear understanding. The draft MHSA 3-Year Plan indicates over $30m which appears to be allocated towards the general budget this year but, we have absolutely no idea as to the availability and use of these funds.

At issue is BHAB has the responsibility to ensure the aforementioned meaningful engagement of stakeholders but, we were given no such opportunity. That is, perhaps the community given the chance might prioritize something they are concerned about vs. what BHS believes they should spend those Excess Funds on. Why does BHS refuse to account for these funds in a manner for the BHAB to fully understand their use?

Conclusion

By not having clear authorities, the ability to plan, budget, review, engage, opine, and ultimately ensure all stakeholders are being properly engaged, heard and made accountable to, we lose many opportunities to help build more effective mental health and substance abuse services.

Granted, these things include process changes, add another layer of complexity to an already complex system, and require a significant change in dynamics. That said, this isn’t optional. We don’t get to decide what laws we follow or skirt.

We must find a way to address these concerns in a timely and productive way and to that end I hope to ensure they are done in the spirit of collaboration and with a truly client-centered focus.

Thank you very much.

Jerry Hall
BHABrehab.com

References

  1. Welfare and Institutions Code (WIC) | https://bit.ly/wic5604
  2. AB1352 (2019) | https://bit.ly/ca-ab1352

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