CALIFORNIA – COUNTY ORGANIZATIONS AND ACTIVITY
During its "reconnaissance phase", IBHP reviewed state, county and local efforts to integrate care. Although it did not conduct an exhaustive review, IBHP has been in active communication with the counties below about their integration efforts. More information about coordination between primary care clinics and county mental health providers is found in the COLLABORATION BETWEEN SPECIALTY MENTAL HEALTH AGENCIES AND PRIMARY CARE BEHAVIORAL PROGRAMS of this website. /uploads/file/IBHPIinteragency Collaboration Tool Kit 2013 .pdf
In 2013, IBHP released its latest edition of Partners in Health: Primary Care / County Mental Health Collaboration Tool Kit, highlighting various collaborative relationships forged between primary care and county mental health agencies throughout California. In addition, the Tool Kit provides practical advice from early adopters; operational forms; sample MOU's, contracts and agreements; issues to consider when brokering agreements; mutual role descriptions; screening instruments; process and outcome measures and more.
California's MHSA (Mental Health Services Act) gave collaborative care a tremendous boost through its Innovation funding. It provides that 5% of revenues raised through the Act be devoted to Innovations - novel and creative mental health approaches and practices that are expected to contribute to learning. Twenty-two of the 91 Innovation work plans submitted by 33 California counties involve some facet(s) of integrated care. With funding from CalMHSA, IBHP created an analysis of all the Innovation plans, taking a closer look at those with an integrated care component. They also developed a more detailed summary of the integration-related Innovation work plans as well as a matrix that reflects the peer supportive services involved in the plans.
More recently, CiMH created a map of integrated behavioral health initiatives in California counties. The map pinpoints the location of the programs, briefly describes them and gives local contacts.
IBHP, this website's host, prepared an "Integrated Initiative Report" at the behest of CiMH in August, 2012 which compiles the results of a survey CiMH undertook to determine integrative efforts across the State. Of the 25 mental health provider respondents, 96% reported that their county or agency was working on integrated initiatives and 67% said they were working to develop person-centered healthcare homes.
Providing another major impetus are the Substance Abuse and Mental Health Administration (SAMHSA) Primary and Behavioral Health Care Integration Grants, supporting the integration of primary care into behavioral health settings. Eight recipients from 2009-2011 are: Mental Health Systems Inc., San Diego; Alameda County Behavioral Health Care Services; Asian Community Mental Health Services, Oakland; Glenn County Health Services Agency; San Mateo County Health Services; Tarzan Treatment Center, Los Angeles County; Catholic Charities of Santa Clara County and San Francisco Department of Public Health.
Several counties have participated in CiMH-sponsored (California Institute of Mental Health) initiatives to accelerate integration; a CiMH-prepared chart reflects the change focus areas each county or agency involved has proposed to work on. Many activities listed below have been made as a result of participation in CiMH's Small County Care Integration (SCCI) initiative.
In May, 2012, the National Alliance on Mental Illness (NAMI) released MHSA County Programs 2012, a comprehensive report cataloging programs created and implemented by each of California's 58 counties that were funded by Proposition 63, the Mental Health Services Act (MHSA).
For more information about how integration between primary care and mental health agencies is being approached, go to the MENTAL HEALTH - PRIMARY CARE COLLABORATION Section of this website.
Here are just a few of the other county-sponsored programs statewide that take an integrative approach:
- Amador Mental Health Services has developed a comprehensive database of local primary care providers, specifying which accept Medi-Cal. They've mailed out brochures to these practitioners informing them of the mental health services they offer and their desire to coordinate these services with primary care. They've also developed a client health form and vitals log sheet for inclusion in the health section of the clients' charts and have increased the core health measures collected. They are refining the process for primary care providers, developing a form soliciting information they require for referral acceptance.
- Butte County has started a mobile medical unit with a behavioral support team to provide physical and mental health services at homeless shelters.
- Calavaras County Mental Health Program is entering primary care information into the consumers' electronic health record during the intake process. They are also concentrating on reducing the rate of smoking among their clientele.
- Contra Costa is building a new health center in which multi-disciplinary teams work in concert to provide mental health, substance abuse and homeless services in one entity with a single assessment and uniform case management.
- Humboldt County is linking its psychiatry services through telemedicine with local community health centers.
- Imperial County Mental Health Department has added a tab in their Avatar IT system, which contains information about the clients primary care physician, most recent primary care visit and medical condition as self-reported. They've also developed a list of local primary care providers to whom their clients can be referred. They've obtained smoking cessation material and are running smoking cessation groups in English and Spanish.
- Los Angeles County is outstationing and co-locating mental health clinicians in primary care clinics, both directly operated and contracted. In conjunction with Jurgen Unutzer from University of Washington's AIMS Center, the Mental Health Department has undertaken a comprehensive program to foster collaboration between the local primary care and mental health systems. The Department is using Innovations funding for four demonstration projects: two with primary care embedded into mental health clinics and two with mental health embedded in primary care. The county has also partnered with UCLA Integrated Substance Abuse Program to sponsor training in this area and has received a SAMHSA grant to implement SBIRT for substance use and alcohol. In October, 2012, they published a Status Report on Integrating Medical Care with Mental Health and Substance Abuse Disorder Services in Los Angeles County.
- Madera County Mental Health is using pharmacists to link and coordinate mental health and primary care. They've also partnered with their health plans to obtain client physical information and have begun to enter the data on the "Doctor's Homepage". Clients with a BMI over 30 or high blood pressure are referred to their health educator coordinator.
- Mendocino County Mental Health Department has developed a smoking cessation awareness class for their clients. They are also utilizing the Stanford "Personal Medication Card" and WRAP (Wellness Recovery Action Plan) to support clients in tracking, evaluating and monitoring their personal wellness.
- Merced County Mental Health, aiming to increase access to its services, has contracted with a primary care agency for three cultural brokers/"promotoras" to do outreach to the local community.
- Modoc County's Mental Health is holding evening acquatic exercises at a local pool and has established a walking club for their clients. They are taking and recording their clients' blood pressure, weight, blood sugar level and other measures, which they share with the clients' primary care provider via an electronic system (PECSYS). Results are also shared with the clients themselves, which appears to be a motivational factor for change.
- Mono County Mental Health Services is taking the blood pressure levels of all their clients and, if indicated by the results, working with them to make a primary care appointment that day. Incentives are being offered to clients for participation in exercise and smoking cessation sessions. They have also created a standardized referral and intake procedure for clients referred from primary care. A psychiatric nurse practitioner will act as a liaison between their local health clinic and mental health services, splitting her work week between the two agencies.
- Napa County, on a pilot basis, is using "cloud" technology to both store client information and, with the clients' consent, allow access to it by both mental health and primary care providers. Primary care and mental health personnel have mutually developed a bi-directional referral process and a release of information form that allows exchange of pertinent information.
- Orange County has created a program within its indigent care medical program to add case management and mental health services in community clinics and health centers. Their Behavioral Health Services is employing trained consumer mental health workers, supervised by licensed mental health staff, to provide behavioral care at primary care clinics and conversely, using consumers to coordinate and monitor physical health care at behavioral sites. Professional consultation about psychiatric medication is also being provided to primary care physicians.
- Plumas County Mental Health has implemented a medical recording system to track their clients' contacts with primary care. In addition, on intake, staff is documenting the clients' medical data, including physical health status, medications, lifestyle choices blood pressure, BMI, and A1C and entering this information into the electronic mental health record. They've also installed a primary care provider to see clients at their Drop-In Center mental health facility and have initated group sessions offering smoking cessation and dietary support.
- San Bernardino County is bridging the two arenas by creating a "Holistic Campus", incorporating yoga, sweat lodges, acupuncture and other nontraditional, culturally-based approaches.
- San Diego County, as part of its Mental Health Services Act expansion, is building a new system of integrated services encompassing both behavioral health care in primary care settings and physical health care within mental health agencies. For a comprehensive look at their multiple initiatives, see the 2011 Environmental Scan: Integrated Physical and Behavioral Health Programs in San Diego, which includes not only descriptions of their program, but lessons learned along the way. See alsoTraining Archives for Powerpoint descriptions of some of these programs. San Diego was one of 13 nationwide recipients of a four-year SAMHSA grant to integrate physical health into mental health settings. SAMHSA also awarded the county a grant to implement SBIRT (Screening, Brief Intervention, and Referral to Treatment for substance abuse and alcohol use).
- San Francisco County, as part of its Coverage Initiative Healthy San Francisco, has expanded its network of contracted community clinics and health centers and is seeking to build a seamless system of health, mental health and substance abuse services. A blending of services is achieved by the stationing of health workers at mental health clinic sites and behaviorists at community health centers for consultations and direct services.
- San Mateo County is home to the San Mateo Behavioral Health and Recovery Services, an early adopter of integrated services which outstations mental health professionals in primary care clinics. In return, primary care nurses perform medical exams and triaging for clients at county mental health clinics. See Training Archives for a Powerpoint summary of its collaborative efforts. San Mateo also makes frequent presentations about its "carved in" model of delivering care under the County Operated Health System, a managed care model providing a full range of medical services and behavioral health services for vulnerable populations.
- Shasta County, as part of its reorganization of publicly funded mental health services, has embraced community clinics and health centers as a strategy to better serve rural parts of its county and integrate care. With MHSA funds, it has contracted with primary care clinics to provide care management and full service partnerships.
- Solano County co-locates county mental health clinicians in its directly operated primary care clinics as part of its managed care program.
- Stanislaus County Behavioral Health and Recovery Services, as part of their PEI plan, contracted with two community health agencies with the goal of providing increased access to mental health services, especially for the county's underserved population. In the first year of this arrangement, the contractors increased the Behavioral Health Service's capacity by 23%; more than 70% of those served via the contract did not have current or past mental health services.
- Tehema County Mental Health Services' approach to primary care and mental health communication is to hold weekly collaborative sessions between the primary care physician and the mental health physician assistant regarding shared clients. The assistant educates the PCP regarding mental health issues, diagnosis and management and is also available for "warm-hand off" referrals. In crisis situations, a mental health worker goes to the primary care site, does an immediate assessment and, if necessary, takes the client to the crisis unit. A new medical history form, completed at intake, is being used by both mental and physical health providers and serves as the basis for information-sharing between the two providers. Primary and mental health services have also been collaborating together to coordinate medications and address poly-pharmacy. Mental health has accessed the Dept. of Justice Bureau of Narcotic Enforcement database to avoid repitition of the same prescriptions and has shared this information with primary care.
- Trinity County Behavioral Health Services is determining where their clients receive primary care and are entering this information, along with information about their medical condition, into the electronic health record. They are obtaining and updating client releases of information to include exchange with primary care providers.
- Ventura County is co-locating primary and behavioral health care for adults and children and has implemented the IMPACT model (screening for and treating depression).
All counties' departments of mental health can be reached from the California Department of Mental Health's web site.