Mental Health Merry-Go-Round

Last Tuesday the Board of Supervisors heard a short presentation from consultant Lee Kemper about the mental health system audit CEO Carmel Angeo has hired him to do.

Angelo: “There has been interest and obvious concern regarding our ongoing mental health services, particularly the changes that have been made over the last couple of years. With that interest the executive office has moved to hire Kemper Consulting to do a review of the mental health system. We have made such a substantial change in our service delivery and we are two years into that change so it is a really is a good time to ask for expertise to come in and do a review and give us some recommendations on our system as a whole. … During the budget hearings in September we talked about mental health services and the actions of staff in the Department moving forward. We said then that we would be coming forward in January to ask the board to form an ad hoc committee to work with staff and the Department to review the contracts, essentially the statements of work for the administrative service organizations, with the possibility of moving the renewal date for those contracts up and doing another RFP process. We think it was premature on the part of staff go ahead and make that statement publicly. What we would like to do is do the review and have the review brought to the board and then staff will ask for direction from the board at that time.”

Lee Kemper (with consulting associate Lee Featherstone, former Alcohol & Other Drug Programs Director in Napa County): “We will conduct an organizational review of Mendocino County's mental health system and identify areas that are working well and areas where system improvements are needed. This is not a program or financial audit. We are not looking back to see if what happened in the past was right or wrong. We are looking at the system as it is and how it has come to be in today's realm. We will be looking at barriers and constraints to service delivery and oversight and policies. We expect to deliver the review at your last meeting in December. The review will involve looking at reports, data and participants in the system [whom Kemper referred to as "informants."] They expect to speak to staff, contractors, law enforcement, hospitals, etc. We want to see what services were billed for and paid, both before the contracting out and now.”

(Significantly, in his list of “informants” he intended to interview, Mr. Kemper did not include any mention of clients, patients or family members of clients or patients.)

Supervisor Dan Gjerde: “The broad areas of concern that members of the public have raised with me and which I share would be: Conflicts of interest, excess administrative expenses, and a lack of an ombudsman role — someone a parent or guardian could go to if things are not working for them, and who do they go to. An independent person. And the thing that seems to me to be a conflict of interest is at least with the Ortner contract, a doctor would see a patient and potentially make a decision to send a patient to an out-of-County facility, a long-term care facility and the Ortner company has financial ties with that long-term facility. It seems there should be a firewall there between the doctor that's making the recommendation of sending someone to a long-term facility and the financial relationship with that long-term care facility. That seems like a conflict. I think in most areas of government you would not have that kind of a conflict in existence, but it seems to me that it does exist. Examples of excess administration which I brought up previously, are the Ortner contract has an excess of 18% for admin expenses [for adult mental health services] which is more than double the expense charged by RCMS [for services to people under 25 years of age]. That seems excessive. When we voted with a leap of faith to go with contracting out we were told as board members by county staff that there would be 13 county employees still in mental health after contracting out. Over a year later I learned that there are still 43 positions. The only explanation I have been given was that there were 10 county employees working in the Katie-A program which the County did not envision keeping in-house. But that only explains an increase from 13 to 23. What are those other 20 people doing? Why was the estimate so far off the mark? Why was it a week before we were voting on it we were going to have 13 county employees and now we have 43 authorized positions? [And why is Supervisor Gjerde only bringing these questions up now for the consultant? Why didn’t he simply ask staff these questions months ago? Could it be he doesn’t trust them for an honest answer?] I'm not saying they are all filled, but 43 authorized positions. Something seems amiss there. I have heard reports of parents with an adult child who are not satisfied with the service they are getting. I'm not saying who's right or who's wrong. There's a lot of stress involved in a family situation. But who does a parent go to if they can't get the service they think they need for their adult child? Right now they go to one of the contractors, but if they are not satisfied with what they are being told or the assistance they are getting, maybe there needs to be a little less money spent on administration and one or two positions countywide established that are independent of the contractors and employed directly by the county.”

Mr. Kemper agreed that "those matters" would be investigated.

Supervisor Tom Woodhouse: "My thoughts are not very organized today. Mental health has been keeping me awake worrying at night so I am taking it more and more seriously. I've reached the point of becoming angry about it and that's never helpful, that's not my nature, so I'm sure I can deal with that. There is a lot of hope out there that what you are doing will make a big difference. We have been building up to this and allowing poor behavior for a number of years now. It's time to make a change. I can't stress enough to you how much I request that you spend whatever time you can speaking to the employees. That's really the only place where I have gotten my knowledge. [Knowledge Supervisor Woodhouse has yet to mention in public so far.] We are very fortunate to have so many quality employees that are courageously working in very uncomfortable positions. They are afraid to speak out. If we can just solve that one problem we would have a rich source of information. We have the makings of a great mental health group but we are not applying it correctly. At this point a lot of money is being wasted and we are in denial that a lot of what we are doing now is incurring bills that we will be paying three or four or five years from now. It's alarming to hear the stories from the people and very emotional. I'm looking forward to getting your report. People are holding their breath and hoping that this is a change we've all been looking for. This is a rare time for Mendocino County to make a crack in this problem and if the board stands up with the community we can make a tremendous difference. I know we can do much better. It's not out of our reach."

Supervisor Dan Hamburg: “I'm glad you're here. It's a great time to be doing this. It's time to take a good hard look. There's a lot of interest, a lot of money. We could spend a lot more. We spend about $20 million. I'm very concerned about how the money is distributed between the two ASOs. Perhaps OMG is taking too big a bite out of the administrative cost apple and it's costing our other services. I do think though, and this may be contrary to what my two colleagues have just said, that all things considered we are delivering more and better and more cost-effective mental-health services today than we were before we went to the ASOs. Having watched this evolve for the last two years I would not favor the board jumping from one extreme to another extreme. I would not like to take the mental health services and all that it implies back under a County system. I think that would be a real mistake. I don't think there are unlimited choices out there where you go to contract with an administrative service organization. I think OMG has a lot to offer. I'm not sure about the conflict of interest that my colleague spoke to. I'm not sure that situation is a conflict of interest. But it's definitely out there in the community. Mental health service delivery is a very emotional subject. Not only is there a lot of money involved but there is a lot of pain, a lot of family distress so there are a lot of— scores if not hundreds of stories that circulate out there, many of which end up in the press. So it's a very controversial area and a very emotion laden area. It will be very helpful to have a somewhat dispassionate look at where we are with mental health services two years into these contracts and still looking at the part that the county has retained under its own control.”

Supervisor John McCowen: "I agree that it's appropriate to have an objective look at where we really are. Do we have the appropriate systems in place? Do we have a way to measure whether they are operating appropriately? Mental health has been a controversial issue for the last 30 years in Mendocino County that I'm aware of. There has never been a time when significant numbers of people have not had serious questions about the ability of the mental health system to deliver the service to the people who need it. Nothing has changed there. What is ironic is once the county took a fairly dramatic step in an effort to, we hope, improve the system it seems to really unleash the floodgates of criticism. No matter what we do and I agree with my colleague that although many people have questions and certainly in some areas we are delivering more service and better service today than we did previously. For whatever reason when the county was in the mental-health services delivery business — and I think we've always had a lot of dedicated conscientious people working for us — but now there seems to be a disconnect in actually getting the system to deliver services to the people who need it and the county getting appropriately reimbursed for the work that it was doing. I am also concerned that we have not really solved that issue. We recently had notice of significant audit exceptions from previous years prior to the contracting out. I'm concerned that a year or two from now we will get the next round of exceptions including for the time we have been contracting out. One of the main focuses should be to assess how well the county is doing its job of holding our contractors accountable. I know there are people who are ready to end the contracts and go out for new RFP. I don't think we're anywhere near close to having the necessary information to know if that's a wise decision or not. Part of the challenge is to make sure the county is doing what it needs to do to hold our contractors accountable. It would be inappropriate to make an announcement that we are going out for a new RFP or end the contracts. Those decisions will be made by this board. No decision has been made to terminate any contracts or issue an RFP. If that happens it will happen in the future based on information we get and recommendations made and board deliberation and a public meeting. We also may appoint an ad hoc committee to do further review and make recommendations to the board.”

Curiously, Supervisor Brown was silent on the entire obvioiusly important subject. Then she opened up the meeting for public comment.

There was no public comment. Nada.

McCowen: “I guess it's not as controversial as I thought!”

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Ms. Angelo and the Board then announced that Health and Human Services Director Stacey Cryer would be the new "interim" mental health director. Former Director Tom Pinizzotto was mysteriously "promoted" to "Assistant Mental Health Director" without explanation. Supervisor Hamburg read a written note from Mental Health Advisory Board chair John Wetzler citing government code (Welfare and Institutions Code 5604.2(6): “Each County’s Mental Health Advisory Board shall… Review and make recommendations on applicants for the appointment of a local director of mental health services. The board shall be included in the selection process prior to the vote of the governing body.” So the law requires the County to consult with the Advisory Board before such appointments are made.

Hamburg then commented, "It is not the intent of the Board of Supervisors to marginalize the mental health board in making these decisions. This is not an appointment that is being made for a permanent position. [The Government Code does not distinguish between permanent or non-permanent appointments.] As the CEO made clear, this is an interim position. We have to have someone in that position just to meet our legal obligations. Mr. Pinizzotto has taken a different position within the agency and Ms. Cryer who as everyone knows already wears many many hats is for a short period of time being asked to wear one additional hat and that is as the interim mental health director. So that is where this item comes from."

“Mr. Pinizzotto has taken a different position.” What? He gets to pick and choose the “positions” he “takes.”

Mental Health Board member Nancy Sutherland remarked: "There is a concern that this was done without any — we didn't know about it until we read about it on the agenda. We think as members of the mental health board we are concerned about who the director is. We serve at the pleasure of the board but we also serve the department. So there was some concern about that. What is Stacey's capacity to handle this position? What are her qualifications? You used the word ‘temporary’ which — and I am happy to see that the job was posted because it was just posted yesterday — so another question was how long was this appointment going to last — the mental health board wants some information about that. We want to know about the chain of command and the responsibility. Who is staff reporting to? Is it to Stacey? Is it to Tom? What is the recruitment plan? We are just concerned about the continuity of leadership in the department as a whole. That's our biggest concern. There's been a lot of turnover in directors in the last five or six years. As a board we would like to be advised about changes like this in advance. We didn't know Tom was going to leave. We didn't know he was going to come in. It's a request from the mental health advisory board that we be consulted according to the Government code which says we are supposed to be part of the process."

Nobody answered Ms. Sutherland’s question about who reports to who.

Gjerde: "How will the permanent position be filled? Will the mental health board be involved in some fashion in the selection process?"

Angelo: "The mental health board will be involved. I am leaving that up to Ms. Cryer and the Department. In the past the mental health board was involved. Honestly, I have had to ask Ms. Cryer to take this position. I don't think anybody is jumping up and down wanting this position right now. It's a difficult position. Everybody in this room knows that. I have the utmost confidence in Ms. Cryer even with her busy schedule. She is taking it. There is no increase in salary or benefits. We hope to do the recruitment process not only involving the mental health board but whoever else Ms. Cryer has on the interview panel. Usually for a position like this we do bring in community people as well. I would like to hire a headhunter to find a person to come in to Mendocino County for this position. That's the plan right now. I believe Ms. Cryer will be sharing that information as we move forward. The recruitment is out. It went out this morning. We certainly could give the board an update on November 3rd as to how many candidates we have for the position, and what is happening with the headhunter for this position.

Woodhouse: "I think I baffle Ms. Cryer because I am so supportive of her and yet I am very critical of the programs in mental health. I think she's doing her very best to continue and will continue to do that. I have been talking to other counties about mental health and gathering information and there are at least six other mental health directors that are in the process of being hired this year just replacing retirees. It's very hard to find a mental health director. We will be competing with a lot of other placements. I wish everybody good luck on that."

McCowen: "I think it would go a long way toward building confidence in the general community as well as with the mental health board if the mental health board itself were given an opportunity to directly interview the applicants rather than simply having the Chair be on an interview panel. I think we could have an interview panel as a separate item. We could have a separate interview before the mental health board because how else are they to review and make recommendations on the applicants according to the Government code? There could be no question then that they are being included in the process. I would like staff to review the possibility of taking that approach. It's been a challenge sometimes for people serving on the mental health board — and maybe all of our advisory boards at times — to feel like they are really being included in the process and being given the full opportunity to fulfill their role. I would like to underline this point. I think it would serve us well. If the mental health director does not have the confidence of a strong majority of the mental health board that would indicate a problem right from the beginning. This is an opportunity to build that relationship from the ground floor.”

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Note to Mr. Kemper:

Why, Hello! We couldn't help but notice that you're NOT a double dipping gray-haired retiree with no interest in career advancement. Did you know you’re auditioning for a high paid position with Mendocino County? I'm sure you did. How long do you think you'll stick around? Maybe no one told you that Tom Pinizzotto was a consultant before he was quietly hired as Mental Health Director a couple of years ago, just about the time his former employer, Ortner Management Group, got the contract that you'll be "reviewing." Let's hope that after you (or you're consulting associate Mr. Featherstone from Napa County) punch your career ticket by taking a director job in Mendo, that you'll stick around at least long enough to make sure all the ruffled feathers are smoothed and the current uproar dies down. Then (maybe; see below) you can go back to Sacramento (or Napa County in Mr. Featherstone's case) with the satisfaction of a job well done. By then enough time will have passed for Mr. P. to re-assume his “oversight” responsibilities for his former bosses at Ortner Managment Group, and you and/or Mr. Featherstone can go away confident (and nicely paid) that the Ortner Management Group is doing a great job (according to Dan Hamburg) and Mendocino County mental health business will go on as usual, i.e., privatized mental health services undelivered, Ortner pulling maximum profits out of an essential public government service.

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PS. To CEO Angelo: You really have to orchestrate these moves a little more carefully and discretely. The timing’s a bit off. If you’d staged the Kemper “audit” a little sooner, Mr. Kemper could have moved right in behind Mr. Pinizzotto to implement his deck chair rearrangements on the good ship Mendo himself and poor overburdened Ms. Cryer wouldn’t have had to bother with Mental Health and Ortner for a few months. Now, the Board will have to waste their time rubberstamping Kemper’s bureaucratic proposals in some time-consuming ad hoc committee, instead of issuing proclamations about how great everybody is. And Supervisor Gjerde might even gripe about the proposals not going far enough. This way, however, a few of us rubes will see what you’re up to and Supervisor Hamburg will be unhappy that it “ended up in the press.” Then the Mental Health Board might even notice, and worse, they might even remind the board about some other pesky government code they’re casually violating. Remember, Tom P. didn’t have to actually prepare a report for the Board about Mental Health before he took over; he just slid right in with Ortner on his coattails, smoothly moving from Ortner Exec to consultant to Mental Health Director — no annoying Mental Health Board interviews or anything. Good job postponing the RFP indefinitely though.