Dr. Jonathan Sherin, director of the Department of Mental Health (DMH) for Los Angeles County, is thinking outside the box about ways to optimize mental health by preventing trauma. He sees working closely with the foster care system as critical, and he’s proposing to invest millions of DMH dollars to prove it.
With the passage of California’s Assembly Bill 114, in which Sherin played an influential role, L.A. County has the opportunity to retain $200 million in unspent Mental Health Services Act (MHSA) funds that were slated to revert to the state in 2017. Those Prevention and Early Intervention (PEI) funds must be spent on innovative programs according to a plan recently submitted to the state Oversight and Accountability Commission.
DMH’s plan proposes using some of these funds to augment existing services provided by the County’s Department of Children and Family Services (DCFS) and Department of Public Health (DPH), including family finding, home visiting and more.
Sherin spoke to The Imprint recently, in the wake of the tragic death of Anthony Avalos. Prior to his death, Avalos and his family were known to DCFS, the agency responsible for investigating allegations of child abuse.
This tragedy speaks to both the urgency of needs addressed in the PEI plan and the need to clear bureaucratic hurdles so that the plan can be implemented as quickly as possible.
In a county with so many people and such tremendous need, how did DMH wind up with $200 million in unspent funds?
There was a lack of flexibility in terms of thinking about how moneys can be used. We had become very constrained and handcuffed ourselves as a department historically, particularly around prevention money.
Because of the complexity of the brain and behavior, and because of fear and stigma around mental illness, we’re 10, 20 years behind the rest of the medical field. Prevention and innovation money allows us the opportunity to catch up and to create parity — not just in terms of quantity, but in the quality and types of care that we deliver.
But it’s not cookie-cutter stuff. We’re identifying what prevention and innovation and parity mean in our field. We’re creating the future. In order to do that, you have to have courage, you have to have vision, and you have to figure out ways to implement programming and create systems that dramatically improve access, influence the efficacy of care and promote recovery at a different level.
Let’s talk about how your plan could change the landscape for kids and families affected by the foster care system.
There are red flags all over the place. If people are trained to recognize signs, if we have DCFS staff helping to monitor the environment for red flags, then we can triage and engage individuals and get them help. Then we follow up to make sure that help is delivered, and that we’re getting results.
It’s a different paradigm, a much more aggressive way to use those funds to go after people in need and get them assistance, because they’re not necessarily going to come to us. We need to be going out to them.
We are never going to prevent all horrible outcomes. But we’ve got these amazing DCFS workers, who are alerted on a regular basis that there’s something going on in a household. They go in, and they determine if there’s an immediate safety issue.
If they find significant trauma or active mental illness in the home, DMH needs to be available to those caseworkers to say, “Let us know, and we’ll come.”
We’re going to come with deliverables, to say, “How can we help you? How can we improve your lives, your family dynamic? What resources do you need?” Maybe it would be helpful for you to have family therapy, maybe there are parenting issues. Maybe we can deliver those services in the home, or find a place that is convenient for you and find child care for while you’re there.
So you’re giving DCFS workers a place to turn, in situations when they might otherwise close a case without services because the risk to children is not acute in that moment?
Yes, these are things that we are in the process of building. They don’t exist right now. We have the resources to begin consolidating systems around these issues, leveraging community platforms, whether it’s a school, library, court or household. I think we are compelled to do that. It will improve the lives of our citizenry, and it will begin to mitigate some of the horrendous outcomes that we see.
What are some specific things in the PEI plan that will support DCFS right away?
We would like to co-locate DMH staff at regional offices where DCFS has their staff. That would be what we would call our specialized foster care program.
We also want to have a specialized foster care program that is mobile, for kids already in the system. Our role there will be proactive, aggressively involved in actually assessing what’s going on with kids and families. Those assessments will lead to triage and linkage to a set of services, not just for the kids but for the families.
We are not done when we make those referrals: We will make sure that the services are being delivered, and that they’re having an impact. We will follow up and make sure that the care is actually helping. That’s tough work, but that’s what makes the difference. And when it doesn’t work, we will reassess and figure out a solution.
Do you have the infrastructure in place to do that follow-up now?
We’re building it right now.
We are also investing $14 million per year in the DCFS Prevention and Aftercare Networks. Once those initial assessments have been completed, that money will provide for ongoing aftercare activities. So, ideally, we don’t have an outcome like we had last week [the death of Anthony Avalos], where we have a child that’s in the system, maybe there’s an intervention and there’s some improvement, and then a few years later, things explode.
An outcome like that is devastating to everybody. It checks the system. It says to us, “Get back in there, dig in, find solutions.” We owe this kid and his family and siblings follow-up and response, and DMH and DCFS are doing that. We are all saddened by it, but we are going to use it to increase our resolve.
The other thing we are investing in with the plan is home visiting, funded through First 5 and DPH [Department of Public Health].
We are going to apply PEI funds in many of the ways that have already been effective, leveraging our partners. We can use this system as it exists. We don’t have to create it ourselves.
What are some of the challenges to implementing your plan?
We’re looking to ramp up capacity now; it’s not easy to do. It’s very difficult to hire people, and it’s difficult to get contracts started. These things take a long time in bureaucratic systems.
That said, we currently have a Board of Supervisors that is unusually aligned around providing services to the most vulnerable people in Los Angeles County. They have the courage to take on and transform this bureaucracy. They’re hiring leaders that come in with that ethos, that we are going to figure out how to use this system in a way that will take care of people much more effectively and efficiently than it has in the past.
How will you ensure the funds are spent effectively? Are you implementing performance-based contracting?
Yes, absolutely. Performance-based contracting is not a very complicated concept. You pay a contractor money, and they have to deliver a service consistent with what it needs to be.
But in a system this big and this complex, which has evolved over many years, it’s not easy. We have thousands of contracts totaling $1.2 billion. The contractors do different things in different parts of the county; they have different assets, different sizes, different liquidity and access to resources.
At the same time that we are not currently demanding high performance in their contracts, we’re also not providing good customer service to our contractors. We need to take care of them, so they can pay it forward. We have to be able to respond in real time when they have issues that limit their ability to provide care. We have to create contracts that allow us the flexibility to do that.
For example, sometimes a contractor will have funds that they can’t use, even though there’s a demand for the service, because they have already drained a certain bucket of funds and they can’t access another one. That’s on us. The contracts have to be written in a way that that’s not a problem.
We also have to help them project their performance in an ongoing way. We want to have communications daily, weekly about where things are, so we don’t get off course. We have to restructure contracts and reboot the dynamic.
How are you approaching that?
We are enlisting the help of a gold-standard nonprofit known as Third Sector Capital, which helps re-engineer public contract departments. One of the key pieces of that is, what is performance and how do you monitor it?
Enter Steve Ballmer and The Ballmer Group Philanthropy. They are intensely focused on traumatized kids, and families that are fractured. After hearing our vision, they expressed interest in helping us re-engineer our contract division.
But they were very clear that they don’t just want to go after DMH contracts. They want to influence the county. They want to help us transform, and we need to transform, and they gave us close to $3 million to work with the [LA County] CEO’s office to do that.
If this works, what will that look like for kids?
When we think about the outcomes we want, we know that people need a place to live, someone to love and something to do. Those are the basic categories.
If you’re looking at kids, what is something to do? You’re in school, there’s less truancy, there’s less detention, your grades are going up, you’re graduating. A place to live? You’re not bouncing around the foster care system; if you have a family, you’re in one, that’s it. And ideally, you reconnect in a healthy, constructive way with your family of origin, which gets to the issue of someone to love.
Jill Rivera Greene is a strategy and communications consultant specializing in child, family and community well-being.