ADOPTED MINUTES
Mental Health Board
Wednesday, March 11, 2009
City Hall, Room 278
San Francisco, CA
BOARD MEMBERS PRESENT: James L. McGhee (Chair); Jagruti Shukla, MD, MPH (Vice- Chair); James Shaye Keys (Secretary); ; Officer Kelly Dunn; LaVaughn Kellum King; and Lisa Williams; Hale M. Thompson; Virginia Wright, Mary Ann Jones, PhD; and Errol Wishom
BOARD MEMBERS ON LEAVE: M. Lara Siazon Arguelles; Tom Purvis; Njoroge Tho-Biaz; Bridgett Brown; and John Kevin Hines.
OTHERS PRESENT: Dr. Robert Cabaj, Director of Community Behavior Health Services (CBHS); Helynna Brooke (MHB Executive Director); Loy M. Proffitt (MHB Administrator); Perry Lang, Health and Wellness Network, Black Coalition on AIDS; Laura Barber; Visitacion Valley, Carolyn Kaufman, Director, Mobile Crisis Treatment Team and Evelyn Daskalakis, Urban Services YMCA.
CALL TO ORDER
The meeting was called to order at 6:43 PM. by James L. McGhee, Chair.
ROLL CALL
Ms. Brooke called the roll.
AGENDA CHANGES
No agenda changes were made.
ITEM 1.0 DIRECTORS REPORT
Mr. McGhee: Dr. Bob Cabaj, the Director of Community Behavioral Health Services (CBHS), will give the Director s report and then he will follow that with a presentation of the current state of budget cuts and its impact on mental health services.
Dr. Cabaj: The California External Quality Review Organization (CAEQRO) is going on in the next two days, March 11-13. I will report back on their results and recommendations sometime soon in the future.
The Proposition 1E required the May 19, 2009 special election. Governor Arnold Schwarzenegger would like to tap into the Mental Health Services Act (MHSA) money for California s Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT).
Monthly Director s Report
March 11, 2008
APS Healthcare will be visiting San Francisco for their fifth yearly external quality review site meeting (known as the CAEQRO) on March 11-13, 2009. The CAEQRO review is an evaluative process of the overall service delivery system as it relates to organization and structure, quality improvement, performance management, business practices, and progress towards strategic goals over the past year. Discussions will focus on the CBHS s utilization of data, specific reports and activities designed to manage and improve the access, timeliness, quality, and outcomes of services. Details of the results and recommendations of the CAEQRO will be presented in future director's reports.
SPECIAL ELECTION, TO BE HELD ON MAY 19, TO INCLUDE PROPOSITION 1E, REGARDING THE DIVERSION OF MHSA FUNDS
A special election is scheduled to be held on May 19, 2009, as part of the budget package as agreed upon by the California state legislature and signed into law by the Governor. State Senate President pro Tempore Darrell Steinberg has written an argument in favor of the passage of Proposition 1E, which seeks to divert funds from the Mental Health Services Act account to the state s Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) program for the next two years. In part, he writes, Proposition 1E will save the state s General Fund over $225 million in 2009-10 and up to $234 million in 2010-11 by redirecting funds from the Proposition 63, I support diverting funds only as a last resort to help balance the budget this year. The success of Proposition 63 has saved the state hundreds of millions of dollars in unnecessary hospital and prison costs and reversed decades of neglect for people living with mental illness. Nonetheless, delays in redirection of funds at a time when we face an economic crisis like we have never seen before. This should not be a precedent for diverting Proposition 63 funds in the future. The focus is now on finishing our work to close the budget gap.
(SEE ATTACHMENT 1)
MHSA ANNUAL PLAN UPDATE FOR FY 09-10
On Wednesday, March 11, 2009, the Mental Health Board meeting, from 6:30-8:30pm, will feature a hearing on the MHSA Annual Plan Update for FY 09-10. Also included on the agenda is a request for funding for the Community Supports and Services and Workplace Development, Education, and Training components of the coming year s Plan. The public is invited to attend.
CAPITAL FACILITIES PLANNING COMMITTEE PROCESS CONCLUDES
Three meetings of the Capital Facilities Planning Committee took place on Thursday, February 24, Thursday, February 26, and Friday, February 27. A formal Plan has been posted on the DPH website at http://www.sfdph.org/dph/comupg/oservices/mentalHlth/MHSA/mnu30-DayNotice.asp. A public hearing will be held at the April Mental Health Board meeting. Further information will be posted as it is available. The public is invited to submit comments on the plan.
CALIFORNIASTRATEGIC PLAN FOR MENTAL HEALTH STIGMA AND DISCRIMINATION
You are invited to attend a public workshop to provide input on the draft California Strategic Plan on Reducing Mental Health Stigma and Discrimination. The California Department of Mental Health is holding a Northern California Workshop at the Hilton Garden Inn, 1800 Powell Street, in Emeryville, California, on Tuesday, March 17, 2009, from 1:00-4:00pm. Public transit accessible by BART, Amtrak, and bus.
MHSA IT UPDATE
The final stages of the MHSA IT Planning Committee meetings are well-underway. The various stakeholders have generated ideas during a previous brain-storming session of what to include in this phase of the Mental Health Services Act. At this point, costs have been calculated for each idea and will be reviewed at the committee meeting, to be held on Tuesday, March 10, 2009. The Committee will choose the ideas that have the most impact and will apply a litmus test which includes a series of questions such as feasibility, sustainability, adequate funding, etc. to narrow down the list. The last meeting will be on March 24, 2009 in which the Planning Committee members have an opportunity to submit a final vote on what to be funded.
MHSA ADVISORY COMMITTEE MEETINGS
The Mental Health Services Act Advisory Committee meets bi-monthly from 3-5pm, alternating between advisory meetings and community forums. The next scheduled meeting is: Thursday, April 16, 2009, Community Forum, Location: TBD
At the last meeting of the MHSA Advisory Committee, it was announced that the state has changed their guidance to counties about funds for Stigma Reduction, Student Mental Health, and Suicide Prevention. Previous direction from the state required counties to re-assign county funds back to the state in order to fund state-directed initiatives on these issues. Although the state still strongly urges counties to assign these funds, assignment is now not required. Based on this change, the MHSA Advisory Committee voted that San Francisco not assign these funds to the state, but keep the funds (approximately $3 million allocated for 4 years, or $755,000 per year) in order to develop local Prevention and Early Intervention efforts designed to meet the special cultural and local needs of the county. Ethnic diversity, suicide rates, and the Golden Gate Bridge were specifically cited as circumstances unique to San Francisco that warrant develop specialized local initiatives with this funding.
LAW AND ETHICS TRAINING FOR BEHAVIORAL HEALTHCARE PROVIDERS:
Friday, March 13, 9:00am-4:30pm. St. Mary s Cathedral Conference Center. This will be a 6 hour review of current legal issues and ethical concerns for staff working in the Behavioral Health Care Setting. Issues covered will include 1) consent, including consent in an emergency, informed consent, conservatees and minor consent, 2) confidentiality and privacy, HIPAA review, 3) mandated reporting including a review of child abuse and neglect reporting laws and the Tarasoff "duty to warn," and how the Ewing cases have impacted the obligation to warn when the threats are conveyed by third parties, and 4) dual relationships and boundary issues, including employees as clients, and clients as employees, pre-existing personal relationships, and relationships that develop after a clinical relationship is established. Registration for this conference is closed.
ADULT MENTAL HEALTH DOCUMENTATION TRAINING:
Friday, April 17, 2009. San Francisco Federal Building, 90th Seventh Street. This training will be targeted to Adult Mental Health providers. This training will occur in two parts. The morning session will focus on issues related to authorization, consents, HIPAA, PFI, CSI, Compliance and Billing. The afternoon session will focus on the clinical aspects of the record, e.g., assessment, treatment planning, progress charting and treatment plan update. Each training will allow sufficient time for practice and question and answer. You may register for either or both sessions. The trainings are NOT mandatory. These trainings will be offered on a quarterly basis and are open to all but newer provider staff are especially encouraged to attend.
To register for this training, please contact Norman Aleman, CBHS Training Coordinator at 415-255-3553 or email norman.aleman@sfdph.org
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Past issues of the CBHS Monthly Director s Report are available at:http://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSdirRpts.asp
To receive this Monthly Report via e-mail, please e-mail richelle-lynn.mojica@sfdph.org
ATTACHMENT 1
The California Council of Community Mental Health Agencies, who were leaders in the partnership that developed and promoted Proposition 63, have taken a different view of the proposed ballot measure and presented the state Attorney General with their concerns.
Specifically, CCCMHA has grave concerns about the ballot label and summary of Prop. 1E prepared by the Legislature. (Attached.) For starters, the ballot label does not inform voters that Prop. 1E is in any way related to Prop. 63, a major oversight.
CCCMHA has requested that the ballot fiscal impact statement reference the following issues:
1. Prop 1E amends Prop. 63. The ballot label makes no reference to the voter initiative that is amended by Prop. 1E. The summary references it but calls the amendments flexibility . Neither piece adequately informs voters that they are being asked to change the language of measure they approved and to change the purposes toward which they have previously decided to put these specific funds.
2. Funds are actually diverted to the state General Fund. The language of Prop. 1E speaks of certain funds being redirected to support the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program (see SBX3 10, Sec. 2, proposed new W&I Code Sec. 5892(a)(7)). But what does redirected mean in this case? The EPSDT program is an entitlement program (Medicaid) that is an ongoing obligation of the state General Fund. Service levels and funding for EPSDT will be the same regardless of the passage or defeat of Prop. 1E. (Except for the unlikely case that the state terminates all Medicaid Programs.) Therefore, the reference to redirect[ing] the funds to that program is arbitrary and, in fact, misleading. As a practical matter, these monies taken from Prop. 63 programs are simply going to the state General Fund. The fiscal note could clarify this major issue for voters.
3. Diverted funds exempted from oversight/accountability in Prop. 63.
As you may know, the voters, in supporting Prop. 63, placed rigorous auditing and accountability requirements on the money they approved for mental health programs. It is not a minor issue, then, when $460 million is removed from these accountability requirements. The fiscal note might reference this important change in the law that Prop. 1E would effect.
4. Likely cost increases. We do not know what the Legislative Analyst s Office will have to say about Prop. 63 program impacts to date, but we do believe that the program has plainly reduced state and local government costs in many areas. There are 200,000 people enrolled in Prop. 63 mental health programs across the state, virtually all of whom had no services prior to implementation of the voter-approved law.
Without treatment, what happens is well understood; kids drop out of school, adults are unable to work, house or care for themselves or their families, and state and local government costs for hospitalization, homelessness programs and criminal justice all go up steeply. Indeed, the high costs of the old way of doing mental health care were a major reason why voters approved Prop.63. We believe it is an obvious and easily anticipated impact of Prop. 1E that service levels will be reduced, with costs shifted to other areas as a result. Please take note of this vital issue in the fiscal note.
2.0 The Current State of Budget Cuts and Its Impact on Services
Mr. Keys: Since there is a big concern over Governor Schwarzenegger s proposal of diverting some of the MHSA money and we are responding with fast track mental health plans for the Department of Mental Health (DMH) for reviews, does this limit the public response time?
Dr. Cabaj: We still maintain the 30-day review period for public comments before we submit plans to the State. It just means our staff must work diligently to get the planning process finished. We hope to get the State approval of our plans before the Proposition 63 s money is diverted away by the governor.
Mr. Keys: Can you highlight the key updates of these plans?
Dr. Cabaj: There are overall reductions in homelessness, time in jail and time in the hospital, 63%, 42% and 44% respectively. In the Transitional Age Group, we see 76% reduction in homelessness and 49% reduction in juvenile incarceration.
Mr. Keys: Do you have any updates on the Behavior Health Access Center at 1380 Howard?
Dr. Cabaj: Both the Behavior Health Access Center (BHAC) and the Treatment Access Program (TAP) provide direct client services, meaning face-to-face interaction, rather than serving them over the telephone. The pharmacy at TAP is a block from the DORE Urgent Care program.
Mr. Keys: I am hoping to do more outreach to the community to let people know different mental health programs exist, because during this economic recession, people hesitate to come for help.
1.2 Public comment relevant to Item 1.0
No public comments.
ITEM 3.0 PRESENTATION: IMPACT OF TRAUMA ON PHYSICAL HEALTH by Dr. Nadine Burke
3.1 Presentation:
Mr. McGhee: Dr. Burke is the Medical Director for the Bayview Child Health Center for California Pacific Medical Center (CPMC). She essentially created and developed the center for the hospital. She got her medical degree at the University of California, Davis, then went on to do her residency at the Lucile Salter Packard Children s Hospital, Stanford. She also got a Master s in Public Health at Harvard University and is bilingual in Spanish. We are honored that she is here to share with us about her research. The title of her presentation is Child Abuse Is Bad For Your Health: Clinical Sequelae of Child Trauma.
Dr. Burke: The California Pacific Medical Center (CPMC) wanted to reduce health disparities for African Americans and my specialty is pediatric care in Bay View Hunters Point (BVHP).
The African American population appears to have a disproportionately high rate of asthma, immunodeficiency, obesity and sexually transmitted diseases, compared to the general population. Also, many people were saying that African American children have attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD) and anti-social behaviors.
In my years of practice in medicine, I have never heard of a child wanting to be bad , because most children want to be good to please adults. Thus, I started to wonder about the following possibilities, which medical schools do not teach doctors.
Perhaps, children in BVHP do not have ADHD per se, as people were telling me. It is more likely that these impressionable children have been forced to live in a hostile or dysfunctional environment where substance abuse, suicides, senseless killings and violence occur daily. It is more likely these children have PTSD and have not received proper treatment.
I ask you rhetorically: could these children act out on what is truly going on in their homes or neighborhood? If so, it is not ADHD children causing problems in their neighborhood, but familiar dysfunction causing children to have PTSD where they display inattentiveness and anti-social behaviors. And would not ADHD be misdiagnosed for these children, and medicating them on highly potent psychotropic drugs is simply wrong.
Adverse childhood traumas can become the mechanism of clinical sequelae (symptoms). We see chronic health problems such as chronic obstructive pulmonary disorder (COPD), cancer, premature death, ischemic heart disease, sleep disorders, overweight and obesity, hepatitis, sexually transmitted infections and diabetes when these children reach adulthood. The health disparity in the African American population could be explained by the multiple unresolved adverse childhood experiences!
According to the Adverse Childhood Experiences (ACE s) Study of 17,421 adults by Vincent J. Felitti, MD at Department of Preventive Medicine of Kaiser Permanente in San Diego California and Robert J. Anda, MD, MS Centers for Disease Control and Prevention (CDC), they found that people with adverse childhood experiences such as psychologically, physically or sexually recurrent abuse including being neglected physically and emotionally, violence against the mother; or substance abusers in the household, suicidal, or imprisonment, if left untreated, are at a higher risk of developing organic diseases in adulthood. Quantifying the data, they compared the person with a 4+ (four or more adverse childhood experiences) ACE score and a 0 ACE score and found the followings:
- 260% at higher risk of COPD, hepatitis, and contracting sexually transmitted diseases
- 4.6 times at higher risk for depression and 12 times at higher risk for suicide
When I compiled my data in San Francisco, I found that 45% of African Americans compared to 20% of White and Asian Americans have been diagnosed with high blood pressure and that 15% of African Americans compared to 3.5% of White and Asian Americans have been diagnosed with diabetes. At my Bayview clinic I found 48% of the people there reported to have experienced adverse childhood traumas and 37% have an overweight problem. If a person has had more than seven adverse childhood experiences, like many in this community, they are360% more likely to have COPD, and a 180% higher heart disease risk even if the individuals practice a healthy lifestyle. Children raised in stressful environments have an increased risk for all bad health outcomes even if they do not participate in any high risk behaviors such as smoking or substance abuse.
Adverse childhood experiences can be treated to prevent health problems in adulthood, and psychotropic medication is not a panacea. I believe other treatments are available. We can use Mindfulness Based Awareness or Dialectic Behavior Therapy, and studies have shown that these treatments have positive effects of reducing high blood pressure, inflammation, depression and anxiety and post-traumatic symptoms.
I would like to conclude the presentation with the following recommendations. I believe a universal screening for adverse childhood experiences is a good start. When the board considers mental health programs to reduce health disparities, please incorporate the trauma model. Also, there should be a network of treatment options to break the generational cycle of adverse childhood trauma.
3.2 Public comment relevant to Item 2.0
Public member: She mentioned that when incarcerated people are released they often do not have mental health support or social services to help them become acclimated back into society. Often these people get caught up in the cycle of recidivism.
ITEM 4.0 ACTION ITEMS
4.1. Public comment
No public comments.
4.2. Resolutions
4.2. a PROPOSED RESOLUTION: Be it resolved that the minutes of the Mental Health Board meeting of January 14, 2009 be approved as submitted.
Resolution unanimously approved
4.2. b PROPOSED RESOLUTION: Be it resolved that the minutes of the Mental Health Board meeting of February 11, 2009 be approved as submitted.
Resolution unanimously approved
4.2. c PROPOSED RESOLUTION: Be it resolved that the minutes of the Mental Health Board commends Carolyn Kaufman, Director of Mobile Crisis Treatment Team (Attachment A)
Resolution unanimously approved
4.2. d PROPOSED RESOLUTION: Be it resolved that the Mental Health Board honors Claudia Lebish, for her advocacy for the mentally ill. (Attachment B)
Resolution unanimously approved
Mr. McGhee: Ms. Claudia Lebish served on the Mental Health Board from July 2005 until July 2008 in a consumer seat as an appointee of Supervisor Mirkarimi. We are saddened by her loss to alcoholism at the young age of 46. In her honor the Board is donating $50 to A Home Within, an organization she supported after hearing the presentation to the board by its Executive Director.
ITEM 5.0 REPORTS
5.1 Report from the Executive Director of the Mental Health Board.
5.2 Report of the Chair of the Board and the Executive Committee:
Mr. McGhee: I want to welcome our two new board members who were appointed on March 5th by the Board of Supervisors Rules Committee. Dr. Mary Ann Jones fills Dr. Rebecca Turner s mental health professional seat. She obtained her PhD from the Wright Institute in Berkeley and was the Clinical Director of Westside several years ago.
Errol Wishom was appointed to a consumer seat. He is a peer volunteer at San Francisco General Hospital helping inpatients in the psychiatric wards. Would you both say a few brief words about yourselves and why you wanted to be appointed to this board?
Dr. Jones: My name is Mary Ann Jones, and I want to bring to the board my knowledge and clinical skills.
Mr. Wishom: I am Errol Wishom. Thank you for having me on the board.
5.3 Report by Members of the Board on Their Activities on Behalf of the Board.
Mr. McGhee: Ms. King will give a brief report of the Southeast Group Meeting.
Ms. King: Our meeting in the Southeast sector has been going well. We have a lot of support from community leaders.
5.4 New business - Suggestions for future agenda items to be referred to the Executive Committee.
Mr. Keys: I would like to have the executive committee create a policy on universal screening of children with adverse childhood experiences and traumas. Like what Dr. Burke said in her presentation, the lack of effective and efficacious treatments for early childhood adverse experiences and traumas often manifest into physical health problems. Children in the Southeast Sector and Bayview Hunters Point, including children at risk of trauma and stress, can benefit from universal screening.
Ms. Dunn: I have been approached by people from the Homeland Security Administration who are looking for proposals to help homelessness in San Francisco, and I would like to have a grant-writing team work with me to write proposals to the federal government to get some of those.
5.5 Public comment relevant to Item 3.0
No public comments.
ITEM 6.0 PUBLIC COMMENT
Ms. Wilson: She is a client council member and has noticed that mentally ill people are not getting services on a continual basis. She has seen these people falling through the cracks of the mental health system and they often become susceptible to the vicious cycle of violence.
Adjournment
Meeting adjourned at 8:29 PM.