3 Santa Fe County Cemmunity Services Department Behavioral Health Strategic Plan "Leadership and Services? 2019-2024 ll ll THIS PAGE INTENTIONALLY LEFT BLANK Santa Fe County Behavioral Health Strategic Plan Santa Fe County Behavioral Health Strategic Plan July 2019 – June 2024 TABLE OF CONTENTS Section TABLE OF CONTENTS INTRODUCTION AND VISION LEADERSHIP AND SERVICES THE PLANNING PROCESS CURRENT EFFORTS Behavioral Health Crisis Center Accountable Health Community Community Behavioral Health Service Needs STRATEGIC GOAL I – LEADERSHIP The Core Leadership Team Resource Optimization and Revenue Enhancement Analysis, Evaluation, and Accountability Building a Foundation – System and Provider Alignment STRATEGIC GOAL II – SERVICES Peer Support Services Navigators A. Suicide Prevention B. Behavioral Health Services for Children, Youth, and Adolescents C. Behavioral Health Service Options for Adults D. Affordable Housing E. Workforce Development F. Advocacy and Community Education Efforts CONCLUSION STRATEGIC GOAL 1 – LEADERSHIP: PERFORMANCE OBJECTIVES STRATEGIC GOAL 2 – SERVICES: SUMMARY OF INDICATORS MASTER GRID – INDICATORS AND ACTION STEPS Priority Services Goal A: Suicide Prevention Priority Services Goal B: Behavioral Health Services for Children/Youth/Adolescents Priority Services Goal C: Behavioral Health Service Options for Adults Priority Services Goal C-1: Behavioral Health Crisis Response Capacity/Services Priority Services Goal D: Affordable Housing Priority Services Goal E: Workforce Development Priority Services Goal F: Advocacy and Community Education Santa Fe County Behavioral Health Strategic Plan Page 2 3 4 5 5 6 6 6 8 9 9 9 10 10 10 11 11 12 15 21 23 2 24 25 26 28 28 29 30 31 32 32 33 2 Santa Fe County Behavioral Health Strategic Plan July 2019 – June 2024 INTRODUCTION AND VISION The Santa Fe County Community Services Department (CSD) has engaged in a strategic planning process for the purpose of developing a Behavioral Health Strategic Plan for Santa Fe County. Behavioral health encompasses prevention, early intervention, treatment, engagement, rehabilitation, and recovery supports for individuals who experience mental illness and/or substance use disorders, especially those who experience or are at risk of experiencing serious disorders and their consequences. In 2017, the County engaged in a health services needs analysis in order to identify key gaps in existing services available to meet community needs. One recommendation of the report produced as a result of this analysis (Leadership and Alignment – Santa Fe County Community Services Department – Health Services Gap Analysis)1 is the development of a Behavioral Health Strategic Plan. In order to build on work already performed, not duplicate effort or recreate ground already covered, and move forward in a logical manner, this Plan builds upon the findings, themes, and recommendations of the Gap Analysis process and report. The Gap Analysis contains multiple themes and recommendations that provide the springboard for this Strategic Plan which sets a course of action to address challenges of more efficient access to and more effective delivery of behavioral health services. A primary focus of this Behavioral Health Strategic Plan is to address what the Gap Analysis determined was an overriding theme, “…the need for clear and effective leadership and alignment of resources and efforts…the County and community players need to agree on the priorities for action….” This Plan builds on the findings and recommendations of the Gap Analysis process and report as well as the input provided by key informants and groups during this planning process. The vision driving this Plan is for a cohesive community that:  Understands the importance of behavioral health in the life and health of individuals, families, and the community as a whole;  Implements outcome-oriented, evidence-based behavioral health initiatives;  Aligns its resources and advocates for additional resources to address the priority needs of its most at-risk members;  Focuses on prevention and early intervention to mitigate the adverse impacts of childhood trauma; and  Incorporates an individual and family-centered approach that provides efficient access to services at each step in the behavioral health service delivery continuum and supports an integrated transition from one step to the next. 1 See https://www.santafecountynm.gov/media/files/FinalReportGapAnalysis.pdf for the full Gap Analysis report. Santa Fe County Behavioral Health Strategic Plan 3 The vision of this Plan is expansive in that it includes the important role of government entities such as the Santa Fe County Community Services Department, City of Santa Fe, New Mexico State, and Tribal/Pueblo governments and it extends to the need for private and non-profit providers and funders to collaborate in new and increasingly effective ways. Governments cannot and should not attempt to lead in isolation. Although government entities are imbued with authority that can make a difference, they also experience challenges that can impede or slow meaningful progress. Additionally, when multiple bureaucracies have to interact, as is the case with furthering behavioral health services throughout Santa Fe County, if ineffectively directed, unintentional consequences, most notably immobilization or duplication of effort, can and will ensue. While Santa Fe County may be able to provide some funding to accomplish some aspects of this Plan, perhaps the most important role County government can play in this process is that of convener and coordinator. The role of convener connotes the capacity to bring people together, and to share in the responsibility and accountability for the steps taken forward collectively. The role of coordinator connotes assuring needs are identified, priorities are shared, responsibilities are assigned, activities are accomplished, and outcomes are assessed and reported. Together, these roles will create results for the community as a whole and for those who live in Santa Fe County. This Plan focuses on recommended actions toward strengthening the leadership function, the importance of which cannot be overemphasized. It is a central component of the path forward and can mitigate the wasted time and energy of those acting in separate organizational structures operating in limited confines. The development of a more functional system of leadership will also reduce the level of burden and pressure placed on any one or two entities and open the community to more opportunities to address the complex consequences of unaddressed or underaddressed behavioral health issues. Although valuable input was provided on a wide variety of behavioral health challenges facing the County, the input can be categorized into two primary components, with multifaceted aspects to each primary component. These two components are Leadership and Services, including advocacy efforts to increase resources and opportunities. Given the preponderance of input on these two primary components, these will comprise the two primary strategic goals and the focus of this plan. LEADERSHIP AND SERVICES Aspects of the leadership component of this Plan include prioritization, resource-targeting, decision-making, and accountability. From the Gap Analysis: “Overriding themes emerging from this gap analysis include the need for clear and effective leadership and alignment of resources and efforts…. Providers, along with government entities and advocates can work to collaborate effectively, maximize resources and advocate collectively…. Together, the County and Community players need to agree on the priorities for action. This need for leadership and alignment is the overriding theme….” The Santa Fe County Behavioral Health Strategic Plan 4 Gap Analysis further notes “[c]ollaborative efforts are significant, but are often experienced as unfocused with multiple activities drawing on limited provider capacities.” Aspects of the multi-faceted services component of this plan include prevention; early intervention; services for children and adolescents, adult treatment; and recovery supports. From the Gap Analysis: “Priority service needs are housing, behavioral health, and navigation of the existing service system… Cross-cutting needs include…prevention/early intervention, and support to address social determinants…” THE PLANNING PROCESS The process for the development of this Plan included a review of data and input provided for the behavioral health aspects of the Gap Analysis in addition to conducting 21 key informant interviews and four facilitated group sessions specific for this planning effort. A presentation of concepts for and feedback from the Santa Fe County Health Policy and Planning Commission also helped to inform this Plan. The individuals who participated in these processes were truly impressive for many reasons including their energy, “boots-on-the-ground” knowledge, and commitment to the community. Absent their thoughtfulness and honest assessment of the state of the County’s behavioral health needs and existing service array, this Plan would be a far less substantial enterprise. Absent their on-going support as well as that of a larger team of individuals throughout the community, this Plan will not be actionable or successful. This Plan is intended to support Santa Fe County in charting a course of action as well as outlining the parameters of successful steps along the way. The timeframe for this strategic plan is five years – from July 2019 through June 2024. As such, some of the initial action steps will be preliminary and later steps will build upon previous ones and lay a foundation for change over time. Actions already in progress will be a critical part of the foundation for the action steps in this Plan. This Plan will describe and seek to expand new initiatives that have recently been developed and implemented, such as the Accountable Health Community (AHC) initiative and initiatives that are currently being developed but not yet implemented, such as the Behavioral Health Crisis Center (BHCC). It is worthy of note that Santa Fe County and its community partners have, for many years, provided crucial funding for essential treatment services, such as funding for substance use disorder detox and treatment as well as funding for the Mobile Crisis Response Team. Absent these and other treatment options too lengthy to list here, the status of individuals in the community who experience behavioral health issues would be even more tenuous than it is today. CURRENT EFFORTS This Plan would be remiss if it failed to acknowledge the responsive work that has been done in the community for many years and it would be incomplete if it did not also provide a map and a framework from which the next set of steps can be taken. Santa Fe County Behavioral Health Strategic Plan 5 Behavioral Health Crisis Center – An important event and pivot point that will occur during this Plan’s timeframe is the initiation of operations at Santa Fe County’s Behavioral Health Crisis Center, planned to open in 2020. Although several challenges will need to be successfully navigated, including managing the impact of State regulations and licensing requirements, several obstacles have already been overcome, namely the location of the Center as well as the securing of both nonrecurring capital and recurring operational resources. Given some level of uncertainty, it is anticipated that the Center will open in 2020. The opening of this Center, the impetus for which can be traced back to Santa Fe County’s Behavioral Health Summit in May 2016,2 will be a key milestone in enhancing the opportunities for recovery for adults experiencing crises involving mental illness and/or substance use issues. Some of the recommendations contained in this Plan will help inform an assessment of services the Center will provide and functions the Center will perform for the Santa Fe County community. Other recommendations will point the way to addressing issues that are independent of the functioning of this Center, as the Center will address an important community need, but in no way be a “cure all” for the challenges that must be addressed in order for the community to meet the needs of those experiencing mental illness and/or substance use disorders. Accountable Health Community – Santa Fe County has recognized the role social determinants such as housing, income, transportation, food, utilities, and education play in the health of individuals and a community and in reducing health care costs. This recognition has resulted in a commitment by the County to support the development of an Accountable Health Community3 by funding navigators and other critical services for individuals with challenges addressing these social determinants in order to improve their health outcomes. This effort is reflected in this Plan as well since poverty, lack of housing, and inadequate transportation, utilities, and social supports are issues often experienced by persons with significant behavioral health needs. Community Behavioral Health Service Needs – In its most recent community health needs assessment and implementation plan, CHRISTUS St. Vincent Regional Medical Center identified behavioral health, including suicide prevention, as high needs for Santa Fe County. 4 The New Mexico Indicator Based Information System (NM-IBIS) recently released data on its age-adjusted deaths by suicide for the 2012-2016 timeframe. Deaths by suicide were 23.2 per 100,000 for Santa Fe County. This is higher (7.9 percent higher) than the State average of 21.5 percent and higher (71.85 percent higher) than the national average of 13.5. In 2016, suicide in New Mexico was the second leading cause of death for the 15-44 age group.5 From this data and 2 See https://www.santafecountynm.gov/media/files/ReportofMay19SFCoBHSummitFINAL7-7-16.pdf for the report from this summit. 3 See https://hbex.coveredca.com/stakeholders/plan-management/PDFs/CMS-Accountable-Communities-NEJM2016-January.pdf regarding AHC development by CMS in Medicaid and Medicare. For further information about Santa Fe County’s efforts, see https://www.santafecountynm.gov/community_services/hhsd/ahc 4 See https://www.christushealth.org/-/media/files/homepage/giving-back/chna/2017--2019-chna-christus-st-vincentapproved.ashx?la=en for the health needs assessment, and https://www.christushealth.org/-/media/files/chip/2017-2019-chip-christus-st-vincent-w-cover.ashx?la=en for the community health implementation plan. 5 See https://blogs.psychcentral.com/healing-together/2013/09/preventing-teen-suicidethe-importance-ofinformation-and-connection/ for information about FACTS, the aspects to watch for in youth suicide prevention. FACTS is an acronym for Feelings, Actions, Changes, Threats, Situations of Risk. Educating school personnel, parents, and students to watch for these things can help prevent suicide in young people. Santa Fe County Behavioral Health Strategic Plan 6 the public input for this Plan, it is clear that the community is in need of improved suicide prevention services. Similarly, the County currently experiences shortages in a number of needed community-based services. Only eight psychiatric inpatient beds for adults are available in Santa Fe County and none are available for adolescents. The closest additional inpatient or emergency room capacity for adults or adolescents is in Albuquerque or the State-operated facility for adults in Las Vegas, New Mexico. Similarly, no partial hospitalization services exist in the county for any age group and no intensive home-based treatment or multi-systemic therapy – evidence-based services for high-need youth – exists for children/youth. One assertive community treatment (ACT) team exists for adults with serious and persistent mental illness, but it is over-taxed and needs to expand to serve more individuals. The ACT model is an evidence-based approach that can help reduce costly and short-term inpatient care as well as reducing engagement with the criminal justice system and increasing housing stability in this population. One participant in this Plan’s input processes described ACT as a “psychiatric unit without walls.” The lack of alternatives for this adult population makes sufficient ACT capacity critical for Santa Fe County. Presbyterian Medical Services (PMS) currently operates the only ACT team in Santa Fe County. With increased understanding about the evidence-base behind preventive programs such as, universal home visitation,6 and first episode psychosis (FEP)7, and the lack or inadequacy of such programs in Santa Fe County, it is not surprising that the input for this planning process included recommendations about working with schools and other entities to increase prevention services for individuals at risk of behavioral health issues. 6 See https://www.rwjf.org/en/blog/2016/11/home-visits-make-them-universal.html for universal home visiting results; for New Mexico’s targeted home visiting program for at risk families, see https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/pdf/nm.pdf 7 See https://www.nimh.nih.gov/health/topics/schizophrenia/raise/fact-sheet-first-episode-psychosis.shtml Santa Fe County Behavioral Health Strategic Plan 7 Priority Strategic Goals STRATEGIC GOAL I – LEADERSHIP A. Establish a Core Leadership Team to implement the Behavioral Health Strategic Plan 1. Agree on behavioral health priorities and direct action steps to address these priorities. 2. Optimize limited community resources and partnerships to assure a more comprehensive array of behavioral health services. 3. Collaborate with other County systems, local foundations, hospitals, providers, and other local resources to repurpose and maximize use of existing or emerging local resources for priority service needs. 4. Identify common advocacy priorities and approaches to increase resources for programs and services. 5. Collaborate with other jurisdictions (including City, State and Federal Governments and Tribal/Pueblo governments) and national organizations on priority advocacy and funding efforts. The County is hearing a clear call for both an immediate and on-going evolution in the current leadership paradigm. It is also clear that there is no lack of passion or skill entailed by this feedback. There is a call for collective and collaborative leadership absent which the path forward cannot be appropriately paved. This involves providing leaders with the framework necessary to optimally utilize their leadership skills and positions of authority to agree on action steps to best serve the community’s behavioral health service needs. This Santa Fe County Behavioral Health Strategic Plan is the framework from which the Core Leadership Team will prioritize action and direct implementation. One point consistently made throughout this process is the emphasis on the quantity of meetings held and attended and a lack of tangible outcomes derived from these meetings. High level individuals engage consistently in high quality partnerships of benefit to at-risk individuals in the community. This is an invaluable asset absent which behavioral health outcomes would be far less favorable. However, these informal working relationships appear to perform in the vacuum of a more functional structure, a more formalized set of agreements, and a more directed process. One suggestion arising out of this process is the possible use of professional facilitation services from an individual or team experienced in addressing the array of complex community behavioral health needs; provider limitations and capacities; government bureaucracies; and management and leadership challenges. This facilitation process would help CSD establish and steer the core leadership team as it forms; develop working processes, agreements, and priorities; and assure effective and efficient leadership for behavioral health issues across the County. The Core Leadership Team Santa Fe County Behavioral Health Strategic Plan 8 A core leadership team is proposed to be created comprised of government officials, individuals with lived mental illness and/or substance use experience, family members/advocates connected with these individuals, representatives of community providers both large and small, and key community funders. This Core Team will work to reduce duplicative or ineffective time, effort, energy, and productivity associated with disparate entities being led by different people heading in different directions. Community- and County-wide decision-making authority vested in one cross-cutting central core team that works together to agree upon targeted priorities for limited resources would help to reduce bureaucratic entropy and create forward moving momentum. Several important ramifications will emerge in moving to a Core Leadership Team, primary of which is to produce more outcome-oriented alignment of providers and optimization of resources (human and financial). Based on the input received as part of this planning process, this lack of alignment and the resultant waste of resources is a major impediment to addressing behavioral health issues with which the community is confronted. A fearless assessment of existing meetings, priorities, and efforts to identify and address shared approaches to collaboration will be needed. Another interesting and creative idea from a provider group was to find a way to pool resources from various sources for the purpose of meeting the different needs of each person served on a case-by-case basis. This multi-disciplinary team approach to resource utilization and service delivery is endorsed by multiple providers for, among other reasons, its potential to mitigate the too few “warm” handoffs and the too many clients “falling through the cracks in the system.” Resource Optimization and Revenue Enhancement An initial charge for the Core Leadership Team in directing the implementation of elements of this Strategic Plan is a full financial accounting of the total budget (for all entities and from all funding sources) currently being directed toward behavioral health services. It is impossible to optimize and target resources absent a full accounting of both dedicated and available resources. The Team must also develop options to broaden the resource base through an array of revenue enhancement strategies. These options could include joint advocacy efforts with the New Mexico Legislature; presenting priority proposals to funding entities; and dedicating current staff to the consistent search for grant-funded opportunities. Analysis, Evaluation, and Accountability Another important component of the Core Leadership Team’s work would be the Team’s analytical arm. At the outset of this enterprise, a thorough analysis and accounting will be needed of the programs and funding that currently exist and, to the extent possible, to gather any data available to inform an assessment of service effectiveness. In the same way that New Mexico’s Legislative Finance Committee has a highly functioning program and performance evaluation unit, the Core Leadership Team may want to incorporate such a function. Theoretically, this work could be done by a cross-section of program, budget, and analytical staff that already exist in various entities throughout the County. This program and performance unit could help support an additional primary function of the Core Leadership Team – establishing priorities. Finding ways to optimize existing resources is Santa Fe County Behavioral Health Strategic Plan 9 as important as the search for new revenue sources to address the gaps in behavioral health services confronting the community. A sound process to prioritize the most pressing issues will need to be developed and it will need to be data driven and have a basis in the evidence of what works. Another important function will be the implementation of an accountability framework. The State (through the Accountability in Government Act of 1999) as well as the County and the City (Results Based Accountability) are experienced in the use of frameworks to support program assessment and evaluation, target key outcome measures, and emphasize continuous quality improvement. Building a Foundation – System and Provider Alignment A group of key informant providers were clear in their feedback when asked what programs or services should be prioritized, that “we are not ready to do that yet – this is premature”. Some preliminary processes need to be developed and put in place within a newly developed structure that has a stronger foundation and one that promotes overall system alignment. Community providers are clear that absent an iterative and deliberative process for prioritization led by a multi-faceted leadership team committed to sharing and focusing resources across entities with a strong analytical and accountability element, improving the behavioral health service delivery system will not be possible. This foundational work must occur as a preliminary step and only by doing so will future steps be made feasible. A critical first step is to effectuate agreements (such as Memoranda of Agreement and/or Memoranda of Understanding and/or Business Associate Agreements) between multiple entities to allow for essential sharing of client information and data without violating important confidentiality concerns. These agreements will require in-depth discussion (and debate), but also will ultimately build a necessary bridge of service providers for those in need of services. These agreements will clarify and formalize collaborative relationships many of which have, heretofore, been unclear and informal. These agreements will create a clear basis for information sharing to better serve the complex needs of the community’s most at-risk members through a series of multi-provider partnerships that will fill-in more of the gaps in a more aligned continuum of care. STRATEGIC GOAL II – SERVICES The categories of services needed cannot be considered in isolation from an aligned behavioral health delivery system. One key informant asserted that we do not really have a delivery system, but rather we have uncoordinated, scattered and disjointed services. The expanded use of navigators and peers will help to further the process of system and provider alignment. Peer Support Services One key element of navigation is the use of peers to provide these and other supportive services. Per the State Office of Peer Recovery and Engagement, the peer worker is an integral and highly valued member of the multi-disciplinary team. Whether adult, youth, or family peer, the peer specialist provides formalized peer support and practical assistance for individuals who are receiving services to help them regain control over their lives and unique recovery process. Through wisdom from their own lived experience, they inspire hope and belief that recovery is Santa Fe County Behavioral Health Strategic Plan 10 possible. Through a collaborative peer process, information sharing promotes choice, selfdetermination and opportunities for the fulfillment of socially valued roles and connection to their community. An international expert and one of the originators of the peer services approach recently provided training to County staff and key collaborators on the use of peer services, particularly in relation to the Behavioral Health Crisis Center. Although peer support services will be an important element of the Center, certified peer specialists can also contribute to the overall delivery and navigation of services community-wide. Navigators The County’s work during the last few years in developing an Accountable Health Community (AHC) has been praised, along with the use of “navigators” to connect residents to resources within an aligned and cohesive provider network that aims to address the unmet, non-medical social needs of individuals. The relationship between individuals served and these navigators is at the core of an AHC and this Plan. The navigators’ role is to help steer the individual through the system. Trained, skilled, and experienced navigators are a key element to assuring individuals gain access to the services they need and are able to transition from one service to another. Navigators will also help the County and the core leadership team understand where service gaps exist and where provider disconnects are resulting in unacceptable outcomes for service recipients and their families as well as for the service system itself. One action step in this Plan is to further solidify and expand the current AHC network that currently includes four Federally Qualified Health Centers and eight non-profit community service providers and programs. A primary component of the expansion of this initiative is the further extension of the navigators specifically for behavioral health services and populations. Service priorities for Santa Fe County’s efforts are described below. A. Suicide Prevention 1. Implement Zero Suicide and other suicide prevention initiative(s). 2. Establish a firearms storage and risk avoidance education program. Zero Suicide The Zero Suicide framework8 is defined by a system-wide, organizational commitment to safer suicide care represented by a shift away from fragmented suicide care to a more comprehensive approach. This approach, implemented through the use of a toolkit, is aimed at filling the gaps that those at risk of suicide often fall through with evidence-based tools, systematic practices, training and embedded workflows. Significant positive results have been experienced, such as the 75 percent reduction in suicide rate among Henry Ford Health Center health plan members,9 through implementation of this methodology. 8 See https://zerosuicide.sprc.org/ See https://www.henryford.com/news/2016/03/the-silent-epidemic-a-conference-on-suicide-opens-with-henryford-behavioral-health-services 9 Santa Fe County Behavioral Health Strategic Plan 11 Firearms Safety One aspect of this Strategic Plan is to bring focus to actions that can be taken to tackle what might be considered insurmountable problems. Tackling a problem such as gun violence can becoming overwhelming for those attempting to find solutions. This Plan also aims to bring focus to smaller more practical actions that can make a big difference and save lives. One such program is Project ChildSafe,10 an education program that promotes the safe storage of firearms in the home. The Program raises awareness on firearm safety by distributing gun locks and educational materials to gun owners. Since 2003, over 37 million firearm safety kits have been distributed free of charge to gun owners. Additionally, during the 10-year period 2006 through 2015, firearms accidents were reduced by nearly 24 percent. Given that almost half of deaths by suicide occur with firearms, an additional effort that might grow from this beginning is firearm lock-up education and/or advocacy for red flag laws, temporary restrictions for those identified as at risk of suicide or of causing harm to others.11 B. Behavioral Health Services for Children/Youth/Adolescents 1. Develop a strategic plan for children/adolescent behavioral health services to consider. a) Establishing navigator specialists for teens and their families; b) Developing a designated psychiatric program (including intensive home-based treatment, behavioral interventions and supports, multi-systemic therapy, and other evidence-based or innovative practices for children and youth with intensive behavioral health needs; c) Establishing capacity for medication assisted treatment (MAT) for youth. 2. Expand Teen Court. 3. Establish Youth Services Division within Santa Fe County’s Community Services Department. 4. Coordinate with school-based prevention/early intervention programming. 5. Consider utilizing existing or developing a universal screening tool for youth/families. 6. Implement a program to address adverse childhood experiences (ACEs). 7. Expand Home Visitation for at-risk youth/families. 8. Consider implementing Friendship Benches initiative for Native American youth/seniors. 9. Consider development of inpatient, partial hospitalization, or residential beds, if necessary, for adolescents. Behavioral Health Planning for Children/Youth/Adolescents Although aspects of this Plan touch upon the needs of children, youth and adolescents, Santa Fe County will work on a separate comprehensive behavioral health strategic plan to address 10 See http://www.projectchildsafe.org/. See https://www.usatoday.com/story/news/politics/2018/03/25/red-flag-laws-allow-temporary-restrictions-accessguns-gain-momentum-across-nation/454395002/ 11 Santa Fe County Behavioral Health Strategic Plan 12 prevention, early intervention, treatment, and supportive services for this population and their families. This planning process is expected to begin in 2019 and will include consideration of evidence-based intensive home-based treatment and behavioral health interventions for children and youth with intensive behavioral health needs, as well as exploring the need for and possibility of developing residential, partial hospitalization, and/or inpatient services for adolescents. Medication assisted treatment for youth experiencing substance use disorders will also be considered. Consistent with a theme presented throughout this Plan, consideration will be given to expanding the Accountable Health Community network of navigators to include specialized navigators to support intervention and services for children, youth and adolescents. Teen Court Enhancing programs for teens, such as those operated by and through Santa Fe County’s Community Services Department’s Teen Court Program, is an essential element of the direction forward. Teen Court is a first-time offenders program with alternative sentencing run for teens, by teens. In existence 25 years and a nationally recognized early prevention and restorative justice program for youth ages 12 through 17, this community-based intervention and diversion program provides an alternative to entry or further engagement in the criminal justice system. Youth Services Division Given the multiple needs facing the community’s youth, it makes sense to create an entity to oversee the expansion of current programs that are successful and to oversee the development and implementation of new initiatives to meet unaddressed and under-addressed behavioral health services. Creation of a specific unit within the County’s Community Services Department to focus on youth and youth-related services and needs is also included in the Santa Fe County Strategic Plan12 and will help address prevention and early intervention needs for youth and their families and will ultimately have an impact on adults as well. School-based Programming At the heart of the prevention aspect of services is the need to recognize children and youth that are at-risk at the earliest possible stage of development. Alignment with the evolution of programming at Santa Fe Public Schools (SFPS) is an important aspect of this partnership. The Santa Fe Public Schools have implemented or are in the process of implementing several initiatives focused on prevention. There is an enhanced focus on multiple levels of prevention that include a systems approach known as the Multi-Tiered System of Support (MTSS) and the youth-driven Student Wellness Action Teams (SWAT) that exist in middle schools and high schools. The development of teen health centers brings focus to issues impacting teen parents and provides an opportunity to recognize at-risk behaviors at an early intervention point. As the schools enhance their capacity to track behavior frequency (such as bullying behavior) and perform functional assessments on a wide range of issues impacting youth, a specific focus consistent with a primary goal of the County’s Health Action Plan will be targeted on reducing deaths by suicide and suicide attempts among youth. 12 See https://www.santafecountynm.gov/media/files/FinalSTRATEGICPlanADOPTED6-26-2018.pdf Santa Fe County Behavioral Health Strategic Plan 13 Universal Screening Among the priorities summarized in the report from the May 19, 2016 Northern New Mexico Four-County Behavioral Health Summit13 is to assure that universal screening for children, youth and their families occurs at critical junctures in children’s lives. In addition to the screening for Adverse Childhood Experiences (ACEs) universal screening for behavioral health needs of children and families should occur at ages 0 – 6 months, in kindergarten (around age 5) and in high school. A special emphasis for this screening would be placed on those most at-risk and include referral and provision of needed services identified through the screening process. Additionally, this information can be utilized to establish advocacy priorities for additional resources and services. Adverse Childhood Experiences (ACEs)14 Adverse Childhood Experiences are stressful or traumatic events including abuse and neglect. They may also include dysfunction in the home such as witnessing domestic violence or growing up with family members with untreated substance use disorders and/or mental illness. Research studies have shown that ACEs are a significant risk factor for substance use disorders and are strongly related to the development and prevalence of a wide range of health, behavioral, and social problems throughout a person’s lifespan. Implementation strategies include early identification; ACEs screening for at-risk youth and their families; data collection; trauma-informed education/approaches and resiliency-building practices; advocacy for legislation and/or funding; and work with community partners such as Resilience Leaders through their Safety and Success Communities ACEs Prevention Project.15 Research is showing that the adverse impact of childhood trauma is deeper and more prevalent than was previously thought. The trauma, if not effectively addressed, can not only negatively influence individuals through adulthood, but also can have multi-generational impacts. Data from a community health survey conducted in 2018, indicates that 78 percent of Santa Fe County residents have experienced at least one adverse childhood experience and 43 percent have experience three (3) or more.16 Home Visitation Home visitation programs support families expecting a child and/or with young children in promoting positive parenting practices for their young children, screening for risk, and referring families to appropriate community supports. The program promotes child well-being as well as prevent adverse childhood experiences. Home visiting is intended to be research-based, grounded in best practices, and linked to goals that include children that are mentally healthy, ready for school, and connected to community supports. According to the State’s report,17 the 13 See https://www.santafecountynm.gov/media/files/ReportofMay19SFCoBHSummitFINAL7-7-16.pdf for the report from this summit. 14 See https://www.cdc.gov/violenceprevention/acestudy/index.html 15 See https://www.course.rleaders.org/ 16 See https://SFPA 2019 community health survey-ACEs Report 17 See https://cyfd.org/docs/FY17_HV_Annual_Outcomes_Report.pdf Santa Fe County Behavioral Health Strategic Plan 14 State invested (State, Federal and TANF funds) $17.5 million in these programs in FY 2017 and served 4,587 families statewide. According to NM IBIS, of the 4,587 families served, only 304 families were served in Santa Fe County, 6.6% of the statewide families served. Given the efficacy of home visiting as a key early intervention option, additional resources and advocacy for home visitation for additional Santa Fe County families will yield additional positive results Friendship Benches The Friendship Benches program is an evidence-based talk therapy initiative that is rooted in indigenous concepts. This program engages seniors (particularly grandmothers) who are trained to provide services to youth in rural areas that may not have access to either any behavioral health providers or to behavioral health providers with a culturally sensitive perspective. Based on the feedback we received from Native American behavioral health service providers, this could be a program worthy of consideration. C. Behavioral Health Service Options for Adults 1. Complete development of the Behavioral Health Crisis Center (BHCC) incorporating a peer-based Living Room model. 2. Plan, build, fund and execute behavioral health crisis services in the underserved parts of Santa Fe County, including Edgewood. 3. Expand Mobile Crisis Response Team (MCRT) response capacity; develop protocols/working agreements for use of MCRT and BHCC to mitigate use of emergency rooms, law enforcement, and jail/detention. 4. Provide crisis response/intervention training for law enforcement; collaborate with the County court system. 5. Establish protocols and navigation for adults transitioning from jail. 6. Expand advocates/mentors for persons with behavioral health needs, especially in emergency rooms and post-stabilization. 7. Expand Program of Assertive Community Treatment (PACT) Team services and capacity for eligible adults with serious mental illness. 8. Expand use of Multi-Disciplinary Teams (MDTs) for high-need, high risk individuals and/or create Community Engagement Teams (CETs) using peers and clinical supporting personnel. 9. Consider expansion of needed inpatient services and/or creation of partial hospitalization or residential treatment program(s) for adults with significant mental health needs. 10. Work to assure Medication Assisted Treatment is available. 11. Develop First Episode Psychosis (FEP) program. 12. Create expanded Peer Drop-in/Recovery Center with additional supported employment/education services and other psychosocial skill-building opportunities (e.g., Clubhouse Model or similar). Behavioral Health Crisis Center Santa Fe County has provided both capital and operational funding for a Behavioral Health Crisis Center (BHCC). Santa Fe County has contracted with a primary provider, New Mexico Santa Fe County Behavioral Health Strategic Plan 15 Solutions, to design and operate BHCC services. Per the Health Services Gap Analysis, the nonresidential BHCC, anticipated to open in 2020, will include direct and co-located services with agreed upon protocols for client flow, medical clearance, and decision-making. Included in the array of services available at the BHCC will be training and support for caregivers and first responders about managing crisis situations and expanded treatment guardian and other capacity to seek or provide immediate stabilization and support for individuals experiencing a crisis. Services delivered through the BHCC and co-located providers will include:       A Living Room with peer supports; Mobile Crisis Response Team; Crisis triage, brief intervention, and recovery support; Navigation center with information and referral; Co-located intensive navigation services; and Residential enhanced social detoxification treatment and services. Mobile Crisis Response Teams Mobile Crisis Response Teams (MCRTs) are an essential component of the behavioral health services array. The team operates in coordination with law enforcement (some teams consist of both a clinician and a member of law enforcement specifically trained in crisis intervention) and Emergency Medical Services (EMS). MCRTs provide immediate response and stabilization for individuals experiencing a behavioral health crisis. Team members conduct immediate on-site assessment and counseling to de-escalate the situation and provide linkages to community-based behavioral health services. The goals of this service include helping to prevent the need for emergency department use, reduce deaths by suicide, and reduce the number of individuals with behavioral health issues arrested and detained in the County jail. MCRTs also help train and support law enforcement personnel in their interactions with individuals with behavioral health needs to assure safety for everyone involved in such crisis situations. Santa Fe currently has one MCRT. In its first year of service (2016), the team was dispatched 266 times and performed 421 follow-ups that included diverting 102 individuals from the CHRISTUS St. Vincent Hospital’s emergency department to community-based services. Given the success of the community’s MCRT, the County and its community partners should consider an expansion of this initiative as an aspect of enhancing its overall crisis response capacity. Law Enforcement Training and Court Collaboration A consistent theme throughout the key informant interviews and the Gap Analysis project was the need for training of and collaboration with law enforcement officers. A priority should be placed on working to assure all officers and deputies have the opportunity to participate in Crisis Intervention Team (CIT) training and City and County law enforcement entities are engaged in the development of protocols for the Behavioral Health Crisis Center and for efforts working on re-entry into the community after jail detention of individuals with behavioral health needs. Santa Fe County Behavioral Health Strategic Plan 16 Along with training of law enforcement, mechanisms for utilizing the justice/court system to support the engagement of individuals in need of treatment and services should be explored, including utilization of mental health or drug courts and assisted outpatient treatment (AOT). Reintegration from Jail/Incarceration A consistently noted gap in the system is the lack of transition protocols for those leaving an incarceration setting and preparing for community reintegration. Although the County Jail has added programming such as parenting groups, trauma informed care, substance abuse/addiction treatment, and life navigation and skill building classes, there is a lack of sufficient re-entry support. As part of Santa Fe County’s AHC project, re-entry specialists were funded and are currently engaged in addressing these re-entry issues. These efforts may need to be expanded. The Community Services Department and the County Detention Center (within the Department of Public Safety), along with community collaborators, will need to work to formalize protocols for those transitioning into the community and support these efforts with peer navigators. Emergency Rooms - Behavioral Health Peers/Mentors Recent data reveals that more than 4 million Americans will present to emergency departments each year with behavioral health complaints and hospitals are struggling to keep up with demand. Research indicates that approximately 80 percent of these situations can be successfully resolved within 24 hours.18 One key to effectively addressing these issues is a collaborative mentoring approach that centers on both the patient’s immediate needs while in the emergency department and subsequent post-crisis needs upon discharge. It is for this reason that this Plan includes the placement of peers/mentors in hospital emergency department(s) to support patients experiencing a behavioral health crisis by navigating subsequent treatment options and receiving follow-up services and supports quickly. Multi-Disciplinary Team/Assertive Community Treatment An effective approach for working with and supporting individuals with complex behavioral health issues is a multi-disciplinary team approach. The benefits include mitigating the “unmerry go round” for individuals experiencing multiple visits to multiple providers, the emergency room(s), and engagement(s) with the criminal justice system. Individuals that are high/frequent utilizers of behavioral health services not only produce a significant cost on the system, but also contribute to the frustrations and disappointments associated with unmet needs and poor outcomes. A multi-disciplinary and multi-provider intervention approach that focuses on common goals and collective actions taken toward shared beneficial outcomes was one of the primary recommendations from key informants and focus groups. Currently, only one Assertive Community Treatment (ACT) team operates in Santa Fe County utilizing a multi-disciplinary team approach to community-based treatment, rehabilitation, and supportive services for adults with serious and persistent mental illness (SPMI). This evidence-based approach has shown 18 See https://www.vituity.com/blog/addressing-one-of-today-s-fastest-growing-challenges-behavioral-health-inthe-emergency-department Santa Fe County Behavioral Health Strategic Plan 17 success in averting hospital admission, residential placement, and criminal justice intervention for those living with SPMI. This program should be assessed to assure fidelity to the evidencebase and then considered for expansion based on unmet community need. Community Engagement Teams Community Engagement Teams (CETs) are a recovery-focused approach to help individuals and their families cope with the effects of mental illness and substance use disorders in their homes and communities. Efforts include both pre- and post-crisis phases and avoiding unnecessary hospital emergency and/or inpatient treatment and engagement with the criminal justice system. CETs are designed as a short-term alternative to inpatient care and are designed for individuals facing challenges to living safely in the community and those at high risk of experiencing a crisis. The team often consists of three to five (3 – 5) members including a clinician, peer specialist, and case manager. Santa Fe County will explore the addition of CET(s) to augment BHCC and MCRT efforts already underway and being developed during the period of this Plan. Hospital Behavioral Health Services Santa Fe County currently has limited acute care psychiatric inpatient capacity for adults and no inpatient capacity for adolescents. Representatives from the Behavioral Health Division of CHRISTUS St. Vincent (CSV) Hospital indicated that changes on the horizon at CSV include an extension of the hospital’s emergency department to include eight (8) beds for those with cooccurring issues (staffed by psychiatric nurses and crisis triage personnel) as well as a 9-bed residential unit. Staff also identified the need for all levels of care and treatment for adolescents, including psychiatric inpatient beds, but noted CSV is not currently considering taking this on due to costs involved. The new Presbyterian Santa Fe Medical Center is not currently planning on any specialty psychiatric inpatient services for adults or adolescents although is planning general outpatient psychiatric services for those with insurance or other ability to pay. Both of these hospital systems will need to address psychiatric and addiction needs for all ages in their emergency departments where they are unable to refuse to provide basic stabilization services for those presenting with such needs. One or both of these hospital systems along with other community providers and Medicaid managed care organizations will need to be approached to determine the feasibility and possibility of developing partial hospitalization and/or additional inpatient or residential crisis stabilization services for adults or for youth as the State’s regulations change about licensing and payment for these services are changing. Partial hospitalization provides an intensive level of non-residential services similar to inpatient care but in a non-inpatient setting. This service can be of particular benefit for individuals with substantial clinical treatment needs but who can be safe going home at night. This program can serve the purpose of a structured level of support to avoid inpatient or residential care or after an inpatient stay for an individual with on-going but short-term intensive treatment needs. Needle/Syringe Exchange Program and Medication Assisted Treatment Santa Fe County Behavioral Health Strategic Plan 18 The public health benefits of needle exchange/syringe access are clear. Syringe access programs curb the spread of infectious diseases (such as HIV and Hepatitis C) and have been shown to reduce the likelihood that those who inject drugs develop other bacterial infections. Needle Syringe Programs (NSP) are a significant means of collecting used syringes to prevent infection of others who come in contact with such drug paraphernalia. Santa Fe County needs to find a way to provide support for such a program. Medication Assisted Treatment (MAT)19 is a critical and necessary treatment option for individuals in need of detoxification and/or on-going treatment for opioid and other substance use disorders. To the extent MAT is available and approved for any substance use, it should be available as determined best by the individual and/or their clinician. MAT includes methadone, naltrexone, buprenorphine, and any other medication approved by the Food and Drug Administration to assist in detoxification or recovery support from substance use disorders. Additional efforts to assure adequate numbers of clinicians are trained, willing, and have the required waivers to provide MAT and that MAT of all kinds is available for individuals served in the BHCC, in inpatient settings, in detoxification programs, in the County jail, and in all commercial and publicly-funded community service settings will be needed in Santa Fe County as part of this Strategic Plan. First Episode Psychosis Early psychosis, also known as first-episode psychosis (FEP)20 is more common than many realize. Often beginning when a person is in their late teens to mid-twenties, it is estimated 100,000 adolescents and young adults in the U.S. will experience FEP each year. Research supports a variety of treatments for FEP, in particular coordinated specialty care (CSC). FEP involves components such as individual/group therapy; family support and education; pharmacotherapy; supported employment/education; and case management. The results of FEP are positive in preventing future disability among youth and young adults experiencing such a first episode. Currently, the only FEP program funded in New Mexico is at the University of New Mexico. Santa Fe County will need to partner with UNM and community-based providers to assure this approach is available for Santa Fe County young people and their families. Peer Support/Drop-in Centers Based on input of those who utilize these services, the County needs to consider expanding The Life Link’s consumer drop-in center hours and/or create a separate drop-in center for social and service supports for persons who are homeless and have behavioral health issues, especially when the shelter is unavailable. Peer support/drop-in centers are peer-directed centers where individuals experiencing behavioral health issues develop their own programs to support and supplement mental health and addiction services, address issues such as social isolation, and engage in educational and other peer support activities. Clubhouse Psychosocial Rehabilitation Model 19 20 See https://www.samhsa.gov/medication-assisted-treatment See https://www.nimh.nih.gov/health/topics/schizophrenia/raise/fact-sheet-first-episode-psychosis.shtml Santa Fe County Behavioral Health Strategic Plan 19 This model is a strengths-based model that emphasizes teamwork and provides opportunities for members to contribute to the day-to-day operation of the clubhouse. The clubhouse provides socialization and belonging as well as support to gain and maintain a productive life in the community. Participants and staff work side-by-side as colleagues to operate the program which places an emphasis on participation in mainstream employment, educational opportunities, and community-based housing and has been shown to reduce hospitalization/institutionalization and involvement with the criminal justice system. Clubhouses21 tend to have both a supported education program component as well as an independent employment and supported employment program component. One key informant indicated that for individuals with serious mental illness, this is “real life skill building and it’s cheap.” The Life Link operates the only clubhouse model program in Santa Fe County. The County will need to consider how to increase this or other psychosocial rehabilitation programs for individuals with these needs. Supported Employment/Education Supported employment22 is an evidence-based service often combined with supported education that has shown success in finding and maintaining gainful employment and/or educational opportunities for individuals with disabling serious and persistent mental illness. Public input indicates Santa Fe County needs to expand its Peer Support Center capacity and work to include additional supported employment/education components. In conjunction with supported employment services, Santa Fe County could work with the Social Security Administration and its providers to increase access to the Ticket to Work and SelfSufficiency Program23 for individuals with behavioral health needs in Santa Fe County. This voluntary program, for individuals receiving Social Security disability benefits, is designed to support individuals in finding and maintaining good jobs. Program components include career counseling, job placement, and employment support services. Transportation and workplace accommodation assistance are also available program components. Another evidenced-based employment program is the Individual Placement and Support (IPS) program, a preferred type of supported employment service. A 2018 report by the Bazelon Center for Mental Health Law24 indicates that people with serious mental illness have among the lowest employment rates in the country. This report further indicates that the IPS approach “has been thoroughly analyzed and shown to result in substantially better employment results than other forms of vocational rehabilitation for persons with serious mental illness.” This program helps individuals secure and maintain employment in a manner that is coordinated and integrated with clinical treatment services. Work provides income, socialization, and meaning in people’s lives. Supported employment programs such as IPS and Ticket-to-Work present a fertile opportunity for individuals with disabilities related to behavioral health issues and also opportunities for the expansion of the network of navigators with a specialty in this area. 21 See http://clubhouse-intl.org/ See https://store.samhsa.gov/shin/content/SMA08-4365/BuildingYourProgram-SE.pdf 23 See https://choosework.ssa.gov/ 24 See http://www.bazelon.org/wp-content/uploads/2018/10/Supported-Employment-Report_Oct-2018.pdf 22 Santa Fe County Behavioral Health Strategic Plan 20 D. Affordable Housing According to the City of Santa Fe’s Housing Needs Assessment Report,25 in the decade between 2000 and 2010, purchasing power for low and middle-income earners has declined. That decade saw City rents increase by 65 percent while income remained flat (no growth). The report found that three thousand (3,000) renters earning less than 25 percent of Area Median Income are likely to be cost-burdened and not able to find affordable rental homes in Santa Fe. While this affects all income individuals (including needed healthcare workforce), an update of this report26 focusing on impediments to and access to affordable housing in 2016 indicates those disproportionally impacted by the affordable housing shortage are individuals with the lowest incomes and those in need of supportive services such as case management. The under-addressed service component raised most consistently was housing. In the same way the need for “a place” is giving rise to the development of Santa Fe County’s Behavioral Health Crisis Center, the need for “a place” for individuals and families in various stages of crisis and recovery must be similarly addressed by enhancing affordable and supportive housing capacity. Actions include the following: 1. Create navigation specialists for those in need of housing and housing supports. 2. Increase financial incentives and revenue dedicated for affordable housing projects, including construction, rental support, and move-in expenses 3. Support additional transitional housing and a summer shelter program for men. 4. Further County/City development and implementation strategy to support short-term and permanent housing options for adults in crisis or in recovery and consider: a) Advocating for use of the college campus on St. Michael’s Drive for low-income housing options; b) Providing short-term respite and post-crisis housing assistance. Housing Specialist Navigators This plan proposes that as part of the Accountable Health Community expansion, navigators will be recruited that are entirely focused on housing and supportive housing services. This Plan, as has been mentioned, places a premium on the further development of the navigator network formalized by the AHC initiative. Although not a “cure-all” to successfully address the myriad 25 See file:///C:/Users/Michael/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downlo ads/Housing_Needs_Assessment_Update_Santa_Fe_NM_MAR_19_2013%20(1).pdf 26 See file:///C:/Users/Michael/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downlo ads/DraftPlan_AL_4.29_%20(3).pdf Santa Fe County Behavioral Health Strategic Plan 21 of barriers adversely impacting the status of affordable housing in the community, enhancing the County’s expertise in this area is a meaningful step in the right direction. Increase Revenue for Affordable Housing Projects An array of financial/budgetary initiatives will need to be undertaken in order for the community to move forward in addressing the continuum of housing options requiring development. These include, but are not limited to increasing funding for the Housing Trust Fund; pursuing a multiprovider commitment to pooled resources for short-term housing and rental assistance; providing incentives (subsidies) for land purchase/construction of affordable housing; and expanding the community’s limited transitional housing/supportive services capacity. In fact, the Santa Fe Housing Coalition is looking to grow a Housing Trust Fund with approximately $4 million in revenue to $15 - $20 million. Exploring options to increase this Fund will be critical for this Plan’s success. County/City Prioritized Implementation Strategy Although a significant amount of groundwork has been covered and several plans have been produced, the need to arrive collaboratively on an implementation strategy that prioritizes initiatives in a manner that best addresses the community’s housing needs is critical. As some of this work is already underway through the work of the Santa Fe Housing Coalition, the Santa Fe County Housing Authority’s Five-Year Plan,27 and the City’s Affordable Housing Plan of 2016,28 the County and its partners will need to work together to build upon that work to address the housing needs of individuals with behavioral health needs and the behavioral health workforce. Santa Fe County’s Strategic Plan, released in June of 2018, includes a housing objective and associated strategies to bolster the Housing Trust Fund, to provide additional affordable housing units in the County, and to provide down payment assistance. The City of Santa Fe’s Mayor Webber has recently undertaken a taskforce to provide input and direction regarding addressing affordable housing issues within the City, an effort with which the County as well as a number of local providers will need to continue to collaborate. Santa Fe County Housing Authority’s five-year plan as well as the City of Santa Fe’s Affordable Housing Plan must be embraced and implemented. The Mayor’s Affordable Housing Taskforce has encouraged a cross-section of impactful players to bring their expertise to bear on these issues. Also of note is the work of the Santa Fe Housing Coalition, a public/private partnership that supports a Housing First Model. This model is a recovery-oriented, evidenced-based approach to reducing homelessness that revolves around efficiently moving people experiencing homelessness into independent and permanent housing and then providing additional supports and wraparound services. Input received in the development of this Plan regarding housing and residential treatment options for persons with behavioral health needs runs the gamut of short-term and transitional residential treatment capacity to increased shelter, respite, and post-crisis living arrangements, to 27 See https://www.santafecountynm.gov/userfiles/PHA_5-Year_and_Annual_Plan.pdf See file:///C:/Users/Michael/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downlo ads/DraftPlan_AL_4.29_%20(3).pdf 28 Santa Fe County Behavioral Health Strategic Plan 22 permanent affordable supportive housing. These issues are complex and, potentially, expensive options to explore as the Core Leadership Team and the BHCC emerge. Consideration for the development of housing on the St. Michael’s college campus (Santa Fe College of Art and Design) is supported by several key informants. The positive aspects of this possibility include the central location of the campus, access to city services, and existing living quarters (dormitories) that could provide elements of the housing continuum. Given the substantial influx of both recurring and nonrecurring General Fund revenue, development of this campus could be a point of advocacy with the Legislature and the Governor. However, scattered site housing throughout the County is critical to address the overall housing needs in Santa Fe County and may be a priority rather than concentrated low-income housing in one location within the City. Recommendations to address these issues are provided in the Gap Analysis report. Two of these recommendations specific for the behavioral health workforce and those with behavioral health needs include providing housing vouchers for practitioners with student loans working at nonprofit health and human services agencies; and advocating with the Human Services Department and the New Mexico Mortgage Finance Authority to collaborate to develop supportive and scattered site housing for persons with serious mental illness and with special needs, using a housing first model. These could be advocacy efforts undertaken by the Core Leadership Team to advance priorities identified through that Team’s collective efforts. The lack of affordable housing is also an issue impacting the community’s workforce. It is estimated that 65 percent of individuals that work in the City of Santa Fe do not live here29 largely due to housing affordability and availability issues. E. Workforce Development Workforce development was a consistently stated element of the feedback received during the information gathering process. Although addressing this issue is not listed as one of the primary priority goals in this Plan, the Core Leadership Team will need to consider workforce issues in order to make service improvements effective. Joint efforts to attract and support workforce or to advocate for workforce resources (including housing, rates/pay, and workforce supports) will be needed for this Plan to be successful. A first step in addressing this issue will be through the training and hiring of individuals as part of an expanded navigator and certified peer support network. Certainly, as the Core Leadership Team begins utilizing the framework this Plan provides, they may opt to consider additional steps that can be taken to identify, quantify, and address additional workforce issues. F. Advocacy and Community Education Efforts As important as the process of prioritizing initiatives and targeting existing resources toward addressing those initiative, is the process of determining advocacy priorities. One aspect of the 29 Per discussion with Director of Santa Fe County Housing Authority. Santa Fe County Behavioral Health Strategic Plan 23 rationale for creating a Core Leadership Team is for the purpose of collaborating in a more focused way in advocating, with clear, collective, and common messages, for the resources and flexibility necessary to better meet the community’s behavioral health challenges. This Team approach to focused advocacy (a common set of consistently messaged priorities) can be expressed in multiple forums including advocacy to the State legislature and the Governor relative to State funding, regulations, and plans as well as proposals to federal, regional, and local funders and overseers to provide the resources and contexts necessary for Santa Fe County to be successful in meeting its behavioral health needs. An additional aspect of this advocacy initiative involves educating and providing leadership training for family members and other advocates (one aspect of community education goals) on how to navigate the behavioral health system, how to train others to do the same, and how to connect with the community’s key decision makers to “plant the seeds” of resource enhancement. It takes the efforts of a focused group of organized advocates to combat the challenges of meeting the community’s behavioral health challenges including the misinformation and prejudice often associated with mental illness and substance use disorders. Community awareness and education initiatives jointly undertaken by committed collaborators will go a long way toward assuring needed resources and capacities are available to meet needs for prevention, treatment, and recovery supports for everyone in Santa Fe County. CONCLUSION The path forward for Santa Fe County involves a further engaged community-wide effort. The two primary goals of this strategic plan concern coordinated joint leadership and expanded services to meet community needs. Primary to improving the behavioral health service delivery system is to expand the service alignments that exist and to work with providers to align services that remain disjointed and unconnected. In order to effectuate these changes, a newly designed leadership team will need to be created to direct the building of a sound structure and usher in a new level of cooperation, optimization of resources, advocacy, and accountability. Prevention and recovery will be the outcome goals for early intervention, treatment, and rehabilitation/recovery support services. Expanded behavioral health services focusing on evidence-based proven approaches to achieve these outcomes will be the commitment of Santa Fe County and its government and private sector collaborators. This Plan continues and builds on actions already underway to build a better and healthier Santa Fe County. Santa Fe County Behavioral Health Strategic Plan 24 STRATEGIC GOAL I – LEADERSHIP: PERFORMANCE OBJECTIVES Actions Establish Core Community Leadership Team to implement Behavioral Health Strategic Plan Contract/Hire leadership/management facilitation/staffing services Produce an accounting of both dedicated and available BH budget resources Timeline 2019 Responsible SFC - CSD Initial Performance Objective Core Community Leadership Team kick-off; charter developed with agreed mission and first-year action steps. 2019 CSD/Core Community Leadership Team/Procurement Agreed upon scope of work, facilitator selected and contract executed. 2019 County/City/Provider Budget Staff Establish prioritization process for service development 2019 Facilitator and Leadership Team Target available resources to selected priorities 2019 Core Community Leadership Team Produce provider alignment/information and data sharing agreements Establish complex case focused facilitated multidisciplinary team provider meetings Develop common advocacy priorities, along with common messages and approaches 20192020 Core Community Leadership Team/Legal Staff Production of consolidated BH budget that accounts for all dollars from all funding sources dedicated to behavioral health services in Santa Fe County. Produce documented process for prioritization; select initial joint priorities; establish implementation plan for outcomeoriented, evidence-based initiatives with a focus on prevention and early intervention in mitigating childhood trauma. Align resources to documented priorities and establish priorities for revenue enhancement and advocacy. Agreements negotiated and executed. 20192020 Facilitator and Leadership Team Action steps and follow-up steps established for each responsible party and outcomes tracked from each meeting. 2019 for 2020 legislative session and beyond Facilitator and Leadership Team Develop options and written process for agreement on advocacy priorities, messages, action steps, and commitments to action Santa Fe County Behavioral Health Strategic Plan 25 STRATEGIC GOAL II – SERVICES: INDICATOR SUMMARY Priority Goal A Problem Suicide deaths Goal Reduce suicides Indicator(s) Rate of death due to suicide – Deaths per 100,000 (NM-IBIS) Rate of Adult Suicide Attempts (BRFSS) Percentage of youth (Grades 912) who have seriously considered suicide (NMYRRS/YRBSS) Percentage of middle school youth (grades 6 – 8) that have made a plan to kill themselves (NM-YRRS) B Lack of behavioral health services for children, youth, and adolescents Increase Behavioral Health Services for Children, Youth and Adolescents Percentage of youth (Grades 9 12) with persistent feelings of sadness and hopelessness (NMIBIS/NM-YRRS) Percentage of youth experiencing caring and supportive relationships with adults (NM-YRRS) C Limited service options and capacity for adults Increase service options for adults Number of families with newborns served through home visiting programs (CYFD Home Visiting Database) Percentage of adults (18 and older) experiencing frequent mental distress (NM-IBIS) Percentage of adults (18 and older) who reported current depression (NM-IBIS) Percentage of adults (18 and older) who experienced suicidal ideation in the past year (NMIBIS) Number of adults with serious mental illness and/or substance use disorders accessing services for behavioral health needs Santa Fe County Behavioral Health Strategic Plan 26 C-1 Limited crisis response capacity other than emergency room(s) and law enforcement/jail Expand Behavioral Health Crisis Response Capacity/Services. Number of individuals served by Mobile Crisis Response Number of individuals served through the Behavioral Health Crisis Center Percentage of discharges in which continuing care plan is transmitted to the next level of care provider Percentage of documented attempts to contact family or other supports Time (in minutes) from an individual entering the center to being seen by a provider D E F Lack of affordable housing Insufficient workforce to meet community behavioral health needs Limited success of advocacy efforts in support of behavioral health initiatives Enhance affordable housing capacity to decrease individuals with behavioral health issues experiencing homelessness or precarious housing. Additional revenue allocated to the Affordable Housing Trust Fund (City of Santa Fe Affordable Housing Plan of 2016) Collaborate funding from the City and County for “Housing Specialist Navigators”. Number of low-income and affordable housing units in Santa Fe County. Establish collaborative efforts to secure and support behavioral health workforce Enhance advocacy efforts Number of individuals placed in appropriate, safe and affordable housing. Wait time for appointments to see practitioners needed Reduced vacancies and turnover rate among behavioral health workforce Additional funding secured for priority behavioral health initiatives New legislation or amendments to existing legislation in support of behavioral health initiatives signed into law Santa Fe County Behavioral Health Strategic Plan 27 Santa Fe County Behavioral Health Strategic Plan MASTER GRID – INDICATORS/ACTION STEPS Priority Services Goal A: Suicide Prevention Indicators:     Rate of death due to suicide – Deaths per 100,000 (NM-IBIS). Rate of Adult Suicide Attempts (BRFSS). Percentage of youth (Grades 9-12) who have seriously considered suicide (NM-YRRS/YRBSS). Percentage of middle school youth (grades 6 – 8) that have made a plan to kill themselves (NM-YRRS). Communitywide Actions 1. Implement Zero-Suicide Prevention Program Expand SKY Center suicide prevention services 2. Educate public and health practitioners on firearm safety for individuals at risk of harm to self or others County Government Planned Actions Convene Community Partners Performance Measures for County Government Planned Actions Conduct a minimum of two meetings with community partners Establish Implementation Timeline Adoption of timeline for implementation Develop Training Schedule Training schedule developed and adopted Implement Program Zero-Suicide Program is initiated Work with SFPS on analysis of program performance Summary of outcomes produced Coordinate acquisition of firearm safety kits Firearm safety kits ordered Schedule training/education sessions Training schedule established Establish distribution process Kits distributed Identify priority education opportunities and develop materials Brochures and educational workshops distributed by community providers; red flag laws passed Santa Fe County Behavioral Health Strategic Plan 28 Priority Services Goal B: Behavioral Health Services for Children, Youth and Adolescents Indicators:    Percentage of youth (Grades 9 -12) with persistent feelings of sadness and hopelessness (NM-IBIS/NMYRRS). Percentage of youth experiencing caring and supportive relationships with adults (NM-YRRS). Number of families with newborns served through home visitation programs (CYFD Home Visiting Database). Communitywide Actions 1. Develop strategic plan with targeted actions specifically for youth County Government Planned Actions Fund development of strategic plan for youth Performance Measures for County Government Planned Actions Funding committed, scope of work developed, LOI/RFP distributed, agreement finalized for plan development YSD created and sufficient budget provided 2. Establish a Youth Services Division within Santa Fe County’s CSD 3. Coordinate with school-based prevention and early intervention programs 4. Consider utilizing current or developing a universal screening tool for kids/families 5. Initiate school-based ACEs screening and programming Increased funding provided for a Youth Services Division (YSD) Work with SFPS to assess current programs and identify options for expansion Work with providers in performing an environmental scan of screening tools currently being utilized Coordinate ACEs training Establish and formalize working strategy 6. Consider expanding home visitation program Work with State to increase number of families with newborns served Convene leaders of Native American Tribes/Pueblos to study feasibility of establishing this initiative Expand network of Accountable Health Community (AHC) navigators to include designated children, youth and teen navigator(s) Convene community partners Percent increase in number of Santa Fe County families served 7. Consider implementing the evidence-based Friendship Benches Program for Native American Youth and Seniors 8. Develop navigation programs for children and youth with intensive behavioral health needs 9. Consider development of inpatient, partial hospitalization, and/or residential treatment for adolescents Santa Fe County Behavioral Health Strategic Plan Scan and analysis performed ACEs training schedule established Friendship Benches Native American leadership group established Resources designated for specialized children, youth and teen navigator(s) Record of proposed community actions proposed 29 Priority Services Goal C: Behavioral Health Service Options for Adults Indicators:     Percentage of adults (18 and older) experiencing frequent mental distress (NM-IBIS). Percentage of adults (18 and older) who reported current depression (NM-IBIS). Percentage of adults (18 and older) who experienced suicidal ideation in the past year (NM-IBIS). Number of adults with serious mental illness and/or substance use disorders accessing services for behavioral health needs. Communitywide Actions County Government Planned Actions Assure a peer support program component is included in new/expanded programming Review training and certification options to ensure consistency Performance Measures for County Government Planned Actions Produce briefing (“white”) paper on benefits of peer services 2. Expand use of specialized navigators Expand AHC provider network to include specialized navigators Number of additional BH navigator positions funded 3. Enhance training for law enforcement; collaborate with courts Organize Crisis Intervention Team (CIT) training for County law enforcement officers Identify ways to utilize courts to engage individuals in treatment Training schedule established Establish and document transition protocols Documentation of protocols into agreement between County Detention Center and CSD Position established and placed 1. Expand peer support services 4. Reintegration of incarcerated individuals into the community 5. Establish enhanced support in emergency departments for more effective management of behavioral health situations 6. Expand Assertive Community Treatment (ACT) team capacity 7. Build multi-disciplinary team (MDT) capacity and/or community engagement teams (CET) 8. Consider expansion or development of inpatient, partial hospitalization, and/or residential treatment for adults 9. Expand capacity for and availability of Medication Assisted Treatment (MAT) Establish specialized BH advocate/mentor position as part of Accountable Health Community (AHC) network to be placed in Emergency Department(s) Work with provider(s) on plan to justify expansion of this program Presentation of training and certification options presented Programmatic approach and priority agreed upon with County judges Develop cost avoidance/benefit analysis Propose expansion of MDT capacity through “pooled” resources to newly formed core leadership team Work with Provider(s) on plan to develop or expand CETs Expand access and options through partial hospitalization Enlist provider commitment to a “pooled” resource approach Analyze settings and clinician capacity for providing MAT Develop options for MAT expansion Santa Fe County Behavioral Health Strategic Plan Develop cost avoidance/benefit analysis Research and recommend options 30 10. Implement First Episode Psychosis (FEP) program 11. Expand recovery supports and psychosocial rehabilitation capacity Convene meetings with relevant community partners (such as NAMI, UNM and SFPS) Conduct environmental statewide scan of psychosis treatment programming Research revenue/funding sources including federal funds Establish meeting schedule Work with partners in developing an implementation strategy Implementation strategy developed Provide or advocate for resources for expansion of local clubhouse model to include more supported education and supported employment components Commitment of and advocacy for funds Environmental scan completed Funding possibilities explored Priority Services Goal C-1: Behavioral Health Crisis Response Capacity/Services Indicators: Establish baseline indicators for the behavioral health crisis center such as:      Number of individuals served through MCRTs. Number of individuals served through the BHCC. Percentage of discharges in which continuing care plan is transmitted to the next level of care provider. Percentage of documented attempts to contact family or other supports. Time (in minutes) from an individual entering the center to being seen by a provider. Communitywide Actions County Government Planned Actions 1. Open Behavioral Health Crisis Center (BHCC) with multi-provider commitment to regular on-site availability Finalize programming and protocols w/ law enforcement, EMS, and community providers 2. Expand MCRT Capacity Performance Measures for County Government Planned Actions Programming and protocols in place Develop written agreements with providers of on-site navigation services Initiate operations at the Behavioral Health Crisis Center (BHCC) Agreements developed and signed Insure inclusion of peer-driven Living Room model Finalize building plan; engage peers in building design and in services approach and delivery Analysis completed Conduct cost/benefit analysis of MCRT expansion Establish budget need and justification for enhanced MCRT capacity Santa Fe County Behavioral Health Strategic Plan Center opened Budget with justification proposed 31 Priority Services Goal D: Affordable Housing Indicators:    Additional revenue allocated to the Affordable Housing Trust Fund (City of Santa Fe Affordable Housing Plan of 2016). Number of low-income and affordable housing units in Santa Fe County. Number of individuals placed in appropriate, safe and affordable housing. Communitywide Actions 1. Establish housing navigation specialist positions 2. Increase revenue/financial incentives land purchase and building of affordable housing projects Streamline County processes for affordable housing projects Increase funding for the Housing Trust Fund 3. Expand transitional housing and supportive services capacity Create summer shelter capacity for men 4. Further develop and implement County/City housing development strategy and priorities County Government Planned Actions Expand AHC navigation network to include housing specialists Performance Measures for County Government Planned Actions Position(s) established and filled Convene funders of housing initiatives Increase in dollars committed Combine Housing, growth management and Economic Development Departments/functions Provide one-time/nonrecurring influx of funding in support of Santa Fe Housing Coalition/Affordable Housing Taskforce initiatives Work with SF Housing Coalition/Affordable Housing Taskforce and providers on a shortterm transitional housing plan Work with adult shelter(s) to develop plan and budget as well as advocacy capacity Work with City to consider and prioritize affordable housing strategies/options especially for adults in crisis or in recovery Prepare reorganization plan Increase in dollars allocated Plan developed for housing with a range of 72 hours post-crisis or postincarceration to six (6) weeks, and move-in expense assistance County/City joint strategy and implementation plan produced Priority Services Goal E: Workforce Development Indicator:   Wait time for appointments to see practitioners needed. Reduce vacancies and turnover rate among behavioral health workforce. Communitywide Actions 1. Identify approach to workforce support, development, and advocacy County Government Planned Actions Core Leadership Team analysis of needs Santa Fe County Behavioral Health Strategic Plan Performance Measures for County Government Planned Actions Collaborative action steps identified and agreed to 32 Priority Services Goal F: Advocacy and Community Education Efforts Indicators:   Additional funding secured for priority behavioral health initiatives. New legislation or amendments to existing legislation in support of behavioral health initiatives signed into law. Communitywide Actions 1. Prioritize initiatives that will be the focus of advocacy efforts 2. Create consistent common messaging 3. Provide leadership training for family members of clients 4. Consider community training and education initiative County Government Planned Actions Convene advocates Performance Measures for County Government Planned Actions Priorities established Support the prioritization process Co-create agreed upon messages and messaging format Messages and messaging format(s) created Research and develop training options Training options explored and presented Research existing initiatives for evidence of success and cost Present viable initiative options and explore opportunities for nonrecurring sources of funding for this initiative Santa Fe County Behavioral Health Strategic Plan 33 THIS PAGE INTENTIONALLY LEFT BLANK Santa Fe County Behavioral Health Strategic Plan 34