Health
Care for Low-Income Families
Summary
The
Grand Jury followed up on the 2000-2001 Grand Jury investigation of health care
services for low-income families in Santa Cruz County, which proved to be an
extremely worthwhile and revealing endeavor. The simple truth that became
apparent throughout this investigation is that most of the 2000-2001
recommendations were not implemented for a variety of reasons. However, the
County has met or exceeded expectations over the past seven years in the areas
of improving both the availability and the quality of health care to low-income
families.
As an example, the 2000-2001 Grand
Jury called for the simplification and consolidation of categorical health
plans. The County’s response was that the recommendation would be implemented. For
a number of very good reasons, however, it was not. Rather than accept status
quo, the County has restructured resources to guide applicants through the maze
of health services and health insurance programs.
One important result of that effort
is a state-of-the-art call center where electronic files have replaced paper.
It can be accessed by staff members in seconds. Because of these and other
initiatives, the number of low-income families covered by some type of
insurance has increased significantly since 2000, and the number of children
enrolled in the Healthy Families program has more than doubled.
Since there is no universal health
care presently in the United States, many people must try to find access to
medical services without the benefit of insurance. That is where the county
safety net coalition comes into play. These 15 county-funded and nonprofit
clinics provide primary health care, family planning, dental and mental health
services to uninsured individuals. The Grand Jury finds that clinic services
have been enhanced since 2000 despite budget challenges. They are more
accessible to low-income families, and the clinics have done a better job of
outreach to the community.
Finally, we are impressed by the
spirit of cooperation and dedication exhibited among county health officials,
nonprofit health organizations, and the private health care sector. They work
together to apply maximum available resources to the needs of low-income
families in the county. This effort requires creativity, compromise, and
sometimes handshake agreements outside of formal policy, and the emphasis is
always on “the patient.” This spirit will be even more important in the future
as the road to health care becomes steeper and more slippery. An aging
population, the State’s current budget crisis, and demands for across-the-board
service spending cuts all contribute to an environment of stress and
uncertainty for health care resources.
Definitions
Categorical Health Programs: Programs that target defined classes of vulnerable people,
specific health conditions, and diseases. These programs are mainly focused on
poor individuals and families, the disabled and the aged, and can provide
significant financial assistance to county governments by helping them pay the
rising cost of health care for indigent people.
Coalition for Health Care Outreach (Coalition): A group of agencies and community organizations in Santa
Cruz County whose goal is to be a main resource for low-income families dealing
with health care issues.
Community Provider Plan
(CPP): The CPP, located in all 58 California counties, is the health plan offered at a discount to
subscribers participating in the Healthy Families Program. Each county reviews
competing plans and select the best one as its CPP.
First 5 California (First 5): Also known as the California Children and Families
Commission, First 5 California supports children from conception to age five by
creating a comprehensive and integrated system of information and services to
promote early childhood development and school readiness. It is funded by
Proposition 10, an initiative approved by voters in November 1998, which added
a 50 cent-per-pack tax on cigarettes and a comparable tax on other tobacco
products. Proposition 10 generates approximately $590 million annually.
Healthy Families: A
state and federally funded health plan for children who do not qualify for
Medi-Cal. Healthy Families provides medical, dental and vision coverage to children
from birth through 18 years of age, in families with incomes above the level
for no-cost Medi-Cal and does not exceed 250 percent of the federal poverty
level.
Healthy Kids: In 2004
the Healthy Kids program was established in Santa Cruz County. It is a locally
developed and funded health plan for children who do not qualify for other
state-sponsored health insurance (i.e., Medi-Cal or Healthy Families). The plan
provides low cost health, dental, vision and mental health services for the
children of families with incomes up to 300 percent of the federal poverty
level.
Medi-Cal: California’s
version of the federal Medicaid program, Medi-Cal is a state and federally
funded health insurance program for low-income children, single parents,
seniors and persons with disabilities.
No-Cost Medi-Cal: Sometimes
called “free Medi-Cal,” it does not have a share-of-cost component so Medi-Cal
pays the entire medical bill.
Share-of-Cost Medi-Cal: This
program has no monthly insurance premium. However, when a beneficiary has
medical expenses, a portion of the cost must be paid by the beneficiary; then
Medi-Cal will pay the balance.
Medi-Cal Administrative Activities: A federal program with money reserved for promoting the
enrollment of children and adults in Medi-Cal.
Background
Two
principles upheld by the California Grand Jury system are consistency and
follow-through. It is important that investigations, while unique in
themselves, build upon findings and recommendations of past Grand Jury efforts
and that there is some follow-up work done to ensure that the County responds
to and implements past Grand Jury recommendations. Within the spirit of
consistency and follow-through, the 2007-2008 Grand Jury decided to conduct a
thorough review of the 2000-2001 Grand Jury report on health care services for
low-income families in Santa Cruz County and investigate whether the
recommendations contained in that report had been implemented.
As the 2000-2001 Grand Jury noted,
County government is obligated under state law to provide medical care for
indigent residents. The extent of this responsibility has never been set forth
in precise terms by the legislature. Federal and state governments have enacted
a number of categorical health programs that aid the County in meeting the health
care needs of indigents.
Uninsured families tend to rely on
hospital emergency rooms or public clinics for treatment. Because they cannot
afford to pay for these visits, they also delay seeking medical help resulting
in more serious illnesses requiring extensive care as well as more and longer
hospital stays. The result is a significant financial burden on both health
care providers and taxpayers who underwrite the care of uninsured families.
A
categorical approach to a variety of health care needs has produced tangible
benefits but also notable drawbacks;
·
Eligibility
requirements are confusing even to experienced health professionals.
·
Lengthy and intrusive
application procedures act as a disincentive to seek help, especially for some
Hispanic families who are wary that any official inquiry might adversely affect
their immigration status.
·
Fragmentation of local
services prevents a cohesive delivery system that is responsive to the needs of
the entire family. Each family member may be eligible for important health
services, but each service is delivered at a different time and location.
Families have a difficult time coping with this patchwork delivery system.
These are the underlying issues the
2000-2001 Grand Jury investigated. Each of their recommendations listed below
is followed by the result of this Grand Jury’s investigation.
Demonstration
Site
2000-2001
Grand Jury Recommendation 1: The Board of
Supervisors should take the necessary course of action to have the county
designated as a demonstration site for the integrated provision of local health
services subsidized by state and federal government for counties of similar
characteristics.
County
Response: The recommendation requires further analysis.
2007-2008 Grand Jury Finding
1.
The County did apply
to become a demonstration site, but there were ten sites funded and Santa Cruz
County ranked eleventh on the final list of qualified counties.
Conclusion
1.
The County made a
sincere effort to qualify as a demonstration site.
Consolidation
and Simplification
2000-2001 Grand Jury Recommendation 2: The Board of Supervisors should direct the Health Services
Agency (HSA) to develop a plan for incremental consolidation and eligibility
simplification of categorical health plans.
·
This plan should be based on prepaid capitation payments
and a local public commission should govern its operations.
·
Eligibility requirements should be simplified and extended
to a term of at least one year.
·
Eligibility should be based on family income, rather than
assets, and tied to federally designated poverty guidelines.
·
The entire family, not individual members, should be
designated as the beneficiary for health service coverage.
·
The Central Coast Alliance for Health and its principles of
practice should be used as a model for the administration of other categorical
health programs.
·
The Board of Supervisors should urge the state to engage an
independent non- governmental entity with credentials in the healthcare field
to monitor the demonstration and track its impacts on both program costs and
clinical outcomes. The Medical Information Management System should facilitate
this tracking.
County
Response: This recommendation had not yet been implemented, but will be
implemented in the future.
2007-2008 Grand Jury Findings
2.
While the County has
pursued a goal of consolidating categorical health plans and simplifying
eligibility requirements, there is no published plan or public commission in
place to oversee it.
Response from the County: DISAGREES.
The Public Health Commission is charged with overseeing the
operation of preventative health programs, medical clinics and medical
programs, which includes review of eligibility requirements and categorical
health plans.
3.
Eligibility
requirements for health plans have not been simplified in any significant way,
but the County has structured resources to guide applicants through the maze of
health services and health insurance programs that are offered by non-profits
and various government agencies.
4.
Santa Cruz County now
uses One-e-App, a web-based system for connecting families with a range of
publicly funded health and social service programs. Applicants, usually with the help of Certified Application
Assistants or county eligibility workers, enter their personal information to
learn about and apply for programs that best meet their family's needs. System
administrators, supervisors, and case management staff, can run reports and
determine eligibility.
5.
Santa Cruz County
Health Care Outreach Coalition expands access to health care coverage for
uninsured county residents, promotes awareness of government- funded health
insurance programs and conducts outreach to schools, community-based
organizations, businesses, faith-based organizations, childcare providers, and
the general community.
6.
The Benefits Call
Center was established in 2000 to provide an easily accessible source of
information for Medi-Cal recipients and to ensure that recipients complete all
program requirements to maintain their coverage.
7.
There is no new
program, or expansion of an existing program, to extend health care to entire
families instead of just individual members.
8.
In 2008, Medicare’s
Hospital Insurance Trust Fund (HI) is scheduled to pay out more in
hospital benefits and other expenditures than it receives in taxes and other
dedicated revenues. Growing annual
deficits are projected to exhaust HI reserves in 2019. In addition, the
Medicare Supplementary Medical Insurance Trust Fund that pays for physician
services and the prescription drug benefit will continue to require general
revenue financing and charges on beneficiaries that grow substantially faster
than the economy and beneficiary incomes over time.
9.
Private health care
providers, both physicians and dentists, have been recruited to treat patients
who can’t afford to pay. They do this without remuneration as a community
service.
10.
In order to simplify
access to categorical health programs, the 2000-2001 Grand Jury recommended
using the Central Coast Alliance for Health as a model for administering them.
Health Services Agency determined it would accomplish the same goal to make
those programs part of the Alliance where possible.
11.
Some Grand Jury
recommendations hinged on the county becoming a demonstration site for the
integrated provision of local health services subsidized by state and federal
governments. This did not happen as explained in Demonstration Site
Finding 1.
Conclusions
2.
Since the most
pressing concern today is from where the money will come to maintain Medicare
and Medicaid services for those who qualify under today’s system, extending it
to include low-income families is not being discussed.
3.
Santa Cruz County
public, non-profit, and for-profit medical resources have worked together to
make health care more accessible to low-income families.
Commendation
1.
The Human Services
Department and the Health Services Agency are to be commended for ongoing focus
on the delivery of adequate health care services to Santa Cruz County
residents.
Health Insurance
Coverage
2000-2001
Grand Jury Recommendation 3: The Healthy Families Program should include parents in its
coverage. Premiums should be set at more affordable levels in order to
accelerate enrollment of families without insurance. Coverage should be
maintained during short periods of seasonal unemployment. The Central Coast
Alliance for Health should approach local employers to continue premium
payments for families during short periods of seasonal unemployment to keep
insurance coverage from lapsing. It
should continue to expand the participation of specialists in its programs.
County Response: This recommendation has been implemented.
2007-2008
Grand Jury Findings
12.
The Healthy Families
Program does not include parents in its coverage. Healthy Families insurance
premiums vary depending on the health plan selected. Families receive a
discounted premium if they select the local Community Provider Plan, which is
the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The
Alliance’s maximum monthly premium for a family with three or more children is
$36 (or $108 per quarter).
13.
Recent local funding
contributions to the Healthy Kids program, which came primarily from Sutter
Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children
off the waiting list and into enrollment.
14.
Seasonal unemployment
only affects the eligibility of adults in a family receiving Medi-Cal. The
Alliance reports that their Medi-Cal membership fluctuates by about five
percent each year according to the growing season and migration of Medi-Cal
recipients out of the area. Typically, a seasonal employee becomes eligible for
Medi-Cal when the work season ends or slows down because the worker’s income
decreases. When an individual’s work hours increase again, Medi-Cal eligibility
could be lost due to the corresponding increase in income. Thus, an individual
may qualify during periods of little work or unemployment but no longer qualify
for Medi-Cal when working full-time.
15.
Medi-Cal has no
provision for continued eligibility if an adult no longer meets the criteria.
However, children can maintain Medi-Cal eligibility for 12 months even if the
adults in the family are terminated due to an increase in income or assets.
16.
Although families pay
no premiums for the Medi-Cal program, there are premiums associated with the
Healthy Families and Healthy Kids programs. However, regardless of changes in
family income, once a child is deemed eligible for Healthy Families or Healthy
Kids, that child remains eligible for 12 months unless he or she becomes
eligible for no-cost Medi-Cal, is covered by other health insurance, or turns
19. Children also lose Healthy Kids eligibility and coverage when they move out
of Santa Cruz County.
17.
In 2000, the Santa
Cruz County population was 255,602. In 2007, the population increased slightly
to an estimated 264,125 (3.3 percent). But the supply of health care
specialists for Alliance programs has increased by almost 30 percent since that
year. In 2000, the Alliance had an average of 499 specialists available to
serve Santa Cruz County residents. As of March 2008, 697 specialists are
available.
18.
The Alliance
collaborates with over 60 community coalitions and organizations to promote its
programs, including the Santa Cruz County Human Services Department. It also
promotes health care resources to the public at events, such as farmers’
markets, health fairs, community block parties, and other festivals. In
addition, the Alliance publishes a provider bulletin in which providers are
urged to encourage their Healthy Families and Healthy Kids patients to stay
enrolled and thereby continue their health care coverage.
19.
In March 2008, at
California’s annual Medi-Cal Quality Conference, Central Coast Alliance for
Health tied for first place with Health Plan of San Francisco, winning the Gold
Award for the highest rate of preventive care services among all 39 Medi-Cal
health plans in California. The Alliance also won a second place Silver Award
for member satisfaction.
Conclusions
4.
Because Healthy
Families is a state and federally funded health plan, Santa Cruz County cannot
change the eligibility requirements for the program.
5.
The 2000-2001 report
recommended, “Coverage should be maintained during short periods of seasonal
unemployment.” But, in fact, qualifying seasonal workers are covered while
unemployed. They risk losing coverage when employed because their income may exceed
guidelines. That issue has not been
addressed by Medi-Cal or any county agency.
6.
A public/private
partnership exists in the county to provide affordable access to health care
for low-income individuals and families.
Recommendations
1.
The Santa Cruz County
Health Services Agency should continue to partner closely with the Central
Coast Alliance for Health.
Response from the County: HAS BEEN IMPLEMENTED.
The Health Services Agency has a very close partnership with the Central
Coast Alliance for Health and will continue working closely together.
2.
The Santa Cruz County
Health Services Agency should continue to expand local outreach and enrollment
resources for low-income persons in the county by continuing to partner with
local agencies, both public and private.
Response from the County: HAS BEEN IMPLEMENTED.
The Health Services Agency will continue to expand outreach and
enrollment resources throughout the County.
3.
The Santa Cruz County
Health Services Agency should consider expanding contracts with the Alliance
for other categorical health program administration, where and when
appropriate.
Response from the County: WILL BE IMPLEMENTED.
The Health Services Agency will continue to work with the
Alliance in considering future expansion.
4.
If the Health Services
Agency is unable to transfer other appropriate categorical health program
administration to the Alliance, the agency should adopt the Alliance’s
principles of practice for categorical health program administration.
Response from the County: HAS BEEN IMPLEMENTED.
Although the meaning of “categorical health program administration” is
unclear, the agency will continue to work closely with the Alliance on all
programs allowed within the law.
Commendation
2. It is admirable and impressive that Central Coast Alliance
for Health has been able to expand local coverage to improve low-income
families’ access to health care at a time when statewide reform has failed to
gain traction.
Increased Reimbursement Levels
2000-2001
Grand Jury Recommendation 4: In order to assure that appropriate care is provided at the
least costly level, the outpatient services of local hospitals need to be
reimbursed at a higher percent of reasonable costs. The same is true for
on-call private physicians who provide care to indigent patients in need of
admission to the hospital. The level of reimbursements to private health
service providers must be set at a reasonable percent of costs to assure
retention of physicians and hospitals participating in Medi-Cal and Healthy
Families Program. Rates should be subject to annual negotiation.
County
Response: This recommendation will not be implemented
because it is not within the County’s purview.
2007-2008
Grand Jury Findings
20. Since Medi-Cal and Healthy Families reimbursement rates are set by state and federal
government agencies, the County of Santa Cruz has no authority to revise them.
21. Congressman Sam Farr, the California Medical Association
(CMA), and others have called the reimbursement fee schedules for county
doctors inequitable and continue to work to require that the U.S. Department of
Health and Human Services fix a system viewed as unfair to local qualified
participants.
Conclusion
7.
While low
reimbursement rates for medical providers inhibit the delivery of adequate
health care to Medi-Cal and Healthy Families beneficiaries, county residents
must depend on state and federal entities to resolve the problem.
Coalition for Health Care Outreach
2000-2001
Grand Jury Recommendation 5: The Coalition for Health Care Outreach should be supported
in the budget of the Health Services Agency upon expiration of the Packard
Foundation grant.
County Response: This recommendation is being implemented.
2007-2008
Grand Jury Findings
22.
In June of 2001 the
Packard Foundation grant expired. In 2007-2008, funding for the Coalition for
Health Care Outreach (Coalition) came from two sources, First 5 California
(First 5) and Medi-Cal Administrative Activities.
23.
The budget for fiscal
year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive
the additional $103,000 from Medi-Cal Administrative Activities.
24.
The County works as a
middleman for both sources of Coalition funding.
Medi-Cal Administrative Activities
25.
During the month of
September, the Coalition completes a “time survey” to establish the annual cost
of outreach activities in excess of what First 5 already pays. The federal
government agency Medi-Cal Administrative Activities is billed that excess
cost. The turnaround for payment is generally about three years.
26.
The County supports
various organizations associated with the Coalition throughout the year and
receives the money from Medi-Cal Administrative Activities. Many variables
determine what work is being done and how it is being claimed. On average, the
Coalition received approximately 75 percent of what they predicted in their
budget from Medi-Cal Administrative Activities. The County then funds the
remaining budget.
First 5 California
27.
The State of
California retains 20 percent of the money First 5 receives, and 80 percent is
distributed to the 58 counties throughout California based on the number of
children born in the county. Santa Cruz receives approximately $2,700,000
annually.
28.
First 5 has three
established goals: healthy children, children learning and ready for school,
and healthy families. Allowing for local decision-making, the First 5 Santa
Cruz County Commission determines how to distribute funds based on a three-year
strategic plan and annual contracts. Money provided to the Coalition by First
Five has been designated as outreach funds.
29.
First 5 reimburses the
County for payments made to community agencies for contracted services.
30.
In the fall of 2008,
First 5 will create a new three-year strategic plan. This may or may not result
in continued funds for the Coalition for Health Care Outreach.
Conclusion
8.
Since the Packard
Foundation grant expired, the Coalition for Health Care Outreach has secured
funds to continue successful operation in Santa Cruz County.
Recommendation
5.
If First 5 no longer
supports it, the Coalition for Health Care Outreach should be supported in the
budget of the Health Services Agency.
Response from the County: WILL NOT BE IMPLEMENTED.
Although the Coalition for Health Care Outreach is very important,
unless funding is identified to replace the $300,000 First Five contribution,
such support cannot be guaranteed due to other competing high priority needs.
Clinic Hours
2000-2001 Grand Jury Recommendation 6: Additional
sessions in the evening and through the lunch hour would be a great advantage
for family members who now must lose time at work to attend the clinics.
Response from the
County: This
recommendation requires further analysis.
2007-2008
Grand Jury Findings
31. Three community clinics were visited in 2000, Salud Para La
Gente in Watsonville, Santa Cruz Women’s Health Center, and Dientes Community
Dental Clinic in Santa Cruz. The current Grand Jury has confirmed the following
hours with employees at each clinic. All three clinics are closed Sundays and
specified holidays.
·
Salud Para La Gente:
·
Monday through Friday,
9:00 a.m. to 7:00 p.m.
·
Saturday, 8:00 a.m. to
4:30 p.m.
·
Santa Cruz Women’s Health Center:
·
Monday, 8:30 a.m. to
5:00 p.m.
·
Tuesdays and
Thursdays, 8:20 a.m. to 8:00 p.m.
·
Wednesday, 12:20 to
5:00 p.m.
·
Friday, 8:20 a.m. to
5:00 p.m.
·
Saturday, 8:00 a.m. to
noon
·
Dientes Community Dental Care:
·
Monday though
Thursday, 8:30 a.m. to 5:00 p.m. (closed 12:30 to 1:30 p.m.)
·
Friday, 7:30 a.m. to
noon, and 1:00 to 4:00 p.m. (closed noon to 1:00 p.m.)
·
Saturday, 8:30 a.m. to
2:30 p.m.
32. Some discrepancies exist between the clinic hours posted on
websites and the hours provided in email and telephone communication.
9.
Clinic operations are
no longer confined to daytime hours. The three clinics each offer some
lunchtime and/or evening hours. All offer Saturday appointments as well.
10.
The inconsistencies of
the posted clinic hours confuse and possibly inconvenience patients.
Recommendation
6.
The Health Services
Agency should encourage community clinics to accurately communicate clinic
hours to the public.
Response from the County: HAS BEEN IMPLEMENTED and will continue to be coordinated with the Safety Net
Clinic Coalition.
Dental Health Programs
2000-2001 Grand
Jury Recommendation 7: Full-service
dental health programs should be launched in county and community clinics.
County Response: This recommendation
has been and will continue to be implemented through the county’s community
partners.
Background
In
reviewing current dental health programs offered to low-income families and
individuals, the Grand Jury found that quality dental services are available,
but not to everyone. Salud Para La Gente (Salud) and Dientes Community Dental
Care (Dientes) are the only community-based organizations that provide dental
care to low-income individuals and families. While some private dentists serve
Medi-Cal patients, it is estimated that they serve only one percent of those
who need it. Medicare does not cover seniors, so they must have private
insurance or pay personally for any dental services.
2007-2008
Grand Jury Findings
33.
Dientes Community
Dental Care served almost 16,000 patients in fiscal year 2006-2007, including
approximately 3,000 Medi-Cal patients, which is only about one-tenth of the
30,000 Santa Cruz residents on Medi-Cal.
34.
With funds provided by
a county grant, Dientes treats participants in the Healthy Families and Healthy
Kids programs, people with AIDs, and the homeless. But patients have to wait
three months to get an appointment.
Response:
Dientes
Community Dental Care PARTIALLY AGREES.
The average wait time was reduced
due to the addition of two new operatories.
We have hired another full-time Dentist and, in addition, two Dentists
on staff have received additional training to be able to provide care to
children 8 years and older.
·
Homeless emergency patients are seen
the same day.
·
Average wait time for a new patient
adult is 7 days, but the patient will be seen the next day if the patient is in
pain.
·
Average wait time to see a new
patient under 8 years old is 30 days. However, if the child is in pain, then
the child will be seen the same day or the next day.
·
Average wait time to start treatment
is 30 days after a new patient exam is completed.
35.
In 2007 Dientes added
two new dental chairs, which expanded its program by 25 percent as part of a
five-year plan to increase the number of patients treated from the current
16,000 to 25,000 a year.
Response: Dientes Community
Dental Care AGREES.
36.
In 2003 Dientes was
forced to eliminate an educational outreach program when the California
Endowment Foundation ceased funding it.
Response:
Dientes
Community Dental Care AGREES.
37.
Salud began a dental
program in 2002 and provides services in two Watsonville locations and one in
the City of Santa Cruz. As many as 25,000 dental patients are seen each
year.
38.
Salud secured a $320,000
grant, which will allow it to expand current services to county residents.
39.
One source from the
Santa Cruz County Health Services Agency estimates that only 40 percent of
dental needs are met in the county.
Response: Salud Para La Gente AGREES.
As of July 2008 we have added two dental
chairs and have recruited a new dentist who is a specialist in pediatric
dentistry. We have also built out two more chairs for a total of four chairs,
which we will staff when demand and fiscal resources are present.
40.
Both agencies are
concerned that proposed cuts in state and county funding will prohibit any
expansion of services and even force reductions to current levels of service.
Response: Salud Para La Gente AGREES.
Response: Dientes Community
Dental Care AGREES.
We continue to identify and apply for
additional sources of funding through grants, government programs and gifts.
Conclusions
11.
Services are limited
by the lack of funding, and there are still unserved and under-served people in
the county.
12.
More dental care is
offered to low-income individuals and families now than was offered when the
2000-2001 Grand Jury investigated, but there is still a significant part of the
county population that is not being served.
13.
Low-income families
and individuals of Santa Cruz County are receiving excellent care from two
quality agencies and several private dentists.
Recommendations
7.
In light of
anticipated cuts in state and county funding, the Grand Jury urges both the
Board of Supervisors and agencies providing dental care for low-income
residents to identify and pursue alternate sources of funding, such as grants
and gifts.
Response from the County: HAS BEEN IMPLEMENTED.
The Health Service Agency is aggressively working to identify and obtain
grants and alternative funding for dental care.
8.
The Grand Jury
recommends that Dientes resume, as quickly as possible, the outreach program to
children that was terminated in 2003.
Response from Dientes Community
Dental Care: HAS NOT YET BEEN IMPLEMENTED, BUT WILL BE IMPLEMENTED IN THE FUTURE.
Dientes is in the planning stages to
reintroduce its outreach program in Elementary Schools in Santa Cruz County in
February 2009. We are in the process of
obtaining grants to purchase mobile dental equipment and hire staff. Our
goal is to launch a pilot outreach program that provides exams, cleanings,
fluoride applications, and sealants.
Grant funding and cooperation by county schools will be essential for
this outreach program to be successful.
9.
The Grand Jury urges
Dientes to continue with the five-year plan to expand services and secure the
necessary funding to maintain this long-term program.
Response from Dientes Community
Dental Care: HAS NOT YET BEEN IMPLEMENTED, BUT WILL BE IMPLEMENTED IN THE
FUTURE.
Dientes’ five year strategic plan includes
a rolling implementation timeline, so some aspects of this plan have been
implemented, while others remain to be completed. Dientes will increase access to care for the
underserved through an expansion of the Dental Affinity Program, which connects low-income uninsured adults with access to quality, affordable
dental care through a collaboration with local dentists, who will provide pro
bono dental care. Also, Dientes will
improve our preventative oral health program by distributing health education
materials to Santa Cruz community health clinics, social service and
educational organizations.
Regarding sustainable funding sources,
Dientes Board members and management staff are increasing their participation
within the community. A major focus of
this involvement will be on expanding grants and donations, especially
regarding multi-year commitments. At the
same time, Dientes will continue to advocate for the inclusion of Medi-Cal
adult dental benefits in the State budget, as the funding for these services is
threatened each year.
10.
The Grand Jury
recommends that Salud continue to identify and secure alternate sources of
funding, such as grants and gifts.
Response from Salud Para La
Gente: HAS BEEN IMPLEMENTED.
We continue to reach for and receive
sources of funding to continue the mission of Salud to serve the medically
underserved.
Commendations
3.
The Grand Jury
commends both Dientes Community Dental Care and Salud Para La Gente for
providing excellent dental care to low-income residents of Santa Cruz County.
4.
Dientes and Salud are
to be commended for combining Medicare, Medi-Cal, and county funding with
grants and other resources to meet the dental care needs of a significant
portion of low-income families and individuals.
5.
Since the 2000-2001 Grand Jury report, dental
care services available to low-income families and individuals have expanded
significantly. Health Services Agency and the Board of Supervisors are to be
commended for assisting with this expansion.
Expanded
Health Insurance Coverage
2000-2001
Grand Jury Recommendation 8: The County should continue to collaborate
with community health organizations,
local employers and organized labor to expand the numbers of individuals and
working families covered by health insurance which includes mental health and
dental benefits.
County Response: This
Recommendation has been and will continue to be implemented.
2007-2008
Grand Jury Findings
In
2000, the United Way Community Assessment Project estimated that:
41.
Seventeen percent of
county residents had no health insurance. That figure dropped to 11 percent in
2007, a decrease of 35 percent in uninsured individuals.
42.
One-third of the
county residents who could not access health care when they needed it
attributed that problem to lack of insurance. The percentage dropped to 18.6
percent in 2007, a decrease of 44 percent.
43.
Thirty percent of the
county’s low-income families had no health insurance. That estimate dropped to
22 percent in 2007.
14.
Despite decreasing
resources, the County has significantly reduced the number of uninsured
residents during the past seven years.
Mental Health Services
2000-2001 Grand Jury Recommendation 9: The total lack of
primary mental health services needs to be addressed both in County and
community clinics. An intensive program should be mounted to attract mental
health professionals to the County with an emphasis on the recruitment of
family-oriented therapists to provide services in clinics that serve low-income
clients.
County Response: This recommendation is being implemented.
2007-2008
Grand Jury Findings
44.
The Mental Health and
Substance Abuse Services (Division), a division of the Santa Cruz County Health
Services Agency, works with and through many groups to offer a wide range of
mental health care services including emergency shelter, transitional housing,
supported housing, dual diagnosis treatment, crisis intervention, case
management, and peer support. Other services available to clients are
assessment, counseling, medication support, and referrals. Spanish translation
is offered, as is an Appeal Resolution Process for anyone who is denied
assistance. The following is a partial list of these resources.
Adult residential treatment is offered at
·
Transition House, 10
beds
·
Paloma House, 12 beds
·
Pioneer House, eight
beds
·
Opal Cliffs, 15 beds
·
El Dorado Center, 16
beds
·
Darwin House, 15 beds
·
Front St., Inc., 11
beds
·
River Street Shelter,
20 beds reserved
for people referred by County Mental Health
Outpatient
treatment and/or social rehabilitation are available at
·
North County Mental
Health Center
·
South County Clinic
·
Community Support
Services
·
Dominican Hospital
Behavioral Health
·
Pioneer House Dual
Diagnosis Day Program
·
Community Connection
Academy
·
Front Street Day
Rehabilitation Program
Self help resources include
·
Mental Health Client
Action Network
·
Mariposa Activity
Center
·
Community Connection
Mental Health Resource Center and Career Services
·
Community Support
Services Community Organizers Program
Ongoing services for the protection of
low-income mentally ill residents include
·
Advocacy, Inc.
(Patient Rights)
·
Public Guardian’s
Office
45.
It is hard to retain
staff; therefore, continual training programs are necessary. Many new employees
come from the Cabrillo College Health Science/Community Health programs.
46.
Various federal,
state, county and private agencies fund mental health treatment in our county.
Mental health has made effective use of these grants and programs. Some of
these sources (known as funding streams) are designated for specific and
limited uses. Clients often present with a variety of issues and staff
sometimes has difficulty matching funds to the specific needs of the client.
Services offered to individuals and families will be further restricted by
potential state and county budget cuts in the coming year.
47.
Training in cultural
sensitivity is emphasized and employees are trained within their department as
well as by outside resources.
48.
Some families have
difficulty acknowledging the existence of a mental health problem. This can be
a cultural issue or a matter of pride. Successful mental health outreach and
education programs have worked as a part of the network of general health
services.
49.
Access to services is
difficult for South County residents because most service sites are located in
Santa Cruz. Public transit offers only a few routes and limited hours of
operation. The Division is attempting to expand county services and to create
more partnerships with community agencies in South County.
50.
The Division works
with Senior Network Services but does not yet have an early intervention
program for seniors.
51.
Among the ongoing
concerns of the Division is the ever-present worry of patients exhibiting
unexpected antisocial behavior.
Conclusions
15.
The County’s mental
health program is active and in good hands and is continually adapting to the
changing needs of the community.
16.
The Division works
well, has effective coordination with many nonprofit organizations in the
county, and maintains a constant effort for structural improvement.
17.
Financing mental
health programs is a continual struggle. Clients sometimes have problems
finding appropriate services because they do not meet the funding requirements.
Mental health staff strive to find creative ways to match client needs in spite
of restrictions placed on various funding sources.
18.
The Division
recognizes cultural issues in treating county mental health patients. This
perspective is important to ensure the effective delivery of services because
cultural issues may make that more difficult, such as when families feel
embarrassed by a member with a mental illness and may not acknowledge it as a
legitimate health problem.
19.
Effective programs
have been developed that recognize the importance of family relationships. Both
children and adults are treated. Establishing more peer counseling is a
priority.
20.
A comprehensive
approach is the most pressing need in the system. Along with counseling and
medication, affordable housing, tenured living spaces, and job development are
all necessary for proper treatment.
Recommendations
11.
The Grand Jury
recommends that the Health Services Agency continue to build the network of
mental health services countywide.
Response from the County: HAS BEEN IMPLEMENTED.
12.
Staff development,
including improved training and new methods for reviewing program results,
would increase the effectiveness of the Health Services Agency.
Response from the County: HAS BEEN IMPLEMENTED.
HSA will further expand
staff development as additional funding becomes available.
13.
The Grand Jury
recommends that the Board of Supervisors support coordination of the various
funding streams by the Health Services Agency so that available funds can be
used to match the diverse needs of the clients.
Response from the County: HAS BEEN IMPLEMENTED.
HSA will continue efforts to coordinate and increase various
funding streams to meet the needs of our clients.
14.
The Board of
Supervisors should ensure adequate funding for patients’ employment services,
which play an important part in mental health treatment.
Response from the County: HAS BEEN IMPLEMENTED.
The Board of Supervisors restored $50,000 for employment services in the
2008-09 budget.
15.
It would be beneficial
for the Health Services Agency to continue developing mental health outreach
and education programs to provide even more community social support for
recovering patients, so they can feel welcome in their communities. Support
resources can include churches and neighborhood organizations.
Response from the County: HAS BEEN IMPLEMENTED.
HSA will continue developing outreach and educational programs as
funding becomes available.
Commendation
6. The County is to be commended for developing and supporting
vibrant mental health programs managed by experienced and dedicated staffs. The
programs are dynamic and flexible enough to keep up with the demands of clients
and changing methods of treatment.
Clinic Reconfiguration
2000-2001
Grand Jury Recommendation 10: County clinics should be reconfigured to family-oriented
primary and preventive care, backed by clinical specialties and case-managed
group therapy for persons at high risk or suffering chronic and recurring
illness. These measures will require the recruitment of full-time county
physicians and allied practitioners.
County Response: This recommendation is being implemented.
2007-2008
Grand Jury Findings
52.
In the County of Santa
Cruz, “safety net clinics,” (i.e., county or nonprofit clinics), take patients
that are uninsured regardless of their ability to pay.
53.
Current public and
non-profit clinics, as a whole, have not been reconfigured to family-oriented
and preventative care, but rather each clinic has an area or multiple areas of
concentration which are listed below.
Santa Cruz Clinics
Santa Cruz
Women’s Health
·
Primary Care for Women
and Children
·
Family Planning
·
Health Benefits Advocacy
·
Illness Prevention and
Health Promotion
·
Gynecology and
Prenatal Care
·
Pediatrics
·
Acupuncture,
Chiropractic, Naturopathy
Westside
Health Center (Planned Parenthood)
·
Primary Care Services
·
Family Planning
·
Health Benefits
Advocacy
·
Illness Prevention and
Health Promotion
·
Obstetrics and
Gynecology
·
Pediatrics
·
Abortion Services
Emeline
Clinic
·
Primary Care Services
·
Walk-in Immunizations
·
Health Benefits
Advocacy
·
Pediatrics
·
Child Health and
Disability Prevention
·
Orthopedics
·
Family Planning
·
Laboratory, Radiology,
and Pharmacy
Coral
Street Clinic
·
Urgent Care and
Primary Care
·
Integrated Case
Management
·
Mental Health and
Substance Abuse
·
Health Benefits
Advocacy
·
Counseling
Beach
Flats Clinic
·
Primary Care Services
·
Women’s Health
·
Pediatrics
·
Family Planning
·
Dental Care
·
HIV Testing
·
Obstetrics and
Gynecology
Dientes
Community Dental Care
·
Emergency Dental Care
·
Full Range of Dental
Services
·
Oral Health Advocacy
Dominican
Pediatric Clinic
·
Pediatric Services
Elderday
Adult Day Health (Salud Para La Gente)
·
Adult Day Health
Watsonville Clinics
Salud
Para La Gente
·
Primary Care Services
·
Family Planning
·
Dental Care
·
Eye Clinic / Optometry
·
Health Prevention and
Promotion
·
Health Benefits Agency
·
Pediatrics
·
Obstetrics and
Gynecology
Diabetes
Health Center
·
Diabetes
Self-Management
·
Medical Nutrition
Therapy
·
Group Classes
·
Insulin Training
·
Glucometer Training
Clinica
del Valle Del Pajaro
·
Primary Care Services
·
Dental Care
·
Family Planning
·
Women’s Health
·
Pediatrics
·
Child Health and
Disability Prevention
·
Obstetrics and
Gynecology
South
County Clinic
·
Primary Care Services
·
Immunizations
·
Health Benefits
Advocacy
·
Pediatrics
·
Child Health and
Disability Prevention
·
HIV Prevention
·
Laboratory
·
Radiology
·
Breast Cancer Early
Detection Programs
·
Family Planning
Clinic
Mariposa (Planned Parenthood Mar Monte)
·
Primary Care Services
·
Family Planning
·
Health Benefits
Advocacy
·
Pediatrics
·
Obstetrics and
Gynecology
·
Illness Prevention and
Health Promotion
Children’s
Resource Center
·
Pediatrics
·
Child Health and
Disability Prevention
·
Dental Care
Green
Valley Clinic
·
Obstetrics and
Gynecology
·
Women’s Health
54.
Santa Cruz Women’s
Health and Planned Parenthood specialize in women’s health, family care, and
reproductive health.
55.
Specialists are
available when necessary, usually through Sutter Maternity & Surgery
Center, which provides some free services to the community.
56.
The County of Santa
Cruz currently employs 20 full-time doctors: five primary care physicians
(including two pediatricians), and 15 psychiatrists, four of which are bilingual.
57.
The recruitment of
allied health practitioners and full-time county physicians is often a
challenge.
Response from the County: AGREES.
The Health Services Agency and the Personnel Department have
developed a number of successful initiatives to increase the County’s ability
to recruit for various classes of health practitioners and physicians.
58.
The high cost of
housing in Santa Cruz County makes recruiting primary care physicians
difficult.
59.
Psychiatry has only
one vacant position, and nurse practitioner positions are filled through a
“feeder program” from San Jose State University.
Conclusions
21.
While all “safety net
clinics” are not geared toward families, they are putting forth their best
efforts to meet the various needs of the uninsured and Medi-Cal patients in
Santa Cruz County.
22.
Santa Cruz County
needs to recruit more specialists and internists because of the increase in the
number of elderly patients with complex health problems.
Commendation
7.
The Grand Jury
commends Sutter Maternity & Surgery Center for providing the services of
medical specialists to those in need.
Medical Staff Recruitment and Salaries
2000-2001
Grand Jury Recommendation 11: In the recruitment of health care
professionals, salary surveys conducted in nearby agricultural counties are no
longer pertinent to this County. In the
next round of County salary negotiations, surveys should be conducted that use
counties more comparable to the emerging characteristics of Santa Cruz County.
County Response: The County has
utilized the nine-County comparison for over thirty years, and this long-term
base of information is useful in evaluating salaries. The nine-County comparison is used as a guide
along with other information such as the Consumer Price Index, turnover
statistics, recruitment and retention rates, the relationship between positions
within the County, changes in classifications, and operational changes. Other
jurisdictions are also surveyed, as appropriate.
2007-2008
Grand Jury Findings
60.
Currently Santa Cruz
County uses eight nearby counties in salary surveys: Monterey, Santa Clara,
Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to
Santa Cruz than the nine counties formerly used in that they are not strictly
agricultural and have living costs comparable to Santa Cruz.
61.
Recruiting and
retaining physicians and other medical professionals is uniquely difficult in
62.
The county health
programs must compete with Dominican and Sutter for physicians and other
medical professionals. Hospitals are in a unique position to pay higher
salaries as their Medicare reimbursements are based on actual costs. A national
Medicare study released in 2007 shows hospitals in Santa Cruz County have the
highest labor costs in the country, which local health officials say means
higher medical costs and insurance premiums for patients. This situation
creates a difficult challenge when it comes to recruiting medical
professionals.
63.
Salaries and working
conditions for physicians and other medical professionals employed by the
County are negotiated with the respective unions.
Conclusions
23.
The Health Services
Agency is able to recruit adequate medical staff and negotiate appropriate wage
and benefit packages under very difficult circumstances.
24.
The County has found
innovative ways to meet the medical needs of low-income residents through grants
and creative staffing. Anticipated budget cuts threaten this tenuous balance,
but the Grand Jury believes that the County is going to be able to continue to
provide a basic level of staffing to meet the minimal needs of low-income
residents.
Commendation
8.
The Grand Jury
commends the Health Services Agency for the innovative way it has succeeded in
providing quality health care to county low-income residents despite financial
limitations.
Recommendation
16. The Grand Jury urges the Health Services Agency to continue
to seek grants and other alternative sources for funds to pay competitive
salaries to health professionals.
Response from the County: HAS BEEN IMPLEMENTED and will continue to be a high priority for the Health
Services Department.
Responses Required
Respondent
|
Findings
|
Recommendations
|
Respond Within /
Respond By
|
|
County of Santa Cruz Board of Supervisors |
|
7,13, 14 |
60 days September 1, 2008 |
|
County of Santa Cruz Health Services Agency |
2, 57 |
1-6, 11-13,
15, 16 |
90 days October 1, 2008 |
Responses Requested
Respondent
|
Findings
|
Recommendations
|
Respond Within /
Respond By
|
|
Dientes Community Dental Care |
34-36, 40 |
8,9 |
90 days October 1, 2008 |
|
Salud Para La Gente |
39, 40 |
10 |
90 days October 1, 2008 |
Sources
Internet
http://www.cbp.org/pdfs/2006/0612_bb_SCHIP.pdf
http://www.hsd.co.santa-cruz.ca.us/
http://www.californiahealthline.org
http://www.centralcallegal.org/medical/medical_soc.pdf
http://www.healthyfamlies.ca.gov
http://www.healthyfamilies.ca.gov/English/caa/pdfs/manual/06_MC.pdf
http://www.mrmib.ca.gov/mrmib/HFP/CPP_Desig_07-08.pdf
http://www.saludlagente.org/facilities.htm
United States Census Bureau, http://factfinder.census.gov
Interviews
Coalition for Health Care Outreach
Dientes
Community Dental Care
First 5, Santa Cruz County
Salud Para La Gente
Santa Cruz County Health Services Agency
Sutter Health Santa Cruz
Newspaper Articles
Santa Cruz Sentinel articles:
“County hospital labor costs are
nation's highest,” November 27, 2007
“Medicare
reimbursement for doctors continues to fall,” November 3, 2007
“Hunt for health care can be discouraging for Medicare patients,” March 29,
2007
Publications/Documents
Central Coast
Alliance for Health, Annual Report to the Santa Cruz and Monterey County Boards
of Supervisors, January 2006.
Central Coast
Alliance for Health, “Creating Healthcare Solutions.”
Central Coast Alliance for Health
Provider Bulletin, December 2006.
County of Santa Cruz, Human
Resources Agency, Brochure of Services.
Healthy Families Program,
Community Provider Plan Designation, 2007-08.
Medicare Board of Trustees,
“2008 Annual Report.”
Santa
Cruz County Grand Jury “Final Report 2000-2001”
United Way, Santa Cruz County
Community Assessment Project, 2000 and 2007.
Telephone and Email Correspondence
Healthy Families, phone
number for premium rate questions, 1-888-673-4469.
Coalition for Health Care Outreach