SUBJECT
Title
AUTHORIZE ACCEPTANCE OF BEHAVIORAL HEALTH BRIDGE HOUSING GRANT FUNDS, AUTHORIZE A COMPETITIVE SOLICITATION FOR PROVISION OF RECUPERATIVE CARE SERVICES, AUTHORIZE REALLOCATION OF AMERICAN RESCUE PLAN ACT EVERGREEN FUNDS SUPPORTING RECUPERATIVE CARE SERVICES, AND ADD ACCESS TO RECUPERATIVE CARE TO THE LEGISLATIVE PROGRAM (DISTRICTS: ALL)
Body
OVERVIEW
On September 27, 2022 (23), the San Diego County Board of Supervisors (Board) adopted the Behavioral Health Optimal Care Pathways (OCP) model, outlining the optimal and future capacity that would best support people with limited opportunities for placement due to complex needs, lack of existing services, inadequate capacity, and/or other specialty care needs. The model focuses on diversion to the least restrictive environment and supports the medical, social, and environmental needs of people more effectively by improving access and connecting them to ongoing care long term.
According to the OCP model, the region has experienced significant capacity loss across community-based care. The inequity of this level of care continues to have impacts resulting in people remaining in higher levels of care. The model has identified the need for 12,000 new recuperative care bed days, a service which does not yet exist within the behavioral health continuum of care. Earlier this year, a grant opportunity became available to address this need.
On January 16, 2024, the California Department of Health Care Services (DHCS) released a request for applications for the Behavioral Health Bridge Housing (BHBH) Program Round 3, which provided $265.0 million in competitive grant funds to county behavioral health agencies to address the immediate and sustainable housing needs of people experiencing homelessness who have serious behavioral health conditions. The County of San Diego (County) Health and Human Services Agency (HHSA), Behavioral Health Services (BHS) applied for BHBH Round 3 grant funds. Subsequently, on July 25, 2024, BHS received a notice of a conditional award totaling $12.4 million of grant funds for Program Operations and Bridge Housing Start-Up Infrastructure.
On January 9, 2024 (14), the Board allocated $8.0 million in capital funding to support expanding recuperative care capacity using American Rescue Plan Act (ARPA) funds to address hospital overcrowding for medically vulnerable individuals experiencing homelessness. On May 21, 2024 (26), the Board specified use of General Purpose Revenue through the ARPA revenue loss strategy to fund the program. In response to Board direction, HHSA engaged community partners to gather input to ensure awarded funding would address specific gaps and barriers that persons experiencing homelessness face when accessing recuperative care.
Today’s item requests the Board to authorize acceptance of $12.4 million of one-time grant funds, inclusive of $10.0 million for recuperative care services and $2.4 million of infrastructure funding for facility improvements, to establish a minimum of 49 new recuperative care beds. A portion of the grant funding will also be utilized to establish recuperative care infrastructure and services within the County-owned Substance Use Residential and Treatment Services (SURTS) facility. Additionally, today’s item requests the authorization to issue a competitive solicitation and award contract(s) for provision of recuperative care services.
Additionally, today’s action will ensure funding designated for recuperative care will address barriers to access as identified by existing recuperative care providers, health providers, Medi-Cal managed care plans and other community partners who participated in community forums. Approval of today’s action would authorize up to $6.0 million of the designated $8.0 million from ARPA funding to support facility improvements required for the County-owned SURTS facility, specific to recuperative care beds that will serve individuals with serious behavioral health conditions. Today’s action would also authorize $2.0 million of the funds previously designated to recuperative care to invest in strategies to reduce barriers to access for existing recuperative care beds as identified by community providers and health care partners, and add access to recuperative care language to the Legislative Program.
This item supports the County vision of a just, sustainable, and resilient future for all, specifically those communities and populations in San Diego County that have been historically left behind, as well as our ongoing commitment to the regional Live Well San Diego vision of healthy, safe, and thriving communities by supporting housing stability for individuals with behavioral health conditions, including those who are experiencing or at risk of homelessness.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Authorize the acceptance of $12.4 million of one-time competitive Behavioral Health Bridge Housing (BHBH) grant funding and authorize the Agency Director, Health and Human Services Agency, or designee, to execute all required documents, upon receipt, including any annual extensions, amendments, or revisions that do not materially impact or alter the services or funding level.
2. In accordance with Section 401, Article XXIII of the County Administrative Code authorize the Director, Department of Purchasing and Contracting to issue a Competitive Solicitation for recuperative care services that serve individuals with serious behavioral health conditions, and upon successful negotiations and determination of a fair and reasonable price, award contracts for an Initial Term of up to one year, with up to four 1-year option years, and up to an additional six months if needed, and to amend the contracts if needed, to reflect changes in program, funding or service requirements, subject to the availability of funds and approval of the Agency Director, Health and Human Services Agency.
3. Authorize up to $6.0 million in General Purpose Revenue through the American Rescue Plan Act (ARPA) revenue loss strategy designated as capital funding for expanding recuperative care capacity to be reallocated for facility improvements within the County-owned Substance Use Residential and Treatment Services (SURTS) facility that will provide recuperative care services for individuals with serious behavioral health conditions.
4. Authorize $2.0 million in General Purpose Revenue through the ARPA revenue loss strategy designated as capital funding for recuperative care bed expansion to be reallocated to implement strategies and support efforts that optimize and increase access to existing recuperative care services by reducing identified barriers, including but not limited to streamlining referral and authorization processes and supporting enhancements to recuperative care beds to ensure access to care for clients with complex medical and/or behavioral health needs.
5. Add access to recuperative care language to the Legislative Program, consistent with Board Policy M-2.
EQUITY IMPACT STATEMENT
The County of San Diego Health and Human Services Agency, Behavioral Health Services (BHS) is committed to building a system in which mental health and substance use services are equitably and regionally distributed while accessible to all individuals and families within the region who are in need. As outlined in the Behavioral Health Optimal Care Pathways (OCP) model, an increase of 12,064 new recuperative care bed days was projected to optimally support Medi-Cal beneficiaries within the behavioral health continuum of care. The Behavioral Health Bridge Housing Round 3 grant funds will be dedicated toward establishing new recuperative care services, in alignment with the OCP, for people with behavioral health conditions. The new beds are anticipated to support continuity of care and services in a stable location to prevent returns to homelessness and facilitate smooth transitions from specialty care settings.
Complexities of managing multiple healthcare needs coupled with barriers to timely and consistent access to care may allow existing health conditions to deteriorate beyond what would otherwise be safely managed in outpatient settings. In the absence of recuperative care facilities, persons experiencing homelessness (PEH) may be discharged to shelters or the streets, which do not provide necessary care for recovery. Evidence suggests medical respite programs are effective in bridging gaps in care for PEH by reducing hospital readmission rates and overall healthcare costs, while providing a stable environment that facilitates recovery and access to necessary health services (National Institute for Medical Respite Care, 2021).
Recuperative care programs can also help provide stable housing post care. A case study on the National Health Foundation, a recuperative care program in Los Angeles that partners with local hospitals and the county, found that 59% of PEH transitioned to stable housing or reunited with family after the program (McCarthy and Waugh, 2021). Findings from these studies suggest that recuperative care programs can improve health and housing outcomes for individuals experiencing homelessness. The stable housing, support, and connection to services offered by recuperative care facilities provides a place to recover from surgery, illness, and other ailments without concerns about necessities, or how to balance these needs with obtaining health care and social services.
SUSTAINABILITY IMPACT STATEMENT
Today’s item supports the County of San Diego (County) Sustainability Goal #2 to provide just and equitable access by creating policies to reduce and eliminate poverty, promoting economic sustainability for all by pursuing available funding focused on serving historically underserved client populations that are most in need of care. This includes the unique needs of individuals experiencing homelessness who have a serious behavioral health condition. This item supports Sustainability Goal #4 to protect the health and well-being of everyone in the region by creating new recuperative care beds that will allow individuals to continue to receive care. This item also supports Sustainability Goal #6 to ensure the capability to respond to immediate needs for individuals, families, and the region by providing opportunities for people engaged in substance use disorders and/or in the criminal justice system to find longer-term care and housing. This will allow the County to meet the regional need for immediate and sustainable housing, while leveraging the County-owned Substance Use Residential Treatment Services facility along with contracted community-based care providers.
FISCAL IMPACT
Recommendations 1 and 2
Funds for this request are included in the Fiscal Year (FY) 2024-26 Operational Plan in the Health and Human Services Agency. If approved, this request will result in estimated costs and revenue of up to $2.4 million in FY 2024-25 for capital costs associated with renovations to establish new recuperative care beds and estimated costs and revenue of $10.0 million in FY 2025-26 through FY 2026-27 for services. These costs will be absorbed in existing appropriations. The funding sources are State General Fund through the Behavioral Health Bridge Housing (BHBH) Round 3 grant funding. Funding for this request in future years will be included in future Operational Plans. There will be no change in net General Fund cost and no additional staff years.
An estimated $1.2 million of the BHBH Round 3 capital funds will be utilized within the Substance Use Residential and Treatment Services (SURTS) facility specific to the development planning, permits, fees, and renovations for recuperative care beds.
Recommendations 3, 4 and 5
Funds for Recommendations 3 and 4 are included in the Fiscal Year (FY) 2024-26 Operational Plan in the Health and Human Services Agency. If approved, this will result in a one-time cost and revenue of $8.0 million in FY 2024-25. The funding source is General Purpose Revenue made available through the ARPA revenue loss strategy. There will be no change in net General Fund cost and no additional staff years as a result of this option. There is no fiscal impact expected for Recommendation 5.
Up to an estimated $6.0 million of the General Purpose Revenue made available through the ARPA revenue loss strategy will be utilized within the SURTS facility specific to costs for the development planning, permits, fees, and renovations for recuperative care beds that are not fully funded through the BHBH Round 3 capital funds.
The total project cost for the SURTS facility renovations and improvements is estimated at $26.0 million, inclusive of substance use treatment and recuperative care beds.
BUSINESS IMPACT STATEMENT
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Details
ADVISORY BOARD STATEMENT
Due to a lack of quorum, the Behavioral Health Advisory Board (BHAB) meeting on September 5, 2024, was canceled and this item was shared with BHAB members via email.
BACKGROUND
The San Diego County Board of Supervisors (Board) and the County of San Diego (County) Health and Human Services Agency (HHSA) remain committed to supporting the well-being of those with behavioral health conditions and investing in services to meet the needs of individuals. In alignment with this commitment, County Behavioral Health Services (BHS) continues to pursue funding opportunities to expand access to critical mental health and substance use disorder prevention, engagement, housing, and treatment services.
On September 27, 2022 (23), the San Diego County Board of Supervisors (Board) adopted the Behavioral Health Optimal Care Pathways (OCP) model, outlining the optimal and future capacity that would best support people with limited opportunities for placement due to complex needs, lack of existing services, inadequate capacity, and/or other specialty care needs. The model focuses on diversion to the least restrictive environment and supports the medical, social, and environmental needs of individuals more effectively by improving access and connecting them to ongoing care long term. The Behavioral Health Bridge Housing (BHBH) Program created a unique opportunity to advance Board priorities and implementation of the OCP model.
BHBH Program Background
In September 2022, Assembly Bill 179 legislation authorized $1.5 billion in grant funding opportunities for bridge housing expansion, which offers short- and mid-term housing options to people experiencing homelessness who have serious behavioral health conditions, with the goal of connecting them to long-term housing. The California Department of Health Care Services (DHCS) established the BHBH Program and determined grant funds would be utilized to address the following priorities:
• Complement ongoing State, county, and tribal efforts, to address homelessness.
• Provide supportive services and housing navigation to assist people who have serious behavioral health conditions and are experiencing homelessness.
• Serve individuals with serious behavioral health conditions, including serious mental illness and/or substance use disorder, who are experiencing homelessness.
• Provide bridge housing and supportive services throughout the county, including in rural areas, to enable people to remain in their communities.
BHBH funds primarily provide operational and supportive services funding to expand bridge housing capacity within existing settings or new settings and can be utilized across four domains. These domains include 1) County program implementation; 2) Bridge housing outreach and engagement; 3) Bridge housing, including shelter/ interim housing, rental assistance, auxiliary (patch funds) for assisted living settings (board and care), and housing navigation; and 4) Bridge housing start-up infrastructure.
DHCS released BHBH grant opportunities in four rounds. In April 2023, BHS applied for BHBH Program Round 1 grant funds and received an award of $44.3 million and acceptance of funds was approved by the Board on July 18, 2023 (15). These funds are to be utilized through June 30, 2027, including $41.5 million allocated to create new board and care beds within adult and senior residential care facilities licensed by the Community Care Licensing Division of the California Department of Social Services for people enrolled in Medi-Cal. The remaining $2.8 million will be utilized to support infrastructure start-up costs to expedite the ability for new board and care slots by January 2025. BHBH Program Round 2 funding included a $30.0 million competitive allocation to tribal entities only. No allocation was provided to counties.
In April 2024, BHS applied for BHBH Program Round 3 grant funds and on July 25, 2024, received notification from DHCS of a $12.4 million award. BHBH Program Round 3 funding was awarded for two tracks according to county size: Track 1 for Program Operations and Track 2 for Start-Up Infrastructure. The allocation of the $12.4 million through BHBH Round 3 is planned for two projects: new recuperative care beds within the community and renovations to the Substance Use Residential and Treatment Services (SURTS) facility to establish the new recuperative care beds, as further described below.
Track 1 Program Operations: Recuperative Care Beds
In alignment with the findings outlined in the OCP model, a total of $10 million will be utilized to create a minimum of 49 new recuperative care beds for individuals who are experiencing homelessness and have a serious behavioral health condition, including a substance use disorder that will be operational through June 30, 2027. To address the gap between acute care and serious mental illness (SMI) and/or substance use (SU) residential care, the program will operate as part of the BHS continuum of care and will leverage Community Supports services through Medi-Cal in collaboration with Managed Care Plans (MCPs) when available. This approach aims to ensure continuity of care, facilitate smoother transitions from specialty care settings, and enhance overall service delivery for individuals in need. Recuperative care is a Medi-Cal reimbursable service authorized by the MCPs based on identified eligibility criteria. MCPs typically negotiate rates and reimbursement models directly with the providers. Coverage specifics can vary based on the client’s insurance plan, the provider’s agreement with the MCP, and the client’s medical needs.
Recuperative care provides adults with behavioral health conditions who may be experiencing homelessness a safe place to be discharged upon release from acute and other specialty care settings when they are unable to recover while living unhoused and the service is not eligible or available through existing federal, State, or County funds. This service provides a recovery-oriented setting for adults to recover while receiving case management and connection to primary care, behavioral health services, and other supportive services, including transportation, food, and housing. These new beds will be located within the County-owned SURTS facility and within one-or more community-based providers that contract with the County.
Track 2 Start-Up Infrastructure: Substance Use Residential and Treatment Services (SURTS) facility
BHBH funds totaling $2.4 million will be utilized for capital infrastructure to establish new recuperative care beds within the community and for renovations to the County-owned SURTS facility, which will provide a continuum of residential treatment and recovery services to include withdrawal management, substance use treatment, and recuperative care services. Although this facility will serve anyone countywide who meets eligibility criteria, regardless of where they live, placement in the South Region is ideal as there are currently limited residential substance use services and no withdrawal management or recuperative care services available for Medi-Cal clients located in this part of San Diego County.
SURTS, located in National City, is a 28,156 square foot facility in need of renovation and adaptive reuse. This space was formerly used for a substance use residential treatment program and is currently being used as a temporary location while renovations are occurring for a separate substance use residential treatment program. The space includes a supporting annex with a laundry and kitchen, residential rooms, offices, and staff lounge. Proposed infrastructure work includes interior renovation, roof repairs, Americans with Disabilities Act compliance and exterior wall repairs. In addition, termite repairs, electrified heating ventilation and air conditioning, switchgear, distribution panels, fire alarm, new kitchen and laundry equipment, and fire line realignment are needed. To date, life-safety repairs such as new sprinkler heads, paint, flooring, and minor electrical repairs have been completed for use during this temporary occupation.
On May 21, 2024 (14), the Board approved actions that allow for renovations to commence and construction is expected to begin April 2025 with estimated completion in 2026. The total cost for the SURTS project is estimated at approximately $26.0 million and may change based on final design. The County will apply for Behavioral Health Continuum Infrastructure Program (BHCIP) grant funding to cover the majority of $24.8 million or remaining costs for this project. The BHBH funds would pay for up to $1.2 million in development planning, permits and fees specific to the recuperative care beds, as well as a portion of the renovations.
American Rescue Plan Act (ARPA) Evergreen Component Supporting Recuperative Care Services
On January 9, 2024 (14), the Board allocated $8 million in capital funding to support expanding recuperative care capacity using ARPA funds to address hospital overcrowding for medically vulnerable individuals experiencing homelessness. On May 21, 2024 (26), the Board specified use of General Purpose Revenue through the ARPA revenue loss strategy to fund the program.
In response, County Medical Care Services (MCS) conducted a community input process to inform development of a solicitation and ensure requirements to award funding addressed issues, gaps, and barriers that individuals experiencing homelessness face when accessing recuperative care. Eleven community participants from seven organizations participated in the community forum, and six responses were received via a survey link. Analysis of the resulting feedback indicated that expanded bed capacity may not be the greatest area of need regarding recuperative care. The most pressing challenges identified were:
1. Timeliness of referral and authorization: Feedback received mentioned referral and authorization concerns as the most pressing issues to lack of access. Through Medi-Cal Transformation, Medi-Cal MCPs can now include payment for Recuperative Care as a Community Supports service. As such, the MCPs receive referrals for Recuperative Care services for review and authorization of payment. According to Community feedback, because San Diego County does not have presumptive eligibility as some other counties do, authorization for payment by the MCP which is required prior to placement into a recuperative care facility, may take several days. This can result in patients being discharged from a hospital before they are authorized to be transferred to a Recuperative Care Facility. Referral issues cited included unclear processes, as each facility has their own way of managing referrals, lack of a centralized contact person or system, and the overall process can be confusing for both providers and patients.
2. Capacity of traditional recuperative care facilities to address complex service level needs: Feedback received regarding service levels required for persons experiencing homelessness concluded that traditional recuperative care may not be the most appropriate level of care. Instead, the focus should be on recuperative care facilities with additional specialized supports to accommodate physical, social, mental, and behavioral health services; crisis management; connection to housing solutions including permanent housing; education and employment services; legal and advocacy services; and transportation assistance. An emphasis was placed on ensuring patients had a quality of care that would maintain their personal autonomy as much as possible and avoid re-traumatization.
Today’s item requests the Board to authorize acceptance of $12.4 million of one-time grant funds, inclusive of $10 million for recuperative care services and $2.4 million of infrastructure funding for facility improvements to establish a minimum of 49 new recuperative care beds. A portion of the grant funding will also be utilized to establish recuperative care infrastructure and services within the County-owned SURTS facility. Additionally, today’s item requests the authorization to issue a competitive solicitation and award contract(s) for provision of recuperative care services.
Today’s item also requests to authorize up to $6.0 million of the designated $8.0 million to support facility improvements required for the County-owned SURTS facility, specific to recuperative care beds that will serve individuals with serious behavioral health conditions. Finally, today’s actions would authorize $2.0 million of the funds previously designated to recuperative care to invest in strategies to reduce barriers to access for existing recuperative care beds as identified by community providers and health care partners, and add access to recuperative care language to the Legislative Program. Any remaining funding not applied to capital improvements for recuperative care beds within the SURTS facility would shift to support strategies to reduce barriers for existing recuperative care beds.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the County of San Diego 2024-2029 Strategic Plan initiatives of Equity (Health) and Community (Quality of Life) as well as the regional Live Well San Diego vision, by reducing disparities and disproportionality of individuals by pursuing housing stability for adults with serious behavioral health conditions, including those who are homelessness.
Respectfully submitted,
ebony n. shelton
Chief Administrative Officer
ATTACHMENT(S)
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