CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill
No. 686

Introduced by Assembly Member Arambula

February 16, 2021

An act to add Part 5.5 (commencing with Section 5920) to Division 5 of the Welfare and Institutions Code, relating to mental health services.


LEGISLATIVE COUNSEL'S DIGEST


AB 686, as introduced, Arambula. California Community-Based Behavioral Health Outcomes and Accountability Review.
Existing law, the Bronzan-McCorquodale Act, contains provisions governing the operation and financing of community mental health services for persons with mental health disorders in every county through locally administered and locally controlled community mental health programs. Existing law requires the Director of State Hospitals to establish a Performance Outcome Committee, which is charged with developing measures of performance for evaluating client outcomes and cost effectiveness of mental health services provided pursuant to the act.
This bill would require the California Health and Human Services Agency to establish, by July 1, 2022, the California Community-Based Behavioral Health Outcomes and Accountability Review (CBBH-OAR) to facilitate a local accountability system that fosters continuous quality improvement in county behavioral health programs and in the collection and dissemination by the agency of best practices in service delivery. The bill would require the agency to convene a workgroup to establish a workplan by which the CBBH-OAR shall be conducted and to consult on various other components of the CBBH-OAR process.
This bill would require the CHHB-OAR to consist of performance indicators, a county behavioral health agency self-assessment process, and a county behavioral health system improvement plan. The bill would require the CBBH-OAR to be completed every 3 years. The bill would require the agency or its designee to receive, review, and certify all components of county-submitted CHHB-OARs and identify and promote the replication of best practices in community-based behavioral health service delivery. The bill would require a county to fulfill any components of its county behavioral health system improvement plan that it can do with existing resources, but is not required to fulfill any components of its system improvement plan that create new costs unless funds are appropriated for this purpose in the annual Budget Act. By creating new county duties, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Part 5.5 (commencing with Section 5920) is added to Division 5 of the Welfare and Institutions Code, to read:

PART 5.5. Evaluation of County Behavioral Health Programs

5920.
 (a) This section shall be known and may be cited as the Community-Based Behavioral Health Outcomes and Accountability Review Act of 2021.
(b) Pursuant to paragraph (12) of subdivision (d) of Section 5845 and consistent with Section 5610, the California Health and Human Services Agency shall establish, by July 1, 2022, the California Community-Based Behavioral Health Outcomes and Accountability Review (CBBH-OAR) to facilitate a local accountability system that fosters continuous quality improvement in county behavioral health programs and in the collection and dissemination by the agency, and the departments and other entities within the agency, of best practices in service delivery. The CBBH-OAR shall cover county behavioral health services provided to current and former clients, and shall include the programmatic elements that each county offers as part of its county behavioral health service array, as well as any local program components, and shall consist of performance indicators, a county behavioral health agency self-assessment process, and a county behavioral health system improvement plan. For purposes of this section, “behavioral services” shall include mental health and substance use disorder services provided by county behavioral health agencies and funded through county general funds, 1991 Realignment and 2011 Realignment funds, federal Substance Abuse and Mental Health Services Administration grants, Mental Health Services Act funds, and any other source of local, state, or federal funding dedicated to county mental health and substance use disorder services.
(c) (1) (A) By October 1, 2022, the agency shall convene a workgroup composed of representatives from county behavioral health agencies, legislative staff, behavioral health provider organizations, interested behavioral health advocacy and academic research organizations, current and former county behavioral health services recipients and their family members, organizations that represent county behavioral health agencies and county boards of supervisors, the California External Quality Review Organization, the State Department of Health Care Services, the State Department of Social Services, the State Department of Public Health, the California Behavioral Health Planning Council, the Mental Health Services Oversight and Accountability Commission, and any other state entities that the agency deems relevant. The workgroup members shall also include individuals with expertise related to outcomes and performance measures for substance abuse disorders and mental health and individuals with expertise in process and outcome measures that are community-defined, culturally centered, and consumer focused. The workgroup shall establish a workplan by which the CBBH-OAR shall be conducted, pursuant to the provisions described in this section, including a process for qualitative peer reviews of counties’ behavioral health services. The workgroup shall discuss potential costs for state and county participation.
(B) The agency shall report annually to the Subcommittee on Health and Human Services of the Senate Committee on Budget and Fiscal Review and the Subcommittee on Health and Human Services of the Assembly Committee on Budget during the budget process with an update on the schedule for development of and future changes to the CBBH-OAR.
(2) At a minimum, in establishing the work plan, the workgroup shall consider existing county behavioral health performance indicators being measured across various mandates, entitlements, and payer types, alternative, or additional and alternative process and outcome indicators to be measured, development of uniform elements of the county behavioral health agency self-assessment and the county behavioral health system improvement plans, timelines for implementation, recommendations for reducing the existing county behavioral health services data reporting burden in light of new requirements established by the act that added this section and the resulting CBBH-OAR, recommendations for financial incentives to counties for achievement on performance measures, an analysis of the county and state workload associated with implementation of the requirements of this section, and, as recommended as a result of the stakeholder consultation conducted pursuant to Section 14707.7, a standard statewide method for counties to collect race, ethnicity, language, sexual orientation, and gender identity data for behavioral health clients.
(d) The CBBH-OAR shall consist of the following three components: performance indicators, a county behavioral health agency self-assessment, and a county behavioral health system improvement plan.
(1) (A) The CBBH-OAR performance indicators shall be consistent with programmatic goals for community-based behavioral health delivery systems, as identified in Sections 5001, 5585.10, 5600, 5600.1, 5600.2, 5801, 5802, and 5851, and in Section 3 of Proposition 63 (2004), and shall include both process and outcome measures. These measures shall be established in order to provide baseline and ongoing information about how the state and counties are performing over time and to inform and guide each county behavioral health agency’s self-assessment and system improvement plan. These measures shall include performance indicators on addressing behavioral health disparities and promoting behavioral health equity.
(i) Process measures shall include measures of participant engagement, county behavioral health service delivery, and participation stratified by standardized socio-demographic characteristics and across payer types. Specific process measures shall be established by the agency, in consultation with the workgroup, and may include measures of engagement as shown by improvement in program participation, timeliness of service provision, rates of utilization of program components, referrals and utilization of services, and shall consider existing sources of these data.
(ii) Outcome measures shall include measures of appropriate community-based interventions for adults with severe mental illness, children and youth with serious emotional disturbance, individuals with substance use disorders, and those at risk of these conditions or at the early onset of a behavioral health condition, and may include other indicators of recovery and well-being, including, but not limited to, those that are culturally centered, community defined, and consumer focused, as determined by the agency, in consultation with the workgroup. In developing recommendations for outcome measures, consideration shall be given to cross-system outcome indicators related to well-being, including, but not limited to, other Medi-Cal delivery systems, housing status, education, employment, justice involvement, and any quantifiable disparities.
(B) Performance indicator data available in existing county data systems shall be collected by counties and provided to the agency, and performance indicator data available in existing state department data systems shall be collected by the agency or its designee and provided to the counties. This data shall be reported in a manner and on a schedule to be determined by the agency, in consultation with the workgroup, but no less frequently than semiannually.
(C) (i) During the first three-year CBBH-OAR cycle, performance indicator data, as reported by each county, shall be used to establish both county and statewide baselines for each of the process measures. After the first review cycle, the agency shall, in consultation with the workgroup, establish standard target thresholds for each of the process measures established by the workgroup with a specific focus on reducing behavioral health disparities in underserved populations.
(ii) The agency, in consultation with the workgroup, shall develop a process for resolving any disputes regarding the establishment of standard process thresholds pursuant to clause (i).
(D) For subsequent reviews, and based upon availability of additional data from enhancements to any appropriate state data collection system or through interagency data-sharing agreements, the workgroup shall convene, as necessary, to consider whether to establish additional performance indicators that support the programmatic goals for the community-based behavioral health delivery system. Any additional performance indicators established shall also be subject to the process described in subparagraph (C) and include consideration of when data on the additional performance indicators would be available for reporting, if not already available.
(E) If, during subsequent reviews, there is sufficient reason to establish statewide performance standards for one or more outcome measures, the agency may, in consultation with the workgroup, establish those standards for each of the agreed-upon outcome measures. In making a determination as to whether there is sufficient reason to establish statewide performance standards for any outcome measure, the agency shall consider whether all counties could reasonably be expected to meet those standards given local variability.
(2) (A) The county behavioral health agency self-assessment component of the CBBH-OAR, as established by the workgroup, shall require the county behavioral health agencies to assess their performance on the established process and outcome measures that comprise the performance indicators, identify the strengths and weaknesses in their current practice and resource deployment, identify and describe how local operational decisions and systemic factors affect program outcomes, and consider areas of focus that may be included in the county behavioral health system improvement plan, as described in paragraph (3). The county behavioral health agency self-assessment process shall be designed to identify areas of best practices for replication and for system improvement at the county level, and shall guide the development of the county behavioral health system improvement plan, as described in paragraph (3).
(B) (i) The county behavioral health agency self-assessment process shall be completed every three years by the county in consultation and collaboration with local stakeholders and submitted to the agency or its designee.
(ii) Local stakeholders shall include county behavioral health administrators, supervisors, and providers; current and former county behavioral health clients; family members of county behavioral health clients; county behavioral health agency partners; and other community-based organizations recognized as trustworthy and culturally competent. Additional specific county behavioral health agency partners shall be determined by the county and may include, but are not limited to, the local Medi-Cal managed care plans, local office of the public guardian, the county probation department, the county welfare agency, the local housing continuum of care, community-based service providers, and organizations that represent behavioral health recipients.
(3) (A) (i) The county behavioral health system improvement plan shall consist of uniform elements to be developed by the workgroup. It shall, at a minimum, describe how the county will improve its behavioral health program performance in strategic focus areas based upon information learned through the county behavioral health agency self-assessment process and with a particular focus on reducing behavioral health disparities in underserved populations. The county behavioral health system improvement plan shall be approved in public session by the county’s board of supervisors or, as applicable, chief elected official, and submitted to the agency or its designee.
(ii) The county behavioral health system improvement plan shall be completed every three years by the county, approved in public session by the county’s board of supervisors or, as applicable, chief elected official, and be submitted to the agency or its designee.
(B) The county behavioral health system improvement plan shall include a peer county behavioral health services review element, the purpose of which shall be to provide additional insight and technical assistance by peer counties for each county.
(C) Strategic focus areas for the county behavioral health system improvement plan shall be determined by the county, informed by the county behavioral health agency self-assessment process, as described in paragraph (2), with targets for improvement based upon what is learned in the county behavioral health agency self-assessment process.
(D) The county behavioral health agency shall complete an annual progress report on the status of its system improvement plan and shall submit these reports to the agency or its designee. The agency, in consultation with the workgroup, shall develop uniform elements of the progress report.
(e) (1) The agency or its designee shall receive, review, and, based on its determination of the county behavioral health system improvement plan meeting the required elements identified in subparagraph (A) of paragraph (3) of subdivision (d), certify as complete all county-submitted performance indicator data, county behavioral health agency self-assessments, county behavioral health system improvement plans, and annual progress reports, and shall identify and promote the replication of best practices in community-based behavioral health service delivery to achieve the established process and outcome measures.
(2) The agency or its designee shall monitor, on an ongoing basis, county performance on the measures developed pursuant to subdivision (d).
(3) The agency or its designee shall make data collected pursuant to this section publicly available on its internet website.
(4) The agency shall, on an annual basis, submit a report to the Legislature that summarizes county performance on the established process and outcome measures during the reporting period, analyzes county performance trends over time, and makes findings and recommendations for common county behavioral health improvements identified in the county behavioral health agency self-assessments and county behavioral health system improvement plans, including information on common statutory, regulatory, contractual, or fiscal barriers identified as inhibiting system improvements and any recommendations to overcome those barriers.
(5) (A) The agency or its designee shall facilitate the provision of, and provide as appropriate, technical assistance to county behavioral health agencies as part of the peer review that supports the county’s selected areas for improvement as described in its system improvement plan.
(B) If, in the course of its review of county behavioral health system improvement plans and annual updates, or, in the course of its review of regularly submitted performance indicator data, the agency or its designee determines that a county is consistently failing to make progress toward its strategic focus areas for improvement or is consistently failing to meet the process measure standard target thresholds established pursuant to subparagraph (C) of paragraph (1) of subdivision (d), the agency or its designee shall engage the county in a process of targeted technical assistance and support to address and resolve the identified shortcomings. If, after the assistance is provided, the county continues in its failure to meet its goals or performance thresholds, the agency or its designee may engage in corrective action with the county.
(f) A county shall execute and fulfill components of its county behavioral health system improvement plan that can be accomplished with existing resources.
(g) A county shall not be required to execute and fulfill any components of its behavioral health system improvement plan that creates new county costs, unless funding for those costs are appropriated in the annual Budget Act.

SEC. 2.

 If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.