Responses to Commissioners’ Questions
July 18, 2023 Public Hearing on the Behavioral Health Roadmap
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Responses to Commissioners’ Questions
July 18, 2023 Public Hearing on the Behavioral Health Roadmap
Are they on/off strategy? Do they need to course correct? Do MHP’s plans for acute care facility align? Does it fully resolve any specific strategy? How do area hospitals fall in with some of their plans in the next year or two? Which strategy would ASF fall into? What is the vision for how the ASF fits with the roadmap?
The Roadmap vision, goals, strategies and solutions will help to get all stakeholders rowing their boats in the agreed upon direction by providing strategic direction for new and expanding programs and services. Below one can see how a few County and partner programs and services currently in planning phases are already aligning with the Roadmap. MHP’s plans to open a behavioral health urgent psychiatric clinic and to co-locate their acute services are in alignment with the Roadmap.
|Behavioral Health Roadmap Goals||Programs & Services on the horizon|
|Goal: Coordinated System and Workforce to Meet Needs||· BCCSD- Behavioral Health Apprenticeship, Regional partnership|
|Goal: Invest in Prevention & Address Conditions for Community Resilience and Wellbeing||· BCCSD –Community training
· BCPH- Public Health Improvement Plan alignment
|Goal: Early Intervention & Connection to Support||· Community-based navigation & care coordination
· Home — based Therapy, for youth and families, SUD focused, to prevent out-of-home placement/higher levels of care
|Goal: Focused Approaches to Advance Equity & Support Priority Populations||· BCCSD – Mobile Crisis
|Goal: Robust Continuum of Care for Treatment & Crisis Response||· MHP – Urgent Psychiatric Clinic, all ages, evenings and weekends
· MHP – Youth Mental Health IOP
· MHP – Centralize all acute services in one building with onsite navigation
· BCCSD – Mobile Crisis
|Goal: Recovery & Hope|
Alternative Sentencing Facility: The ASF capital costs are not a behavioral health expense. However, some of the ASF programs and services will be. Staff working to develop programming for the Alternative Sentencing Facility are in the planning phases and have been involved throughout the creation of the Behavioral Health Roadmap as part of the Operations Group and other convenings. The future services and programming in the Alternative Sentencing Facility will be focused on those who are justice-involved. Individuals with mental and behavioral health needs are disproportionately represented in the criminal justice system. Partners in the criminal justice system agree that a person should not need to get into the criminal justice system to get care. However, there is a lack of other options in many cases. There is agreement that a person should have the opportunity for offramps out of the criminal justice system wherever possible. These shared philosophies have driven many innovative approaches and increased partnerships within the criminal justice system, including the Alternative Sentencing Facility. One member of the Behavioral Health Planning Team was involved in strategic planning discussions in Community Justice Services to align efforts between development of the Roadmap and planning work for CJS, including the ASF. The opportunities being explored for additional mental and behavioral health services in the ASF are in alignment with the Behavioral Health Roadmap, particularly in the goal area for Robust Continuum of Care for Treatment & Crisis Response. The ASF is not scheduled for operations until Q3 2025.
Challenges with staffing. Which strategy will address staffing issues?
One of the six goals for the Behavioral Health Roadmap is Coordinated System & Workforce to Meet Needs. This goal area includes workforce strategies and solutions to address staffing shortages and other issues. Additionally, two other goal areas have strategies and solutions relevant to workforce and staffing challenges. The goal area, Focused Approaches to Advance Equity & Support Priority Populations has a strategy for Community Leadership & Cultural Brokers with a solution to train and incentivize cultural brokers in the community. The goal area, Recovery & Hope has a strategy for Peer Workforce Expansion.
Where does racial equity and cultural practitioners fit in the overall plan?
Racial equity and cultural practitioners fit into the plan in multiple areas. First, the goal for Focused Approaches to Advance Equity & Support Priority Populations centers around this need and specifies strategies and solutions for culturally relevant supports, supports outside the medical model, and the imperative to invest in and develop specific approaches, messaging, or programming to meet needs based on race, culture, or other identities. Additionally, there is a solution to provide training to those working in the mental and behavioral health field to build cultural competence related to race, other identities, or for other priority populations. This is located in the Coordinated System & Workforce to Meet Needs goal area. The goal statement itself states the need for providers to reflect the community.
The Trusted System Criteria was designed by diverse community members who served on the Equity Advisory Group and elevates racial equity in development of implementation planning as well as accountability. This set of criteria operationalizes racial equity and equity more broadly as it relates to mental and behavioral health and serves as overarching guidance for the Behavioral Health Roadmap. The Trusted System Criteria speaks directly about the need for culturally familiar services and practitioners that are welcoming and reflect the community served. The set of criteria developed by the Equity Advisor Group and supported by all partners is a cornerstone of the Behavioral Health Roadmap. Equity was a guiding principle in developing the Roadmap and will be central in any further design and implementation.
The financial map was created using 2023 budget numbers. Because the map was developed using 2023 budget numbers, spend down rates were not considered, collected or reported. Managing the different spend down rates across all the programs and departments would have exponentially complicated the task and would have provided detail that wasn’t relevant to the actual purpose of the financial map, which was simply to demonstrate the system and its complexity and fragmentation.
Each of the 5 departments (HHS, CSD, BCPH, BCSO, and the District Attorney’s office) were invited to contribute information on their behavioral health programs. Behavioral health (mental health and substance use programs) was defined broadly across the continuum of prevention to recovery. Information requested included: funds into programs and funds out via inter-department contracts, contracts for services and grant to community programs related to direct service therapeutic programs and prevention, harm reduction, recovery, navigation and case management, details on funding source, and descriptions of programs funded.
Because BCSD has no delegated authority over behavioral health, responding departments did so out of a sense of collaboration and generosity. However, it was a collateral duty and a heavy lift in each case. While all departments were provided the same instructions and spreadsheet template, there were naturally inconsistencies. In some departments staff created the spreadsheet and in others the department’s accountant provided the information. Neither had the full detail on the funding, staff were better at identifying behavioral health activities, but accountants were better at understanding funding sources. In rare cases, it was possible to get both involved.
This was the first time that the task of identifying all behavioral health funds has been undertaken. Gathering the information just for Boulder County programs was challenging largely because the County’s accounting system tracks grants and contracts, but not whether a grant has a behavioral health purpose or activities. Ideally, the system would be able to track incoming grants that are all BH-related and those that are for other purposes (ex: criminal justice, homeless services or child welfare) and include BH-related activities. Currently, the system does neither.
Finally, because the function of behavioral health isn’t tracked in the accounting system there is currently no one person or group of people in County government who have the full picture of BH programs and funds (in and out) in County programs. As a result, creating this first snapshot, required relying on the information provided by each department and piecing it together for the full picture. As imperfect as this first attempt to identify, aggregate, and analyze the funding for County BH programs may be, the financial map may now be the closest thing there is to a full picture of the County’s BH programs and investments.
Are funds fully braided numbers? What portion of capital funds is allocated? Does it just include operational funds?
Most of the funds in County programs are operational. Capital funds for behavioral health programs were included when reported by the department. For example, capital funds for recovery homes were included. Capital funds for the alternative sentencing facility (ASF) were not, because the ASF is criminal justice, not behavioral health.
What have we been paying MHP? What portion of that is flexible?
According to the information provided to the BH Planning Team by the departments MHP was budgeted to receive $6,276,836 in FY 2023. Of this, $3,749,000 is for MHP general operations. Whether these funds are truly flexible or have been committed for a number of years is a question for HHS and the accountants. The funding source identified by HHS for the $3,749,000 is HHS general operations.
What is the role we want the county to play around coordination & a workforce?
One of the most powerful parts of the Behavioral Health Roadmap planning process was the collaborative nature to collecting and processing research. This effort brought together hundreds of subject matter experts, service providers, leaders, decision makers, and community members to discuss behavioral health in the region. Each stakeholder showed dedication in improving our local behavioral health system, and all committed their valuable time, experience, and expertise to the vision outlined in the Roadmap. While it is not the County’s role to implement all the strategies and solutions outlined in the roadmap, as the Behavioral Health Roadmap moves forward to implementation, the County is in a prime position to keep these individuals engaged and at the table. One role the County can play in advancing Boulder County’s behavioral health system is acting as a backbone organization in convening and facilitating ongoing discussions in alignment with the Roadmap. From the Roadmap research process, participants elevated collaborative ideas such as ongoing discussions on local data, process mapping to better understand the journey community members face when seeking behavioral healthcare, system mapping the services available to community members and the requirements to participate in specific programs, identifying funding opportunities, new program development, ongoing system evaluation, and implementation of Roadmap strategies and solutions. Discussions are currently happening between a variety of providers and partners, many involving similar sets of participants. There are also duplicative discussion groups occurring across the county. Centralizing discussions will support the creation of a more cohesive system where stakeholders have a thorough understanding of resources available to community members, have space to share and address challenges, and work together to address identified gaps. Looking at other behavioral health systems, Douglas County has a Mental Health Initiative that brings together over 40 providers across different sectors such as healthcare, local government, safety net, and criminal justice. This group meets quarterly. Similarly, Orange County hosts a quarterly open-invite conference that allows for behavioral health stakeholders to come together and learn, discuss, and grow with one another.
The stakeholders in the Operations Advisory Board requested that the goal related to Coordination & Workforce be placed first among the six Roadmap because they identified improved collaboration across silos and the continuum of care as a prerequisite to any success at improving services. (See 8 below)
In the past, Workforce Boulder County (WfBC) has identified specific sectors that need workforce development and expansion. WfBC has developed strategic sector partnerships to help create new workforce pipeline opportunities including education, chamber organizations, and businesses. They have provided funding for training and retention of workers as well as paid work experiences to support sector partnerships. WfBC can be a key partner in developing a new pipeline for a severely anemic behavioral health workforce and are in support of a similar sector partnership approach. WfBC is also involved in regional and state conversations, including a recent regional partnership for behavioral health apprenticeships. As workforce challenges are a statewide and national issue, it is important to have the workforce centers involved as key partners in developing coordinated approaches to building a workforce to meet the community need.
If we were to have additional funding and could expand services, where could we go? If we get new money, what can we prioritize?
The Behavioral Health Roadmap is a shared vision and direction developed collectively with over 700 partners and community members. The next steps to plan implementation, including determining funding priorities, will be co-created with partners and community who will collectively implement the plan. The Roadmap provides a framework with six goal areas that serve as a focus for collective efforts with strategies and solutions identified through the process as priorities. These six goal areas could similarly provide a framework for funding if we had unrestricted funds, similar to the Worthy Cause effort. Most current funding comes from grants. As such, there would need to be a process to obtain new funding based on what sources of funding are available and the areas of need identified through the Roadmap, along with future implementation-specific priorities. The need to have shared funding priorities across the Roadmap collaborative to reduce competition and increase overall effectiveness of efforts was elevated as a need. The goal, Coordinated System & Workforce to Meet Needs, has a Funding Support strategy with various solutions developed through the process.
An additional consideration for funding is sustainability of existing efforts. For County programs, there is a need to obtain funding to continue existing effective programming that will lose a funding source in the future. For example, the Behavioral Health Hub to provide navigation to support and Community Mobile Response are both funded with ARPA dollars. This would be a valuable exercise both as a County organization and for the full set of county partners. There has been an influx in funding related to the pandemic that provided additional services which may need to be maintained.
Did you review any reports on early childhood mental health, specifically the one Dr. Dawson cited?
As Dr. Dawson noted in the public comment, infant mental health is an important field of service provision and is an important focus for prevention and early intervention. While reports reviewed in the design phase of the roadmap were system-wide focusing on gaps and challenges at the local and state levels, infant mental health needs were incorporated into the development of the BH Roadmap in the research phase. Representatives from BCPH, HHS and MHP, partners involved in the nurse family partnership, Family Connects and Kids Connect, were included in key informant interviews for the treatment focus area, and a subset of those interviewed were also invited to convenings precisely so that input on infant mental health was included. It is important to note that Family Connects, which is a home visiting service for families with a newborn, is now, as of June, available to all families with a newborn who are Boulder County residents and deliver at a hospital in the County. There are no income-restrictions or other exclusionary factors. If you have a baby, you’re eligible automatically. Family Connects acknowledges that pregnancy and/or having a new baby are times of change for all families. Home visits start at 3 weeks post-partum and include access to Infant and Early Childhood Mental Health (IECMH) services. The IECMH consultant is a licensed mental health clinician that is an expert in the pregnancy and postpartum period who believes positive change comes from joining together with the family to help understand and respond to mental health needs. Visits with the IECMH can occur with the nurse home visitor or after the nurse home visit. The IECMH consultation strives to meet the family’s needs and supports the family with additional resources and referrals.
The Behavioral Health Roadmap is intentionally broad and aspirational, and the goals are community-driven. The behavioral health system is large and so complex that most stakeholders only have a clear view of the portion of the system in which their services sit. To develop the Roadmap, we asked system stakeholders in the community key questions that allowed us to piece together the full picture of the behavioral health system in Boulder County and to harvest gaps and solutions to challenges from across the continuum of care. The stakeholders then prioritized the gaps and solutions to the challenges gathered. The prioritized gaps and solutions were braided into the six goals as strategies and solutions. The Roadmap is not intended to be just a plan for the County, but for the entire community across all silos, service types and levels, and across the continuum of care. As such, the goals are broad so that stakeholders can see their unique roles in it and how their work will contribute to achieving the six shared goals.
The County is one stakeholder in the overall effort to improve behavioral health for county residents. The County Commissioners’ unique role as a partner in implementing the Roadmap is three-fold:
How do we keep this living? Or is it just a point in time that we review and redo down the line?
The intention is to keep the Behavioral Health Roadmap alive by using the framework and guidance it provides as a shared vision and direction for all future mental and behavioral health efforts. Coordination of efforts through a governance structure would be created to support development of shared implementation plans for the goals, strategies, and solutions outlined in the report. As implementation begins, tracking and regular reporting would also be aligned with the Behavioral Health Roadmap to understand our collective progress and identify areas to adjust based on any changing needs and opportunities. The Behavioral Health Roadmap report itself is not likely a document that we would update, but rather could anticipate regular progress reports that could also include updated data.
What are the recommendations and priorities? Based on this info, here are the priorities we are committing to. Where are we going to be funding, policies creating? What can we look at removing that is not effective? What are we recommending prioritization of goals/strategies.
The goals, strategies, and solutions in the Behavioral Health Roadmap are a collection of high priority solutions prioritized by stakeholders across the 13 focus areas. Through the process, over 700 solutions were collected. These solutions were prioritized in group convenings to 79 high priority solutions, assembled into six goal areas, modified to reduce duplication, and approved by the Roadmap governing bodies including community members. As the Roadmap is a vision shared across the community, ongoing collaboration will be imperative to its success and implementation. No one goal, strategy, or solution is currently elevated over another, nor are any assigned to specific organizations. Determining goals, strategies, or solutions to prioritize for implementation should be done in a manner similar to the Roadmap planning process by involving stakeholders across the behavioral health continuum of care to make decisions in a collective manner. One solution that the County can implement is the formation of a regional behavioral health collective, or other collaborative problem-solving mechanism to bring stakeholders together for ongoing discussion and Roadmap implementation planning. Prioritizing specific recommendations without broad participation from stakeholders will dissolve trust in the Roadmap as a community-wide vision. How solutions are prioritized is as important as the specific solution itself.
Identifying programs that are not currently meeting needs was not within the scope of this project. Moving to implementation, it will be important that decisions are made collaboratively with providers and stakeholders including determining system evaluation metrics. Having an agreed upon, shared set of benchmarks and outcomes will allow partners to hold one another to a high standard. The Trusted System Criteria and funding that the County provides can also be used to ensure alignment with the Roadmap and adherence to expected results.
The Roadmap planning phase brought together hundreds of people committed to improving Boulder County’s behavioral health system. Stakeholders were engaged and bought in to the final Roadmap because they were a part of its creation. There is also a tremendous desire to work together to problem-solve and address behavioral health system needs collaboratively. The Trusted System Criteria created by the Equity Advisory Board is also a useful tool for holding the system accountable. With racial equity being a primary driving value for the work, the Trusted System Criteria can be used to ensure that providers are making decisions and implementing programs that improve equitable access to culturally appropriate supports. Further discussion is needed to design other accountability measures such as funding in alignment with the Roadmap goals, strategies, and solutions, and determining other evaluation metrics and shared goal outcomes.
Equity was a primary value in the Roadmap research process, and will remain front and center throughout implementation, as well. Moving forward to implementation, it will be imperative that the work is done collaboratively with diverse stakeholders. The Trusted System Criteria also elevates racial equity to the forefront of decision-making and accountability. By ensuring that the work is done is a way that shares power between local government, community-based organizations, and the community, as well as utilizes the Trusted System Criteria to hold the system accountable, race can remain centered in implementation of the Roadmap.
▷ means answer to question will take additional work
▶ means question is best answered during implementation phase
▷ Does the report need to be rewritten in an order of priority?
Workforce: ▷ Lack of personnel, staff across spectrum of need – how much can we do? What can we do? Is money the solution? What can we do here?
Trusted System Criteria: ▷ What do we have as policy levers, jurisdiction, statutory authority to do?
▷ Regarding page 79 duplication: What are we doing now? What is missing? What are the gaps?