New DHCS behavioral health assessment identifies disparities, stakeholders give recommendations to improve services

On Jan. 10, the California Department of Health Care Services (DHCS), in collaboration with its stakeholders, published an updated statewide behavioral health assessment for 2022, titled “Assessing the Continuum of Care for Behavioral Health Services in California.” 

 

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The assessment presents an analysis of data gathered from surveys and focus groups conducted by DHCS and reports from various stakeholder organizations, such as the California Health Care Foundation (CHCF) and the Substance Abuse and Mental Health Services Administration (SAMHSA). 

The goal of the assessment is to provide data and stakeholder perspectives to inform DHCS as it “… implements major behavioral health initiatives, responds to new federal funding opportunities, and prepares to submit a Section 1115 Medicaid demonstration waiver in 2022 to strengthen mental health services for people living with serious mental illness (SMI) and youth living with serious emotional disturbance (SED).”

The assessment establishes several key findings from the data that are meant to paint a picture of the current state of behavioral health in California, and includes stakeholder-identified opportunities to improve the following service areas:

  • Preventive, wellness, and outpatient services
  • Crisis services
  • Community, peer, and recovery support services
  • Intensive outpatient and treatment services considerations

The first key finding identified in the behavioral health assessment is that young adults, aged 18 to 25, have the highest rates of SMI and substance use disorders in the state–7.1% versus 4.1% among all other adults for SMI, and 16.1% versus 8.1% for substance use disorders.

Moreover, the rate of SMI in California has increased by more than 50% between 2008 and 2019. The chart below shows a comparison between adults in California living with SMI and adults in the U.S. overall, showing that state rates grew at nearly the same rate as the country’s.

 

Image: DHCS

 

The next key finding discussed in the assessment was that marginalized groups experience higher rates of behavioral health conditions and more difficulties accessing care. For example, the assessment noted that only 16% of Black Californians have reported receiving mental health services for themselves or a family member, compared to 23% of white, 25% of Asian, and 29% of Latino Californians. 

Additionally, individuals who have been incarcerated report significantly higher rates of mental health conditions and substance use disorders. The assessment estimated roughly 60% of incarcerated adults in California have a substance use disorder and a quarter to a third of them have SMI. Over half of all individuals in the county-based juvenile justice system have an open mental health case.

Another key finding was that Medi-Cal plays a critical role in providing health coverage to individuals living with SMI and substance use disorders, citing that Medi-Cal is the primary source of coverage for nearly half of California residents with a substance use disorder. 

However, according to the assessment, many Californians with a behavioral health condition still struggle to access treatment even if they are enrolled in Medi-Cal. Approximately one-third or more of individuals enrolled in Medi-Cal with SMI do not receive any Medi-Cal specialty mental health services. Among all Californians seeking behavioral health services, more than 43% reported that it was somewhat or very difficult to secure an appointment with a provider who accepts their insurance.

The assessment also found that county-level rates of behavioral health conditions varied significantly. The chart below shows the overall drug-related overdose death rate per 100,000 by county in 2020.

 

Image: DHCS

 

The assessment  also identifies several service challenges across the behavioral health continuum of care, as well as short recommendations and considerations for policy changes to improve problem areas.

For preventive, wellness, and outpatient services, the assessment reports that there is a significant shortage of psychiatrists and other individual practitioners, particularly in the Medi-Cal program, and that smaller counties report greater shortages of outpatient services–especially in mental health clinics. Psychiatrists are unevenly distributed across the state, ranging from 1.7 psychiatrists per 100,000 residents in San Benito County to 68.1 in Marin County.

Opportunities identified by stakeholders to improve preventive, wellness, and outpatient services, according to the assessment, are:

  • “Incentivizing providers to adopt a no-reject policy for outpatient and other behavioral health services for incarcerated or formerly incarcerated individuals.”
  • Encouraging programs to strengthen and expand the behavioral health care workforce for early intervention.
  • Encouraging efforts to diversify practitioners and settings that can offer outpatient services.

Peer and recovery support services, while they have great potential, are not yet available throughout the entire state, according to DHCS The assessment stated that peer services can be extremely effective, especially for youth, as they can offer encouragement using their own experiences, keep individuals engaged in treatment, and build a sense of community. 

Opportunities to improve various community, peer, and recovery supports for youth and adults include uilding additional capacity for the peer workforce by creating a process for recruiting and certifying youth peer supports, SUD recovery coaches, and a family peer support workforce.

DHCS has already committed to addressing this opportunity area by implementing its new peer support certification standards, which will become a covered Medi-Cal benefit in July 2022.

For crisis services, such as mobile crisis teams and crisis stabilization units (CSUs), the assessment reports the need for additional mobile crisis capacity. According to survey data, approximately one-third of California counties report that they do not operate or contract with any mobile crisis response teams, and many crisis teams report significant workforce issues related to recruitment and staff retention due to the 24/7 nature of the services provided. Out of 33 counties with CSUs available, 16 had sufficient CSU capacity, and 25 counties reported no CSU bed capacity at all. 

To improve these crisis services, the assessment’s recommendations include:

  • “… [Reviewing and identifying] regulatory barriers preventing the delivery of integrated crisis care and SUD treatment, including ensuring that crisis services offer access to [medication-assisted treatment (MAT)] for those individuals who have both [opioid use disorder (OUD)] and a mental health issue.”
  • Enhancing the workforce of crisis providers by including “… peer support service providers and trained law enforcement personnel in partnership with behavioral health providers.” 
  • More training and technical assistance with the new federal mobile crisis option in Medi-Cal. 

For intensive outpatient and treatment services, such as Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs), the data showed that there is a shortage of medically monitored beds in many counties across the state–more than half of the counties surveyed reported that they need additional IOPs, PHPs, and day treatment services for both adults and youth. and the assessment identified the lack of upstream services that could be helpful in preventing individuals from going to emergency departments and getting admitted to a facility. 

The assessment presented several opportunities for improving the state of intensive outpatient and treatment services and developing additional capacity for existing services, including:

  • “[DHCS educating] managed care organizations and hospitals regarding the current Voluntary Inpatient Detoxification benefit (inpatient withdrawal management) to ensure broader availability of services.
  • … Additional clinical programs and providers to treat eating disorders, as well as clarification on the mutual responsibilities of managed care plans and mental health plans.
  • … Leveraging the proposed SMI/SED 1115 Demonstration program to allow Medi-Cal coverage of high-fidelity [Assertive Community Treatment (ACT)] teams and forensic ACT teams, to support programs to divert individuals from arrest and incarceration into treatment, and/or expand treatment options for eating disorders.
  • Developing standards and admission criteria for inpatient withdrawal management (also known as voluntary inpatient detox), consistent with current [American Society of Addiction Medicine (ASAM)] criteria.”