Special Notice / Hearing: None__
Vote Required: Majority
To: Honorable Board of Supervisors
From: Michael P. Callagy, County Manager
Subject: Board of Supervisors’ Response to the 2019-2020 Civil Grand Jury Report “A Slow-Moving Catastrophe: Finding the Ill Homeless A Place to Heal.”
RECOMMENDATION:
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Approve the Board of Supervisors’ response to the 2019-2020 Civil Grand Jury Report, “A Slow-Moving Catastrophe: Finding the Ill Homeless A Place to Heal.”
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BACKGROUND:
On October 13, 2020, the 2019-2020 San Mateo County Civil Grand Jury issued a report titled “A Slow-Moving Catastrophe: Finding the Ill Homeless A Place to Heal.” The Board of Supervisors is required to submit comments on the findings and recommendations pertaining to the matters over which it has some decision-making authority within 90 days. The Board’s response to the report is due to the Honorable Danny Chou no later than January 11, 2021.
DISCUSSION:
The Grand Jury made 13 findings and 11 recommendations in its report. The Board responses follow each finding and the 11 recommendations that the Grand Jury requested that the Board respond to within 90 days.
FINDINGS
Finding 1: There is no County department or division which coordinates the County’s efforts to comprehensively address the issues faced by the homeless or ill subset. Currently, the County has at least seven departments or divisions - including HSA, the Department of Housing, SMMC, the Division of Public Health, Policy, and Planning, BHRS, and the Sheriff’s Office - involved in some part of the lives of ill homeless people.
The County partially disagrees with this finding. The County provides multiple programs for homeless residents with health issues, including street medicine, mental health support, and outreach, engagement and case management through the Homeless Outreach Teams (HOT). While there is no one agency that coordinates the health issues for the homeless, the Human Services Agency convenes seven, city based monthly homeless outreach case management meetings for all providers of services to local homeless residents. Those meetings include health providers, and health issues are incorporated into the case management plans for clients. In addition, the Human Services Agency facilitates monthly meetings with managers from the Human Services Agency, the Department of Housing, Health, Probation, Sheriff’s Office and Health Plan of San Mateo to coordinate a broad range of work related to improving the County’s housing and homeless services.
Finding 2: City police officers with duties as Homeless Outreach Coordinators and County Sheriff’s deputies who work with the Psychiatric Emergency Response Team (PERT) play a significant role in identifying the homeless, de-escalating potential conflict involving the homeless, and linking the homeless to services, including providing transportation to medical treatment entities and shelters. Some police have been trained by BHRS to work with outreach teams in the field to help deal with homeless who may be a danger to themselves or others.
The County agrees with this finding.
Finding 3: Determining the financial cost to the County for treating the ill homeless is extremely difficult given the various treatment alternatives (e.g., hospitals, clinics, vans, shelters, respite care options and care delivered “on the street.”) and other programs which are managed across numerous County departments and divisions. The County’s Budget, Policy, and Performance unit estimated that approximately $54 million dollars was directed by the County to help ameliorate homelessness in 2019. According to the latest housing census, there were 1,512 homeless individuals in SMC.
The County agrees with this finding.
Finding 4: The County invests heavily in outreach teams within and across agencies for finding the ill homeless and linking them to necessary treatment before hospitalization is required. However, it is not clearly set forth on any public website or document how these teams coordinate or interact or how their effectiveness is determined.
The County agrees with this finding.
Finding 5: Of the discharge housing options available, there is a lack of appropriate shelter for individuals who are well enough to leave the hospital but still require some help to recover fully. Several County organizations, including HPSM, are funding various pilot studies for “respite” or “recuperative” care that show promise to meet this need. However, at this point, the County lacks a comprehensive plan for this service.
The County partially disagrees with this finding. The recuperative care initiative contracted by HPSM is funded through County dollars through a partnership with County Health. Health-Public Health Whole Person Care contracts with the Health Plan who have hired a CBO, Bay Area Community Services, to operate the recuperative care site called Baden Street. Funding is Measure K funds provided to the Pilot for housing homeless clients.
The pilot appears to be meeting the need for County clients, and the County questions whether there is updated information to support that there is still a lack of this resource for homeless County clients. There is nothing to prevent private hospitals and insurance companies from purchasing such services if their members would benefit, and the County encourages them to do so.
Recuperative care does not directly provide medical care, rather it is a safe, clean residential environment where patients can recuperate from an illness. The staff at the recuperative care site coordinate with medical providers to ensure that medical needs are met. This could include coordinating with a primary care physician as well as working to ensure that a community home health provider is able to access the patient while in recuperative care. Recuperative care is not “similar” to a licensed Board and Care (Adult Residential Facility or Residential Care Facility for the Elderly).
The recuperative care site capacity and use permit do not allow for 15 residents. At the very most the site could accommodate up to 10 persons for recuperative care.
The care navigator that works directly with the recuperative care site is part of the Public Health Bridges to Wellness team and assists with general case management needs as well as in locating and securing more permanent housing to avoid discharge to the street.
The County is implementing a plan to provide housing for all homeless residents who seek housing. That plan includes purchasing hotels, building temporary shelter space and ultimately, building a new navigation center. Respite and recuperative care beds may be included in the new facilities if data supporting such a need for County clients supports this approach beyond the Baden Street program currently operating. Details such as numbers of those types of beds will be determined as the plans for the facilities are finalized.
Finding 6: There is only one County shelter (Maple Street) that has a nurse on staff to provide a level of health care support for ill and recovering homeless. Grand Jury interviews revealed staff are sometimes put in the difficult position of having to decide to take or refuse some ill homeless patient due to their very precarious health status. Only Maple Street and two other single adult shelters are now open to residents 24/7 which allows the ill homeless a safe, clean environment to sleep and recover from illness.
The County disagrees with this finding. With the onset of the pandemic the County has increased bed capacity for homeless residents by contracting with hotels. Over 70 beds have been added to the adult shelter system through the additional of hotel rooms. All shelter residents are interviewed, assessed and placed in an appropriate shelter location through the housing first single intake process managed by the eight Cores Services Agencies located throughout the County.
Finding 7: Most hospitals in the County, BHRS and WPC reserve (and pay for) beds at Maple Street Shelter or Samaritan House for their homeless patients requiring recuperative care. There is a lack of consistency in how to access these beds: some entities use the County’s Coordinated Entry System while others are able to by-pass this risk assessment interview. There are no data evaluating the cost effectiveness of this strategy in terms of county funding or agreement about the cost paid by different entities for these beds.
The County disagrees with this finding. This characterization is not correct. In most cases (unless it’s after hours or on the weekend), everyone uses CES to enter a shelter. In the case when a hospital or program pays for dedicated shelter beds, that entity places using consistent hospital or program criteria into the shelter. WPC does not reserve beds at shelters at this time.
Finding 8: The County is in the planning stages for relocating and rebuilding the Maple Street Shelter. This will provide the County with an opportunity to reassess the needs of the homeless in general and the ill-homeless in particular. The ill homeless are complex, suffering from a variety of physical and mental disorders which impact their ability to access and maintain housing. Female homeless individuals and the elderly are especially at risk for future homelessness and resulting poor health.
The County agrees with this finding.
Finding 9: Beginning in 2015, the Medicare/Medi-Cal funded “Whole Person Care Pilot” (WPC) project offered an opportunity and significant funding for SMC to develop an integrated health care plan for vulnerable individuals, including the ill homeless. As a result of WPC, the County began implementing significantly improved collaboration among partners and developing of new programs as well as expanding existing programs for treating the target populations.
The County agrees with this finding. Much of the description of Whole Person Care is derived from the original application to the State. As with many grant applications, the actual on the ground implementation often diverges significantly from what is originally envisioned. There are a few substantive corrections that should be considered in the report:
1. WPC is a five-year pilot. 2016 calendar year was a planning year and implementation began in 2017 and originally was planned to operate through December of 2020 or 4 years. The County has recently learned from the State that they fully expect to extend the program through December 2021.
2. WPC has three target populations: seriously mentally ill (SMI), substance use disorders (SUD), and those who may experience SMI, SUD and homelessness.
Programs funded by WPC for the third target population include:
a. Bridges to Wellness - operated by PHPP is an intensive field-based case management program staffed by persons who may have a lived experience of either homelessness, SMI, SUD but who also professional experience with the population served. Some Care Navigators identify as peers, and others do not. This team also include an RN, 2 social work supervisors and a nurse practitioner. This program is not part of the Street Medicine Team, but rather collaborates closely with them as well as all other Health providers within the department. While the County originally thought the County would hold classes or groups, it became quite apparent that this population does not access these types of services well. Health education and chronic disease management are done one on one between Care Navigators and clients.
b. WPC contracts with LifeMoves to provide two community health outreach workers (CHOWS) to help us locate homeless individuals who may need to be connected to the Bridges team for more intensive care. The CHOWS do carry a small case load of homeless clients who do not require the intensive case management services provided by Bridges to Wellness.
c. The Psychiatric Emergency Response Team is not funded by WPC.
d. The WPC funded Social Workers who work within the medical center ambulatory care clinics are not mentioned here. These social workers provide substantial case management services to the ill homeless population. While this case management is not field based, it has provided a direct connection between clients, other providers and the medical staff thereby increasing greatly the coordination of care between Health Divisions.
e. Also not mentioned here is the Integrated Medication Assisted Treatment Program (IMAT). This program began prior to WPC but has been funded and expanded with WPC dollars over the last five years. This team often works with homeless individuals who have substance use disorders. The goal is to assist patients to consider medication assisted treatment to curb cravings and achieve better control over substance use. They provide outreach to clients within the emergency department and at the sobering center. This outreach has been remarkably successful in helping clients to regain control of their lives.
Finding 10: WPC goals related to addressing Medi-Cal churn as well as HIPAA confidentiality concerns have not yet been achieved. Furthermore, The County’s WPC project lags behind other counties with regard to data sharing capabilities to support care coordination.
The County partially disagrees with this finding. The County has undertaken to maximize allowable information sharing without jeopardizing patient privacy as required under the law. Data sharing between Health, the Department of Housing and the Human Services Agency has been a challenge due to laws that sometimes either prevent sharing or sometimes are unclear about the permissibility of data sharing. There are on-going substantial efforts to resolve some of these data sharing efforts at the local level, however success will largely depend upon leadership by the State.
Finding 11: In order to receive and maintain Medi-Cal benefits, a home address is required. By definition, the homeless do not have one, so they substitute temporary locations such as the SMMC, shelters, or someone else’s address. As a result, homeless individuals often do not receive important insurance and medical documents and become uninsured. This causes a critical gap which results in potentially insurable patients not being treated or the County health services unable to obtain reimbursement.
The County disagrees with this finding. When homeless clients apply for Medi-Cal, they must provide proof of County residency and a mailing address given by a client for where they receive mail. The County does not substitute addresses.
Finding 12: Within the County, there is a lack of affordable permanent housing of various types (e.g., Board and Care type facilities, supervised group homes, single room occupancy hotels) for the homeless with chronic or long- term conditions that require support (e.g., stable mental illness, diabetes, cancer, heart disease). Without such options, the ill homeless will likely recycle back into encampments or the streets and again rely on emergency departments for needed treatment obviating any reduction in health care savings.
The County agrees with this finding. There is a lack of funding for affordable permanent housing of various types that has kept pace with increasing cost of housing and increasing rents. Individuals who receive an SSI payment of $1100 a month do not find that sufficient to cover rent. The County would prioritize the need for permanent housing over the need for additional medical respite resources.
Finding 13: While the County should be applauded for reaching out to grant agencies for funding programs that support the ill homeless, it appears that such programs may not be sustainable after grant funding ends. Given that the County support system is already complex, the addition and subtraction of pilot programs without institutionalization provides only a finger in the dike and potentially adds to client and provider confusion about resources.
The County partially disagrees with this finding. While pilot programs do not offer permanent funding, they do test approaches to addressing complex issues and many times offer the ability to refine approaches based on lessons learned during the pilot. Pilot programs that improve client outcomes create efficiencies or improve services in other ways benefit clients and may receive ongoing funding from federal, state or local sources. WPC is one such example that has a strong likelihood of receiving continuing funding through the next new State/Federal Medi-Cal Waiver.
RECOMMENDATIONS
Regarding Pre-Hospitalization
Recommendation 1: The County Board of Supervisors (BOS) should direct the County Manager to develop a clear outline of the departments, agencies, and community partners who receive county funds involved in assisting the homeless and the specific subset of the ill homeless focusing on points of overlap and duplication of services. The Board should also direct the County Manager to report back to the Board in a public meeting, what efforts are being undertaken to better coordinate County efforts and potentially reduce bureaucracy and costs. This report from the County Manager should be publicly presented to the Board by December 31, 2020.
The recommendation has not yet been fully implemented. The County Center on Homelessness within the Human Services Agency coordinates all programs and services for homeless residents, working in coordination with other County departments. The priority now is the purchase, staffing and occupancy of the soon to be acquired hotels. After that work is complete and the health system is not fully consumed with the COVID-19 response, a review of the homeless system of care will be a priority.
Recommendation 2: The BOS should direct the County’s Budget, Policy, and Performance unit to annually determine the actual costs for helping the homeless and the specific subset of the ill homeless to the County by December 31, 2020.
The recommendation has not yet been implemented. The costs of assisting the homeless will be presented to the Board of Supervisors in June 2021 as part of the Human Services Agency FY 2021-23 budget presentation.
Recommendation 3: Because the homeless move from place to place, the BOS should request that the County Sheriff and Police Chiefs convene a task force to increase cross-jurisdictional coordination and communication. As part of this collaboration, they should determine if the number and training of officers is sufficient to address homeless outreach and crisis management in those localities where homelessness is the biggest problem. The task force should hold an initial meeting by December 31, 2020 and regularly thereafter to exchange information and best practices.
The recommendation has not yet been implemented. The local police are key members of the seven local multi-disciplinary teams that meet monthly to review case management plans for homeless residents. Many cities have officers dedicated to working with their homeless residents. However, there can always be better coordination and the review of homelessness services in 2021 will include working with the County Sheriff and local Police Chiefs on ways to improve program outcomes.
Regarding hospitalization, discharge options and SB1152
Recommendation 4: By June 30, 2021, the County’s Human Services Agency (HSA) should collaborate with the Governing Board of the Health Plan of San Mateo (HPSM) to create a standard option as a housing address proxy for the homeless and ill homeless so County hospitals and services can be reimbursed for services.
The recommendation will not be implemented. The County appreciates any effort to ensure the organization can receive appropriate reimbursement for services provided. Due to the availability of Hospital Presumptive Eligibility (which ensures that patients can be enrolled in Medi-Cal at the time of admission if certain criteria are met), however, the County does not fully understand how a housing address proxy would influence reimbursement of services. Given the logistics and cost associated with such an effort, in the absence of firm return in the form or increased reimbursement, the County would not advise pursuing this effort solely for the purpose of hospital billing.
When homeless clients apply for Medi-Cal, they must provide proof of County residency and a mailing address given by a client for where they receive mail. The County does not substitute addresses.
If one of the problems is to avoid the loss of Medi-Cal due to a lack of ability to receive mail to comply with paperwork requirements, the recommendation should be geared toward assisting clients to meet the paperwork requirements at access points that do not require mail.
Recommendation 5: The County should develop a comprehensive plan for medical respite/recuperative care for the ill homeless by including key representatives from appropriate County departments to collaborate with the Health Care for the Homeless and Farmworker Program and the Hospital Consortium by June 20, 2021.
This recommendation will not be implemented. Health does currently partner with the Health Care for the Homeless and Farmworker Program and other partners regarding addressing medical respite/recuperative care needs for the homeless. The County contracts with HPSM for a 6-bed recuperative care site using local funds. This service appears to be filling most of the gap for County clients. There are no funds from health insurance or ongoing sources for this recuperative care service nor for medical respite, which would require substantial medical supervision and staffing. Generally, this level of medical supervision and staffing would not be found in a shelter site. While medical respite could meet the needs of homeless clients requiring a higher level of care post hospital stay and some instances replace the need for short term skilled nursing there is no funding for such a service, it is unclear what the demand would be and it seems unlikely it could be provided for less expense than a skilled nursing day, which at least has reimbursement under the Medi-Cal program. Private insurers and private hospitals may have resources to pursue other options, but the County is not recommending the County invest in additional medical respite/recuperative care resources at this time compared to other high priorities such as permanent housing.
Recommendation 6: HSA should allow the CES assessment to be more available outside of normal business hours and standardize its inclusion into all hospital or shelter discharge plans by October 31, 2020.
This recommendation will not be implemented due to lack of resources.
Recommendation 7: The County should conduct an overall evaluation of the County’s homeless shelters through the lens of the ill homeless, e.g., ability to assist with a range of medical needs and 24/7 availability of housing by June 30, 2021.
This recommendation will not be implemented. Shelters are not medical facilities and are not meant to serve people with significant medical issues who may need a different level of care.
Recommendation 8: In the planned design and rebuilding of the Maple Street Shelter, the BOS should direct the County Manager to work with departments to prioritize addressing the needs of ill homeless, especially vulnerable women and the elderly by December 31, 2020.
This recommendation has not yet been implemented. The new Maple Street Navigation Center will include respite beds for homeless residents. When a site has been identified for that facility, which is expected to happen in spring of 2021, staff will start working on the facility design.
Recommendation 9: The County’s Department of Housing should evaluate the feasibility of securing added board and care type housing facilities to provide long-term care, staffed with appropriate medical personnel, for homeless with chronic medical and mental illness needs by December 31, 2020.
This recommendation will not be implemented. Since the advent of the County’s Affordable Housing Fund (AHF) in 2013, the County has invested over $180 million to leverage an additional $1.7 billion in affordable housing financing to create or preserve 3,300 affordable homes. Over 1,000 of those units are now complete and occupied, with roughly 700 in construction and 1,600 more in various stages of predevelopment. Most leveraged sources of affordable housing financing require local matches. Allocations of County AHF dollars allow affordable housing developers to pursue these additional financial resources to help acquire and construct permanent affordable housing in our high-cost region where construction of new units can cost over $600,000 per apartment, and acquisition of aging stock averages more than half this cost. Licensed board and care facilities and other forms of transitional housing where clients do not hold residential leases are not eligible for these leveraged affordable housing financing resources, most notably Low Income Housing Tax Credits, that allow the County’s Department of Housing to produce affordable housing at this scale. Acquisition or construction of new board and care facilities would need to be done at extreme cost to the County versus the County’s existing process for financing affordable housing.
Through partnership with County Health, HSA, and HPSM, DOH targets units in its AHF-financed portfolio to clients of Health and HSA. In the past five years, DOH, Health, and HPSM have moved 327 medically-frail individuals at risk of homelessness from institutional settings to permanent affordable housing and Board and Care homes with wrap-around services provided by Health and its nonprofit partners through the Community Care Settings Pilot, operated by HPSM and funded under Whole Person Care. In 2019, DOH was awarded nearly $20M in State capital funds to help finance affordable homes that will be targeted to County WPC clients. A $5 million award was made this year to Mercy Housing for its Middlefield Junction project, which will house 20 WPC clients in a 180-unit affordable housing project. The County recommends pursuing additional similar partnerships that will allow the County to create more permanent housing targeted to the County’s homeless, high-need clients.
The Department of Housing assists with the financing and development of affordable housing through the distribution of County, state and federal funds that must be used for the construction or rehabilitation of affordable housing. The Department does not own or operate board and care homes. However, board and care homes will be evaluated as an option in the plan for meeting the needs of all homeless residents of San Mateo County.
Regarding WPC
Recommendation 10: The County Manager’s Office should work with the relevant County departments to determine if it is possible to permanently fund the integration of psychiatric personnel into all outreach efforts/teams given the high presence of mental health issues among the homeless, and should have the relevant County departments publicly report the results of this effort to the Board during a regularly scheduled Board meeting by March 31, 2021.
This recommendation has been partially implemented. Mental Health personnel are embedded in or otherwise connected to all of the outreach teams in the County including the HOT. Some examples include the Street and Field Medicine team, which includes a psychiatrist who travels into the community 16 hours each week. The Psychiatric Emergency Response Team (PERT) embeds full-time mental health staff at the Sheriff’s Office. These individuals provide mental health consultation to all officers and frequently travel into the community with a Deputy to engage individuals with mental health needs. The Family Assertive Support Team (FAST) operated by Mateo Lodge includes full time mental health staff. FAST provides services to families attempting to connect loved ones with mental health services. In addition, Mateo Lodge a field-based Mobile Support Team. Anyone in the County experiencing mental health issues can contact this team directly for assistance. This is not a crisis response team. The Assisted Outpatient Team (AOT) is staffed with mental health professionals who are available to a variety of stakeholders in the community concerned about someone who is not able to recognize their need for treatment. The San Mateo Assessment and Referral Team (SMART) closely coordinates with BHRS. SMART consists of paramedics with additional mental health training who respond to mental health situations in the community. Finally Public Health Mobile Health Van and BHRS Adult Resource Management (ARM) staff collaborate with homeless shelter personnel throughout the County providing consultation to stakeholders and individuals seeking treatment. All programs provide performance and outcome data annually.
Recommendation 11: The County Manager should prioritize the completion of the integrated data systems (i.e., Health Information Exchange and Enterprise Data Warehouse) which were begun under the auspices of the WPC and report back to the Board in a public meeting by December 31, 2020, whether the funding of such integration is possible and, if so, by which date it will be completed.
This recommendation has been partially implemented. The development of the HIE and Data Warehouse has been a multi-year project funded by the Department with an infusion of funds under the WPC grant. Health currently records services within several different Electronic Health Records which have limited interoperability. The Health Information Exchange solves for this problem by pulling data from these various sources and providing it in a single view at the point of care. The HIE currently pulls from internal health records as well external health partners such Kaiser, Stanford, Zuckerberg San Francisco General Hospital and Trauma Center, and Sutter Health as well as the Health Plan of San Mateo. The County can connect to other Health Information Organizations across the State in order to pull in data for patients who are seen outside of the local community. There have been a number of enhancements to both improve the quality of the data and expand its use including the ability to pull in pharmacy fill information, exchange information with first responders who can use the information at point of service and relay back to the emergency departments. The County has set up as part of California EMS Authority’s PULSE for queries in cases of emergency such as the COVID-19 response. The Enterprise Data Warehouse pulls in data from Health’s multiple E.H.R systems, matches data across the disparate E.H.R’s and then allows for the development of reporting at the cohort or individual client level. Unfortunately, the County has been unable to achieve the goal of data integration with housing and social services as the County is prohibited, in many cases, by state law, and sharing information will require a State solution.
Funding for the integrated health data systems will be evaluated through the County budget development process and a report back to the Board will occur during the June budget hearings.
FISCAL IMPACT:
There is no fiscal impact associated with accepting this report.