SUBJECT
Title
ADDRESSING THE NEEDS OF VULNERABLE AND HOMELESS POPULATIONS: SUPPORT FOR COMMUNITY ASSISTANCE RECOVERY AND EMPOWERMENT (CARE) COURT (DISTRICTS: ALL)
Body
OVERVIEW
San Diego is facing a growing behavioral health and homelessness crisis. The most recent Point-in-Time Count in 2020 found at least 3,971 unsheltered people experiencing homelessness, some of whom have untreated behavioral health needs. The County of San Diego (County) is charged with providing care and support to our most vulnerable populations. To achieve the best possible health outcomes, people experiencing homelessness or a behavioral health crisis need coordinated care amongst various systems, community partners, and governmental agencies. We must find innovative and compassionate solutions to help those most urgently in need.
In March 2022, Governor Gavin Newsom introduced a policy framework that seeks to assist people living with untreated mental health and substance use disorders. The policy framework, the Community Assistance, Recovery, and Empowerment (CARE) Court, is a court-ordered plan that connects a person with 24 months of case management and services. These services include a public defender and clinical support services, as well as a housing plan.
In San Diego County, the CARE Court framework could play an important role in helping people with very specific needs access treatment. However, successful implementation of CARE Court is dependent upon building and scaling out a new system of care, workforce, and infrastructure that aligns with the proposed framework. The responsibility for CARE Court, as currently envisioned, places these responsibilities with counties, however, collaboration, resources and support on the part of all levels of government are required.
Today’s action would direct the County to support the CARE Court framework while also advocating for the necessary funding, workforce development assistance, adequate time for implementation, and cooperation at the local municipal level to provide the necessary housing to ensure the successful implementation of the CARE Court program.
RECOMMENDATION
CHAIR NATHAN FLETCHER AND VICE CHAIR NORA VARGAS
1. Direct the Chief Administrative Officer, consistent with Board Policy M-2, to advocate in support of the CARE Court framework, in the form of Senate Bill 1338 or another legislative vehicle, through a letter of support to the Governor and through advocacy with State regulatory agencies, the State budget process, and other legislative efforts, while advocating for dedicated and ongoing funding, clearly defined eligibility standards for participants, adequate time for implementation with a delay in the court’s ability to sanction, and cooperation at the State and municipal level to build the necessary housing to ensure the successful implementation of the CARE Court framework while expressing desire to participate in any future pilot programs related to CARE Court and ensuring necessary funding for such pilot programs.
EQUITY IMPACT STATEMENT
The County is committed to finding equitable solutions to address the ongoing behavioral health and homelessness crisis. CARE Court is a proposed framework to deliver mental health services and other support to the most severely impaired Californians who too often suffer from homelessness or incarceration without the treatment they need. The framework strives to provide individuals with a clinically appropriate, community-based set of services and supports that are culturally and linguistically competent. Successful implementation of this program is predicated on both sufficient funding and establishing a framework that provides the necessary supports for the participants. By advocating for policy changes that can make a CARE Court program successful, the County will improve the outcomes and address the needs of a vulnerable and underserved population who have a serious mental illness.
FISCAL IMPACT
There is no fiscal impact associated with this action. There may be future fiscal impacts associated with future recommendations and implementation of the CARE Court. Any such recommendations would return to the Board for approval as necessary with identified costs and resource needs. There will be no change in net General Fund cost and no additional staff years.
BUSINESS IMPACT STATEMENT
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Details
ADVISORY BOARD STATEMENT
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BACKGROUND
Over the past few years, the County has made progress in reimagining our behavioral health system. However, there are opportunities for new policies that can provide additional care for those who have a serious mental illness.
CARE Court is a new policy framework from Governor Gavin Newsom that seeks to assist people living with untreated mental health disorders. The policy framework, CARE Court, is a court-ordered plan that connects a person with 24 months of case management and services. CARE Court has the potential to provide much-needed help to those individuals who have a serious mental illness, and for whom other treatment options are not working. This is a new approach to try to match behavioral health services, housing, and other assistance to those who may not be able to seek this out on their own. These services include a public defender, a trained supporter, a clinical team, and a housing plan.
Under the current proposal, a person is eligible for CARE Court if they are 18 years of age or older, have a serious mental illness or a related disorder, are not currently stabilized and in treatment with a county behavioral health agency, and currently lack medical decision-making capacity. There are many methods of referral to the Court, which may include a family member, behavioral health provider, first responder, or other approved party.
Once a CARE Court proceeding is initiated, both a public defender and a “support person” would be appointed to assist the individual during the court process. The CARE Court process allows the individual to work with county behavioral health to determine if they can reach a voluntary plan for care. If they cannot, the court would order an evaluation of the individual and, based on the results of the evaluation, order the individual, their public defender, their support person and county behavioral health to develop a CARE plan which must be followed for one year.
The CARE plan must include medically necessary treatment, including medication if recommended. CARE plans must also include a housing plan, but the court may not order the county to provide housing. After one year, the individual may request an additional one-year term in CARE Court, or to be graduated. If a person fails to follow the plan there is a presumption that there are no suitable community alternatives and that a conservatorship under the Lanterman-Petris-Short (LPS) Act may be warranted. If a county fails to comply with the CARE plan, the court may fine the county or, in the case of persistent non-compliance, appoint a receiver to provide the court-ordered treatment at the county’s expense.
In San Diego County, the CARE Court framework could play an important role in helping people with very specific needs access treatment. However, certain concerns would need to be addressed in order to successfully implement CARE Court. Implementation of the program is dependent on dedicated and ongoing funding, adequate time for implementation, a robust and trained workforce, and housing.
If the CARE Court framework is adopted, the County would need to build and scale out a new system of care. In order to provide these new services and to assist this new population, the County will need dedicated and sustainable funding to implement CARE Court. Simply redirecting existing funding, which supports existing County services that are proven and evidence-based, and which may have very prescriptive requirements that do not align with CARE Court, is insufficient. Further, punitive sanctions, as currently proposed in SB 1338, on counties for failure to implement elements of CARE Court could exacerbate already existing budgetary challenges.
Developing an adequate workforce is foundational to the expanded services that would be required under CARE Court. Currently, the County is working to address the already existing workforce shortage for services that would be employed by CARE Court. Chair Fletcher has convened the Behavioral Health Workforce Steering Committee to analyze regional workforce issues and seek creative solutions to address these gaps. It is reasonably anticipated that CARE Court would increase the number of people who will utilize County Behavioral Health Services, Public Defenders, Public Conservators, court administration, and the larger nonprofit and provider community. Matching the increase in demand for services would require the County to accelerate its attempts at hiring, training, and retaining the already diminished workforce.
State-level investment and new, creative approaches to build up our local workforce are needed to successfully implement CARE Court. High housing costs, stagnant wages, licensing barriers, and currently impacted caseloads have reduced the behavioral health workforce. However, it should be noted that even with State resources, increasing our workforce capacity will take time.
In addition, because many participants are expected to be experiencing homelessness, housing for CARE Court participants is identified as a critical component. The County does not control zoning, shelter, and housing in most of the areas in which unsheltered people live and receive services. Without local jurisdictions providing necessary housing, the CARE Court treatment provided by the County will likely be unsuccessful. Therefore, funding from the State and cooperation from local jurisdictions to meet housing needs are necessary.
The eligibility criteria for CARE Court participation must be carefully crafted to target the population in need. By clearly defining eligibility in consultation with behavioral health experts, the program will avoid the severe unintended consequences of involving people in the court system who are not in crisis. Additionally, carefully defining eligibility will ensure that those in need receive the full benefit of CARE Court rather than over encumbering the program with unintended recipients.
The County appreciates the Governor’s commitment to supporting our vulnerable populations and we are eager to work with the Administration and other stakeholders on a proposal that can be successful, improve outcomes, and address the needs of our communities in a sustainable way.
Today’s action would direct the County’s legislative advocate and Chief Administrative Officer to advocate in support of the CARE Court program while also advocating for the necessary dedicated and ongoing funding, workforce development assistance, adequate time for implementation, and cooperation at the local municipal level to build the necessary housing to ensure the successful implementation of the CARE Court program.
We urge your support for the actions before you.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
The requested action supports the County’s 2022-2027 Strategic Plan initiatives of Equity and Community by creating a multifaceted system to serve individuals experiencing a behavioral health crisis.
Respectfully submitted,
CHAIR NATHAN FLETCHER NORA VARGAS Supervisor, Fourth District Supervisor, First District
ATTACHMENT(S)
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