Board of Supervisors Committee - Regular Meeting

Good morning, everyone. I'd like to welcome everyone this morning for those in person and viewing online to the Alameda County Board of Supervisors special meeting. This is a joint meeting of the Health and Public Protection Committee. If we could please start with a roll call.

Supervisor Tam. Present. Supervisor Marquez. Present. Supervisor Miley, excused.

We have a quorum. Thank you so much. Supervisor Miley will be joining us shortly and we'll decide if he wants to take over chairing or if he wants me to continue. We'll be flexible. So thank you everyone for your patience. If the clerk can please give the announcement of how to participate under public comment when we get to that point.

For all participants, please state your name for the record prior to your presentation. If you wish to speak on an item not on the agenda, please wait until the chair calls for public input on non-agendized items. Only matters with the committee's jurisdiction may be addressed. To notify the clerk you wish to speak, for in-person participants, please fill out a speaker card and hand it to the clerk. The speaker cards are at the front of the room. For online participants, please use the raise hand function when we are on an item that you wish to comment on. For dialed in participants, please dial star nine to use the raise hand function. Dialing it again allows you to lower your hand. The clerk will call your name when it is time for public comment. If you are in person, please come up to the podium to speak. If you're online or dialed in, the clerk will call your name and allow you to unmute. Thank you.

Thank you. We do have three informational items on today's agenda. So at this, what I'm gonna suggest is that we allow public comment at the end of each presentation, but since we have three presentations and I know we have a lot of engagement, I'm gonna limit public comment to one minute per section. And then after we're done with the three informational items, there is general public comment. under items that fall under the purview of Health or Public Protection Committee. So we're going to go ahead and start with item number one. As I mentioned, this is an informational item. This is Care First Jail's last Behavioral Health Advisory Board 2026 update. There were two slide decks attached to this presentation, and we are now going to hear from the Chair of Behavioral Health Advisory Board, Brian Bloom. Welcome and good morning. And before I get started, can we do an audio check for those listening online? Is everything coming in clearly, audio and visuals?

Check, one, two, check, check.

We got thumbs up? Okay, we're good to go. Welcome.

Great. Good morning, supervisors. Thank you so much for this opportunity. And I know you want me to do this in 30 minutes, so I'm going to do my level best to go through these slides in that time allotment. As you know, there's a narrative report that we prepared yesterday Okay, like this? Better, better? There's a narrative report that we submitted that contextualizes a lot of these slides and provides background. And although I'm going to be presenting the slides as the chair of the BHAB and the chair of the Ad Hoc Care First Committee, I don't want that to obscure the fact that this is a team effort. This is a great collaboration of the members of the Ad Hoc Committee, many of whom are in the room today. Others are online. And if you have some specific questions about some of this material, and I hope you do, some of the members of the ad hoc committee will chime in because they have areas of lived expertise and comments they're going to want to make. So I'll be the figurehead, but this is really a team effort. I know it's an informational item, supervisors, and we're calling it an implementation report. but I hope you take this and hear it as a call to action. You asked the BHAB to monitor implementation of care first policies and the implementation of the recommendations. And I told you last year that we do our best and we wouldn't sugarcoat anything. And there's areas that we believe are urgent that need your attention, that need your intervention. So as much as this is an informational item, I think of it more really as an urgent call to action. Next slide, please. This comes under the category, you've heard me say before, you can't change what you don't measure. We have to keep abreast of crucial data points. This isn't the only measurement of how we're doing in terms of care first, jail's last. But last May, when we presented initially to you, I started with this slide, the prevalence of mental illness in the jail. Three salient points on this slide. First, the jail population continues to decrease. This is a huge victory for our county. Decarcerating this county is a huge victory that we should feel proud of. 15% decrease just since last year. Jail population, I just checked last night at the jail, it's even less, it's 1,214. As of last night, a slight downtick from the figure from June. This is a 50% reduction from 10 years ago. population in the jail last night was a third of what it was 20 years ago. We've seen a significant and stabilizing reduction for all kinds of reasons that we don't need to get into. But the bottom line is that the jail population as a whole has gone down. Unfortunately, we haven't yet, and I'm going to return to this in a future slide, we haven't yet enjoyed the benefits financially of the reduced jail population. You would think that we could spend much less money on the jail and use that money in community-based treatment services, which we'll get to in a second. The second salient point here is that the level of care numbers, and you'll recall that these are the product of an initial assessment when anyone gets booked into the jail, they have stayed the same. Unfortunately, no change from 350 a year ago to 348. More people, I said this before and I'll say it again, there's more people in jail with serious mental illness and serious behavioral health challenges in general than there are any night at John George, Gladman, Villa Fairmont, all the crisis residential beds. and the CSUs combined. We still haven't been able to, despite good intentions, despite this board's political expression of care first, still haven't been able to bend that number down. More disturbing is that the seriously mentally ill population seems to be increasing quite substantially from 76 people last year to 113 in June. Again, I checked the, and these are all, by the way, these numbers come from the sheriff to the sheriff's credit. They produce these every week in a publicly facing portal that's easy to access. As of last night, that 113 has jumped up to 124. So these are folks in jail that are seriously mentally ill. A huge increase comprising some 10, 12% of the entire jail population. And that's what we need to address. Why aren't we making inroads? Why aren't we making a difference? Why haven't we been able to bend these numbers down? Next slide, please. Viewing some of this through a racial equity lens, unfortunately, the burden of this does not fall equally. It falls disproportionately on African-American and Black members of our community, 33%. Now, this is the entire adult forensic behavioral health population, not just LOC's level of care numbers two through four, but the entire population at the jail who is getting some level of mental health services, including level of care one people, 33%. of that population is African American or Black, whereas it's nine to 10% of the population in the county. Next slide, please. This graphically shows the rise of serious mental illness at Santa Rita Jail. And the takeaway here is there is nothing inevitable about this. There is nothing preordained about this. There's nothing natural about this. We don't have to accept a rise of mental illness in the jail. We don't have to understand it as, well, that's just the way things are. This graph in my mind, and I'd like, I submit to you, is the result of policy choices. It's the result of specific things that we have done and choices we have made. It's not natural. It doesn't have to be this way. Next slide, please. So the question is, why is the number of SMI folks in the jail increasing? And the answer is, next slide, please. We continue to underinvest in the kinds of treatment programs that have a proven track record of keeping people who are living with behavioral health challenges out of jail. That's... the real nub of the issue. In the next series of five or six slides, we're gonna give you sort of a suite of interventions that could be made that are cost-effective, that aren't that expensive, that could be made to properly invest and that would, we believe, BHAB believes would make an impact on the level of mental illness in the jail. Next slide, please. Next slide, please. Thank you. So the first one, full service partnerships. Next slide. Oh, we're going to do it that way. Okay, cool. Thank you. So Actually, you can just keep, I didn't know this was how you're going to do it. So just, yeah, that's fine. There's been, you know, we all understand that full service partnerships, sort of the Cadillac of outpatient assistance and support does make a difference. It keeps people out of jail. It keeps people out of John George. There's just no doubt that all of the evidence shows in our county and nationwide that these kinds of interventions do have an impact. The county did an assessment pursuant to the DRC lawsuit. The county did an assessment and learned that 1,400 slots are needed in Alameda County. This was a a comprehensive assessment that looked at all kinds of factors. And these are annual slots for 16 years and older, 1,400 are needed. At best, the best, the county is funding 1,155 FSP slots. That includes care court slots, that includes AOT, FSPs, et cetera. But the total looks to be around 1,155. What is supposed to happen to the 245 people who aren't going to get an FSP. When our own assessment says that 1400 slots are needed. Well, we would expect that amongst those 245 people that aren't going to get an FSP slot, some will end up in jail. Some will end up at John George at huge costs to the county. FSPs are a great deal. Now, $20,000 per slot is what I wrote on the slide because your board passed on June 2nd, item 16 from your board agenda, $40 million for two years for 1,045 FSP slots. That was item 16 on that agenda. So I just did quick math and came to 20,000. The assessment done by the Indigo Project says that the cost of slots are more like $25,000, $30,000. But any way you cut it, it's a great deal. Because if it lowers incarceration and lowers hospitalization, then we're going to save money. So a call to action is for this body to... elevate to the full board a proposition that we fully fund all 1,400 slots in Alameda County, just like the assessment calls for. Next slide, please. Thank you. Court-based diversion. You recall we were with you in October, and I remember Supervisor Miley especially caught his attention. All the various treatment courts, veterans court, collaborative drug courts, behavioral health court, they all had clinicians embedded in the court to help process cases, to help treatment planning, et cetera. The Mental Health Diversion Court, which now has an enrollment of over 350 defendants, has no clinicians in court. It's the only treatment court in Alameda County that has no clinicians assigned to it. So the public defenders are left trying to, on their own dime, figure out what kind of treatment is available and what kind of plan needs to be created. Again, a call to action. for this body to elevate to the board to staff the Mental Health Aversion Court without any further delay. Again, it's a cost-effective treatment. It keeps people out of jail, lowers costs in that way. And along with that, the Office of Collaborative Courts, which does not do Mental Health Aversion Court, does the Drug Courts, and some of the family courts, they needed a $200,000 infusion for this year because of loss of federal funding. So again, another easy, low-hanging fruit, cost-effective measure to lower the number of mental illness in the jail. Next slide, please. I I'm low to get into the weeds about the incompetent to stand trial diversion program. This is of course the sickest of the six. These are folks that are suffering so severely from mental illness that they don't understand the, criminal process. They can't rationally help their lawyer in the case. Every year, it's about 120 or so criminal defendants that fall into this category. The state is very keen on getting counties to divert, when possible, people who fall into this category into treatment. And The state provided the county with an $8.2.5 million grant in 2024. We declined the grant. We got BCHIP funds that hopefully will the expectation and hope is that the BHIP funding will fit the bill. But we have still yet to, we had a pilot program, but we have still yet to transition into a permanent IST diversion program in Alameda County. And frankly, the BHIP is not very clear on what is preventing the relevant parties District Attorney, public defender in the courts in signing a contract and coming up with a memorandum of understanding to get this program off the ground to divert people. I will tell you that the state has a cap for every county. And the cap for Alameda County is 88 defendants, IST defendants. Every county has what they call a growth cap that you can't, that there are financial sanctions if you go over that number of IST defendants. It's a way that the state is trying to encourage counties to divert some of this population. For fiscal year 25-26, just the first three quarters, we're already at 90 IST defendants. So the fourth quarter, which we don't want to know the results of for another few weeks or months, is going to put us way over the cap. We're going to end up paying money to the state in terms of financial sanctions for being over the cap because we have failed to divert meaningfully some of these defendants who would be eligible to be diverted. And again, we're asking the board to determine why the contract hasn't been finalized. What are the hurdles? What's preventing this program from seeing the light of day? Next slide, please. And then we come to pretrial release services. What a great program. Now, I don't know if you've seen the local press, and we'd be happy to provide you and your staff with some articles in the local press recently, but this is a program that started in January of 2026, and already we're seeing the... the results of decreases, significant decreases in re-arrest rates. Folks in 2024 and 2025 who were released from jail in the moderate risk category had a 43% chance of re-arrest. That's not recidivation, but just re-arrest, 44% chance. The study that just came out showed that for 2026, with the help of these services provided by the pretrial release program, the rate's down to 18%. So again, keeping people out of jail isn't just a moral calling and isn't just the right thing to do, but it's incredibly cost effective. The BHAB is not clear what is causing the problem in getting future funding. This year's funding was provided through AB 109 funds. And the size of the pretrial population is going to grow. recent California Supreme Court case expands pretrial release mandates really for judges to grant pretrial release to more criminal defendants so that the population is going to grow. And the idea that we would just release people to the streets with no services, no support, no case management, no help at all, no navigation services and expect them to do fine and come back to court when told is is really doesn't make much sense. Again, it's a smart investment. It's a smart investment that would keep folks out of jail. Obviously, pretrial services is not just for the folks that have mental health and behavioral health challenges, but it's certainly that population is among that. Next slide, please. And next one, please. So this is just a summary so far. This is just a summary. You know, when I presented to this body last May, Supervisor Marquez, you asked me at the end, well, what's the low-hanging fruit? What interventions do you think can be made immediately and what's low-hanging fruit? And I got to admit, I should have been more prepared for that question because it's obviously a very smart question. And so I gave that some thought, and the whole team gave that a lot of thought in putting this together for you this time. And this just summarizes. This is the low-hanging fruit, or I should say amongst the low-hanging fruit. FSPs fully funded to the 1400 slots that the assessment calls for, fully staffed the Mental Health Diversion Court, the collaborative courts need funding for this year, treatment beds necessary, dedicated forensic treatment beds for the IST diversion program, and then the pretrial release program. All sound wise investments. Next slide, please. And while we're talking about low-hanging fruit, we really urge this board to elevate again to the Board of Supervisors as a whole to renew the contract with Wendy Ware. You recall Wendy Ware worked with Wendy Still, the two Wendy's integral to the RHA contract. re-imagining adult justice process. And you received a terrific report from Wendy Ware, November of 2025, just last fall, which was sort of her final report. It provides great analysis of jail data It provides a system that can be built on going forward. And the only thing it doesn't do, and what RAJ recommended, you will recall in one of their closing recommendations, was add to the jail data and analysis behavioral health data. treatment needs, an assessment of behavioral health treatment needs of the jail population. Because if you know what the needs are of the 350 folks in the LOC 2, 3, and 4 category, if you know what their needs are, and we're not talking about thousands and thousands of people. We're talking about 350 people. It's not a... a terrifically burdensome task to figure out what are the treatment needs of that group and then build out in the community, make the sound investments so that you cater to the needs and you know that you're creating the treatment facilities that are appropriate for the level of need that exists. That analysis can be done. Wendy Ware can do it. She's an expert. She's a nationally recognized expert. certainly wouldn't be a great investment in terms of the cost. And again, this fits under our category of low-hanging fruit to renew that contract going forward. Next slide, please. Thank you. If you're going to remember one slide this morning, I hope this might be it. The relative annual per person cost of incarceration versus community treatment. This is really what it's all about. Your board approved $387.3 million for the sheriff to run the jail for next fiscal year, $387.3 million. That doesn't include, by the way, the money that behavioral health gets for adult forensic behavioral health, which of course is spent on the jail population. So that number is even lower. It's probably all told maybe $400 million that this county spends on a jail population that continues to decrease. Now, you would think that if we're incarcerating fewer and fewer people every year, that we would enjoy some savings. But we haven't seemed to be able to capture that. And it's actually worse than that, because you remember from the RAJ report, I thought this was the most stunning, one of the most stunning and salient facts that came out of that report. Out of the folks in jail, and when we ask, you know, the jail population, of course, it's a freeze frame. We you know, how many people are in jail at this moment. And the RAG report tells us that 40% of the people in the jail spend less than 24 hours in the jail. They're released in 24 hours. Four out of 10. Six out of 10 spend less than three days, 72 hours in the jail. And an astonishing 82% spend less than 10 days. We're spending $400 million, close to that, on a jail. that is housing people and people are getting released, the majority of them, under two, three, four, five days. Clearly, they're not a public safety risk. If they were a public safety risk, they'd be in jail. So we can't argue that, oh, there's some public safety justification. There must be. Now, Wendy, still you recall suggested site release centers locally to just get people cited and released and not use the jail for that function. There's probably a lot of good ideas. But when you think about the kind of expense for a population that the majority of which spend less than a week in jail, disrupting their lives, disrupting their work, disrupting their family situations, et cetera, we urge you to get smart, dedicated folks around the table and figure this out. The other way to think about it is just like this. And I submit to you, we talk about AB 109 money and we've enjoyed, this county has enjoyed the AB 109 money and the savings. Where does that come from? In 2011, the state of California made a decision. They decided to decrease the prison population by realigning and changing the sentencing laws. And the goal was to decrease the prison population and then send the savings to the counties. That's exactly what has happened. From 2011 to the present day, 15 years, the prison population in California has gone from 160,000 to 90,000, a 45% decrease. The money that California saved by reducing the prison population is what AB 109 money is. Every year we get Alameda County, like all the counties in California, Alameda County gets $70 million of that savings. We enjoy, the county enjoys the savings from the reduced prison population, and we spend that for reentry, we spend that for case management, we spend that on appropriate services for that population. Well, it's curious that in the last 15 years in Alameda County, the jail population has decreased at a much greater clip than the state prison population. In 2011, there were 3,800 people incarcerated at both Santa Rita and then North County Jails. And as I showed you, 1,200 or so, 1,225 is the current census. So we've decreased the jail population in Alameda County in the last 15 years by some 70%, well above the 45% that the state decreased. But where are the savings? Why don't we enjoy the savings of that? The state prison population goes down and we get AB 109 money. So I think... My point is that I'd encourage you to ask yourself, well, what's the local county level of AB 109? Why can't we enjoy savings given this greatly reduced jail population? And then reinvest those savings just so that folks stay out of jail, they get housing, full-service partnerships, SUD treatment, and the like. How am I doing on time? Let's go to the next slide, please. We're going to turn to the next one, please. I think my time says about six or seven minutes to go. So I'm going to go at a good clip through the balance of this. Excuse me. There's a few slides here about housing. All of the diversion programs, the full service partnerships, et cetera, the pretrial release would be for not if folks don't have secure housing. That's sort of an obvious point that no one would be able to quibble with. So we, again, a call to action is to direct managers of the Home Together Plan and the Housing Plan at HCD to figure out how to prioritize justice-involved folks with SMI and SUD challenges as beneficiaries for some of these deep housing subsidies. You're gonna hear from CARE Court in a moment. And one of the brilliant things about CARE Court pursuant to the state legislation is that the bridge housing money is prioritized for care court participants. And so there's a real incentive for folks to get into care court and to participate in their treatment because housing comes with it. It's been a game changer for that, the population of folks in that court, because again, they're prioritized. The same thing we're suggesting should happen for what we'll call the care-first population. Their housing and security needs need to be analyzed, assessed, addressed, and then prioritized so that along with treatment comes secure housing and, again, reduction in their time spent in jail. Next slide, please. A different slant on the same thing. Licensed boarding cares are a unique place, a unique spot in the continuum of behavioral health care in the county. These are folks that need more than permanent supportive housing. They need to be in a place, primarily really medication management is one of the biggies, that they need support and help making sure that their medication is managed. You know, the BHAB gets to do site visits every year. It's one of the great, frankly, one of the great virtues of the Behavioral Health Advisory Board is we can site visit at the jail, various facilities. We always go to Villa Fairmont. at least every year or two. And we are told continually by the discharge planners and the social workers at Villa Fairmont that there's people there that are ready to be dropped down. They're ready for a lower level of care. And what they need is a licensed board and care, which would be the perfect drop down from Villa, but no room at the end. We've seen about a 200 bed decrease in board and cares in the last four or five years. What a shame, because a bed at Villa Fairmont is so much more expensive than a bed at a licensed board and care. Again, it's not just doing the right thing morally, but it's doing the right thing financially and making prudent financial decisions. So the discharge planners at Villa continued to tell us that if there was more room at board and cares, they could... move people out of Villa. And, you know, that goes right up the system. You know, the admin day rate at John George, this was not in the slide. I wasn't going to mention it, but I just, it's so important. 30% of the beds at John George on any given night are occupied people that don't meet acuity criteria to be a John George. And the reimbursement for an admin vet is, I think, and Dr. Tribble can correct me if I'm wrong, but I think it's like 10 or 15% of what the reimbursement rate is for someone who's really acute. Well, why is someone at John George without meeting acuity criteria? Because there's no room at Villa. They can't get, there's no room there. Why isn't there room at Villa? Because we don't have licensed boarding cares for that population. We got to think of the continuum as a continuum and ask ourselves, where are the wisest interventions to be made? Where's the most sound investments to be made? And we really urge you to figure out how to increase the patch. I know that it's, you know, reimbursement rates are low for board and cares. And that's why the operators have struggled and we've lost beds. But this is really an urgent need in the county. It fills a unique spot. And it's, again, it's a fiscally, it's a sound thing to do. Next slide, please. Luckily, There should be money to do this. This board in 2023 allotted $26.6 million to build, along with about $60 million of state money, to build and construct the mental health services unit at Santa Rita Jail. So that money was available. That money was allotted. That money was earmarked, if you will, to build the service unit at the jail. public outcry, some more analysis. Turned out Sheriff Sanchez wasn't so keen on the idea. The board backed off. And you might recall the Care First Task Force at the time urged the board to back off. And I thought the board and we thought the board made a wise decision in not going through with the plans for the additional building service unit at the jail. Well, that's $26.6 million that was allotted for the jail. And so the Care First Task Force recommended amongst the 58 recommendations, it's 6C if you're keeping track, to use that money for housing, supportive housing needs and board and care needs. So the money should be there. We'd ask you to ask the CAO exactly what happened to that $26.6 million that was allotted earmarked, but then wisely in our estimation, not spent. on an additional building at Santa Rita jail. Did that money just go back into the capital improvement project fund? And if so, why isn't it available to support some of these deep subsidies and to support the license board and care like we've talked about? Next slide, please. And I'm coming, I'm wrapping up. This is a broader theme of transparency of funds. The BHAB is enjoying a good working relationship with the CAO. We've met several times. We want to continue meeting, but what's really needed is some more transparency. What funds are available for the care first population? What are the funding streams? Where are the savings and what can be used to support the needs of the care first population? Next slide, please. When the task force met for those two years in 23 and 24, Almost done. We called for an assessment of beds, the need for treatment beds in Alameda County. We still believe that's important, but it's really what's more important at this juncture is the realization that we are going to witness in the next few years an incredible expansion of via BCHIP treatment beds. We're talking about doubling the number of crisis residential treatment beds, substantially increasing crisis stabilization beds, SUD, and all of the things listed there. This has been described by ACBH leadership as a once in a career opportunity. So rather than an assessment at this moment, what we're urging the board to do is don't lose sight. Keep our eyes on the ball. Make sure that all of these beds get online, that the appropriate beds go to the appropriate people. You know, I'm reminded from the World Cup, you know, the team that got scored on, you were most vulnerable to getting scored on when? Right after you scored a goal. Or if you like mountaineering terms, 70, 75% of the accidents in mountaineering take place on the way down, not the way up. So we have this great victory with BCHIP. Let's not lose sight of getting all of these beds online. Dr. Tribble gave the BHAP a great update just last Monday. actually, on some of this expansion. And four or five projects are ready to go. They're going to be, beds will be online by summer of 27, maybe summer of 28. But there's several projects that are still in the planning stages. No sort of a TBD kind of, you know, when's it going to happen. And I would encourage you to just continually ask and demand to know when these beds are coming online and then obviously funding the operational costs over the next period of time to make sure that they're fully funded. And the last slide, please, I think. Yes. So after two years of meeting the task force, after two years of the ad hoc committee meeting, it has become painfully obvious to us that the political will to advance the care first agenda is not the issue. Your board unanimously passed the resolution. Your board unanimously adopted the 58 recommendations. The political will is not the issue. Frankly, I don't think money is as much of an issue as other people do. I think it's really more of an issue of how we decide to spend the money and how we apportion it. But the issue really is the fragmented nature of county government, no different than any other county. Different agencies, different departments. What you need and what we really urge you to think about creating is some kind of a seat in CARE First GLS implementation director, if you will, a CARE First czar, if you will. The title probably isn't as important as the fact that you need someone who has authority to bring the people together, to make decisions, to make sure that there's not duplicity or redundancies, that metrics are standardized across all the agencies. Without that, without a centralized champion with authority, to make decisions and bring people together and make things happen. The BHAB is concerned that although we will continue at your behest to monitor and report back as best we can, but we don't have any power. We're volunteer citizen group. And what you really need in this county is a director, a care first director to make all of this happen and to put it all together. So with that, I'm going to, I think on a few minutes over, I apologize. But please, if you have questions, ad hoc members of the committee are here and I'm here and we'd be happy to answer any questions.

Thank you very much for your detailed information. thorough presentation with a lot of good updates and things for us to consider. At this time, are there any clarifying questions?

Thank you, Chair Marquez. I also appreciate the update on what we had as a board discussed last year in terms of the implementation of at least the 23 recommendations at that time from the Care First Jails Last Task Force. The issues that arise, I see a theme in the presentation and there's questions about, well, we got all these savings here, why can't we use it there? We have a decline in the jail population, So we should need less staffing and why can't we use that for mental health care beds? And so we on the board have asked that question numerous times, whether it's on a one-on-one with our staff, whether it's through the health committee. And so I'm not as articulate as staff is when it comes to explaining some of the practical and the legal constraints over that shift in funding. So I'm hoping that some of our staff that are here can help respond to some of those issues because for example, we are undertaking, the Sheriff's Office is undertaking a staffing study because of the decline in the jail population. But then it's not clear to me when you say you need 1,400 beds and you have 1,200 people in jail, are you saying everybody in jail are part of people? I know the data shows about 60 to 65% of the people in jail often have mental health care, serious mental health care issues. And I would... And we've asked this question repeatedly when we have presentations from our behavioral health staff on what we are doing. We get updates from them on the progress on the BCHIP funding for the treatment beds like at St. Regis. So I'm hoping that maybe some of our staff can help. address some of these underlying concerns and themes. And I don't know whether somebody from probation is here because we did get some clarification about the use of AB 109 funding for the pretrial services and how that's also constrained by AB 339 right now when it comes to labor issues. So perhaps that can also be addressed.

Thank you. Is there anyone that would like to respond to those questions? We could also follow up offline. I do want to be conscientious. We've only heard one presentation. We still need public comment. We have two more presentations to go. And I believe two of us have a hard stop before one because we have another meeting. Is that correct, Supervisor Miley? There's a goal to be done by one if possible. Yeah, yeah, yeah. Okay. So I think a lot of this stuff we're going to have to follow up outside of this meeting, but it's on the record. You're getting what our questions and follow-up questions are. So I have a few questions that I think could be answered rather quickly and whoever is best to respond. But I wanted to know how many beds are at Villa Fairmont? as well as John George. And then also the assessment with the recommendation of the number of full service partnerships we should have. When was that conducted?

I'll take them in reverse. The FSP assessment was completed in the spring of 25, I think, or maybe the summer of 25. It was a presentation to the BHAB from the Indigo Project that was mid-25, so something like that. And There's 69 beds at John George. It's licensed for 89 by the state, but we use the front end of John George as the psych emergency services as sort of a crisis stabilization unit. So there's 69 hospital beds at John George. Villa Fairmont, you know, the county in its wisdom bought back some of the beds at Villa Fairmont that other counties were using and Kaiser was using. I think the total beds at Villa Fairmont is 79-ish. Is that right? 90. 90 beds at Villa Fairmont. And did you have another question?

No, I think all my other questions I could take up with the department heads, but really appreciate the information. As mentioned earlier, we are going to take public comment on each item. So if you haven't already done so, please fill out a speaker card on item number one or raise your hand online. And we're only going to do one minute because we're going to take public comment after each presentation. And then Supervisor Miley, would you like to take over chairing after public comment? You're good.

Okay. First four in-person speakers, Merle Lustis, John Lindsay Poland, Richard Spiegelman, and Jean Moses.

Good morning, board. Thank you for entertaining my comment. I am a resident of Alameda County. My name is Merle Lustig. I'm a resident, a property owner, and a taxpayer. I am in full support of the recommendations being presented by the ad hoc committee. and want to focus mainly on one particular recommendation. The pre-trial release services program has been in a very short period of time, a major success. And I think it's really incumbent upon the board to continue funding the program, either through AB 109 funds or some other funding source. It not only is cost effective, but it affects the lives of individuals who have been incarcerated at Santa Rita Jail. It gives them an opportunity to have housing, case management services. It really affects their lives. And the number of folks being charged against

Okay. Good morning.

Just for everyone's knowledge at the one minute, the mic will mute is just so you could. Okay.

John Lindsay Poland with the American Friends Service Committee. Licensed boarded cares provide supervised residential support that serve people with the most severe behavioral health needs who can't make it in permanent supportive housing, which has been the primary strategy for homelessness in this county is PSH. They otherwise languish in the streets. They decompensate in jail. or they cycle through psychiatric hospitals and sub-acute facilities and incur far higher social and economic costs to the county. During the last year, new licensed boarding cares have opened in Alameda County. That's the good news, but more licensed boarding cares have closed. The county has had a net loss of 198 licensed boarding care beds since 2021. We're calling for braided funding sources to increase support for licensed boarding cares, including BHSA funds and or SSI client income, Measure W funds, and other sources. Thanks.

Good morning, I'm Richard Spiegelman with the Interfaith Coalition for Justice in our Jails. Thank you for this opportunity to hear this remarkable report that Brian Bloom and his colleagues put together. It's so comprehensive that I really have very little to say except that I too want to emphasize or underline the importance of funding for pretrial and mental health diversion costs. And I could repeat everything that Brian said, but what I really want to end with is that I think it's absolutely critical, you've heard me say this before, that there are data. More work for Wendy Ware, comprehensive reporting. She's done amazing work and needs to continue. And then a care first implementation director, as the advisory board suggested, I think has to be in place.

When Wendy still was operating, she could do magic.

I don't think we have anyone who can do that kind of magic anymore. And I agree that that person probably doesn't belong in the office of one member of the board of supes, but up the chain of command. Thank you.

Good morning. Jean Moses, the Interfaith Coalition for Justice in our Jails. Thank you for this opportunity to pursue this critically important topic. The points that I would like to raise relate to the savings. It's been a challenge, as Supervisor Tam appropriately pointed out, to recognize those savings. And I remember when Supervisor Miley said he's never seen savings actually achieved. I want to strongly recommend that the Board of Supervisors require a serious study of how the cost of running the jail can be achieved, not piecemeal, not passively waiting for the sheriff to come. but demand that a serious investigation be taken up and pursued and that the sheriff and whoever she needs to work with come up with recommendations for a substantial change reduction in the cost of running that jail. Thank you.

Sherry Novick, please unmute. Thank you. One significant strength of the CFJL progress report is that it recognizes that people's lives change over time. Yet county programs tend to look at a person for the specific period they're touching that program which means it's simply not surprising that people fall through cracks. As has been pointed out, licensed board and care homes are a prime example of this phenomenon. They've never been viewed as a county responsibility. They're provided in the private sector with some minimal county patch funding, yet they are a critical part of addressing the continuum of an individual's life. These are homes that, if funded, can provide clean, safe environments with medication management, full-time staff, healthy, consistent meals, and coordination with other services. Yet the county has not recognized this as an important part of the county's continuum of care. I urge your committees to jointly address this intense failure of the system. Thank you.

LA Journey Hillman, please unmute.

Good morning, everybody. Eladria Hillman from the National Union of Healthcare Workers. I'd like to echo the statement about Wendy Ware. I believe that her contract should be renewed with the county. It is important that we actually get a clear understanding of the population that is entering the jail. A lot of our folks are entering the jail due to being what's called a quote-unquote medical refugee because the insurance that they may have or may not have is not sufficient. So they end up in the jail system in order to provide services. Also, it is important for the county to understand that mental health care is health care. We have to do a better job of combining the body as a whole and making sure that the services are provided as a whole. Medicare does provide services through Kaiser if you have been a prior Kaiser patient. And some of these folks are not receiving the benefits from the mental health and behavioral health portion that Kaiser provides. And it is important that the county make sure and they force these providers to actually provide mental health services so that way they don't end up in the jail system, trying to receive services at that point in time. Thank you for your time.

Margo, Julia. Margo, please unmute.

Thank you. I'm Margo Dashiell, and I want to thank Brian for representing us so beautifully with the comprehensive recommendations that he brought forward. I want to speak particularly to the licensed board and care situation. It does feel like as a county, we're backing away from that as an important strategy for housing people who have been very seriously impacted from mental illness and need a lot of support in stabilizing their lives and maintaining a medical and psychiatric regime. So I do hope that we will look again at the Supportive Housing Creative Community Land Alliance as a strategy for increasing our housing and improving our licensed board and care environment. Thank you.

Lonnie Hancock.

Lonnie, please unmute. I'm unmuting. Thank you. Thank you. Well, I want to note the excellent, really superb report from the Care First, Jail Last implementation group. And I want to thank you, Supervisor Marquez, for continuing the Reimagining Adult Justice effort of Richard Valle. Of Richard Valle. point out this report has four very concrete recommendations. The mental health diversion court, pretrial services, a board and care development strategy for the continuum of care, and data through Wendy Ware's contract. Please direct the staff, make a motion. Pursue this work. You have willing partners and great opportunity for success. Thank you. Tony Velchia and Alison Monroe.

I'm a family member. And I also want to thank Brian and the whole task force for their report, their work, volunteer work. I would like the council to adopt the recommendations and put some teeth into it with an implementation director as they recommend. I also want to talk about the board and care situation. It's not 98 beds that were lost. 198 people with probably no family support. No one looking out for them. Where do they go? They're not a bed. They're somebody's family. And some of us are getting older and not going to be able to support, help these family members anymore. So who's going to do it? So please keep the board and cares in mind. And maybe there's a new model that the county can adopt. Have we looked at best practices in board and cares across the country?

Alison Monroe here with FASME. I hope you enjoyed Brian's excellent report about some low hanging fruit. I urge you to look at not just the need for slots, This is kind of an amendment to what he said perhaps, but at the need for beds, programs that actually have beds. The footprint of the program for the seriously mentally ill is actually pretty small and only a fraction of what it needs to be. I'm thinking about subacute beds, crisis residentials, and boarding cares in particular. Those places aren't just programs, they're places with beds. They constrain the size of the system and the number of really seriously mentally ill people we can help. I'd encourage you to look at beds. And I think it might be a good idea to have a Care First Jails last implementation director. Thank you.

Ann, please unmute. Hi, my name is Ann Foley. And my comments are related to keeping people I am out of jail and expanding family advocacy, this personal story. When I called police in Berkeley in 2007, a team arrived with experienced clinicians, spent time escalating the situation. Rather than treating a mental crisis as a law enforcement problem, they knew how to talk to my partner and they accepted my information and the AB form I provided them. I called the Berkeley non-emergency response in April of this year when my partner was becoming physically aggressive and he was immediately taken to jail. I tried to offer information about his history with the AB form, but the police were not interested in information about his history of mental illness. They were on their own separate track. The message they gave me was you can and should have been removed and file a restraining order to protect yourself. They seemed to think I'd be greatly relieved by this information.

Kathleen Sikora.

Good morning and thank you. I'm a member of the Ad Hoc Committee and the East Bay Supportive Housing Collaborative. I'd like to speak to two points, both relating to specific ones relating to licensed board and cares. If the county is still positioned that the licensed board and cares are not eligible for Measure W funds, I would ask for a reconsideration of that position via county council. measure w was enacted to address homelessness and it seems that licensed board and cares fit within that purview the saying is that once a licensed board and care closes it's a pipeline to homelessness my second request is that the board and and this is one of the ad hoc committee's requests as well that the that the ad hoc that the board um uh fund a comprehensive independent assessment of unmet needs for licensed board and cares and we cannot make informed decisions without real data we've heard this before but we need to know what we have so we know what we need thank you teslim carl

Good morning. I'd like to thank Brian and the volunteers of the task force. My name is Tesla McCarroll, Executive Director of Supportive Housing Community Land Alliance. SHCLA is a community land trust specifically identified in the Care First Jail's last recommendations. Under the recommendation, expand funding and support for innovative housing models. The recommendations have been very clear. The challenge has really been implementation and the quality of the implementation efforts. For example, SHCLA is mentioned in the report, but over the last year has seen its operating budget significantly, has seen a lack of access to acquisition capital, and believes that in line with the report and presentation, that its care first jail implementation director housed in the county administrator's office would likely be the best path to ensure that the quality of implementation is in line with the task force recommendations.

There are no more speakers.

Again, I want to thank everyone for their engagement on this important topic. Thank you to Brian Bloom and all of the ad hoc committee members on the Care First Gels Last Committee. There's a lot of information that was shared. A lot of requests were made. So I just want to speak on behalf of myself and my team is that we are taking all of your requests into consideration. But specific, I will just spend a couple of seconds talking about pre-trial since I co-authored the letter back on December 17, 2024 with Supervisor Carson. So I would highly encourage everyone to revisit that letter. It was item 21.2. And yes, we currently have a model in place. It is for one year in the letter that kick-started this conversation that there was a strong emphasis for an evaluation. So just want to let the public know there are several conversations having with the courts, with probation, And the contract does expire in December. And I'm hopeful that we can have a one year evaluation to determine next steps. But I fully acknowledge in the interim, there will have to be a bridge and a transitional plan. So just know that I'm committed to figuring that out. And then lastly, I did want to ask from the sheriff's department. I know there's also been ongoing conversations when Wendy were presented to public protection November of last year. Just wanted to check on if there's anyone that can report on the status of engaging her or what is being discussed in terms of jail analysis in the future. I don't know if anyone in person or online would like to respond to that. Thank you and welcome.

Hey, I'm Charles Joe. I'm a captain at Santa Rita Jail over the administrative duties. We're currently just building our internal capacity. The analysis of jail data is going to be very helpful for us, and we'd like to be able to produce it on a periodic basis so that internal capacity will allow us to do this continuously. It will help us to streamline operations and also be more transparent with what the public can see and how we're working things.

And the components that were covered in Wendy Ware's analysis and the recommendation to also track our inmates that have behavioral health issues, is that going to be a part of that analysis as well?

Yes, so we are working on building the electronic connections that we have to have a process to build these reports. So we're looking at all of that data and finding a way to create it on a periodic basis.

OK, thank you. Are there any other questions or comments on item number one, Supervisor Miley?

Yeah, thank you. Apologize for being late, but I was at another JPA meeting for that abatement. So if I'm hearing the public testimony and review the report, if implementation is the key. I'm not sure if we'll be discussing this at our retreat the first part of August, but I mean, just to get a handle on this, it might be good for us to discuss this at our retreat so we can provide some direction on how we want to pursue this. That's just a thought at the moment because it just seems like the report's excellent. Appreciate Brian and the committee for what they've done here. I just think now we need to figure out how we're

of marshaling this forward and get it done thank you for your comments and appreciate everyone's engagement again we are going to take public comment on item two and three so and fill out a speaker card if you have comments for those presentations but now we're going to start with item number two this is an update on care court we have three presenters uh dr roberta chambers arvana Sorry, I don't have my readers, so everything's flaring on the page for me right now. And Dr. Karen Tribble, I'm not sure who's going to, Dr. Tribble will kick us off. Welcome.

Testing.

Testing. Thank you, Supervisor. Appreciate the opportunity for the update, and I also want to affirm the commitment, and we will look forward to any other questions you have for us in response. And part of what you'll see here is an update, and our colleagues here are poised and ready to provide the update, partly with Indigo and some of our leaders. Juan Tizon is also online. He's working diligently, again, at the jail and working, as well as Kate Jones, Kira Gunther, and Dr. Chambers is actually online. But for now, we will have our in-person speakers in addition. The one thing that I will add is this is a follow-up. And as you know, the governor visited and was very highly complimentary to the implementation. And so we're very proud of that. The data speaks for themselves. And so what you'll see here, as well as the other presentations, is concretely where we are, what the process is, and the implementation update. So I thank you for the opportunity and I will defer to our colleagues.

Supervisors, it's a pleasure. Can you, is that a good distance from the mic? Does that work? Awesome. I'd be remiss, Dr. Tribble mentioned it, just not to acknowledge the tremendous amount of work that all the departments have put in to get this program up and running. You know, as you mentioned, Governor identified the county as a champion, and that's because of the number of petitions per capita as a county level. Just really, the capacity of this program has grown in such a short time, ACBH. public defender's office, the courts, backs, the contracted provider, and housing and homelessness services, just the tremendous amount of time, energy, and work they've put in to get this off the ground. I just wanted to highlight that before diving in because it's really been a sort of her, what's that saying? Herculean effort to really get this off the ground and running. So I just wanted to highlight that before diving in and providing the implementation updates.

Can you introduce yourself?

Oh, I'm so sorry. And my name is Artavon Davaron. Thank you very much for having me this morning. There's going to be three key parts to the presentation, a short summary of the planning work we did. We were able to present that about a year ago, but I just want to remind the group sort of the planning that went into the county's implementation. And then we want to provide that concrete implementation update of the work that has been done to date. And then finish the presentation off with a summary of some of the lessons learned today. And so you can move to the next slide, please. That would be great. And you can go to the next one as well. Just a reminder that the CARE Act is a legislation that authorizes CARE Act court. It's a new civil court process to engage a targeted group in community-based treatment, right? To avoid the unnecessary crisis, hospitalization, homelessness. And as we just heard, incarceration of people with serious mental illness in Alameda County. The partners began planning for the CARE Act Court over a year before they would receive their first petition. So really this time and energy that's been put into implementation has been long before they saw their first petition to really imagine a program that they could see supporting the people who need it most. And then the county began accepting petitions in late November and having their first care respondents in December of 2024. You can go to the next slide, please. And this slide just provides a brief overview of the process. There's a lot more, you know, nuance and detail to it, but the process starts with a CARE Act petition being filed by a qualified requester to the Superior Court. Support is available through the Self-Help Center. At this point, once the petition is filed, the judge, typically Judge Bean when she's here, would review all petitions and determine if the petition meets prima facie standards. meaning that there's really enough evidence or information presented to warrant that order of an investigation and assessment. At that point, the judge would order ACBH to complete the care assessment and appoint the investigation. ACBH, in collaboration with BACS, conducts that investigation and submits to the court. within 30 days of court.

I know it's a lot of information, but respectfully, can I ask you to slow down mainly for accessibility reasons, just to make sure everyone can follow along, please?

Absolutely. Thank you. Cheers. So at that point, once the investigation is conducted, CARE Act proceedings would commence. Based on the investigation, care eligibility is determined. Once somebody is deemed eligible, a care agreement or plan would be negotiated amongst the partners. The care agreement is in place, and then they would be in court providing progress updates for up to 12 months. At that point, they may graduate from the CARE Act court or be extended for a period of time if they had not met the goals of their care agreement. Next slide, please. So this is a summary of some of the care planning activities that the county did prior to implementation. There were monthly interagency meetings beginning in October 2023, really starting thinking about at a philosophical level what the court would look like and then moving into that tactical development. There's been quarterly advisory group meetings since the beginning of October 2023 so that as implementation planning was taking place, the agencies were able to obtain concrete feedback from an advisory group consisting of members from cross-departmental staff, community members. It's really evolved into quite a large group. I think over 70 or 80 folks are on the group and many attend on an ongoing basis. There were also informational sessions and trainings provided to ensure that qualified requesters and different people who come across people with serious mental illness who may be eligible for this program knew when it was coming online, what the process was like and how to file a petition. There were site visits to many counties that were the cohort one counties to support the work. There was training with the Department of Healthcare Services and the Judicial Council and also the departments attended the cohort two readiness form. So a lot of work going into planning and being ready for implementation. We can move to the next slide, please. Here you just see just a snapshot from the website. The Superior Court and Public Defender's Office, I believe, also have similar websites with resources dedicated to the Carrot Court. Again, this was with the intent for people to be able to learn about the court, get materials online as easily as possible. And many of these documents that you see here are translated in many of the threshold languages of Alameda County. So it was a real effort to ensure that not only was the planning done, but that there were the, again, the informational sessions, the trainings, and then the online materials. And we think a lot of this work may have contributed to what you'll see as a very steady stream of petitions being filed and a program that is really just getting built, growing and growing and reaching capacity. Frankly, just the petitions keep coming and you'll see that in a moment. Next slide, please. And we can go to one more. So this slide just looks at the roles and responsibility or is really just wanted to highlight that these are these are the partners i've mentioned them before. And then this group of partners in some iteration is meeting every day to either coordinate petitions coordinate outreach and engagement for people who have had petitions or to coordinate service planning. for all the care respondents. Now, it's not that all six are meeting five days a week, but some iteration of this group is meeting every day. So it's a very high resource, high time commitment to ensure that the folks who need it the most are able to, you know, get into the program and then once into the program, get the services they need. Partners are also continuing to meet quarterly to review overall implementation of and make adjustments to the program and the approach on an ongoing basis. So again, there's these daily meetings to coordinate services for people who have been petitioned for care, and then there are, sorry, the daily meetings, and then there are the quarterly meetings for the partners to get together, reflect on how things have gone in the past quarter, and think about any shifts that need to be made at that time. Next slide. This slide looks at the number of care petitions filed since the start of the CARE Act court. So December 2024, we see it trickles in to start. And then really what we see on a monthly or quarterly basis is that on average, there's about 20 or so petitions every month. And if anything, I think if you wanted to draw a trend line, you might be seeing it go up. but certainly we're seeing a consistent flow of petitions filed. And so this is just, again, highlighting the time and energy and resource that goes into this, but really shows the success of the County to get the word out there and the success of qualified requesters to really do their part and file those petitions. And so what this slide really does highlight though, is that it's not sort of plateauing. It's not sort of, reaching a point where, you know, numbers look like they might, you know, come back down and steady it. These petitions keep coming in. And so the county is continuing to work together, leadership and program leadership to figure out what's the best way to manage the number of petitions that are coming in. Next slide, please. When we look at who is filing the care petitions, you may recall, but likely not, it's been about a year. Early on, what we saw was a lot of petitions came from Alameda County Behavioral Health. That's because in that planning process, the department made a conscious effort to let people on our radar, let's get them into the CARE Act court. We know who they are, let's help support this process. Family members, first responders, and Alameda County Behavioral Health have really made the bulk of the petitions filed. But as you see, family members and first responders comprise about two-thirds of all care petitions that have been filed to date. We also have about 35 from the state hospital or prisons, 19 from themselves, and then also 16 other requesters. Next slide, please. So when we think about what are the demographics of people with care petitions filed, we see 42% are African American, 27% white, approximately 10% identify as Hispanic, and 20% other are unknown. Those numbers include all races based on HIPAA protections that didn't meet the threshold for providing an individual level. And then there are a few that were unknown. 68% male, 32% female, and a majority of care respondents are adults between the ages of 25 and 59 that would be served through the adult system. There are a smaller number of transitional age youth and older adults in the program as well, about 8% and 9% respectively. Next slide, please. So this slide shows a little bit of the flow of the petitions being filed to date. And I actually think This may be an outdated slide, to be frank. And so I'm going to give the numbers here on my slide deck, and then maybe we can officially slide that in if something needs to happen. But there have been 339 petitions filed to date. There were seven that were sort of filed at the kind of simultaneously for the same individual. So you'll see the next two branches actually add up to 332. Of those, a vast majority have met prima facie and resulted in an investigation order. The 15 that did not meet prima facie typically they were not a resident of Alameda county or they did not require or they did not have adequate information in the petition to warrant a order of an investigation, but, as you see. 317 of the 332 did meet prima facie and were ordered for an investigation of those. We see that actually that number up top, it looks, it should be closer to about 120 have already agreed to care act services. Majority of those have been enrolled in the care FSP, the backs care FSP. There has been a small number that have engaged with another FSP in the county. There are approximately 90 or so receiving outreach and engagement services at the time. So this means that there are, this means that the backs outreach and engagement team are actively working to, conduct the investigation and work with the county team to ensure eligibility. And then once do so to get them to agree to care act services, work with them, see if there's something they would like to do and then get them over to the FSP if possible. Approximately 100. And I think I have 38 petitions have been dismissed based on not being care eligible. And most of these petitions were because the, the, Client was not care eligible. They did not meet some criteria. It may not be the diagnostic criteria. There are a number of criteria someone might need to meet. And these folks are connected to a lower level of care often or to the appropriate level of care if they meet an FSP level of need. And then finally, a large number of those folks were also unable to be located. And then there are a handful of elective clients, and that means that they had their petitions dismissed. They had sort of demonstrated that they were able to engage prior to the petition being filed in a service like an FSP, and they were able to remain engaged in that service. So they did not meet the need of the CARE Act court, but they were then connected to ongoing services. You can go to the next slide. This slide looks at the outreach and engagement phase. I mean, one of the keys that folks talk about is how can we get people connected to care as quickly as possible once a petition filed? That's been one of the key you know, goals of this program is how do we get them engaged in the FSP? If we look really just at the first two columns, looking at the days from petition filing to enrollment, and I guess one thing I want to highlight is what we've seen is in the last six months, people are getting engaged much more swiftly than they were in the first year or so of implementation. And so when we look at those first 13 months, it took about 99 days on average to get from petition filing to the BACS FSP. And in the last six months, that number has gone down to approximately 52 days on average. So we've seen quite a change here. And I think a couple of keys have really led to that. One is, you know, they have the push notification system that's been developed when someone lands in a jail or someone lands in a hospital, the BACS team is being notified immediately and going out and engaging that person. So it's allowing folks who are unable to be located to be found at a time where they might be able to be engaged in services. At the same time, the BACS team has really made a concerted effort in collaboration with Alameda County Behavioral Health to ensure that once they get that engagement in that outreach and engagement phase, let's get them over to the FSP as soon as possible. And so there's really been an emphasis placed on not stretching out that outreach and engagement period and really getting them to meet the folks who are at the FSP earlier and do that handoff in a more quick way. So we've seen that improvement in the last six months and I think Partners are really excited about that. We also see on the right-hand column, if you look at that, that's just looking at a very similar number, but from the time that someone is served and from the time a person has been served, so the time that they've sort of been approached and learned about the CARE Act petition, it's taken about a month and a half or a little over a month, 43 days on average to get them from being served to then enrolled in that BACS FSP. So again, at this point in the past six months, taking about a month and a half, And less than two months from the time a petition is filed to get somebody into the BACS FSP. And I do want to highlight during this outreach and engagement period, folks are also getting engaged with a lot of, you know, some of the basic needs they met. And they are getting engaged and having some support through that outreach and engagement process and then getting connected to the real ongoing wraparound services in less than a couple of months. Next slide, please. So this slide looks at the Behavioral Health Bridge Housing. We see that, again, this program requires people who are enrolled in the CARE Act Court to be prioritized. So we just wanted to highlight some of the beds that are available for this. And the CARE Act Court has done a really wonderful job of getting people into these housing services, but also anyone who meets eligibility for the bridge housing program. would be able to obtain these resources as well we see that there's over 300 beds of interim on housing and emergency shelter there's 210 nights per month for um hotel and motel vouchers This looking at the Tier 4 licensed facility beds, the adult residential beds, they should actually say 40 beds again. So I don't know that's a type of that 40 beds across eight facilities. There's six forensic peer respite beds and then there are 55 rental vouchers available. So this is sort of what bridge housing has available at this point and what sort of. online. And if we go to the next slide, we can see some of the engagement from care respondents. We see that to date or through June 77 care respondents had utilized motel vouchers. So, you know, almost a quarter or a fifth of that opportunity to utilize motel vouchers and 130 care respondents have been housed in the bridge placement. So looking at Regis Peralta, Washington and Men of Valor and Eddie's Place. So there's been a very large proportion of folks who have been engaged in housing through CARED. Brian Blue mentioned one of the key functions of this program has been able to really mesh that and provide the housing support and the mental health services and that real wraparound approach from the core partners and Alameda County Behavioral Health and VACs to do everything possible to coordinate services, get the services in place needed and really get folks the support they need who are in the CARE Act program. Next slide, please. And we've highlighted this already, so I don't know that we need to highlight it too more, but just wanted to highlight, you know, again, they were, the governor came and actually from St. Regis gave their speech to talk about sort of the CARAC court champions and Alameda was named as one of the 10 counties who are one of those champions. And again, that's really thinking about the vast number of petitions that are coming in in Alameda County. So it's really just a continual flow of petitions and the governor has acknowledged that and work and the work keeps on. And I know it's a tremendous amount of work for partners and there's a tremendous value for the participants that are in this court and a lot of wonderful work being done for people in the court. Next slide, please. A few more slides. This looks at ongoing implementation. You know, as the program has matured, we've seen, we've gotten to the point that the county seeing folks getting close to graduating from the CARE Act court. So as that part of those quarterly meetings was coming up with a framework for how will we manage the folks who are in the CARE Act court. The partners are working together. And so we think about the public defender, we think about the court, we think about BACS, and we think about ACBH really working together to begin to assess and determine a transition plan with respondents in month eight of their engagement in the CARE Act program. And then if sort of the initial thought is this person may be ready for graduation at the 12-month mark, transition planning would really begin right then or the next month, if applicable. By month 10, they're making the referral for a respondent to the appropriate program. And then in the 11th month, there would be the one-year status review. And then finally at one year, there would be formal dismissal if applicable. Again, at the 12-month mark, if a person, and we'll on the next slide talk a little bit more about the criteria, if they haven't met the key tenets of the care agreement, if there's still a clear high need from the person to be engaged in services and that there's a utility for the court to be a part of that process, that care respondent may be extended for an additional 12-month period. So that's the decision-making process that's going on from these sort of months 8, 9, and 10. And then you go into that status review hearing in 11, where that is sort of formally determined and moving forward. Next slide, please. So this slide really looks at sort of four pathways that someone may move through at that graduation decision, right? So when they're working together at that month eight and nine and 10 and thinking about next steps. When we look at that first bucket, that's looking at people who may remain in the CARE Act courts, who may not graduate and stay there for an additional 12 month period. This would be a group of people who really were not actively engaged in treatment or housing while they were in the CARE Act court. And that's unlikely that they would engage in services without court intervention. More time would have been spent maybe working on engagement than actual service participation and goals related to sort of basic needs that are included in the care agreement have not been met yet. And if they have goals that would acquire sort of care at court engagement, these are the group that are gonna be likely to be extended in for another 12-month period. The next two columns, you see the first three bullets are identical, and what it would be looking for is these folks would be, if we go just to that second column, someone may be graduating from the CARE Act court and transitioning to the non-CARE FSP, so not transitioning down from the BACS FSP. So these folks would have demonstrated active engagement in treatment and housing for at least the last three months that they've been in the CARE Act court They have protective factors in place and key goals would not be disturbed by transitioning out of the care court. They have a transition plan in place for ongoing housing and mental health services. Right. And key here, the person continues to meet medical necessity for an FSP level of care. If those criteria are met, this is a person who would graduate from the CARE Act court likely and move on into another FSP. If they met all those same criteria but no longer meet the medical necessity for an FSP, they could graduate from the CARE Act court and be transitioned to a lower level of care and get that behavioral health support or case management they still do require, but just not at that FSP level. And then for some folks, they may be dismissed from the CARE Act court sort of at any point if they're not meaningfully engaging in treatment, they're not meaningfully engaging in housing services, and other legal mechanisms may need to be considered in those cases. So those are sort of the four key pathways that people are going on at the graduation sort of point or at the point of transition, if you will. So here are the list of some of the ongoing projects. The Quality Improvement and Data Analytics Division continues to do data analysis and reporting with the state. That is a monthly requirement that is fulfilled. They're continuing to build out the push notification system. Ideally, in the future, right now, there is this The John George Psychiatric Pavilion in Santa Rita Jail, where the agencies are pinged and they're able to do that work. The idea is in the future to hopefully be able to build on that. They're also continuing to refine the bridge housing process, really just on a case by case basis. get as many care respondents in need engaged in housing and at the appropriate spot that would that would really benefit and support their recovery. And then finally, on a case by case basis, they're working through the process for justice involved individuals who are referred to the mental health diversion or behavioral health court and have also been petitioned to care. So these are cases that on a case by case basis that they're really working through. What are the best ways to support these individuals? There's some challenges, nuances to work out there, and they do that on a case-by-case basis. And we can go to the next slide. So there are five key kind of lessons learned that we wanted to highlight today after about a year and a half of CARAC Court implementation. One of the keys here is really that Alameda County's, and I've alluded to this sort of throughout the presentation, care program has really grown very, very rapidly. And this has placed quite a bit of stress on a new program. The partners continue to work together to address issues related to capacity, related to budget, related to workload and collaboration that are really imperative to the program's ongoing success. But as the program moves from the implementation phase into the more sort of sustainability phase and into the sort of natural the go you know of the program there's a lot of sort of stress that's placed on the program based on the vast number of petitions the county is receiving um it also when you when you sort of couple the steady flow of care court petitions that are coming in with the significant investment from all partner agencies including at the highest levels it really makes for um a pretty challenging lift for the county partners to say the least. And many of the costs associated with the investment really aren't captured and come at a time where agencies are managing multiple large wide-scale initiatives. Finally, we've highlighted this already, that the attention from the state, but one of the things that we think is important to highlight is really just getting the word out there really led to a wide variety of petition partners engaging in the process, and I think it's been Great to see that the work of the county to really put in that extra effort, to put in that extra time to hold those sessions and make sure the public were aware of sort of the processes has really both paid off in getting people engaged in the CARAC court, but also led to this sort of, you know, challenge and stress on a new program where they're getting those petitions. We saw that it's really in the past six months, improved quite a bit. And that outreach engagement phase has really shortened, but it does continue to take quite a bit of time to locate and engage people in care. And there's a lot of effort put in in that phase. And then finally, if we look at that fifth bullet, one of the things I think that partners have highlighted is, you know, some care respondents who have struggled to engage in mental health are absolutely seeing huge benefits from being in the care court after years of struggling to engage in a meaningful way. they are engaging in a meaningful way in the care court. There could be some opportunity to maybe lessen the load of the care at court as some care respondents may have likely been able to engage with maybe a smaller investment, disengagement in a traditional FSP and others maybe will not engage sort of regardless of the level of outreach. And so really continuing to work together as partners and see who are the appropriate folks for this care at court is something, you know, all partners want to think about to ensure that the, program is sort of right-sized and being targeted to the folks who will really benefit from the intervention the most. And finally, I believe Juan is online, Juan Tizon, Director of Forensic Services, and he wanted to speak a little bit about sort of this intersection of the CARAC Court and Welfare Institution Codes 5200. Thank you.

Welcome, Director Tizon. If you could try a meeting, please, Director Tyson.

Yes, I think I've been lifted to presenter now. Thank you. Good morning, supervisors. And I apologize. I am at the jail for a tour where we have received really great updates on our progress for our consent decree. So just excited to report. It's related to CARE Court because some of our clients that we work with, who are incarcerated are also eligible for care court and we've been supporting their transition into care court and supporting those referrals and the teams who are working with those individuals. Just a little bit of data as it relates to those clients and our clients at Santa Rita Jail, about 34% of incarcerated individuals are in what we call our therapeutic housing units. So 34% of those individuals are connected to intensive behavioral health services while they're incarcerated. And currently, there are only 121 individuals who have been identified as serious mental illness. All of those individuals are supported through our reentry team, part of which also involves referrals to CareCourt. So I just wanted to mention that as we talk about overall efforts towards diversion, reentry, and support of CareCourt clients. We were also specifically asked to speak to WIC 5200, Welfare and Institution Code 5200, as it relates to care court. You'll see here the slide we have here. 5200 is part of the larger LPS Act, which was passed in 1967. So it's not something that was passed as it relates specifically to care court. It is a process that has been established. Anyone can apply for a 5200 evaluation on behalf of an individual who they believe to be gravely disabled or a danger to themselves or others. But it is a process. The individual still has... rights and still goes through a process. So the designated agency would receive that application, would petition on behalf of that application to the LPS court for a court order. The person who's being petitioned would have due process rights still, and a judge would then decide to proceed with that order for evaluation or not. If the judge does order a 52 evaluation, the individual can voluntarily choose to be evaluated. In our case, the individual would go to John George voluntarily to see if they meet criteria for an involuntary hold. If the person does not voluntarily comply with the order, at that point, law enforcement would need to be involved in order to carry out the order and then transport the individual to be evaluated, potentially against their will and potentially by use of force. So this is the established process for WIC 5200 as background was requested on this. And we can go to the next slide, please. We have looked into WIC 5200 and how it's being applied throughout the state. We've reached out to several other jurisdictions, other counties to see how they are using WIC 5200. And we have not received a response of any county actively using WIC 5200 as it relates to care court. In fact, most counties have reported back that they find that WIC 5200 is obsolete because of the treatment courts that we have available, other treatment options, and specifically the 5150 process. For us as a department, we believe that 5200 is not the best option for our community members and our clients. Again, because we, and as it relates to care court, an individual who voluntarily is a part of care court already receives an evaluation. They receive a care plan, which guides their treatment as part of care court. And so there's no need for an additional evaluation once someone is involved in care court. For those individuals who may not be involved in care court, we also have a continuum of other treatment options. And that includes our assisted outpatient treatment, our behavioral health court, our sub-acute treatment facilities, and our community-based treatment facilities, such as our full-service partnerships, our reentry treatment teams. All of those programs have evaluation and treatment planning built in to their process. And then finally, for our community members who do require an evaluation because they are presenting as gravely disabled or a danger to themselves or others, the 5150 process that we have in place provides more immediate access to care, evaluation, and treatment, rather than the steps required in WIC 5200. So it's a more direct path to treatment. So I just want to present those updates here as it was requested of the department. And I'll hand it back over to Artavan to conclude the presentation.

And I think that actually does conclude the presentation. So if there are any questions, of course, we are happy to take them. Thank you.

Thank you so much for the great work in the updates, Supervisor Tramp.

Yes, thank you very much for the update. I just have a couple of clarifying questions. So in your slide 12, you show that about 317 out of the 339 petitions filed met the prima facie, but about half don't qualify for care court. And so when I had briefings in the past on care court, it sounded like you had to meet basically schizophrenia, almost a certain level of serious mental illness before you could qualify. So the people that don't qualify, you said go to the FSP. So they are still seriously mental ill that qualify for the FSP programs?

Yes, there are people who...

And are you seeing a shortage in the need for FSB slots that was presented in the earlier Care First Jail's last presentation too?

I don't think I could personally speak to that very well. I don't know. Dr. Tribble, Kate, Vanessa, have any thoughts?

Thank you, Supervisor, for the question. Dr. Carentrell, Behavioral Health Director. We increased our care court slots by about 100 for FSP last year, so they are being utilized, and we are seeing exactly what you're saying, and so even if they don't receive care through the FSP slots, we have other treatment modalities, and so, oh, she's miraculously on my other side. I'm going to defer to Director Kate Jones, our adult and older adult system of care, so she can

Good morning. Pleasure to be here. What we do in this investigation process, a prima facie is found by the judge. We then go through a series of, you know, assessments with the individual. BACS does that on our behalf. If a person is determined to meet a lower level of care, one of the goals is to find the least restrictive care. right match care for somebody. So if they meet that least restrictive or non-care FSP level of care, we do refer them and ensure that they're connected to that service. All the while keeping in mind that this is voluntary, all of our services are voluntary.

When you connect them, is there any follow up if they voluntarily take advantage of the care?

Our team, our internal team is in constant contact with the teams that our folks are referred to to see if they are getting connected. And then we are required to follow these individuals for three years after the petition is filed.

Thank you. The last question I had is I noticed that in the past briefings, you said there's been a decline in 5150 holds that we've experienced in the county, at least over the last year. What do you attribute that to?

That is a wonderful question. It is actually a precursor to what we'd like to talk to you about. Absolutely. So if I may respectfully defer, love to answer. Thank you.

Thank you for the presentation. Excellent work and just exciting to see that we're able to engage and connect people. With respect to the push notification system, I know you said there's a desire to expand that. Can you give us a sense of timeline and where we will be implementing that system?

My understanding is at this moment, there isn't a concrete timeline for expanding that system. I think with all the push for data just for the program and many other programs, frankly, in the behavior health department and the work that's being done already with what is there. I think right now that isn't sort of top list priority. I don't know if folks have any other thoughts, but right now there's no concrete timeline, but I think the idea is to get some additional hospitals added. The idea would be that would be one of the key additions would expand the hospitals that could be in the group.

Okay. And my understanding of CareCorps is to reduce barriers. I really appreciate The outreach, the education, really anyone can file. I'm not sure who heard this, but I worked for Santa Clara Superior Court for 10 years as a probate court investigator, so I hope the Judicial Council is listening. It is so frustrating to not have even law interns to prescreen petitions. The time and energy the courts waste on, you didn't check this box, you didn't do that. So with this system, I know there's a self-help center, but what are we doing to ensure that the petition is as ready as possible? Not the evidence that's separate, but just is the petition in good standing to receive?

Our petitions go through county council for review. So the judge will, on occasion, reach out. If the petition is incomplete, they might reach out to us. We might have a conversation about that. Somebody will then reach out to that family member and give them some feedback. We do direct them also to the Office of Self-Help. If it's an internal petition from ourselves or one of our partners, County Council assists in a review of all petitions for completeness.

Okay, that's good to know. Thank you. Let's see if we have public comment on item number two. And again, we'll do one minute. And if you could tell us how many speakers we have. If you want to speak on this item, please fill out a speaker card or raise your hand. We are going to close that out in about 30 seconds.

We have one speaker, Alison Monroe.

Hello. It's wonderful that Care Court exists. It's especially wonderful that it includes housing, including good board and cares. As the presenters stated, some people are too sick to make use of Care Court. they will not voluntarily engage with a program like this. And we as parents, when we supported care court in the legislature, we understood it would have an exit conservatorship if necessary. And that's important because there are anecdotal incidents of people that are just too unable to engage to be helped by care court. My friend Kano Hopper in Sacramento, my friend Anita Fisher in San Diego, there are other accounts like this. And that is why we want SB 1016 in the legislature, which would clarify that WIC 5200 is the way to exit care court to go to conservatorship. 5150s are not the answer.

Lonnie Hancock, go ahead. Thank you. This was a very interesting and good report. Two questions. You kept saying case by case basis. Is there some structural lessons you can learn? For example, what kind of permanent supportive housing might be needed for some of the care court graduates? And more hospital beds was mentioned. It seems to point out the need for a serious need analysis. So we know what our goals are in terms of what kinds of beds for people. And I appreciated the representative of the sheriff's office saying that we're building internal capacity for jail data. Does that mean they're not using WendyWare? I think her expertise would be very important at this point.

There are no more speakers. Thank you, everyone. Ms. Monroe, I should have gave you a chance. Ms. Monroe, do you want to, Ms. Monroe, Alison, do you want to finish your thought? I know it's only a minute, but you could finish your thought.

Thank you. My thought was that my daughter, who would have qualified for care court if it had been around when she was alive, was 5150 probably 30 times that I know of or can guess at. And most of those occasions did not result in any lasting treatment or help. And a 5150 at some point in the future outside the court doesn't replace the opportunity to have a 5200 right there with a judge who knows the history and can order somebody to be evaluated. I disagree with behavioral health about this. Thank you.

Thank you. We're now going to move on to item number three. This is also an informational item regarding Senate Bill 43, SB 43, implementation update. We are going to hear from Dr. Karen Tribble. Welcome back.

Thank you, Supervisor. I appreciate the opportunity. And we do know the time is of the absence. So we will try to respectfully cover as much information as possible and answer your questions. To my right is Deputy Director Vanessa Baker, who has been instrumental with our team as well to implement this. I will start off by saying, acknowledging Supervisor Tam, we will plan to discuss some of the implications. As you may know, historically, I'm in the county-led the state and in some cases arguably the nation and the number of 5150s. Over the last 10 to 15 years, several programs have been implemented which we think are impacting. So we're going to talk a little bit even further to see that there is a steady decrease. However, there is an increase in acuity. So those who are placed on 5150 appear to be more ill. And we're watching the state because they will call the data and release the information about two years behind just historically. So we want to make sure we speak truthfully about what those numbers are. But thus far, our internal data do continue to see a decrease in numbers and increase in acuity. So with that, I will begin the presentation. So we will provide a brief overview, talk about the operational changes and the key implementation of milestones. Also, your directives and the board support for a lot of this work has helped us to be very successful and also has posed some questions that we hope to address in the future. So with that, I will defer to Deputy Director.

Good morning, Supervisors. Again, Vanessa Baker, Deputy Director, Plan Administrator with Behavioral Health. Next slide, please. So just to provide some background, some reminders, again, in October of 2023, Governor Newsom signed Senate Bill 43, which made the first substantive changes to the Lanterman Petra Short Act, which you heard a little bit about earlier from Director Tizon, and a related provision of the Health and Safety Code. So really, just to summarize very quickly, Senate Bill 43 broadened involuntary treatment criteria. So it expanded... the grave disability definition. I'm actually going to have you move to the next slide, please, because I can cover everything in this. So again, Senate Bill 43 expanded grave disability to include individuals who are unable to provide for their basic needs, which Basic needs of food, clothing, and shelter was the prior definition. And now this edition included individuals who also have a severe substance use disorder as a standalone disorder or a co-occurring mental health and a severe substance use disorder who can't meet their basic needs or are unable to provide for their necessary medical care. or personal safety. So again, the addition of a severe substance use disorder and then inability to provide for medical care or personal safety. So those were really significant changes. And again, and we've talked about this, the addition or SB 43 also clarified that the use of less restrictive alternatives is still required. So again, care court, we just talked about that assisted outpatient treatment. Next slide, please. So just to remind this board, and we thank you for this, in preparation for this expansion, because of course SB 43 went into law in 2023 or was, began in 2023 with implementation, allowed for deferment until January of 2026. And of course, In our preparation and our effort to really gear up and appropriately prepare our stakeholder community, our board, our community members, we came to the board with, you'll see on here in the second and third boxes, Welfare and Institutions Code 5270 and then Welfare and Institutions Code 5121. And again, just to summarize, 5270, we adopted this, which allows for an additional hold 30 days past one of the legal holds. And really the goal of this was to allow for our system to have fluidity and transitions. And you've heard a lot about that today, allowing for movement throughout our system and the clinicians and the community members to have a hopeful process. positive experience with this process. And then of course, 5121, your board thank you, approved delegated authority to our director, Dr. Karen Tribble, for her to designate professionals to initiate involuntary holds. This is key so that it doesn't bog down our system. Next slide, please. So this is very small apologies. We've talked about this before, but during our very robust stakeholder engagement, which began with community members, and family members, those really impacted. We then, ourselves and our Indigo partners, met with many groups from fire to medical providers, law enforcement, and highlighted on here, of course, your board. We also met at the All Cities meeting. We had multiple public information sessions, and really our goal was to make sure that everyone is fully trained around SB43. And with that, I will now hand it back to Dr. Tripple.

Thank you. Next slide, please. So I want to reiterate again, as Deputy Director Baker mentioned, that your board did allow us to, and I want to underscore the word by I recall Supervisor Halbert directed us to not just implement on, but by. And so a lot of the activities you saw was us certainly responding to that directive and making sure that we did have systems in place to support. There was quite a heavy lift in terms of training and coordination, as well as the stakeholder engagement. And I want to speak to that because again, in some ways, In addition to preparing our system for SB43, we also provided information about other services. So in some way, we not only provided training on how to access and what to use, but in some ways, I believe we also invited people to participate in care court and to some of the services that were launched at the same time. So again, we'll talk about that later in terms of data analysis, but it was very helpful, I think, thus far we are fully engaged. As was mentioned, we have several BCHIP sites. Again, we reported to you that would be our plan, and we are on track to move forward with those sites. Residential facilities, as well as specifically to SB43, facilities that will help people who are needing medication assistant oversight and treatment who are influenced by substance use and intoxication. That continues to be one of our areas, basically all of our assessments in terms of leading to our BCHIP applications. showed that the county did need more resource for those who are intoxicated, medically assisted in a very safe location. And we're happy at any point in the future to provide an update on the VCHIP projects. I believe that was something that the community raised and Care First shows last. So again, we will defer to you about that. One of the things that we also did is we completed our expansion of designated LPS providers. So as Deputy Director mentioned, Alameda County had operated, aside from how the state operated historically, for whatever reason, meaning the Welfare Institution Code requires that the behavioral director, whoever is in that seat, designate individuals and persons and facilities that also the facilities need co-support from the Board of Supervisors. So what that 50... That other legislation, 5129, that escapes my mind, allowed us to align it with the state. So we quickly moved to ensure that all of our hospital EDs were certified. Many of our providers, we moved from pilot to expanding that use. And even today, even in recent meetings, we're identifying additional providers or systems that would benefit from that. And again, to clarify why that's helpful, is if a facility is able to initiate a 5150, then they are not likely having to call out our sheriff or our law enforcement to assist them. Law enforcement need not be involved unless it's needed to. We also are designated providers and organizations to be able to release a psychiatric hold pursuant to LPS. Our requirement, though, as a county is that we're requiring that they do have the highest level of medical as well as support. So a psychiatrist must be consulted in order to release a hold. We thought that was also something to put in place to ensure, to minimize a bit of the risk to the county as well as ensure that they are making sure to look and clear any issues before that hole is released. So again, I want to acknowledge that, that in our preparation, we did quite a bit, which probably impacts our numbers of those are actually impacted by SB 43, which we'll show you. If you go to the next slide. So some of these other activities that we did as Deputy Director mentioned was we provided new crisis intervention training. As you probably are already aware, Alameda County and the Bay Area lead this in the state. in terms of, and they often will come to us to determine how it can be and what it should look like. And we incorporated some of the SB43 content and made sure that our law enforcement and others were apprised at what the distinction is. We thought it would be helpful, not only for adult learners, but for everyone. And I actually have it on the back of my card. We created pocket size cards, which will, if you're interested, you can see that helps. And it could help members of the public determine What now is the criteria? What is the basis for which they can seek to have support for their loved ones? And so this card has been heralded by our law enforcement across the county, but it has been very helpful, particularly with new recruits. When new people come in, they may be aware of the 5150 laws because it's been statutory and on the record since the 60s, but this new nuance gives them a little bit more authority should they show need it. We now have about 174 individuals across the county and 21 designated facilities. So that is all of the work that we've been doing since planning. And again, we took to heart your direction by January, but this is the activity we've done. We've also required now all providers complete law and ethics and voluntary treatment 5150 and 5585, which is the equivalent for children and youth under 18. And the training is offered and updated monthly. And right now, it is offering also a recording because we do know that law enforcement and others Times are precious, and so they can access it that way. We are requiring recertification, and that is the process for licensed clinician and those that are eligible every three years. We've also designated six level one and just explain that level two is just our county vernacular that we established many years ago. Level one is for a facility, a receiving center. designation. So my office is able to designate. Those require your co-support for us. So when we open those BCHIP facilities, if they do have this level one designation, and if they are, for example, slated to help support SB 43 as well, we will be seeking your approval later. And 35, level two, meaning they were not receiving centers, but we did believe that they needed the ability to engage with this process and that is what your approval earlier allowed us to do as well and next slide now this is where it is very surprising to us our county operated clinics actually initiated zero SB 43 based 5150s. Now that does not mean we did not do 5150s. They did occur. However, what our team organically, which is what we want to analyze the data we're seeing is that many individuals were going to care court. Many individuals were going to some of those treatment programs that we had outreached. Our pre-planning may have helped people to identify other types of services. And so instead of placing the LPS 5150, some of the folks that we designated said this may not be clinically appropriate right now. Let's instead refer them to X, Y, and Z. We've also started and had a lot more collaborative relationship with Alamy Alliance. We have enhanced case management for those that are on the mild to moderate spectrum. So literally the investment and the efforts that we've done across the healthcare system is a blessing. It also though impacted our yielding of that in terms of However, the data is not on the slide to protect their confidential information. We dug deeper. And what we found from our hospital is that in Again, I'm choosing my words to make sure that I'm not too specific. But in two of the districts, I'll say District 1 and District 2, there were SB43 holds initiated and treatment was provided. The numbers are at less than a handful, and they were all at medical facilities. So what that told us is those that did meet the criteria of grave disability because of their medical or other issue, or as Deputy Director mentioned, because of a substance use or intoxication, they needed medical treatment. So that does align with our earlier assessments. And that's why, again, we're very pleased to have a partnership with Alameda Health System. We will be opening a, it will be geriatric at this point. Things have shifted at the state, but nevertheless, for a med psych unit that will allow that treatment. So it really does show that in Alameda County, as I mentioned, the acuity goes up, for people who are being placed on psychiatric hold. But as far as really meeting this threshold, at least how our system deals with it, it is more on the medical intervention side. So that could explain, again, for us, we want to do more data, but it could explain, again, why we're not seeing it except for the facilities, the medical facilities in those districts. The other things that we're looking at, a previous slide, is that... ironically, we are consistent with statewide, but we have been trying to break the barrier of being like everyone else in the state. And so, as you could see with care court, we were very robust in that. And we are, again, following this, even though other counties had nominal impact, other counties also had nominal utilization of care court, which we did not. So we're continuing to monitor, but we are seeing a through line in terms of people accessing different levels of care. The other piece that I'll mention as I begin to wrap up is that we have already, as was mentioned earlier, both by Director Jones and Director Baker, is that the least restrictive activities using conservatorship, assisted outpatient treatment, community conservatorship has been something this county has been doing for at least 10 years as far as assisted outpatient treatment and community conservatorship. So again, other counties had not implemented those things. When you look at care court and also some of this work, they did have to make a shift. So that also could be one of the reasons why Alameda County, because we've been doing this and we typically go to those layers of treatment earlier than other counties as well. So, again, we're looking at more data to look at that. And if you next page we are creating, we'll be looking and trying to work with our quality improvement data and analytics division to create a report that actually analyzes more fully the 5150s when they are created at SB 43 rationale. And the state, again, it takes a little bit of lag time, so we want to jump ahead to analyze what that is. And as I mentioned before, we're looking at what is the impact of us, the care duration. For example, as Deputy Director mentioned, we have, through your board support, extended the amount of time, for example, that a person can be in John George. after they've been 5150 by 30 days. Is that what is also helping to preserve people and not have to necessarily recidivate and need another 5150? We're not sure exactly, but these are some of the things we're looking at. Homelessness, is it housing? What is actually the rationale and where we are at the system and what more do we need to do. But in the meantime, we'll continue to do the designation, enable people to help because we do think this is a countywide health care support. It's not just our department. It really does need to be respectfully with our other health care providers to do those site level designations. And as we complete those and nearing complete any of the buildings, we will be seeking your authority if it's a level one, if it's going to be a receiving center, for example, and or somewhere that will help the system. So next slide with that, I thank you for your time and complete.

Thank you both for the great information and updates. Do we have any clarifying questions at this time, Supervisor Tam?

Thank you very much for this presentation. And you covered our earlier question about what is attributing to the decline in 5150s. Currently, the geriatric med psych patients, do they go to John George? That's a great question.

So Right now, Alameda Health System is the expert. Certainly other facilities are, but in terms of the safety net. So right now what happens is John George, and I can speak because I used to work for Alameda Health System, John George would triage any person that comes through their bay, whether that's walk-in, ambulance, police, law enforcement. If the person needs to be medically stabled at a higher level than a psychiatric care, they will typically refer back within their system. In some cases, if the person comes from another hospital, they will do doctor doc nurse to nurse and say, well, this person really is not stable. the treatment that was initiated may need to be readdressed. So there's a variety of issues. When they get to John George, again, typically John George will work with Highland Hospital, San Leandro. They have various levels of expertise. So they will triage within their system and presumably other hospitals do it in the same way, making sure they're medically stable first. And the other thing is with CAT, it's in the field.

med assessment so before they're even transported to john george or anywhere else that hospital unit will determine or transport unit will take them to an appropriate medical facility if they need to be stabilized first okay so uh you were talking about uh needing additional um facilities for the geriatric med psych unit are and this would be under ahs yes okay We supported and the state approved their grant. And there was, I think, AHS staff informed me that they were hoping to try to use one of the wings at St. Rose for this facility.

Yes. The goal, the initial application was two parts because, again, it's around health care for the whole county. It was to be a med psych for geriatric patients as well as a med psych for period unit general for general population based on construction and some needs. The state was not able to approve the way they had based on construction and needs that way. So in an effort and we supported and I submitted another letter to the state, the state is now reevaluating and we believe it'll be supported for them to continue to have the dollars and instead have a complete facility dedicated to Gerald Sykes. which for us, it does work well because the population appears to be aging that are behavioral health condition in Alveda.

Thank you. Thank you. Just a quick follow-up. I'll get back to you, but just a quick follow-up on that thought. What is the age for geropsych? I think it's a younger threshold. Is it 55 or 60?

I would say 55. It's 55.

57. 57. Okay. And do we have a status update in terms of timeline changes?

Yes, well, first we had hoped, actually I have a picture of all of those dates, but we had hoped that we would be farther along, but based on the pivot for Alameda Health System, it looks like for their facility, the geropsych inpatient unit, once we get approval for the SNF, then the site will come back and the site will be certified. So right now we anticipate it'll be sometime in 2028 potentially, but this is again, now that the scope of the project has changed, I believe I trust that AHS may accomplish it even faster than that. But again, the first step is, which is, I think was mentioned in the care court. That's because the approval process now has been not rescinded, but they have to approve the new scope before they give us a target date.

Okay. And how many beds will that be? The Gerald site will have 14 beds. 14 beds. And that would just depend on the individual's circumstances, how long they spend time there?

Correct. Once they are, it'll be a psychiatric acute. So it'll be very similar to a John George there for them.

Is there a model similar to this in any surrounding counties? Yes. Because I've been to one in Santa Clara, so I don't know.

Santa Clara has a closest model, but theirs also was forensic. As you may know, we used to utilize theirs for the forensic population. So we do have, meaning in our system, Alameda Health System has already provided psychiatric consultation and rounding in their inpatient units. We've done that and we funded that for many years. But this is more close to what Santa Clara. Most don't have them. I don't believe statewide. We're not familiar with any others.

Okay. I'll get to Supervisor Miley in just a second. But since we're staying on this topic, I just want to be consistent with comments I've made. I feel like I always make them in the training center because they happen to be days that we do work sessions. But yeah. As you know, we've been intimately involved in conversations, bless you, with the city of Hayward and just want to consistently flag that it is really important that we communicate often and early and come together, which we have been, in a collaborative manner to problem solve. Because although I'm really, really excited about the BCHIP money and we want to get people the proper care, but when you look at the majority of the services, they are coming to Hayward. So we really need to coordinate and communicate. And I believe there's going to be hiccups. That's life. But the goal is to try to minimize those. I just really appreciate. We were all in a meeting together yesterday and we'll be in another one next week. And there's a lot going on folks, but just really appreciate that. And just wanted to thank everyone for their participation, expertise, and I'm confident we will continue to work together. And so on that point, are there any thoughts or plans in terms of, and I think this is a joint opportunity between the county and the city of Hayward, but I do think we need to start thinking about And communication outreach to the broader public, like what does this mean to have these services? There's a lot of, you know, people draw their own conclusions. So I think education, I've talked to backs about this, like this whole notion of being a good neighbor. It goes both ways. We have to receive people, but we also have to treat people. them with respect, you know, so just, I don't have an answer to that, but just something to think about. Maybe our public health team could help us with the PSA. I don't know, but just going to put that out there. I think it would be good to get ahead of that. Supervisor Miley.

Thank you. So first of all, I want to thank the director and her staff for the report today and all three reports. A lot of information. I'm trying to wrap my small brain around all of this massive information and see how it's all interconnected. So with SB43, we can do involuntary holes, right?

SB 433 expands when a 5150 can be made for, i.e., this is a very basic medical reasons or substance use, severe substance use.

And how long can they be held?

The 5150 itself is 72 hours. However, that's again why we did that your board has approved us to once that 5150 is is made, then and then there's a 5250 that adds additional 14 days, your board has enabled the county, based on the approval of our board letter. to add additional 30 days. So we're talking almost 60 days where a person can potentially be treated in the place that they need to be, which is why the locked acute setting, the subacute partial hospital settings that we're looking to build as well will help. Once those folks are stabilized, if they still need a locked high level of care, they will also have more opportunity to go there.

Now, I wanna make sure I'm clear on this, I understand it. So after the involuntary hold, if it's for that 60 day period, can they choose not to go to another facility?

The choice is the clinical presentation and the court process. And we happen to have an expert here in terms of the next step. So if, go ahead.

Yeah, can you answer, cause I'm trying to look at all this holistically.

Yes. So, of course, during the entire process, the 5150, etc., there are multiple points of due process, multiple hearing types. I could go on and on. I won't give the details. But at each point in the process, there are obviously public defender involved. county council, judges, and most critically, as Dr. Tribble mentioned, the clinical presentation. So at each point in that process, if an individual desires to be released and clinically they require treatment, ongoing care, there is a process by which they can receive that care involuntarily. And of course, as we've discussed at different points in the process, ongoing efforts to engage those individuals in voluntary treatment are made at whatever point they are in the process. So the answer is yes. After 60 days, it's after 72, after 14, after 30, after 60, and so on, there are opportunities to for ongoing treatment.

Now with AOT, I thought we set up, there's a limited number of AOT slots or have we've expanded that?

We've expanded, I think initially when we, I'm going back now about 14 years in my memory banks, but we came to your board and you allowed us to expand and we've been utilizing some of that work. If you'd like specifics. Just how many? We've expanded to 25 for AOT and community conservatorship. About 15 or so.

So what's the total number of ALT slots?

Of ALT slots.

And community conservatorship is 15.

Do we need to expand any? we have enough slots? Because once again, my concern is if people need treatment and they don't want to get treatment, we need to be able to, you know, obviously you don't want to give up due process rights, but we need to be able to keep them in treatment. So do we need more expansion of those slots?

Thus far, we have not yet seen them go beyond our need and capacity. However, because of, again, everything that's occurring in our system, we'll be looking at that. One thing that we, as I mentioned earlier, since we increased CareCorp by 100 slots, there is treatment happening. So again, we may not see the need grow because they may be receiving care elsewhere, but yes, we've already, we know that there is a need for involuntary treatment, so we will definitely pursue.

Yeah, because my big concern is, I just want to make sure when constituents approach me and we see problems out on the streets and people ask me, well, why is this occurring? I need to understand why is this occurring? If it's invol- I mean, if it's voluntary, are we using other mechanisms to get them into treatment? Care court, AOT, et cetera, et cetera, et cetera. Obviously, SB 43 is the most severe, I guess, but go ahead.

I'll make a correction on the numbers. I would argue this is a good thing that the slots are actually higher. AOT is 30 and community conservatorship is 25, but I think what that speaks to in terms of our memory and working through these programs is that the right number of individuals are in these programs at the right time. And so we have such a variety from care court to CC to AOT that really individuals are, are being connected to the right program.

Now,

In the past, your board has authorized us to increase. So as I mentioned, excuse me, we will do that.

I have all the confidence in the world, in you and your staff and the whole system. I just want to give you that support. Now, we know with putting the mental health Act behind us and moving into the Behavioral Health Act. And we've provided bridge funding for prevention and some intervention. We could anticipate if we are not careful that we might have more people entering this other phase of mental health necessity in the future. How are we contemplating managing that or looking at that?

Absolutely.

Or getting ahead of that?

All three of that. I think I'll start concretely because we actually did find the actual numbers. Thank you to whomever did in real time, just to give you context to that. So in 2023, about 8,100 psychiatric holds were completed per the state information in Alameda County. In 2024, 3,934 holds. And so there's been a 45% reduction, which again is very unique, but it's the trend that we've been seeing because our goal is to be putting out preventative programs and community-based programs. So to that end, we have built our system, both from a behavioral health, healthcare, housing, all of our system has been intricately created with MHSA funding. So we already anticipate there absolutely will be challenges. So one of the things that our team, as I mentioned, are putting into place analytics and analytics to look at right now, the providers already have a flag. I think this may not have been what you were saying, but if a person goes into John George, for example, they get an automatic alert in the system. So we are probably going to have to do a little bit more because those that receive preventative care were not in the system because we tried to prevent them from meeting psych holds, from doing this work. So most counties across the state acknowledge we're probably going to see a rise in treatment. So for us, the prevention is around outreach and engagement, working with Alameda Alliance, working with Kaiser even more diligently, because now this the way that the shifts have happened, the state is really relying on them to care preventatively. And we're also trying to advocate to the state as they begin to determine what kind of prevention activities to do that they really need to focus on really concrete things that counties can benefit from and not esoteric themes. And they've been very responsive to listening to that. So it's really about data outreach. The other thing that we've done recently, I think we launched it last year under Deputy Director Wagner's office as we created a community-based, even a substance use IHOT team. Because some of our populations in prevention typically may or may not have been psychotic, for example. They may have actually indulged in substance use issues. So we've launched those programs to try to go into the community. And we also have shifted our access, which will be releasing a new name. It's called One Step, formally. But our access unit actually now has people stationed in the community. So those are concrete things that we want to see in real time what's happening. And we're also looking at the data in terms of our contracts. So it's a precarious place, but everyone around the state is looking.

on top of all of this. And I got two more questions. The next one is, oh, well, this is a statement. I really appreciate you expanding the number of folks, like 170 or so that are now trained that can identify and make these determinations around SB 43. That's great. So the other question is back on, the interrelationship between this and uh care for jails last do we have a sense of the number of folks who enter santa rita and then the number that are in santa rita that need to then go into sp 43 yes um and i certainly want to defer obviously to the to the sheriff's office but

They have done a tremendous amount of collaborative work with us. And we're hearing that, you know, with the visit that's actually happening this week. What we created under, and I think Director Taizan mentioned it, we created a diversion team. you know, a diversion team that actually is stationed in Santa Rita and they follow them. And some of the changes that their team have made, they now evaluate at the door, essentially an intake for psychiatric issue. Before, a person could be incarcerated. And when we came and we assessed you or if they wanted services, then we would evaluate you and log. Now we're actually doing it from the door. The other thing that has expanded and kind of the interrelationship that, again, our numbers are different than what was presented, again, in terms of our records. And again, Dr. Tyson's in the jail. looking literally at the census, is that we are seeing an increase in identification because now we're also assessing for intellectual disability. So if a person had literally, I'll use that word, I won't use the prior historical word, but They may have had physical altercations. They may have been fighting. They keep having interactions. And now through this consent decree and all of the quality improvement works that we've jointly been doing, now we are looking past, did this person come in because there's an intellectual disability? And if so, we go deeper. this person is masking a psychiatric condition. And so we're also seeing again an increase and we don't want that to stop because we don't want to miss people who are suffering in the community by no fault of their own. So there's much more intensive screening and evaluation and treatment. And I believe this came up later though that diversion team actually connects them to Kaiser, to Medicare, to that middle alliance. So it's been doing that work as well.

Okay, I'm good.

Great. Thank you very much for the information. We are now going to move to public comment on this item. How many speakers do we have?

One.

Just one. Okay. If you'd like to make a comment, please fill out a speaker card or raise your hand if you are participating remotely.

Allison Monroe. Hello.

Hello. SB 43 is another example of a victory we've thought we had won in the legislature, family members of the seriously mentally ill. And it turns out, after all this, very few people have been helped by it. And it's just remarkable how often the California Behavioral Health Directors resist any chance to expand the size of the system for the seriously mentally ill. I don't know exactly what the mechanism is here. One factor in the reduction in the number of 5150s might be the police abdication of their role in doing that. but we had a lot of hopes for this legislation and they haven't been fulfilled. Thank you.

Brian Boom.

Thanks. I'll put on my citizen hat. I was really hoping that Supervisor Miley would be here. He asked exactly the right question. Do we in Alameda County have capacity to treat the people who because of their illness do not have the insight to understand that they could voluntarily engage in treatment and they need treatment over objections. I use that term rather than involuntary treatment, treatment over objections. Do we have the capacity? I think the honest answer is we don't know because we've never done a real assessment to try to figure that out. We do know this. that when folks go to John George, out of 100 people that go to John George on any given day, 28 get admitted to the hospital. And the balance gets discharged from the front end, PES, within 24 hours, since you can't be held there more than 24 hours. So an officer on the street, a first responder, makes an evaluation. The person meets legal criteria for a psychiatric hold. They get to the front end, PES, and the vast majority, 72%, do not get a hospital bed. I infer from that, to answer Supervisor Miley's question, I infer from that, that no, we don't have adequate capacity to treat those folks. Care Accord's great, right? It's the sweet spot. You have just enough insight so that you willingly engage in services and you get these tremendous services, including housing. But what about the folks that because of their illness don't appreciate that they need help and they refuse it? Do we have capacity for those folks Again, I think the answer is we don't know, but my hunch is we don't, and we should, and hopefully, as Dr. Tribble suggests, we'll start expanding some of those level ones, but we have to keep our eye on... There are no more speakers.

Thank you, everyone. Thank you to our presenters. We are now going to go to public comment. So this is for any general public comments for items that pertain to either the Public Protection Committee or Health Committee, but not the items that were heard previously. Public comment for those items have already closed. Do we have any public comments? John Lindsay in Poland.

I hope you'll permit me to make this comment. All three of these items and many more require an understanding of the funds available. And Supervisor Tam earlier asked about savings and trying to find out about savings. So I just want to go back to something that is on the Care First agenda, but really does have to do with understanding what are unspent funds, what are in reserves. There has been some advances in understanding that there are savings But for you to do your job, for the public to weigh in, there really needs to be a complete implementation of that particular recommendation that has to do with the CIO not only sharing with the BHAB that financial information, but publishing it on a regular basis. You know, the sheriff's office underspent at the jail in relation to its budget last year, even when you count in $52 million in overtime expenses. So there needs to be that information in order to really navigate how to address all of these different needs, not just for Care First, but for other behavioral health and public protection needs.

There are no more speakers.

Okay. I want to thank everyone for their participation today and community for their engagement. I want to specifically give my sincere gratitude to Erin Armstrong. She did a tremendous job coordinating all these presentations. So thank you. This meeting is