Health Care for Low-Income Families
Summary
The Grand Jury followed up on the 2000-2001 Grand Jury investigation of health care services for low-income families in Santa Cruz County, which proved to be an extremely worthwhile and revealing endeavor. The simple truth that became apparent throughout this investigation is that most of the 2000-2001 recommendations were not implemented for a variety of reasons. However, the County has met or exceeded expectations over the past seven years in the areas of improving both the availability and the quality of health care to low-income families.
As an example, the 2000-2001 Grand Jury called for the simplification and consolidation of categorical health plans. The County’s response was that the recommendation would be implemented. For a number of very good reasons, however, it was not. Rather than accept status quo, the County has restructured resources to guide applicants through the maze of health services and health insurance programs.
One important result of that effort is a state-of-the-art call center where electronic files have replaced paper. It can be accessed by staff members in seconds. Because of these and other initiatives, the number of low-income families covered by some type of insurance has increased significantly since 2000, and the number of children enrolled in the Healthy Families program has more than doubled.
Since there is no universal health care presently in the United States, many people must try to find access to medical services without the benefit of insurance. That is where the county safety net coalition comes into play. These 15 county-funded and nonprofit clinics provide primary health care, family planning, dental and mental health services to uninsured individuals. The Grand Jury finds that clinic services have been enhanced since 2000 despite budget challenges. They are more accessible to low-income families, and the clinics have done a better job of outreach to the community.
Finally, we are impressed by the spirit of cooperation and dedication exhibited among county health officials, nonprofit health organizations, and the private health care sector. They work together to apply maximum available resources to the needs of low-income families in the county. This effort requires creativity, compromise, and sometimes handshake agreements outside of formal policy, and the emphasis is always on “the patient.” This spirit will be even more important in the future as the road to health care becomes steeper and more slippery. An aging population, the State’s current budget crisis, and demands for across-the-board service spending cuts all contribute to an environment of stress and uncertainty for health care resources.
Definitions
Categorical Health Programs: Programs that target defined classes of vulnerable people, specific health conditions, and diseases. These programs are mainly focused on poor individuals and families, the disabled and the aged, and can provide significant financial assistance to county governments by helping them pay the rising cost of health care for indigent people.
Central Coast Alliance for Health (Alliance): A non-profit health plan serving Santa Cruz and Monterey Counties and operated by a local public agency. The Alliance works to improve health care locally with a focus on access, prevention, cost savings and quality. Alliance members are eligible lower-income persons in specific aid categories (e.g., aged, disabled, single parent) and include almost all Medi-Cal beneficiaries in the region. In Santa Cruz County, the Alliance programs include Medi-Cal, Healthy Families and Healthy Kids. The Alliance currently has a staff of 150.
Coalition for Health Care Outreach (Coalition): A group of agencies and community organizations in Santa Cruz County whose goal is to be a main resource for low-income families dealing with health care issues.
Community Provider Plan (CPP): The CPP, located in all 58 California counties, is the health plan offered at a discount to subscribers participating in the Healthy Families Program. Each county reviews competing plans and select the best one as its CPP.
First 5 California (First 5): Also known as the California Children and Families Commission, First 5 California supports children from conception to age five by creating a comprehensive and integrated system of information and services to promote early childhood development and school readiness. It is funded by Proposition 10, an initiative approved by voters in November 1998, which added a 50 cent-per-pack tax on cigarettes and a comparable tax on other tobacco products. Proposition 10 generates approximately $590 million annually.
Healthy Families: A state and federally funded health plan for children who do not qualify for Medi-Cal. Healthy Families provides medical, dental and vision coverage to children from birth through 18 years of age, in families with incomes above the level for no-cost Medi-Cal and does not exceed 250 percent of the federal poverty level.
Healthy Kids: In 2004 the Healthy Kids program was established in Santa Cruz County. It is a locally developed and funded health plan for children who do not qualify for other state-sponsored health insurance (i.e., Medi-Cal or Healthy Families). The plan provides low cost health, dental, vision and mental health services for the children of families with incomes up to 300 percent of the federal poverty level.
Medi-Cal: California’s version of the federal Medicaid program, Medi-Cal is a state and federally funded health insurance program for low-income children, single parents, seniors and persons with disabilities.
No-Cost Medi-Cal: Sometimes called “free Medi-Cal,” it does not have a share-of-cost component so Medi-Cal pays the entire medical bill.
Share-of-Cost Medi-Cal: This program has no monthly insurance premium. However, when a beneficiary has medical expenses, a portion of the cost must be paid by the beneficiary; then Medi-Cal will pay the balance.
Medi-Cal Administrative Activities: A federal program with money reserved for promoting the enrollment of children and adults in Medi-Cal.
Background
Two principles upheld by the California Grand Jury system are consistency and follow-through. It is important that investigations, while unique in themselves, build upon findings and recommendations of past Grand Jury efforts and that there is some follow-up work done to ensure that the County responds to and implements past Grand Jury recommendations. Within the spirit of consistency and follow-through, the 2007-2008 Grand Jury decided to conduct a thorough review of the 2000-2001 Grand Jury report on health care services for low-income families in Santa Cruz County and investigate whether the recommendations contained in that report had been implemented.
As the 2000-2001 Grand Jury noted, County government is obligated under state law to provide medical care for indigent residents. The extent of this responsibility has never been set forth in precise terms by the legislature. Federal and state governments have enacted a number of categorical health programs that aid the County in meeting the health care needs of indigents.
Uninsured families tend to rely on hospital emergency rooms or public clinics for treatment. Because they cannot afford to pay for these visits, they also delay seeking medical help resulting in more serious illnesses requiring extensive care as well as more and longer hospital stays. The result is a significant financial burden on both health care providers and taxpayers who underwrite the care of uninsured families.
A categorical approach to a variety of health care needs has produced tangible benefits but also notable drawbacks;
· Eligibility requirements are confusing even to experienced health professionals.
· Lengthy and intrusive application procedures act as a disincentive to seek help, especially for some Hispanic families who are wary that any official inquiry might adversely affect their immigration status.
· Fragmentation of local services prevents a cohesive delivery system that is responsive to the needs of the entire family. Each family member may be eligible for important health services, but each service is delivered at a different time and location. Families have a difficult time coping with this patchwork delivery system.
These are the underlying issues the 2000-2001 Grand Jury investigated. Each of their recommendations listed below is followed by the result of this Grand Jury’s investigation.
Demonstration Site
2000-2001 Grand Jury Recommendation 1: The Board of Supervisors should take the necessary course of action to have the county designated as a demonstration site for the integrated provision of local health services subsidized by state and federal government for counties of similar characteristics.
County Response: The recommendation requires further analysis.
2007-2008 Grand Jury Finding
1. The County did apply to become a demonstration site, but there were ten sites funded and Santa Cruz County ranked eleventh on the final list of qualified counties.
Conclusion
1. The County made a sincere effort to qualify as a demonstration site.
Consolidation and Simplification
2000-2001 Grand Jury Recommendation 2: The Board of Supervisors should direct the Health Services Agency (HSA) to develop a plan for incremental consolidation and eligibility simplification of categorical health plans.
· This plan should be based on prepaid capitation payments and a local public commission should govern its operations.
· Eligibility requirements should be simplified and extended to a term of at least one year.
· Eligibility should be based on family income, rather than assets, and tied to federally designated poverty guidelines.
· The entire family, not individual members, should be designated as the beneficiary for health service coverage.
· The Central Coast Alliance for Health and its principles of practice should be used as a model for the administration of other categorical health programs.
· The Board of Supervisors should urge the state to engage an independent non- governmental entity with credentials in the healthcare field to monitor the demonstration and track its impacts on both program costs and clinical outcomes. The Medical Information Management System should facilitate this tracking.
County Response: This recommendation had not yet been implemented, but will be implemented in the future.
2007-2008 Grand Jury Findings
2. While the County has pursued a goal of consolidating categorical health plans and simplifying eligibility requirements, there is no published plan or public commission in place to oversee it.
3. Eligibility requirements for health plans have not been simplified in any significant way, but the County has structured resources to guide applicants through the maze of health services and health insurance programs that are offered by non-profits and various government agencies.
4. Santa Cruz County now uses One-e-App, a web-based system for connecting families with a range of publicly funded health and social service programs. Applicants, usually with the help of Certified Application Assistants or county eligibility workers, enter their personal information to learn about and apply for programs that best meet their family's needs. System administrators, supervisors, and case management staff, can run reports and determine eligibility.
5. Santa Cruz County Health Care Outreach Coalition expands access to health care coverage for uninsured county residents, promotes awareness of government- funded health insurance programs and conducts outreach to schools, community-based organizations, businesses, faith-based organizations, childcare providers, and the general community.
6. The Benefits Call Center was established in 2000 to provide an easily accessible source of information for Medi-Cal recipients and to ensure that recipients complete all program requirements to maintain their coverage.
7. There is no new program, or expansion of an existing program, to extend health care to entire families instead of just individual members. California’s Medicare system, Medi-Cal, is governed by federal rules because it is mainly funded by the federal government. Medi-Cal has not acted to extend health care coverage to low-income families.
8. In 2008, Medicare’s Hospital Insurance Trust Fund (HI) is scheduled to pay out more in hospital benefits and other expenditures than it receives in taxes and other dedicated revenues. Growing annual deficits are projected to exhaust HI reserves in 2019. In addition, the Medicare Supplementary Medical Insurance Trust Fund that pays for physician services and the prescription drug benefit will continue to require general revenue financing and charges on beneficiaries that grow substantially faster than the economy and beneficiary incomes over time.
9. Private health care providers, both physicians and dentists, have been recruited to treat patients who can’t afford to pay. They do this without remuneration as a community service.
10. In order to simplify access to categorical health programs, the 2000-2001 Grand Jury recommended using the Central Coast Alliance for Health as a model for administering them. Health Services Agency determined it would accomplish the same goal to make those programs part of the Alliance where possible.
11. Some Grand Jury recommendations hinged on the county
becoming a demonstration site for the integrated provision of local health
services subsidized by state and federal governments. This did not happen as
explained in Demonstration Site
Finding 1.
Conclusions
2. Since the most pressing concern today is from where the money will come to maintain Medicare and Medicaid services for those who qualify under today’s system, extending it to include low-income families is not being discussed.
3. Santa Cruz County public, non-profit, and for-profit medical resources have worked together to make health care more accessible to low-income families.
Commendation
1. The Human Services Department and the Health Services Agency are to be commended for ongoing focus on the delivery of adequate health care services to Santa Cruz County residents.
Health Insurance Coverage
2000-2001 Grand Jury Recommendation 3: The Healthy Families Program should include parents in its coverage. Premiums should be set at more affordable levels in order to accelerate enrollment of families without insurance. Coverage should be maintained during short periods of seasonal unemployment. The Central Coast Alliance for Health should approach local employers to continue premium payments for families during short periods of seasonal unemployment to keep insurance coverage from lapsing. It should continue to expand the participation of specialists in its programs.
County Response: This recommendation has been implemented.
2007-2008 Grand Jury Findings
12. The Healthy Families Program does not include parents in its coverage. Healthy Families insurance premiums vary depending on the health plan selected. Families receive a discounted premium if they select the local Community Provider Plan, which is the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The Alliance’s maximum monthly premium for a family with three or more children is $36 (or $108 per quarter).
13. Recent local funding contributions to the Healthy Kids program, which came primarily from Sutter Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children off the waiting list and into enrollment.
14. Seasonal unemployment only affects the eligibility of adults in a family receiving Medi-Cal. The Alliance reports that their Medi-Cal membership fluctuates by about five percent each year according to the growing season and migration of Medi-Cal recipients out of the area. Typically, a seasonal employee becomes eligible for Medi-Cal when the work season ends or slows down because the worker’s income decreases. When an individual’s work hours increase again, Medi-Cal eligibility could be lost due to the corresponding increase in income. Thus, an individual may qualify during periods of little work or unemployment but no longer qualify for Medi-Cal when working full-time.
15. Medi-Cal has no provision for continued eligibility if an adult no longer meets the criteria. However, children can maintain Medi-Cal eligibility for 12 months even if the adults in the family are terminated due to an increase in income or assets.
16. Although families pay no premiums for the Medi-Cal program, there are premiums associated with the Healthy Families and Healthy Kids programs. However, regardless of changes in family income, once a child is deemed eligible for Healthy Families or Healthy Kids, that child remains eligible for 12 months unless he or she becomes eligible for no-cost Medi-Cal, is covered by other health insurance, or turns 19. Children also lose Healthy Kids eligibility and coverage when they move out of Santa Cruz County.
17. In 2000, the Santa Cruz County population was 255,602. In 2007, the population increased slightly to an estimated 264,125 (3.3 percent). But the supply of health care specialists for Alliance programs has increased by almost 30 percent since that year. In 2000, the Alliance had an average of 499 specialists available to serve Santa Cruz County residents. As of March 2008, 697 specialists are available.
18. The Alliance collaborates with over 60 community coalitions and organizations to promote its programs, including the Santa Cruz County Human Services Department. It also promotes health care resources to the public at events, such as farmers’ markets, health fairs, community block parties, and other festivals. In addition, the Alliance publishes a provider bulletin in which providers are urged to encourage their Healthy Families and Healthy Kids patients to stay enrolled and thereby continue their health care coverage.
19. In March 2008, at California’s annual Medi-Cal Quality Conference, Central Coast Alliance for Health tied for first place with Health Plan of San Francisco, winning the Gold Award for the highest rate of preventive care services among all 39 Medi-Cal health plans in California. The Alliance also won a second place Silver Award for member satisfaction.
Conclusions
4. Because Healthy Families is a state and federally funded health plan, Santa Cruz County cannot change the eligibility requirements for the program.
5. The 2000-2001 report recommended, “Coverage should be maintained during short periods of seasonal unemployment.” But, in fact, qualifying seasonal workers are covered while unemployed. They risk losing coverage when employed because their income may exceed guidelines. That issue has not been addressed by Medi-Cal or any county agency.
6. A public/private partnership exists in the county to provide affordable access to health care for low-income individuals and families.
Recommendations
1. The Santa Cruz County Health Services Agency should continue to partner closely with the Central Coast Alliance for Health.
2. The Santa Cruz County Health Services Agency should continue to expand local outreach and enrollment resources for low-income persons in the county by continuing to partner with local agencies, both public and private.
3. The Santa Cruz County Health Services Agency should consider expanding contracts with the Alliance for other categorical health program administration, where and when appropriate.
4. If the Health Services Agency is unable to transfer other appropriate categorical health program administration to the Alliance, the agency should adopt the Alliance’s principles of practice for categorical health program administration.
Commendation
2. It is admirable and impressive that Central Coast Alliance for Health has been able to expand local coverage to improve low-income families’ access to health care at a time when statewide reform has failed to gain traction.
Increased Reimbursement Levels
2000-2001 Grand Jury Recommendation 4: In order to assure that appropriate care is provided at the least costly level, the outpatient services of local hospitals need to be reimbursed at a higher percent of reasonable costs. The same is true for on-call private physicians who provide care to indigent patients in need of admission to the hospital. The level of reimbursements to private health service providers must be set at a reasonable percent of costs to assure retention of physicians and hospitals participating in Medi-Cal and Healthy Families Program. Rates should be subject to annual negotiation.
County Response: This recommendation will not be implemented because it is not within the County’s purview.
2007-2008 Grand Jury Findings
20. Since Medi-Cal and Healthy Families reimbursement rates are set by state and federal government agencies, the County of Santa Cruz has no authority to revise them.
21. Congressman Sam Farr, the California Medical Association (CMA), and others have called the reimbursement fee schedules for county doctors inequitable and continue to work to require that the U.S. Department of Health and Human Services fix a system viewed as unfair to local qualified participants.
Conclusion
7. While low reimbursement rates for medical providers inhibit the delivery of adequate health care to Medi-Cal and Healthy Families beneficiaries, county residents must depend on state and federal entities to resolve the problem.
Coalition for Health Care Outreach
2000-2001 Grand Jury Recommendation 5: The Coalition for Health Care Outreach should be supported in the budget of the Health Services Agency upon expiration of the Packard Foundation grant.
County Response: This recommendation is being implemented.
2007-2008 Grand Jury Findings
22. In June of 2001 the Packard Foundation grant expired. In 2007-2008, funding for the Coalition for Health Care Outreach (Coalition) came from two sources, First 5 California (First 5) and Medi-Cal Administrative Activities.
23. The budget for fiscal year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive the additional $103,000 from Medi-Cal Administrative Activities.
24. The County works as a middleman for both sources of Coalition funding.
Medi-Cal Administrative Activities
25. During the month of September, the Coalition completes a “time survey” to establish the annual cost of outreach activities in excess of what First 5 already pays. The federal government agency Medi-Cal Administrative Activities is billed that excess cost. The turnaround for payment is generally about three years.
26. The County supports various organizations associated with the Coalition throughout the year and receives the money from Medi-Cal Administrative Activities. Many variables determine what work is being done and how it is being claimed. On average, the Coalition received approximately 75 percent of what they predicted in their budget from Medi-Cal Administrative Activities. The County then funds the remaining budget.
First 5 California
27. The State of California retains 20 percent of the money First 5 receives, and 80 percent is distributed to the 58 counties throughout California based on the number of children born in the county. Santa Cruz receives approximately $2,700,000 annually.
28. First 5 has three established goals: healthy children, children learning and ready for school, and healthy families. Allowing for local decision-making, the First 5 Santa Cruz County Commission determines how to distribute funds based on a three-year strategic plan and annual contracts. Money provided to the Coalition by First Five has been designated as outreach funds.
29. First 5 reimburses the County for payments made to community agencies for contracted services.
30. In the fall of 2008, First 5 will create a new three-year strategic plan. This may or may not result in continued funds for the Coalition for Health Care Outreach.
Conclusion
8. Since the Packard Foundation grant expired, the Coalition for Health Care Outreach has secured funds to continue successful operation in Santa Cruz County.
Recommendation
5. If First 5 no longer supports it, the Coalition for Health Care Outreach should be supported in the budget of the Health Services Agency.
Clinic Hours
2000-2001 Grand Jury Recommendation 6: Additional sessions in the evening and through the lunch hour would be a great advantage for family members who now must lose time at work to attend the clinics.
County Response: This recommendation requires further analysis.
2007-2008 Grand Jury Findings
31. Three community clinics were visited in 2000, Salud Para La Gente in Watsonville, Santa Cruz Women’s Health Center, and Dientes Community Dental Clinic in Santa Cruz. The current Grand Jury has confirmed the following hours with employees at each clinic. All three clinics are closed Sundays and specified holidays.
· Salud Para La Gente:
· Monday through Friday, 9:00 a.m. to 7:00 p.m.
· Saturday, 8:00 a.m. to 4:30 p.m.
· Santa Cruz Women’s Health Center:
· Monday, 8:30 a.m. to 5:00 p.m.
· Tuesdays and Thursdays, 8:20 a.m. to 8:00 p.m.
· Wednesday, 12:20 to 5:00 p.m.
· Friday, 8:20 a.m. to 5:00 p.m.
· Saturday, 8:00 a.m. to noon
· Dientes Community Dental Care:
· Monday though Thursday, 8:30 a.m. to 5:00 p.m. (closed 12:30 to 1:30 p.m.)
· Friday, 7:30 a.m. to noon, and 1:00 to 4:00 p.m. (closed noon to 1:00 p.m.)
· Saturday, 8:30 a.m. to 2:30 p.m.
32. Some discrepancies exist between the clinic hours posted on websites and the hours provided in email and telephone communication.
9. Clinic operations are no longer confined to daytime hours. The three clinics each offer some lunchtime and/or evening hours. All offer Saturday appointments as well.
10. The inconsistencies of the posted clinic hours confuse and possibly inconvenience patients.
Recommendation
6. The Health Services Agency should encourage community clinics to accurately communicate clinic hours to the public.
Dental Health Programs
2000-2001 Grand Jury Recommendation 7: Full-service dental health programs should be launched in county and community clinics.
County Response: This recommendation has been and will continue to be implemented through the county’s community partners.
Background
In reviewing current dental health programs offered to low-income families and individuals, the Grand Jury found that quality dental services are available, but not to everyone. Salud Para La Gente (Salud) and Dientes Community Dental Care (Dientes) are the only community-based organizations that provide dental care to low-income individuals and families. While some private dentists serve Medi-Cal patients, it is estimated that they serve only one percent of those who need it. Medicare does not cover seniors, so they must have private insurance or pay personally for any dental services.
2007-2008 Grand Jury Findings
33. Dientes Community Dental Care served almost 16,000 patients in fiscal year 2006-2007, including approximately 3,000 Medi-Cal patients, which is only about one-tenth of the 30,000 Santa Cruz residents on Medi-Cal.
34. With funds provided by a county grant, Dientes treats participants in the Healthy Families and Healthy Kids programs, people with AIDs, and the homeless. But patients have to wait three months to get an appointment.
35. In 2007 Dientes added two new dental chairs, which expanded its program by 25 percent as part of a five-year plan to increase the number of patients treated from the current 16,000 to 25,000 a year.
36. In 2003 Dientes was forced to eliminate an educational outreach program when the California Endowment Foundation ceased funding it.
37. Salud began a dental program in 2002 and provides services in two Watsonville locations and one in the City of Santa Cruz. As many as 25,000 dental patients are seen each year.
38. Salud secured a $320,000 grant, which will allow it to expand current services to county residents.
39. One source from the Santa Cruz County Health Services Agency estimates that only 40 percent of dental needs are met in the county.
40. Both agencies are concerned that proposed cuts in state and county funding will prohibit any expansion of services and even force reductions to current levels of service.
Conclusions
11. Services are limited by the lack of funding, and there are still unserved and under-served people in the county.
12. More dental care is offered to low-income individuals and families now than was offered when the 2000-2001 Grand Jury investigated, but there is still a significant part of the county population that is not being served.
13. Low-income families and individuals of Santa Cruz County are receiving excellent care from two quality agencies and several private dentists.
Recommendations
7. In light of anticipated cuts in state and county funding, the Grand Jury urges both the Board of Supervisors and agencies providing dental care for low-income residents to identify and pursue alternate sources of funding, such as grants and gifts.
8. The Grand Jury recommends that Dientes resume, as quickly as possible, the outreach program to children that was terminated in 2003.
9. The Grand Jury urges Dientes to continue with the five-year plan to expand services and secure the necessary funding to maintain this long-term program.
10. The Grand Jury recommends that Salud continue to identify and secure alternate sources of funding, such as grants and gifts.
Commendations
3. The Grand Jury commends both Dientes Community Dental Care and Salud Para La Gente for providing excellent dental care to low-income residents of Santa Cruz County.
4. Dientes and Salud are to be commended for combining Medicare, Medi-Cal, and county funding with grants and other resources to meet the dental care needs of a significant portion of low-income families and individuals.
5. Since the 2000-2001 Grand Jury report, dental care services available to low-income families and individuals have expanded significantly. Health Services Agency and the Board of Supervisors are to be commended for assisting with this expansion.
Expanded Health Insurance Coverage
2000-2001 Grand Jury Recommendation 8: The County should continue to collaborate with community health organizations, local employers and organized labor to expand the numbers of individuals and working families covered by health insurance which includes mental health and dental benefits.
County Response: This Recommendation has been and will continue to be implemented.
2007-2008 Grand Jury Findings
In 2000, the United Way Community Assessment Project estimated that:
41. Seventeen percent of county residents had no health insurance. That figure dropped to 11 percent in 2007, a decrease of 35 percent in uninsured individuals.
42. One-third of the county residents who could not access health care when they needed it attributed that problem to lack of insurance. The percentage dropped to 18.6 percent in 2007, a decrease of 44 percent.
43. Thirty percent of the county’s low-income families had no health insurance. That estimate dropped to 22 percent in 2007.
14. Despite decreasing resources, the County has significantly reduced the number of uninsured residents during the past seven years.
Mental Health Services
2000-2001 Grand Jury Recommendation 9: The total lack of primary mental health services needs to be addressed both in County and community clinics. An intensive program should be mounted to attract mental health professionals to the County with an emphasis on the recruitment of family-oriented therapists to provide services in clinics that serve low-income clients.
County Response: This recommendation is being implemented.
2007-2008 Grand Jury Findings
44. The Mental Health and Substance Abuse Services (Division), a division of the Santa Cruz County Health Services Agency, works with and through many groups to offer a wide range of mental health care services including emergency shelter, transitional housing, supported housing, dual diagnosis treatment, crisis intervention, case management, and peer support. Other services available to clients are assessment, counseling, medication support, and referrals. Spanish translation is offered, as is an Appeal Resolution Process for anyone who is denied assistance. The following is a partial list of these resources.
Adult residential treatment is offered at
· Transition House, 10 beds
· Paloma House, 12 beds
· Pioneer House, eight beds
· Opal Cliffs, 15 beds
· El Dorado Center, 16 beds
· Darwin House, 15 beds
· Front St., Inc., 11 beds
· River Street Shelter, 20 beds reserved for people referred by County Mental Health
Outpatient treatment and/or social rehabilitation are available at
· North County Mental Health Center
· South County Clinic
· Community Support Services
· Dominican Hospital Behavioral Health
· Pioneer House Dual Diagnosis Day Program
· Community Connection Academy
· Front Street Day Rehabilitation Program
Self help resources include
· Mental Health Client Action Network
· Mariposa Activity Center
· Community Connection Mental Health Resource Center and Career Services
· Community Support Services Community Organizers Program
Ongoing services for the protection of low-income mentally ill residents include
· Advocacy, Inc. (Patient Rights)
· Public Guardian’s Office
45. It is hard to retain staff; therefore, continual training programs are necessary. Many new employees come from the Cabrillo College Health Science/Community Health programs.
46. Various federal, state, county and private agencies fund mental health treatment in our county. Mental health has made effective use of these grants and programs. Some of these sources (known as funding streams) are designated for specific and limited uses. Clients often present with a variety of issues and staff sometimes has difficulty matching funds to the specific needs of the client. Services offered to individuals and families will be further restricted by potential state and county budget cuts in the coming year.
47. Training in cultural sensitivity is emphasized and employees are trained within their department as well as by outside resources.
48. Some families have difficulty acknowledging the existence of a mental health problem. This can be a cultural issue or a matter of pride. Successful mental health outreach and education programs have worked as a part of the network of general health services.
49. Access to services is difficult for South County residents because most service sites are located in Santa Cruz. Public transit offers only a few routes and limited hours of operation. The Division is attempting to expand county services and to create more partnerships with community agencies in South County.
50. The Division works with Senior Network Services but does not yet have an early intervention program for seniors.
51. Among the ongoing concerns of the Division is the ever-present worry of patients exhibiting unexpected antisocial behavior.
Conclusions
15. The County’s mental health program is active and in good hands and is continually adapting to the changing needs of the community.
16. The Division works well, has effective coordination with many nonprofit organizations in the county, and maintains a constant effort for structural improvement.
17. Financing mental health programs is a continual struggle. Clients sometimes have problems finding appropriate services because they do not meet the funding requirements. Mental health staff strive to find creative ways to match client needs in spite of restrictions placed on various funding sources.
18. The Division recognizes cultural issues in treating county mental health patients. This perspective is important to ensure the effective delivery of services because cultural issues may make that more difficult, such as when families feel embarrassed by a member with a mental illness and may not acknowledge it as a legitimate health problem.
19. Effective programs have been developed that recognize the importance of family relationships. Both children and adults are treated. Establishing more peer counseling is a priority.
20. A comprehensive approach is the most pressing need in the system. Along with counseling and medication, affordable housing, tenured living spaces, and job development are all necessary for proper treatment.
Recommendations
11. The Grand Jury recommends that the Health Services Agency continue to build the network of mental health services countywide.
12. Staff development, including improved training and new methods for reviewing program results, would increase the effectiveness of the Health Services Agency.
13. The Grand Jury recommends that the Board of Supervisors support coordination of the various funding streams by the Health Services Agency so that available funds can be used to match the diverse needs of the clients.
14. The Board of Supervisors should ensure adequate funding for patients’ employment services, which play an important part in mental health treatment.
15. It would be beneficial for the Health Services Agency to continue developing mental health outreach and education programs to provide even more community social support for recovering patients, so they can feel welcome in their communities. Support resources can include churches and neighborhood organizations.
Commendation
6. The County is to be commended for developing and supporting vibrant mental health programs managed by experienced and dedicated staffs. The programs are dynamic and flexible enough to keep up with the demands of clients and changing methods of treatment.
Clinic Reconfiguration
2000-2001 Grand Jury Recommendation 10: County clinics should be reconfigured to family-oriented primary and preventive care, backed by clinical specialties and case-managed group therapy for persons at high risk or suffering chronic and recurring illness. These measures will require the recruitment of full-time county physicians and allied practitioners.
County Response: This recommendation is being implemented.
2007-2008 Grand Jury Findings
52. In the County of Santa Cruz, “safety net clinics,” (i.e., county or nonprofit clinics), take patients that are uninsured regardless of their ability to pay.
53. Current public and non-profit clinics, as a whole, have not been reconfigured to family-oriented and preventative care, but rather each clinic has an area or multiple areas of concentration which are listed below.
Santa Cruz Clinics
Santa Cruz Women’s Health
· Primary Care for Women and Children
· Family Planning
· Health Benefits Advocacy
· Illness Prevention and Health Promotion
· Gynecology and Prenatal Care
· Pediatrics
· Acupuncture, Chiropractic, Naturopathy
Westside Health Center (Planned Parenthood)
· Primary Care Services
· Family Planning
· Health Benefits Advocacy
· Illness Prevention and Health Promotion
· Obstetrics and Gynecology
· Pediatrics
· Abortion Services
Emeline Clinic
· Primary Care Services
· Walk-in Immunizations
· Health Benefits Advocacy
· Pediatrics
· Child Health and Disability Prevention
· Orthopedics
· Family Planning
· Laboratory, Radiology, and Pharmacy
Coral Street Clinic
· Urgent Care and Primary Care
· Integrated Case Management
· Mental Health and Substance Abuse
· Health Benefits Advocacy
· Counseling
Beach Flats Clinic
· Primary Care Services
· Women’s Health
· Pediatrics
· Family Planning
· Dental Care
· HIV Testing
· Obstetrics and Gynecology
Dientes Community Dental Care
· Emergency Dental Care
· Full Range of Dental Services
· Oral Health Advocacy
Dominican Pediatric Clinic
· Pediatric Services
Elderday Adult Day Health (Salud Para La Gente)
· Adult Day Health
Watsonville Clinics
Salud Para La Gente
· Primary Care Services
· Family Planning
· Dental Care
· Eye Clinic / Optometry
· Health Prevention and Promotion
· Health Benefits Agency
· Pediatrics
· Obstetrics and Gynecology
Diabetes Health Center
· Diabetes Self-Management
· Medical Nutrition Therapy
· Group Classes
· Insulin Training
· Glucometer Training
Clinica del Valle Del Pajaro
· Primary Care Services
· Dental Care
· Family Planning
· Women’s Health
· Pediatrics
· Child Health and Disability Prevention
· Obstetrics and Gynecology
South County Clinic
· Primary Care Services
· Immunizations
· Health Benefits Advocacy
· Pediatrics
· Child Health and Disability Prevention
· HIV Prevention
· Laboratory
· Radiology
· Breast Cancer Early Detection Programs
· Family Planning
Clinic Mariposa (Planned Parenthood Mar Monte)
· Primary Care Services
· Family Planning
· Health Benefits Advocacy
· Pediatrics
· Obstetrics and Gynecology
· Illness Prevention and Health Promotion
Children’s Resource Center
· Pediatrics
· Child Health and Disability Prevention
· Dental Care
Green Valley Clinic
· Obstetrics and Gynecology
· Women’s Health
54. Santa Cruz Women’s Health and Planned Parenthood specialize in women’s health, family care, and reproductive health.
55. Specialists are available when necessary, usually through Sutter Maternity & Surgery Center, which provides some free services to the community.
56. The County of Santa Cruz currently employs 20 full-time doctors: five primary care physicians (including two pediatricians), and 15 psychiatrists, four of which are bilingual.
57. The recruitment of allied health practitioners and full-time county physicians is often a challenge.
58. The high cost of housing in Santa Cruz County makes recruiting primary care physicians difficult.
59. Psychiatry has only one vacant position, and nurse practitioner positions are filled through a “feeder program” from San Jose State University.
Conclusions
21. While all “safety net clinics” are not geared toward families, they are putting forth their best efforts to meet the various needs of the uninsured and Medi-Cal patients in Santa Cruz County.
22. Santa Cruz County needs to recruit more specialists and internists because of the increase in the number of elderly patients with complex health problems.
Commendation
7. The Grand Jury commends Sutter Maternity & Surgery Center for providing the services of medical specialists to those
in need.
Medical Staff Recruitment and Salaries
2000-2001 Grand Jury Recommendation 11: In the recruitment of health care professionals, salary surveys conducted in nearby agricultural counties are no longer pertinent to this County. In the next round of County salary negotiations, surveys should be conducted that use counties more comparable to the emerging characteristics of Santa Cruz County.
County Response: The County has utilized the nine-County comparison for over thirty years, and this long-term base of information is useful in evaluating salaries. The nine-County comparison is used as a guide along with other information such as the Consumer Price Index, turnover statistics, recruitment and retention rates, the relationship between positions within the County, changes in classifications, and operational changes. Other jurisdictions are also surveyed, as appropriate.
2007-2008 Grand Jury Findings
60. Currently Santa Cruz County uses eight nearby counties in salary surveys: Monterey, Santa Clara, Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to Santa Cruz than the nine counties formerly used in that they are not strictly agricultural and have living costs comparable to Santa Cruz.
61. Recruiting and retaining physicians and other medical professionals is uniquely difficult in Santa Cruz County because it is labeled by Medicare as a rural county. The Medicare reimbursement rate is the same as Butte, Imperial and other counties with a much lower cost of living.
62. The county health programs must compete with Dominican and Sutter for physicians and other medical professionals. Hospitals are in a unique position to pay higher salaries as their Medicare reimbursements are based on actual costs. A national Medicare study released in 2007 shows hospitals in Santa Cruz County have the highest labor costs in the country, which local health officials say means higher medical costs and insurance premiums for patients. This situation creates a difficult challenge when it comes to recruiting medical professionals.
63. Salaries and working conditions for physicians and other medical professionals employed by the County are negotiated with the respective unions.
Conclusions
23. The Health Services Agency is able to recruit adequate medical staff and negotiate appropriate wage and benefit packages under very difficult circumstances.
24. The County has found innovative ways to meet the medical needs of low-income residents through grants and creative staffing. Anticipated budget cuts threaten this tenuous balance, but the Grand Jury believes that the County is going to be able to continue to provide a basic level of staffing to meet the minimal needs of low-income residents.
Commendation
8. The Grand Jury commends the Health Services Agency for the innovative way it has succeeded in providing quality health care to county low-income residents despite financial limitations.
Recommendation
16. The Grand Jury urges the Health Services Agency to continue to seek grants and other alternative sources for funds to pay competitive salaries to health professionals.
Responses Required
Respondent |
Findings |
Recommendations |
Respond Within /Respond By |
|
County of Santa Cruz Board of Supervisors |
|
7,13, 14 |
60 days September 1, 2008 |
|
County of Santa Cruz Health Services Agency |
2, 57 |
1-6, 11-13, 15, 16 |
90 days October 1, 2008 |
Responses Requested
Respondent |
Findings |
Recommendations |
Respond Within /Respond By |
|
Dientes Community Dental Care |
34-36, 40 |
8,9 |
90 days October 1, 2008 |
|
Salud Para La Gente |
39, 40 |
10 |
90 days October 1, 2008 |
Sources
Internet
http://www.cbp.org/pdfs/2006/0612_bb_SCHIP.pdf
http://www.hsd.co.santa-cruz.ca.us/
http://www.californiahealthline.org
http://www.centralcallegal.org/medical/medical_soc.pdf
http://www.healthyfamlies.ca.gov
http://www.healthyfamilies.ca.gov/English/caa/pdfs/manual/06_MC.pdf
http://www.mrmib.ca.gov/mrmib/HFP/CPP_Desig_07-08.pdf
http://www.saludlagente.org/facilities.htm
United States Census Bureau, http://factfinder.census.gov
Interviews
Coalition for Health Care Outreach
Dientes Community Dental Care
First 5, Santa Cruz County
Salud Para La Gente
Santa Cruz County Health Services Agency
Sutter Health Santa Cruz
Newspaper Articles
Santa Cruz Sentinel articles:
“County hospital labor costs are nation's highest,” November 27, 2007
“Medicare
reimbursement for doctors continues to fall,” November 3, 2007
“Hunt for health care can be discouraging for Medicare patients,” March 29,
2007
Publications/Documents
California Budget Project: Budget Brief, December, 2006: SCHIP Reauthorization: Healthy Families Needs Sufficient Federal Funding. California Department of Finance, California County Profiles, Santa Cruz County.
Central Coast Alliance for Health, Alliance Fact Sheet.
Central Coast Alliance for Health, Annual Report to the Santa Cruz and Monterey County Boards of Supervisors, January 2006.
Central Coast Alliance for Health, “Creating Healthcare Solutions.”
Central Coast Alliance for Health Provider Bulletin, December 2006.
County of Santa Cruz, Human Resources Agency, Brochure of Services.
Healthy Families Program, Community Provider Plan Designation, 2007-08.
Medicare Board of Trustees, “2008 Annual Report.”
Santa Cruz County Grand Jury “Final Report 2000-2001”
United Way, Santa Cruz County Community Assessment Project, 2000 and 2007.
Telephone and Email Correspondence
Healthy Families, phone number for premium rate questions, 1-888-673-4469.
Coalition for Health Care Outreach