To: Sonoma County Board of Supervisors
Department or Agency Name(s): Sheriff’s Office
Staff Name and Phone Number: Sharon Post, 707-565-1119
Vote Requirement: Informational Only
Supervisorial District(s): Countywide
Title:
Title
Jail Medical and Behavioral Health Services
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Recommended Action:
Recommended action
Receive information on medical/dental and behavioral health services agreements in the adult detention facilities.
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Executive Summary:
Per the Board of Supervisors request, information on medical/dental and behavioral health services agreements in the adult detention facilities; specifically contract status, staffing, and service delivery is being provided. All incarcerated persons detained in the Sonoma County adult detention facilities receive comprehensive health care that is delivered through two County contracts: one for medical and dental care, and the other for behavioral health services. Both contracts have been awarded to California Forensic Medical Group, Inc. (CFMG) as the result of County-approved competitive bidding events. CFMG has been providing inmate medical care and dental services to Sonoma County since January 2000, and mental health services since May 2017. Wellpath LLC, as the Management Service Organization, provides services to CFMG such as general accounting, license filing, regulatory compliance, assistance in responding to claims and litigation, payroll, invoice preparation, risk management, and human resources.
Discussion:
The Sheriff’s Office provides health care services to individuals incarcerated at the County adult detention facilities. Services are delivered as required by the standards and guidelines of the California Code of Regulations (CCR), Title 15 Minimum Standards for Local Detention Facilities.
Inmate Medical/Dental Agreement: Approved by the Board of Supervisors 10/26/21 for the term 11/1/21 through 10/31/26, with two one-year options to extend. The estimated cost for FY 22-23, assuming an Average Daily Population (ADP) of 1,000 inmates, is $8,683,161.
Inmate Behavioral Health Services Agreement: Approved by the Board of Supervisors 5/24/17 for the term 5/1/17 through 6/30/22 with three one-year options to extend. The demands of COVID mitigation and safety in recent months made release of an RFP problematic, and the Sheriff’s Office has opted to extend the current Agreement for another year to provide more time for a full RFP which will be released later this calendar year. The estimated cost for FY 22-23, assuming an Average Daily Population (ADP) of 1,000 inmates, is $5,380,334.
MEDICAL & DENTAL SERVICES
RFP and Agreement History:
Requests for Proposals for inmate medical and dental services were released most recently in 2013 and 2020. In 2013 CFMG was selected from a group of three proposals, and in 2020 CFMG/Wellpath submitted the only proposal. As a result of competitive bidding processes the Board has approved consecutive agreements for inmate medical services with CFMG since 2000.
Medical health care services under the current Agreement includes but is not limited to:
1. Title 15 inmate medical and dental healthcare services, 24 hours/day; 7 days/week
2. Sole responsibility for clinical decisions and actions regarding medical, dental, and nursing judgements
3. Completion of initial health assessments/screening to identify special oversight, treatment needs, and critical conditions, through:
a. direct observation (tremors, sweating, signs of trauma or abuse, compromised movement, abnormal breathing or persistent cough, skin lesions, lice, rash, characterization for being at risk for victimization); and
b. clinical screening (illness and special health needs, including asthma, current meds, medical and hospital history, dietary needs, drug and alcohol use and history of treatment, tobacco use, current or recent pregnancy, methadone use, pain)
c. testing (vital signs, oral screening, initial mental health screening, STD, pregnancy, etc. testing as indicated)
d. mental health screening (suicidal or self-destructive behavior or thoughts, mental health problems, psychotropic medications, history of hospitalization or outpatient treatment, current mental health status)
e. information sharing and education (explain right to healthcare and how to access, oral health and hygiene, PREA, grievance process, informed consent)
4. Health maintenance exams, dental care, sick calls
5. Communicable disease management, HIV/AIDS testing and counseling, infectious outbreaks and pandemic events, including prevention of spread, screening, isolation of patients, care, initiation of emergency procedures if escalating outbreak, monitoring potential staff exposures, etc.
6. Identify admission deferrals to offsite emergency care
7. Chronic care management
8. Individualized treatment and discharge plans and medication
9. Detox and substance use disorder treatment, withdrawal management
10. Pharmaceutical and therapeutic diet prescriptions and management
11. Coordination of off-site inmate medical care including billing and payment services
Staffing Challenges:
To address Sheriff’s Office staffing goals and meet rigorous accreditation standards of the National Commission on Correctional Health Care (NCCHC), new positions were added to the recently awarded contract, including:
• 4.2 FTEs of RN coverage, to provide a dedicated Booking Nurse 24/7 (recommended in the 2019 Grand Jury Report and for NCCHC accreditation)
• 1.0 FTE of RN coverage at the Main Adult Detention Facility to assist with the 14-day health assessments (as required for accreditation)
• 0.6 FTE Discharge Planner to assist with the new Medication Assisted Therapy (MAT) Program and ensure substance use disorder (SUD) patients are connected to appropriate community resources upon discharge (also recommended in the 2019 Grand Jury Report). The position was added in February 2021 and incorporated into the new agreement for continued MAT program support.
Hiring and retaining all medical staff, including Licensed Vocational Nurses (LVN)and Certified Nursing Assistants (CAN) but particularly Registered Nurses (RN), continues to present challenges, due primarily to the persistent national nursing shortage that was further exacerbated by the COVID-19 pandemic; potential staff’s ability to pass the background clearance required to work in the detention facilities; the difficult jail environment and inmate patients; and the additional challenges of working in a congregate living/detention facility during a pandemic.
Since the new contract has gone into effect, Wellpath has offered a range of economic incentives to hire and retain staff. They have engaged in in-person and virtual hiring events, and extensive marketing efforts.
Staffing reports (attached) for the first full quarter of the new contract, January through March 2022 show overall actual shift hours are between 67%-69% of the contracted amount, with a greater percentage of contracted hours filled during the day shift when there is more activity than during swing and night shifts. This is not surprising, as there are many fewer positions on the later shifts, so vacancies more dramatically impact the percentage of contracted hours filled. Given the current closure of North County Detention Facility (NCDF), we would not expect 100% coverage.
As in prior months, point-in-time vacancy reports for January through March 2022 clearly show the struggle to hire and retain RN’s. Of the 16.4 FTE contracted RN positions (5.2 FTEs of which were added with the new contract effective November 1, 2021), 9.4 FTEs were vacant on March 31, 2022. This is a gradual improvement since the beginning of the contract, at which time RN vacancies numbered 11.2 FTEs. Of the 16.4 FTE RN positions, 4.2 (26%) are allocated to the NCDF, which remains closed. The remaining 12.2 RN FTEs are allocated to the Main Adult Detention Facility (MADF), which has housed all incarcerated adults since NCDF closed in November 2020. If the allocations for NCDF are removed from consideration, and MADF is viewed separately, the RN vacancy rate as of March 31, 2022 is 51%. All of the dedicated Booking RN-Medic 1 hours have been filled on all three shifts, January through March, despite vacancies.
Contract Oversight:
Internal audit mechanisms include monthly meetings with CFMG/Wellpath and Detention Custody staff, and quarterly Sonoma Quality Assurance meetings conducted with participation from County Public Health, County Counsel, County Behavioral Health, CFMG/Wellpath, Sheriff’s Office, and other medical/hospital community stakeholders. Annual peer review is conducted for CFMG doctors.
The Detention Division is audited on a regular basis by third party organizations including inspections from the Board of State and Community Corrections (BSCC) every two years, and a Prison Rape Elimination Act (PREA) audit conducted by an outside auditor every three years (occurring at present). The Sheriff’s Office was accredited by the Institute of Medical Quality (IMQ) through the California Medical Association (CMA) from 2007-2021, with IMQ audits taking place every two years including review of medical procedures, care and treatment standards, quality management, and personnel standards. The Sheriff’s Office has consistently maintained accreditation and compliance with standards while CFMG/ Wellpath have been providing services. IMQ no longer exists as an accrediting body, given this the Sheriff’s Office Detention Division has initiated the process of achieving new and higher standards of accreditation from the National Commission on Correctional Health Care (NCCHC).
The Sheriff’s Office added additional oversight provisions to the recently awarded contract as a result of Board direction. Board-recommended liquidated damages clause was added; quarterly contractor staffing reports are provided to the Board by the Sheriff’s Office quarterly. Audit reports will be provided to the Board as they are received.
BEHAVIORAL HEALTH SERVICES
Jail-based behavioral health services were provided by the County’s Department of Health Services, Behavioral Health Division from 1983 through 2017. Services were implemented gradually in response to inmate needs, and over time were expanded as the need and regulations increased. An RFP was released in November 2016; CFMG was selected from a group of three responsive proposals, including the County’s Department of Health Services, and began providing services May 1, 2017.
Behavioral health care services under the current Agreement includes but is not limited to:
1. Title 15 inmate behavioral healthcare services - clinical care provided by clinicians and psychiatric staff
2. Suicide prevention
3. Inmate programming - individual and group therapy
4. Pre-release services (discharge planning) - as an individual is preparing to be released from custody, a liaison helps connect that person to services (healthcare, counseling, housing, employment services) in the community.
5. Restoration to competency services for qualifying inmates - to restore to competency individuals who have been determined by the Court incompetent to stand trial, and includes treatment and education services so the inmate is able to participate in his/her/their own defense.
Staffing: Through the years behavioral health staffing has been more consistent than medical/dental, with no specific operational challenges to note at present.
Contract Oversight:
Internal audit mechanisms include monthly meetings with CFMG/Wellpath and Custody staff, and quarterly Sonoma Quality Assurance meetings conducted with participation from County Public Health, County Counsel, County Behavioral Health, CFMG/Wellpath, Sheriff’s Office, and other medical/hospital community stakeholders. Annual peer review is conducted for CFMG doctors.
Third Party Audits and Accreditation: As described above, IMQ no longer exists as an accrediting body. With the upcoming RFP for Detention Behavioral Health Services, the Sheriff’s Office will initiate the process of achieving new and higher accreditation Standards for Mental Health Services in Correctional Facilities from the National Commission on Correctional Health Care (NCCHC).
Extension of Current Contract for One Year: The County’s adult detention facilities are congregate living facilities that are subject to more extensive COVID-19 restrictions than other work environments. The precautions required in response to the multiple virus variants including Omicron; managing the increased number of individuals testing positive upon arrival in Booking; and subsequent focus of staff on mitigation and safety strategies, made release of an RFP, site visits, or bringing together a team of evaluators from other County departments; and negotiating an agreement problematic. The County RFP process is lengthy and intensive. For example, the Inmate Medical and Dental Services RFP took a full year to write, approve, release, host site visits, evaluate proposals, select, negotiate, and bring the agreement before the Board. In this particular example, an additional four months was added to the process to gain Board approval, and negotiation of an interim amendment was required to bridge the resulting term gap and ensure provision of medical services. This work was made more difficult due to the pandemic. For these reasons, the Sheriff’s Office determined that delaying the RFP for six months was the best course of action to insure the process’ integrity and the likelihood of a successful outcome. The Sheriff’s Office will extend the current Behavioral Health agreement for one year to allow time for the lengthy RFP process.
In 2017 the Board of Supervisors delegated the authority to the Sheriff to execute up to three additional one-year extensions after the initial term of the Agreement. As indicated in the approved 2017 Board Summary, prior to executing an extension, the Sheriff’s Office convened a committee to evaluate the current environment and receive recommendations for the negotiation of the terms of the first option period. The committee, comprising members from Risk Management, Behavioral Health Services, County Administrator’s Office, County Counsel, and the Sheriff’s Office, met March 16, 2022 for this discussion, which addressed issues relating to both the amendment and the pending RFP, including but not limited to reporting, staffing, and insurance concerns. The Sheriff’s Office will add the same reporting requirements and liquidated damages clause as were included in the recently approved Inmate Medical and Dental Services Agreement. In anticipation of the new reporting requirements, the Sheriff’s Office has been working with Wellpath on the development of staffing and vacancy reports for contracted behavioral health services. These new provisions will be proactively communicated in the RFP and included in the sample agreement. In consultation with County Counsel, the Sheriff’s Office will be exploring other options and additional provisions to insure accountability from the vendor selected as a result of the upcoming RFP process. It is anticipated that the new RFP will be released in fall of 2022 and that the Sheriff’s Office will return to the Board with a recommended provider in spring of 2023.
Strategic Plan:
N/A
Prior Board Actions:
Inmate Medical/Dental Agreement, Approved 10/26/21
Inmate Behavioral Health Services Agreement, Approved 5/24/17
Fiscal Summary
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FY 21-22 Adopted |
FY22-23 Projected |
FY 23-24 Projected |
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Narrative Explanation of Fiscal Impacts:
No Fiscal Impact - this item is informational only
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Narrative Explanation of Staffing Impacts (If Required):
N/A
Attachments:
Wellpath Medical Shift Coverage Reports, January -March 2022
Wellpath Medical Vacancy Reports, January-March 2022
Related Items “On File” with the Clerk of the Board:
N/A