Lack of State Oversight Threatens Success of California’s Continuum of Care Reform

As California prepares to implement massive changes in how it provides care for foster children, many of the local agencies that will determine the failure or success of the effort — the county behavioral health departments — are completely unprepared to deliver on the promise of improved care. And despite the unprecedented attention paid to these concerns, including newspaper series, legislative hearings and a steady drumbeat of advocates’ warnings, the state agency charged with providing oversight has demonstrated neither the leadership nor the initiative to guide counties appropriately.

The Continuum of Care Reform effort, or “CCR,” is required by California statue pursuant to the passage of AB 403 (Chapter 773, Statutes of 2015). Among other changes, CCR completely upends the system of congregate care, eliminating group homes and directing that a broad range of therapeutic services be delivered locally, including within foster family homes and in the homes of relatives. Children will be assessed regularly by participants in child and family teams, and it is expected that every child with an assessed need for therapy will receive those services in the milieu in which services will be most effective.

But while county child welfare staff has worked with the California Department of Social Services to implement teams, recruit foster parents, revise the licensing/approval processes, pilot assessment tools and partner with foster family agencies (FFAs) and other traditional providers of care, their counterparts in behavioral health have suffered from a thorough lack of direction and support from a dithering California Department of Health Care Services (DHCS).

CCR is a big deal. It’s a big deal for children who often have had to be sent out-of-county (and out-of-state) to receive care that is unavailable in their own communities, rendering concepts of “family therapy” virtually moot and impeding reunification with biological parents. Yet there is a complete lack of behavioral health data, oversight and planning that would promote success of this challenge to bring children home and provide that broad spectrum of care.

Every month, all 58 counties’ child welfare programs’ performance measures are listed on a public website. Nearly 50 factors are measured, including the timeliness of response, the nature and stability of placements, and even the extent to which foster children receive timely health and dental exams. We monitor trends and successes and, when the trends are troubling, we know (and our local partners know) that we need to take action to improve areas in which we are falling short. This kind of transparency helps the public know how we’re performing but, more importantly, it lets us know where we need to devote resources that will improve outcomes.

This kind of data-driven self-examination of our programs is fundamental to improvement and to success. Yet there is no satisfactory equivalent within the world of behavioral health. Despite legislation that required that a comprehensive Performance Outcomes System (POS) be completed by 2014, the implementation has stalled, and only a handful of statewide, aggregated reports have been issued. No individual county data is included.

So we can look at the data and see, for example, that the overall penetration rate (percentage of foster children receiving mental health services) has been declining steadily, that many services to foster youth (measured by minutes/case) have been declining, that there appear to be racial disparities in penetration rates that are unexplained (rates for white youth are consistently higher than those for Hispanic, African-American and others), and other issues that would indicate a need for explanation and remediation. It is apparent, for example that there has been a reduction in the actual number of African-American children receiving services, just as other data suggest that these children are more likely to be prescribed psychotropic medications. We know from conversations with our peers that individual counties’ penetration rates vary dramatically, with some in the low teens and others in the high nineties, but individual counties’ rates are not listed in the state’s reports, so we cannot examine or analyze this phenomenon.

As the agency responsible for overseeing county mental health plans, DHCS has the primary role in addressing these concerns. With the demands of AB 403 and CCR looming, we need to determine the extent to which county mental health plans and their subcontractors are prepared to meet new expectations, a determination that could be made in part by surveying counties and in part by reviewing the POS reports. Even prior to considering the increased expectations of CCR, we often hear reports of waiting lists and other barriers to care for foster children, certainly including the wildly inconsistent application of the “medical necessity” threshold that results in similarly situated children receiving specialty mental health services in some jurisdictions, even as they are denied them in others.

In the past, litigation was required to prod progress in behavioral health services for foster youth. “Emily Q.” and “Katie A.” are short-hand expressions that represent the failures of vision and initiative that ultimately had to be resolved by the courts. More recently, the legislature has stepped in, insisting that the administration of psychotropic and antipsychotic drugs be more closely monitored, in the wake of a damning and well-researched series in the San Jose Mercury News. Other legislation currently pending would require county mental health plans to screen foster youth for trauma; yet another bill would require that county mental health plans participate in the same kind of data review and corrective action plans in which child welfare agencies have engaged for years.

When county social service departments are found to be providing substandard service, whether it be the timeliness of action on public assistance applications or the extent to which we meet federal/state performance measures on any of those factors in child welfare, our state supervisory agency steps in. Questions are asked, and explanations expected. We prepare corrective action plans, and are expected to demonstrate progress.

This is an appropriate role for our supervisory state agency, but DHCS has not been performing this role adequately in ensuring that county mental health plans provide a consistent, minimum level of service to the most vulnerable children in California. It can begin by listing the Performance Outcome System data by individual county, perhaps excepting the very smallest counties where confidentiality could be jeopardized, and where a handful of cases can swing percentages dramatically from month to month. These data would enable members of the county board of supervisors, advocates and others to assess the extent to which local providers of service should be congratulated or challenged. It would generate discussion about program improvement and access.

These kinds of discussion are of compelling interest to those we serve, and to those who rely upon us to serve others well.  It’s a conversation that needs to begin with the State because, uninformed by vision and lacking assertive leadership, California’s fractured and inconsistent system of behavioral health will not succeed in achieving the ambitious and worthy goals of Continuum of Care Reform.

Lee Collins is the director of the San Luis Obispo Department of Social Services. He is the longest-tenured social services director in California, with 33 years experience, and is a past recipient of the County Welfare Directors Association’s Executive Leadership Award.

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