Report 2012-122 Recommendations and Responses in 2014-041

Report 2012-122: Mental Health Services Act: The State's Oversight Has Provided Little Assurance of the Act's Effectiveness, and Some Counties Can Improve Measurement of Their Program Performance

Department Number of Years Reported As Not Fully Implemented Total Recommendations to Department Not Implemented After One Year Not Implemented as of 2013-041 Response Not Implemented as of Most Recent Response
California Mental Health Planning Council 1 2 1 n/a 1
Department of Health Care Services 1 12 9 n/a 9
Mental Health Services Oversight and Accountability Commission 1 5 2 n/a 2
Santa Clara County Mental Health Department 1 2 2 n/a 1

Recommendation To: Mental Health Services Oversight and Accountability Commission

To ensure that counties have needed guidance to implement and evaluate MHSA programs, the Accountability Commission should issue regulations, as appropriate, for Prevention and Innovation programs.

Response

The regulatory process for Prevention and Innovation programs has begun but is not yet complete. The Mental Health Services Oversight and Accountably Commission's notice of proposed regulations for Prevention and Early Intervention (PEI) programs was published in the California Regulatory Notice Register No. 23-Z on June 6, 2014. The 45-day public comment period on this proposed rulemaking closed on July 24, 2014 and the Commission held a public hearing on July 24, 2014 to receive public comments. The Commission voted at its August, September, and October 2014 meetings to revise the language of the proposed PEI regulations in response to comments received during the 45-day public comment period. The revisions required 15-day public comment periods. The Commission, at its December 18, 2014, meeting is scheduled to respond to the comments from these 15-day comment periods. The Commission anticipates submitting the final rulemaking file to the Office of Administrative Law in February or March 2015.

The notice of proposed regulations for Innovation programs was published in the California Regulatory Notice Register No. 28-Z on July 11, 2014. The 45-day public comment period on this proposed rulemaking closed on August 28, 2014 and the Commission held a public hearing on August 28, 2014 to receive public comments. The Commission voted at its October 23, 2014 meeting to revise the language of the proposed Innovation regulations in response to comments received during the 45-day public comment period. The revisions required a 15-day public comment period. The Commission at its December 18, 2014, meeting is scheduled to respond to the comments from the 15-day comment period. The Commission anticipates submitting the final rulemaking file to the Office of Administrative Law in February 2015.

Recommendation To: Mental Health Services Oversight and Accountability Commission

To fulfill its charge to evaluate MHSA programs, the Accountability Commission should undertake the evaluations specified in its implementation plan.

Response

The Evaluation Master Plan, adopted by the Commission on March 2013, is a five year plan and will not be fully implemented until fiscal year 2017-2018. Since August 2013 when the BSA issued this recommendation, the Commission has undertaken all of the evaluations specified in the Commission's implementation plan for this period of time (i.e. fiscal years 2013-2014 and 2014-2015). At its October 23, 2014 meeting the Commission voted on the specific evaluation activities to take place in fiscal year 2015-2016.

Recommendation To: Santa Clara County Mental Health Department

Santa Clara County should ensure that all MHSA invoices are adequately supported with information that demonstrates that MHSA services were provided.

Response

The County has drafted invoicing guidelines for different types of invoicing, e.g., direct service, outreach, flex/housing, cost-reimbursement, and dedicated beds. Initially, the County had planned on sharing the guidelines with the Behavioral Health Contractors' Association (BHCA) of Santa Clara County and all our contract providers in August 2014 but has been delayed to November 2014.

Recommendation To: Santa Clara County Mental Health Department

Santa Clara County should review its existing MHSA contracts and by December 31, 2013, or as soon as is feasible, amend them as necessary to include plan goals.

Response

Please refer to our one-year response.

Recommendation To: Health Care Services, Department of

To ensure that it monitors counties to the fullest extent as the MHSA specifies and that it implements best practices, Health Care Services should draft and enter into a performance contract with each county that contains assurances for effective oversight and furthers the intent of the MHSA, including demonstration that each of the county's MHSA programs are meeting the MHSA's intent.

Response

As of June 30, 2014, 36 counties submitted their Board of Supervisor's approved FY 2013-14 Performance Contracts to DHCS. Of the contracts submitted, 22 are fully executed and 14 are in final processing.

DHCS has continued to work with the County Behavioral Health Director's Association and the California State Association of Counties to address concerns regarding the applicability of certain requirements contained within the contract. Having completed these contract discussions, the FY 2014-15 Performance Contracts were released to the counties on July 28, 2014 with a due date for submission to DHCS within 45 days (by September 12, 2014).

Recommendation To: Health Care Services, Department of

To ensure that counties have the needed guidance to implement and evaluate their MHSA programs, Health Care Services should coordinate with the Accountability Commission and issue guidance or regulations, as appropriate, for Facilities programs and for other MHSA requirements, such as a prudent reserve.

Response

DHCS continues to finalize the MHSA audit and appeals regulations, as well as draft the Initial Statement of Reasons. Draft regulations were provided to the County Behavioral Health Director's Association and the Mental Health Services Oversight and Accountability Commission for review and comment and DHCS is continuing to make revisions. These regulations will provide increased clarity to the audit and appeals process at the county level. DHCS is also working internally with the Office of Administration Hearings and Appeals to update the appeals regulations. The department expects to complete this regulation process by December 2015.

After drafting the audit and appeals regulations, DHCS will begin drafting fiscal regulations, CSS regulations, CFTN regulations, and, finally, WET regulations. DHCS anticipates completing all regulations by March 2018.

Recommendation To: Health Care Services, Department of

To ensure that it monitors counties to the fullest extent as the MHSA specifies and that it implements best practices, Health Care Services should conduct comprehensive on-site reviews of county MHSA programs, including verifying county compliance with MHSA requirements.

Response

Program reviews for FY 2013-14 were completed in June 2014. During FY 2013-14, Sutter/Yuba, Kings, Orange, Merced, Alameda, Stanislaus, Santa Barbara, San Mateo, Ventura, Humboldt, Contra Costa, Sonoma, San Francisco, Tuolumne, San Benito, Marin, Nevada, and Shasta counties were reviewed. Final reports have been issued to six counties; of these counties five are in compliance with the MHSA Section of the Medi-Cal Specialty Mental Health Review Protocol. Final reports for the twelve remaining counties are expected to be released by early October 2014.

DHCS is developing the FY 2014-15 Medi-Cal Specialty Mental Health Services review protocol. MHSA questions have been revised and new questions are being added to Section J: Mental Health Services Act. The final review protocol and schedule will be released during August 2014.

DHCS is currently developing a review tool which will be utilized to conduct onsite program reviews. Approximately 10 county site reviews will be conducted per year.

DHCS Audits and Investigations (A&I) began its MHSA audit of San Diego County on February 18, 2014. A&I expects to complete the audit for Fiscal Year's (FY) 07-08 and FY 08-09 by September 30, 2014. A final audit report is expected to be issued by October 30, 2014. Based on the San Diego audit, A&I will further refine the audit protocol.

DHCS will also conduct an MHSA audit of Solano County for FY 08-09 and FY 09-10. The entrance conference is scheduled on September 10, 2014.

Recommendation To: Health Care Services, Department of

Health Care Services should, as soon as is feasible, revise or create a reasonable and justifiable allocation methodology to ensure that counties are appropriately funded based on their identified needs for mental health services. Health Care Services should ensure that it reviews the methodology regularly and updates it as necessary so that the factors and their weighting are appropriate.

Response

DHCS met with the County Behavioral Health Director's Association, the Mental Health Services Oversight and Accountability Commission, the California Mental Health Planning Council, and Mental Health America in California in April 2014 to discuss the current allocation methodology. DHCS decided to maintain the current MHSA county allocation ratios for the 2014-2015 fiscal year to allow more time for review and discussion; and address the allocation methodology in greater detail for the 2015-16 fiscal year distributions.

Recommendation To: Health Care Services, Department of

To help ensure county compliance with stakeholder regulations, Health Care Services should provide technical assistance to counties on the MHSA local planning review process and ensure that its guidance to counties is clear and consistent with state regulations.

Response

The contract containing funding for MHSA training and technical assistance was fully executed in June 2014. The contract continues to include training to Local Mental Health Boards on their role in reviewing MHSA expenditure plans and annual updates and implementing the MHSA. Additional work orders will be developed during FY 2014-15 for county training specific to the stakeholder process.

Recommendation To: Health Care Services, Department of

To ensure that counties have the needed guidance to implement and evaluate their MHSA programs, Health Care Services should collaborate with the Accountability Commission to develop and issue guidance or regulations, as appropriate, to counties on how to effectively evaluate and report on the performance of their MHSA programs.

Response

DHCS continues to support the Mental Health Services Oversight and Accountability Commission's (MHSOAC) Evaluation Master Plan through ongoing data reporting system improvements, county assistance in data reporting, data monitoring and reporting for compliance, and ongoing data system planning and coordination meetings.

As part of the review and development of MHSA regulations, DHCS continues to consult with the Accountability Commission to determine any regulatory changes needed to ensure data are collected consistently and in support of the Evaluation Master Plan.

If needed, draft regulations will be developed in consultation with the Accountability Commission and made available for public comment in the winter of 2015, with final regulations adopted during the fall of 2016.

DHCS also continues the development of the Performance Outcomes System Plan for Medi-Cal Specialty Mental Health Services for Children and Youth (POS). In September of 2013, DHCS staff began reviewing the status of county data submission to the Client and Services Information (CSI) System. As of June 30, 2014, 79% of counties had submitted CSI data within the 60-day submission window. Data review and cleanup, as well as timely submission of data, is critical to the quality of data for the POS and other mental health services evaluation efforts. Beginning in October 2014, DHCS will provide quality improvement reports to the counties in order to prepare for the initial outcomes reports for specialty mental health, which are scheduled to be released in December 2014.

Recommendation To: Health Care Services, Department of

To ensure that Health Care Services and other state entities can evaluate MHSA programs and assist the Accountability Commission in its efforts, Health Care Services should collect complete and relevant MHSA data from the counties.

Response

DHCS continues to maintain monthly contact with county staff for obtaining status updates and providing technical assistance.

Client and Services Information (CSI):

According to the DHCS June 2014 county submission status report, 46 counties are current in submitting CSI data. The number of counties submitting late went from 9 counties in January 2014 to 12 counties in June 2014. Late submissions went from an average of 7 months delayed in January 2014, to an average of 3 months delayed by June 2014.

Data Collection Reporting (DCR):

According to the DHCS June 2014 county submission status report, 56 counties are current in submitting DCR full service partnership data. The number of counties submitting late decreased from 8 counties in January 2014 to 3 counties in June 2014. The number of counties that never submitted data decreased from 5 counties in January 2014 to 2 counties in June 2014. Late submissions went from 3 counties being an average of 8 months late in January 2014 to 1 county being 21 months late in June 2014.

Recommendation To: Health Care Services, Department of

To ensure that Health Care Services and other state entities can evaluate MHSA programs and assist the Accountability Commission in its efforts, Health Care Services should resolve all known technical issues with the partnership and client services systems and provide adequate and expert resources to manage the systems going forward.

Response

As of March 3, 2014, all of the eight Data Collection and Reporting (DCR) modifications were completed in accordance with the contract timeframe. In addition, DHCS is in the process of creating a plan to update the technology platform of the Client and Services Information (CSI) system in an effort to improve data integrity.

DHCS Information Technology staff continues to work closely with county staff to resolve technical issues in the CSI and DCR systems. Additionally, bi-monthly meetings are held with the Mental Health Services Oversight and Accountability Commission to plan for data strengthening efforts for CSI and DCR data and to coordinate data system improvements.

Recommendation To: Health Care Services, Department of

Health Care Services should develop standardized data collection guidelines or regulations, as appropriate, that will address inconsistencies in the data that counties report to the State. In developing these guidelines or regulations, Health Care Services should consult with the Accountability Commission to ensure that data collected reasonably fulfill statewide evaluation purposes.

Response

As part of the review and development of MHSA regulations, DHCS continues to consult with the Accountability Commission to determine any regulatory changes needed to ensure data are collected consistently and in support of the Evaluation Master Plan.

If needed, draft regulations will be developed in consultation with the Accountability Commission and made available for public comment in the spring of 2015, with final regulations adopted during the fall of 2016.

Recommendation To: Mental Health Planning Council, California

The Planning Council should document and make public the reviews that it performs of MHSA programs to demonstrate that it is performing all required reviews.

Response

As mentioned in the previous response, the Council has launched several projects to collect data and input on program performance from the local level. Reports on the information collected are expected to be released in late 2014/early 2015. Additionally, as the projects continue, additional reports will be released throughout the year. All reports will be posted on the Council's website.

Current Status of Recommendations

All Recommendations in 2014-041