Important note: The following recommendation was approved by the Board of Supervisors on July 23, 2013. For updates on efforts to divert adults from psychiatric emergency services, emergency rooms and jail, visit our Performance Dashboard.

To:             Honorable Board of Supervisors

From:         John L. Maltbie, County Manager

Subject:     Measure A Report Back: Mental Health System of Care for Adults


Direct staff to budget $2,698,794 in the FY 2013-14 budget and $1,397,588 in the FY 2014-15 budget to support collaboration between County services and provide alternatives to incarceration for adults with mental illness and/or substance use problems


Over the past year, the Health System has embarked on a series of discussions with stakeholders to respond to the plight of families struggling with a mentally ill relative in crisis. While there are resources for people in crisis, it can be very difficult for a family member to get their loved one into mental health treatment until and unless the relative so deteriorates that the police or an ambulance must be called.

Recognizing the dilemma this creates for family members, last year Health System staff members worked with NAMI-SMC family member representatives, the Sheriff’s Office, Probation, local police, the District Attorney, and the Private Defender to develop recommendations to address this issue. The plan is outlined in the paper distributed to the Board of Supervisors dated February 5, 2013, Fine-tuning SMC Alternatives to Incarceration for People with Mental Illness and/or Substance Use Problems: Consensus Recommendations for Strategies.

In response to the Board’s direction, and with additional input from stakeholders, the Health System has moved forward already on one of the recommendations, the creation of an outreach team to families whose relatives’ mental state is deteriorating significantly. This team was funded with Mental Health Service Act dollars.


The Health System is requesting funding from Measure A to implement three additional recommendations identified in the multi-stakeholder discussions completed last year related to mental illness response:

•    Creation of a Mental Health Respite Center;

•    Expansion of SMART; and

•    Early Review of Mentally Ill People in Jail for Alternative Dispositions

Creation of a Mental Health Respite Center

As noted above, the Health System has already implemented a pre-crisis outreach team for families. Behavioral Health and Recovery Services worked with NAMI-SMC and Mateo Lodge to develop the Family Assertive Support Team (FAST) to respond to families who are concerned about a relative whose mental health condition is deteriorating. The team will respond to requests from family members and police to assess a client or potential client in the field instead of requiring the individual to be brought to the team.

For many individuals served by FAST, it is anticipated the need for a place to take some people to de-escalate the situation and give respite to the family. Police officers also have asked for a program for people with mental illness that police can use in lieu of taking them to psychiatric emergency services or jail. Thus, it is recommended that Measure A funds be used to create a Mental Health Respite Center through contracted services where people with a mental illness that is not an immediate danger to themselves or others can stay for a short period of time to stabilize and enter long-term treatment . A ten bed facility could serve 365 adults a year.

In addition to requesting Measure A support for the acquisition and operating costs of the Mental Health Respite Center, where there is opportunity the Health System will seek funding available via SB 82 that appropriates money to expand the capacity of counties to respond to persons experiencing a mental health crisis. The state has allocated $142.5 million state general fund appropriation for facility acquisition and $54 million in ongoing funds for staffing.

Expansion of SMART

Secondly, it is recommended that Measure A funds be allocated to expand the San Mateo County Mental Health Assessment and Referral Team (SMART) contract. In response to law enforcement requests, SMART provides a trained paramedic response and diversion to other appropriate resources when individuals are experiencing behavioral health emergencies.       In the six years the program has been operating, serving nearly 5,000 people, fewer than 9% have been served more than once, confirming that the program has a broad reach. Nearly half of the clients present with symptoms of depression and anxiety. The largest age groups served are ages 15-24 and 45-54. At least 18% of SMART clients either are not transported after medical clearance, evaluation and intervention in the field, or they are transported to an appropriate service/housing provider.

Unfortunately, right now SMART only responds to 47% of calls due to capacity limitations. Expansion of the SMART contract from the current 12 hour a day, 7 day a week schedule to 2 overlapping, 12 hour a day, 7 day a week teams would increase the percentage of behavioral health calls responded to by SMART from 47% to 90%. If the mental health respite center is also funded through Measure A, the proportion of clients diverted will increase, because the SMART paramedics will rely on it as a valuable “safe” alternative to psychiatric emergency services and jail.

Early Review of Mentally Ill People in Jail for Alternative Dispositions

Thirdly, families complain that there is no help for those who fall through the cracks of the mental health safety net and end up in jail. The Health System and our criminal justice partners have implemented a number of successful early intervention programs to reduce incarceration of people with serious mental illness. Still, 35% of the Correctional Behavioral Health caseload in the jail is comprised of people with some history in local treatment services, and on average every day one person is admitted to jail who has history in local BHRS treatment services. While most of these people (79%) are discharged within 6 days, a significant number of mentally ill people with relatively minor charges are held in jail for months while their competence to stand trial on these minor charges is determined. Sometimes they are incarcerated for periods longer than their sentence on the misdemeanor charge would have been.

After reviewing cases with local police, the District Attorney, Private Defender,  Probation, and the Sheriff, the Health System believes there are some mentally ill  people with nonviolent, low level misdemeanor charges where a disposition would occur more quickly and public safety would be preserved if information about the client’s community treatment providers, support system and service plan were available early  on to the court (with client consent).  Provision of this information has the potential to substantially improve the follow up for court appearances and other requirements for clients who are linked to case management, housing, medication support, or conservatorship, and their support system is informed of the behavioral issues that led  to the client’s arrest.

This proposal would utilize Measure A funds to create a pilot program to test an organized system for reviewing the cases of seriously mentally ill people upon  admission to jail and providing information to the court before disposition decisions have to be made. The goal during the two year pilot period would be to reduce the mentally   ill population of the jail by linking individuals to committed community supervision and support. This would require an unclassified Correctional Behavioral Health staff person inside the jail to work with an unclassified BHRS staff “navigator” outside the jail to research each case, discuss cases with community providers, and put together the necessary information and service commitments such that a package could be provided to Probation Court Services within one business day. This structure would also  increase understanding of the mentally ill people admitted to jail who are not previously known to BHRS so that the division can improve its strategies for diverting them away from activities that lead to arrest.

Peformance Measures:


FY 2013-14 Projected

FY 2014-15 Projected

Diversion from Psychiatric Emergency Services



Percentage of SMART responses that result in diversion from the Emergency Department / Psychiatric Emergency Services / Jail to other appropriate resources



Percentage of mentally ill people admitted to jail on misdemeanor charges released within six (6) days




It is recommended that $2,198,794 in Measure A funds be appropriated for the FY 2013-14 budget and $1,397,588 in Measure A funds be appropriated for the FY 2014- 15 budget. The Health System has the potential to leverage funds from state and federal sources in the amount of $495,837 in FY 2013-14 and $783,464 in FY 2014-15. Attached is a detailed breakout of the costs of each individual proposal and the funding source.

Measure A funds recommended in this report:


FY 2013/14

FY 2014/15

Mental Health System of Care



Attachment I









FY 2013-14

Measure A Funds


Other Funds

FY 2014-15

Measure A Funds


Other Funds

Respite Center














Criminal Justice Collaborative Review

Health System





Sub-Total Measure A







Sub Total Other Funds






Total FY 2013-14



Total FY 2014-15


Important note: This is a copy of the official report -- item 12C on the Board's agenda.