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Mental health gaps in Mendocino County due to funding, outreach, stigma

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Mental health gaps in Mendocino County due to funding, outreach, stigma

Picture of SJ Black
Thursday, August 30, 2018

(This is the first in a series of articles the ICO will publish examining the state of mental health care in Mendocino County. The articles are funded in part by the USC Annenberg Center for Health Journalism’s California Fellowship, where Black is a Fellow.)

In Mendocino County, mental health is a constant issue. The County clings to the side of the coast, but is detached from the rest of the state, with only two main roads runnning through it. Many county roads that provide eastwest travel are in disrepair, making it difficult even to move within its borders.

Isolation and few resources point to limited services for residents, whose fear of stigma can be stifling and prevent a connection to sources of help. Mendocino County also has fewer funds to spread out, and narrowly escaped hospital and juvenile hall closures in the last year.

Like many rural counties around the country, Mendocino County also suffers almost twice the rates of suicide as urban counties. It currently ranks 13th out of 58 for the highest suicide rate in California, down two places from the last rating. Even though the county’s ranking dropped, data show an actual increase in overall suicides, consistent with a rising rate of suicide across the nation.

On average, about 20 people have died by suicide annually since 2008. The lowest number was in 2012, when 13 people died by suicide, and the highest was just a year later in 2013, when 27 people died by suicide.

People come from out of the area specifically to commit suicide, said law enforcement in Fort Bragg. According to Mendocino County Sheriff Tom Allman, law enforcement has become the de facto handler of severely mentally ill in the county after major budget cuts were made to mental health services and the County shut down its psychiatric health facility in 2000.

“They don’t come here to think,” said Detective Ze Lima. “They come here to finish.”

“I think it’s something to do with the ocean,” said Deputy Jesse Van Wormer.

Drug-related deaths also plague the County. It rates ninth highest in the state, and estimates say 16 to 26 people in 100,000 die from drug-related causes every year in Mendocino County.

Some of the problem is access to care. Rural counties have lower populations, residents have lower average incomes, and the counties have fewer resources such as roads, making longer distances all the more difficult for people trying to access specific care in a location far from home.

In this first installment, a deep dive into the mental health care system shows that many counties, urban and rural alike, suffer from similar issues: an equal pay system for mental health services, dual-diagnosis care treatment and adequate housing for severely mentally ill patients. And along with this, Mendocino County faces universal challenges like stigma, and more local ones like lack of engagement and communication.

Treatment difficulties faced by counties

In 2014, the Affordable Care Act was adopted, changing the healthcare field dramatically, and mental health care was no exception.

Before the ACA, counties provided only crisis care for severely mentally ill patients. “Adults received very little mental health services,” said Chief Executive Officer Camille Schraeder of Redwood Quality Management Company, which manages Mendocino County’s mental health services and programs.

After the ACA, counties had more funding to include care for people with mild to moderate needs. It opened up a whole new market and a whole new set of problems for counties to deal with, like the issue of “parity.”

“Parity,” in simple terms, means health plans and insurers must treat mental and physical health benefits equally. But that assumes mental and physical health services are equally available.

“No one is even close to parity,” said Sonoma County Supervisor Shirlee Zane, who has also worked as a family therapist and inner city social worker. Zane received the 2014 National Alliance on Mental Illness—California Recovery Practitioner Award. “I doubt there is any provider that has provided parity. If you go into the ER you’re going to get a lot of resources for a heart problem, but walk in with a psychiatric emergency … you’re not going to get the same level of treatment.”

Counties also have trouble providing housing for people once they’ve gone through a significant mental health issue.

“It’s difficult to find housing once they get off treatment,” said Solano County Health and Social Services Director Jerry Huber. “And it’s more magnified in California simply because of lack of affordable housing.”

In most counties a good percentage of patients who have substance abuse and mental health problems are marginally homeless as well, he said. “That obviously compounds treatment-related issues,” he said, which he’s seen in every county.

“Those with significant mental illnesses unfortunately are often dealing with significant substance abuse issues as well,” said Huber. But “cross-trained,” providers who understand both mental and substance abuse treatment are still uncommon.

Researchers are still struggling to understand why patients with mental illness often suffer with substance abuse issues.

“[Is a patient] using meth and then becoming psychotic? Or are they using meth … as selfmedication?” Schraeder asked rhetorically. “We don’t know why, we just need to treat it.”

Mendocino County, like other counties, is trying to address these problems. But Mendocino County is also struggling with unique issues. Several analyses say better outreach and engagement are needed to properly administer care. Also, the County was previously found to need better organization and communication within its own ranks.

Mendocino County specific problems

“After 22 months of successes, conflicts, trainings, misunderstandings, learnings, hirings, firings, arguments, meetings and persistence,” said former Chair John Wetzler of the County’s Mental Health Advisory Board, “I would state as Chair … our Board sees improvement in the delivery of mental health services to our clients.”

Wetzler wrote that in the advisory board’s 2015 annual report. Several months later in 2016, the Board of Supervisors hired Kemper Consulting Group to conduct an outside analysis of the County’s mental health services after years of complaints from the public, the Advisory Board, the Mendocino County Grand Jury, an audit by the Department of Health and Human Services Centers for Medicare and Medicaid Services, and complaints from Sheriff Tom Allman.

The County suffered low staffing levels after severe cuts to the mental health budget, had few resources for crisis care after hours and lacked a county psychiatrist (not uncommon for a rural county). But the County also entered into unclear contracts with weak controls with Ortner Management Group, which provided adult services, Kemper said.

Kemper said the county gave the contractors “more latitude than we think should have been delegated.” He cited a lack of a clear authority role, lack of a contract manager, lack of an implementation plan, fundamental weakness in the original contract and a lack of memoranda to spell out how the county and the various contractors and subcontractors will communicate and work together.

The Mental Health Advisory Board lacked proper communication between both Ortner and Redwood Quality, which provided children’s services, and also with the County’s executive office, according to Wetzler. “All of our questions regarding finance, policy, personnel, organization and decision making would have to go through one single person,” Wetzler said. “An Advisory Board receiving all of its information from one source is a self-cancelling phrase.”

Ultimately, Supervisors voted 3-2 to pursue a new request for proposals for adult services, and Ortner ended its contract shortly after the review was made. A complete turnover of services to Redwood Quality happened a few months after.

Now the County is working with Redwood Quality as the only administrative service organization for the County’s mental health services for both child and adult mental health and behavioral health services.

Two years after the transition, improvements have been made. The County completely transitioned to electronic files; substance abuse was included as a co-occurring disorder with mental illness and efforts at collaboration began in earnest.

Members of the newly named Behavioral Health Advisory Board, formerly Mental Health Advisory Board, attended mental health-related state and regional meetings. And the behavioral health director and the chair of the advisory board also began regular monthly meetings.

With the transition to a single organization providing mental health services, Mendocino County Behavioral Health Director Jenine Miller said she’s seen an improvement in relationships between law enforcement, community partners and the hospitals.

“We really have moved to a different system where there’s a lot more happening, and a lot more change and excitement, and I see clients being served,” said Miller.

But communication in general is still a problem in the County, according to current Behavioral Health Advisory Chair Jan McGourdy.

“[There’s a] lack of communication from the County, which we talked about before, and now I realize it’s really a systemic problem,” McGourdy said during a County Board of Supervisors meeting in July. There’s also a disconnect in communicating with the public, as outreach and proper engagement for the severely mentally ill is still a struggle.

“I feel like we’re in a system where no matter what we earnestly and sincerely are attempting to do, it doesn’t seem to transfer,” said Schraeder. In the two years since Redwood Quality has taken over for the County, Schraeder believes “astronomical changes” have been made. But now more than ever there seems to be a disconnect, and people aren’t aware of services being offered, all while suicide and drug-related death rates remain high and are increasing across the United States.

“People think there’s nothing out there,” said Trish Ross, a chaplain at the Mendocino Coast District Hospital. Talk has been going around that doctors, nurses and medical practitioners are leaving, she said, which leads to many people not bothering to try to find services in the first place or assuming there are none.

The hospital has gone through bankruptcy and narrowly escaped being shut down just before a tax measure voted to save it by less than 1 percent in the June election.

And for patients who have attempted suicide or self-harm who do have a social worker to make connections for them, “It’s exceedingly awkward, and for people who are on the brink anyway, it’s overwhelming,” said Ross.

Even after-care has its own engagement challenges, especially in keeping up with severely mentally ill patients to stabilize their treatment, said Schraeder, adding it’s a fine line to tread: “There has to be engagement of the population and early identification and appropriate treatment.”

The global problem of stigma

The largest and most pervasive issue with providing effective mental health services, one that stretches across the globe, is stigma. It’s up to patients to self-identify and take the first step toward treatment, and the stigma for mental illness is magnified in a small community.

“There’s a real fear,” Ross said. “There’s just not a sense of privacy.”

With people either not wanting to be subject to stigma, or simply not knowing programs available, Family Advocate Javier Chavez at Action Network in Gualala said he often has to go out on referrals if the people who need care are to receive it.

And for all over the County, Mobile Outreach and Prevention Services is a program that sends a mental health rehabilitation specialist with a sheriff’s technician to people in need.

Referrals or direct can be made for anyone who has behavioral health symptoms and concerns, who has been or might need to be psychiatrically hospitalized, or has been in jail or the emergency room.

The idea is to connect people to mental health services before a crisis happens, and it has taken hold in several other counties as well, including Sonoma County.

“The important thing is to not be silent,” said Zane, who experienced personally the most severe effects of mental illness, when her husband died by suicide in 2011. “The silence is the deadly part.”

Victims have been shamed into keeping their mental illnesses to themselves, she said, which prevents them from reaching out to get treatment. “It’s easier and cheaper to shame people,” she said.

But in spite of Mendocino County’s unique obstacles, it is ahead of the curve in one regard.

In 2017, by a popular vote of 83 percent in favor, Mendocino County passed Measure B, also known as the Mental Health Tax. It enacted a sales tax to create an entirely separate fund to be used in part for an in-county psychiatric facility for inpatient care of the mentally ill and as a training facility the state has never before seen.

It also allocated money specifically to mental health services, the result of a two-year campaign launched by the Mendocino County sheriff.

“The truth is the election was the easy part,” said Allman after the measure passed. “But now that we have the resources we are going to sit down and have conversations that are going to help rebuild all of mental health services throughout Mendocino County.”

The next installment for the state of mental health care in Mendocino County will look at Measure B: why it was formed, and what could happen as a result of the specifically designated funds.

[This story was originally published by the .]