To: Sonoma County Board of Supervisors
Department or Agency Name(s): Department of Health Services, Human Services Department, Office of the Public Defender, Sheriff Department, Sonoma County Superior Court, County Counsel
Staff Name and Phone Number: Jennifer Solito 707-565-4774
Vote Requirement: 4/5th
Supervisorial District(s): Countywide
Title:
Title
CARE Court Implementation
End
Recommended Action:
Recommended action
A) Adopt a personnel Resolution amending the Department of Health Services Department Allocation List to add 2.00 Full-Time Equivalent time-limited positions, 1.0 Behavioral Health Clinician Specialist, and 1.0 Senior Client Support Specialist, effective November 12, 2024 through November 7, 2027.
B) Adopt a Resolution authorizing budgetary adjustments to the Department of Health Services in the amount of $282,613 to the fiscal year 2024-2025 adopted budget to program funds received from the Department of State Hospitals in order to cover expenditures associated with the administration of the CARE Court Program.
(4/5th Vote Required)
end
Executive Summary:
As proposed within Senate Bill 1338 (Umberg, Eggman, 2022), California will begin a new Community Assistance, Recovery, and Empowerment (CARE) Court program. The bill “…would authorize specified persons to petition a civil court to create a voluntary CARE agreement or a court-ordered CARE plan and implement services, to be provided by county behavioral health agencies, including stabilization medication, housing, and other enumerated services to adults who are suffering from schizophrenia spectrum and psychotic disorders and who meet other specified criteria.”
CARE Court is aimed at helping individuals who are suffering from untreated schizophrenia spectrum or other psychotic disorders and are not being stabilized with current forms of outpatient treatment services. Many times, these individuals have suffered as a result of mental illness and substance use challenges, which has led to prolonged exposure to homelessness and avoidable incarceration. This approach seeks to act early and help connect people to vital services to address their underlying needs. CARE Court intends to be a vehicle that connects a person’s court ordered care plan by way of undergoing a court ordered evaluation to determine eligibility. Each care plan will be monitored by a care team within the community and can include clinically prescribed, individualized interventions with a number of supportive services, medication, as well as a housing plan.
All counties across California are required to participate in the CARE Court state program. If local governments do not meet their specified duties under court-ordered Care Plans, the county CARE court will have the ability to order daily monetary sanctions upon county agencies per California Welfare and Institutions Code § 5979 (b).
The County of Sonoma is in the second cohort of counties implementing the CARE Act and is ready to launch operations by December 1, 2024, which includes being able to increase staffing resources that will be responsible for implementing and managing plans for individuals as prescribed by the state’s CARE Court process.
Discussion:
BACKGROUND
During the first six months of operations, those counties who have implemented CARE Court in their respective communities have received fewer filed petitions than what was initially anticipated. As of October 1, 2024, there were 715 petitions filed for CARE Court across the 7 counties making up the first cohort. Los Angeles County launched CARE Court on December 1, 2023, and has received 155 of 1,900 or 8% of expected petitions in the first six months of operations. Details on successful enrollments into CARE Court are currently not widely available but point to continued lower enrollment during the first year of operations. While there are fewer enrolled than what was anticipated, DHS still has mandatory obligations (court evaluations, legal processing for CARE Act respondents, development of CARE plans, etc.) to fulfill for all petitioners of CARE services and all include extensive reporting obligations to the state.
It is too early to forecast the actual demand of CARE Court in Sonoma County. It is suspected that based on eligible Lanterman-Petris-Short (LPS) conservatorships and misdemeanor incompetent to stand trial (IST) determinations, Sonoma County could potentially receive up to 40 CARE Court petitions in the first year of operations.
IMPLEMENTATION UPDATE
DHS staff kicked off CARE Act implementation efforts on January 25, 2024, and intends to implement CARE services by scaling up operations based on utilization and level of support needed by participants. Over the last several months, the DHS implementation team currently made up of Jan Cobaleda-Kegler (Behavioral Health Division Director), Roy Dajalos (Special Projects Director), and David Evans (Acute & Forensic Services Section Manager) has regularly facilitated cross-department stakeholder workgroup meetings focusing on developing intra-agency workflows, understanding roles and responsibilities of the CARE ACT mandate, and creating a cohesive messaging strategy. DHS staff has collaborated with staff from Superior Courts, Public Defender’s Office, Human Services Department (HSD), Sheriff’s Office, the Information Systems Department (ISD), and County Counsel, as well, as business and community partners, such as Wellpath, Peer Recovery and Advocacy, and the National Alliance of Mental Illness (NAMI) in the rollout of CARE Act in our community.
The DHS staff developed implementation plan includes strategies on communication, outreach, and engagement, increasing racial equity in our community, and standing up a CARE Court care team. In August, staff released a request for proposals for Bridge Housing Site Management and Support Services at 440 Arrowood Drive, Santa Rosa, CA 95407. This is a critical component of the CARE Court plan locally as this interim shelter (for individuals experiencing homelessness with serious behavioral health conditions and/or substance use disorder issues) will focus on serving CARE Court clients with a court-ordered care plan. The one-time capital-expenditure renovation and annual operational costs for the Arrowood facility will be paid from proceeds of the Behavioral Health Bridge Housing (BHBH) grant award of $11,246,961. A condition of the grant award to Sonoma County is allowance for a regional approach where neighboring county behavioral health agencies can partner with Sonoma to benefit from the facility, as well. Sonoma and Marin counties have partnered to meet this regional criterion.
COMMUNICATION STRATEGY
DHS is implementing a three-pronged approach as its communication strategy for educating and informing the community about CARE Court: 1) Creation of a CARE Court resource webpage, 2) Conduct a series of community informational meetings, and 3) Press Release.
1) The CARE Court resource webpage (https://sonomacounty.ca.gov/carecourt ) will include a bi-directional resource link to Sonoma Superior Court’s webpage (https://sonoma.courts.ca.gov/), to create a “no wrong door” approach to accessing vital information. The webpage will also highlight informational videos and provide a link to care-act.org <https://care-act.org/>, where residents will be able to access a large library of video resources, general information about CARE Court, court proceedings, how to file a petition, and a list of frequently asked questions.
2) The implementation team hosted in-person and virtual stakeholder group meetings on 8/8/2024, 8/12/2024, 09/08/204, 09/12/2024, 09/26/2024, 10/03/2024, and 10/23/2024, attended by Buckelew Programs, National Alliance on Mental Illness (NAMI), the Interdepartmental Multi-Disciplinary Team (IMDT), City of Santa Rosa’s inRESPONSE team, DHS Mobile Support team, other DHS Behavioral Health Staff.
3) Lastly a joint press release with the Sonoma Superior Courts will go out prior to the December 1st launch.
OUTREACH & ENGAGEMENT
DHS will promote equitable access to care and effective engagement using a person-centered approach when encountering individuals, ensuring staff are trained in using trauma informed care approaches, and apply cultural humility practices during outreach and ongoing engagement efforts.
The DHS CARE Court implementation team has begun to collaborate with the DHS Community Health Worker team to join scheduled community events and continue efforts to build deeper relationships while educating the community about the CARE Court process.
SONOMA COUNTY INTER-DEPARTMENTAL PROCESS
The successful implementation of CARE Court in Sonoma County will require procedural alignment between the Superior Courts, the Office of the Public Defender, and the DHS CARE Court Team. Operational support from other county departments including the Sheriff’s Office (SO), the Human Services Department (HSD), County Counsel, and the Information Systems Department (ISD) is required for the effective setup of CARE Court within the County. All County agencies will collaborate to ensure compliance with mandates outlined by the Department of Health Care Services (DHCS) in S.B. 1338. The roles of the various County departments are summarized below:
Superior Court
Once a CARE petition is filed, the Sonoma County Superior Court (the Court) will review the petition to make an eligibility determination. If the Court finds the respondent to be eligible for CARE court, the Court will appoint counsel, in many cases from the Office of the Public Defender. The Court will order DHS to interview the respondent and file a written report within 14 business days. After the Court receives the report, it may follow three (3) courses of action:
1) Dismiss the petition if the Court finds that the respondent is not eligible for CARE court;
2) If the respondent is willing to voluntarily work with DHS, the Court will order the parties to reach a CARE agreement including an individualized range of community-based services and treatment; or
3) If the report shows the respondent is eligible, but not willing to voluntarily work with DHS, the Court will order DHS to draft a CARE plan. A CARE plan may include the same services as a CARE agreement.
At its discretion, the Court may modify the CARE agreement (2) or CARE plan (3) before approving it.
Office of the Public Defender
The Public Defender’s role in the CARE court process will be to provide legal counsel to the CARE recipient, ensuring that the recipient is cognizant of all possible options available in the program, which will allow the recipient to make decisions with as much autonomy as possible. While the details for the allocation methodology have not been finalized by the Office of the Public Defender, the Public Defender will be reimbursed for CARE Court cases from a state-wide fund. The Office of the Public Defender will receive $155,819.65 one-time funding from the State Bar of California to be reimbursed for their legal services provided to CARE respondents.
The Sheriff’s Office
The Sheriff’s Office perceives CARE Court proceedings as a viable, state-sanctioned alternative to incarceration for individuals struggling with untreated mental illness. As first responders, Sheriff’s Deputies will be able to initiate a petition with the Sonoma County Superior Court for eligible individuals who meet program criteria--such as schizophrenia spectrum and other psychotic disorders--which would divert such individuals from institutionalization.
The Human Services Department
The Human Services Department (HSD) hopes that the CARE Act will be the upstream diversion from conservatorship and incarceration that it is intended to be. The Public Conservator and DHS Behavioral Health share a current caseload of approximately 200 conservatees, 60% of whom live outside of the County. Although many conservatees have Severe Mental Illness and need the structure of a conservatorship, many conservatees who reside in Board and Care facilities would benefit from the additional resources that are being provided under the CARE Act, and the new Bridge Housing program located in Santa Rosa. Thus, as an eligible petitioner, the Public Conservator intends to work with the Transitional Recovery Team at DHS Behavioral Health to designate eligible individuals who can be better served under the CARE Act. CARE Court clients will receive the behavioral healthcare they need in a 12-month care-plan, or longer if needed. Most importantly, they will receive the supports they need while leading the independent lives they want and deserve.
The DHS CARE Court Team
In order to implement the CARE Act mandate, DHS is currently requesting 2.0 full-time equivalent (FTE) time-limited positions to fill roles in the DHS CARE Court care team:
• 1.0 FTE Behavioral Health Clinical Specialist
• 1.0 FTE Senior Client Support Specialist
The Behavioral Health Clinical Specialist will complete clinical evaluations to determine eligibility for CARE Court for all potential CARE Court clients--not just the eligible few who are approved to participate. The position develops the CARE plan and re-evaluates client progress while in treatment to determine appropriateness for graduation of CARE Court or referral to conservatorship.
The Senior Client Support Specialist will function as lead case coordinator and manager for the caseload of clients entering into CARE Court, collaborating with providers in ACCESS Sonoma and other local healthcare providers, and acting as a liaison to Behavioral Health Bridge Housing. This role will also fulfill the mandated obligation of acting as a legal processor/server notifying respondents of any and all future court appointments regardless of where they may be living. We estimate there will be significant time spent driving, locating, and transporting respondents. Care services will be integrated into ACCESS Sonoma and use IBM Care Manager electronic health record for data tracking and care coordination.
The two FTE positions being requested for addition to the DHS Behavioral Health division in this board item will be assigned the duty of fulfilling the clinical reporting requirements of CARE Court. The two aforesaid FTE will undergo training in data collection from the Electronic Health Record (EHR) system and report generation using IBM Watson Care (IWC) for monthly reporting.
As stated above, the best estimates point to approximately forty (40) petitions annually in Sonoma County. This calculation is based on the number of LPS-Act petitions and Misdemeanor Incompetent to Stand trial determinations. This points to low demand for Sonoma County; however, it is anticipated that staff time will be utilized in pursuing activities beyond those who successfully obtain a CARE plan in CARE Court. For example, CARE Act has identified a process for CARE agreement (not CARE plan) in which a person voluntarily agrees to services but will still be monitored by the courts for a specific period. Additionally, case coordination with community partners in relation to filing petitions, understanding processes, and accessing community treatment services will be time intensive. CARE respondent casework lasts 1-2 years and the positions each play a different role with respondents (one filled by a clinician and the other not).
The State is allowing counties to request reimbursement for some CARE Court activities such as court hearing time, development of court reports and CARE plans, serving notices, outreach and engagement, and data reporting. Some of the time spent by both the Senior Client Support Specialist and Behavioral Health Clinical Specialist would be eligible for these reimbursement activities. However, it is not expected that these reimbursements will cover all of the costs associated with both positions. The cost of these positions will be funded through the Department of State Hospitals’ Incompetent to Stand Trial (IST) growth cap re-directive funding, Department of Health Care Services (DHCS) CARE Act planning funds, and 1991 Mental Health Realignment funds.
All counties are waiting for further guidance and resources from DHCS.
Support from Central County Departments
As mentioned above, County Counsel and ISD will also play supporting roles to assist the CARE Court process. ISD will assist in the setup of the already purchased IBM Care Management (formerly knowns as Watson Care Management) so that clients enrolled in CARE Court will be case-managed with database systems to ensure monitoring of their rehabilitation process and compliance with the care-plan. This system, known as ACCESS-Sonoma, is not state-mandated but already in use within the Department, is maintained by County Information Systems Department (ISD) staff and can be configured to allow multiple county agencies to collaborate on CARE Court procedures.
County Counsel will review the entire collaborative process between County agencies for adherence to state legislation and advise on the intricate departmental procedures required to execute the CARE Court program. Additionally, counsel will be responsible for filing all legal pleadings and litigating all matters as well as sending out legal notices.
Utilization of CARE Court will determine the resulting impact to County Counsel’s budget. Staff will include, as and if needed, adjustments in upcoming quarterly budget adjustments to address impacts, funded through the Department of State Hospitals’ Incompetent to Stand Trial (IST) growth cap re-directive funding and Department of Health Care Services (DHCS) CARE Act planning funds.
Strategic Plan:
N/A
Racial Equity:
Was this item identified as an opportunity to apply the Racial Equity Toolkit?
Yes
CARE Court staff will seek to increase racial equity by analyzing treatment access and engagement, quality, timeliness, and outcomes data for CARE Court. Given our population demographics and state’s requirement to provide data, we will track with the intent to modify our new Program and its associated processes to serve our community. Analytic measures will stratify key metrics by race/ethnicity and other demographic characteristics. The analyses will be used to identify system trends, strengths, and gaps, which in turn will inform program design and resource allocation decisions that promote equitable access to care.
Prior Board Actions:
On June 11, 2024, the Board adopted the fiscal year 2024-2025 budget and position allocation listing.
Fiscal Summary
|
Expenditures |
FY24-25 Adopted |
FY25-26 Projected |
FY26-27 Projected |
|
Budgeted Expenses |
|
$430,621 |
$166,400 |
|
Additional Appropriation Requested |
$282,613 |
|
|
|
Total Expenditures |
$282,613 |
$430,621 |
$166,400 |
|
Funding Sources |
|
|
|
|
General Fund/WA GF |
|
|
|
|
State/Federal |
$282,613 |
$432,412 |
|
|
Fees/Other |
|
|
|
|
Use of Fund Balance |
|
|
$81,274 |
|
General Fund Contingencies |
|
|
|
|
Total Sources |
$282,613 |
$432,412 |
$81,274 |
Narrative Explanation of Fiscal Impacts:
The requested increase to FY 2024-2025 appropriations is equivalent to 8 months of staffing costs for 2.0 FTEs is $244,280. Year 1 costs include one-time and overhead costs of $38,333 for 2 FTEs (e.g., incentive pay, office and computer equipment) for a total of $282,613. The positions will be time-limited for three years through November 4, 2027.
The total three-year cost for the 2.0 FTEs is $881,426. Funding sources include one-time revenues of $414,000 from the Department of State Hospitals’ Incompetent to Stand Trial (IST) growth cap re-directive and existing $386,152 from Department of Health Services Care Act Planning Funds, with the remaining costs covered by 1991 Realignment funds.
FY 2025-2026 represents the full ongoing cost of the requested 2 FTE allocations. FY 2026-2027 positions costs is equivalent to 4.5 months. Future funding will be included in the appropriate year budgets.
|
Staffing Impacts: |
|
|
|
|
Position Title (Payroll Classification) |
Monthly Salary Range (A-I Step) |
Additions (Number) |
Deletions (Number) |
|
Behavioral Health Clinical Specialist |
$8,797.21-$10,694.75 |
1 |
0 |
|
Senior Client Support Specialist |
$6,664.87-$8,101.50 |
1 |
0 |
Narrative Explanation of Staffing Impacts (If Required):
Adding these requested positions will enable DHS to fulfill the basic mandate under SB1338.
Attachments:
Attachment 1 - Budget Resolution
Attachment 2 - Personnel Resolution
Attachment 3 - CARE Act Brochure
Related Items “On File” with the Clerk of the Board:
None