"Culture change" was a phrase that came up numerous times during Tuesday's meeting of the Santa Barbara County Board of Supervisors, who heard about changes being made to the Alcohol, Drug and Mental Health Services Department.
The department's struggles are well documented, and supervisors wanted to know what department leaders have done since the results of an audit commissioned in 2012 found that the department was poorly run and not adequately serving vulnerable patients.
Changes have been made, such as reducing the wait time it takes for a patient to see a psychiatrist, encouraging department staff to point out problems without fear of being penalized and filling some key vacancies in oversight positions. Those highlights represented the bright spots in a presentation that at times was heavy on clinical jargon.
Dr. Takashi Wada, who has been at the helm for the transformation, said there are still areas where the county can improve. For example, the county still sees a high number of people who use a large amount of services — 222 high-cost beneficiaries who represent a third of claims submitted, he said. The average across the state for high users is about 25 percent.
In September 2012, the board commissioned an audit of the department and worked all through 2013 to implement changes to the department.
"We're now starting to see some results," Wada said, adding that the department has seen some large state grants this year that will help beef up services.
A year ago, "there was really a pretty dire clinical situation" at ADMHS, said Andrew Keller of Tri-West, a company the county hired to look at the problems within the department.
Then, the department was described as "reactive" and "crisis driven," he said, and a culture that needed to change.
Now, the department is trying to shift focus to prevention and early intervention rather than letting patients get to such a level that they end up in crisis services, which cost significantly more, he said.
Wada was asked by the supervisors, including Salud Carbajal, about how to ensure that the department doesn't revert back to its old culture.
"Unless it's self-sustaining, it's a waste of time," Carbajal said.
Wada admitted that "it's still a work in progress," but that the department is committed to seeing culture change.
The department is also moving toward adopting a recovery model, "from treatment to people to treatment with people," said Michael Camacho-Craft, director of clinical programs.
Medi-Cal reimburses for quantity of services regardless of patient outcomes, he said, but the department will be working to measure how patients do in the long run and have metrics to back that up.
The department has been able to drop access to psychiatrist time by 40 percent since starting the improvements, despite the fact that they need to hire six additional psychiatrists and additional clinicians. People are waiting anywhere from 10 to 60 days to see a psychiatrist, staff said.
Ideally, people in crisis would be seen immediately, and others would be seen in a two-week window, which would most likely be accomplished when the vacant psych positions are filled.
"Care delivered when it's needed, even in a pre-crisis situation, keeps the system from backloading," Camacho-Craft said.
Camacho-Craft's position was one that had been vacant for five years before he was hired, which meant clinical programs lacked coordination.
Others said that the community-based organizations that contract with the county for mental health services also have been brought into the process to a greater degree, helping to create more of a spirit of partnership.
A committee of those organizations was formed, including Cecilia Rodriguez of CALM, who said she was surprised when the department was open to the suggestions from the committee.
Before, the department would issue quarterly scorecards to organizations that "felt like a trip to the woodshed," she said.
"It felt really demoralizing," she said. "We want to be accountable but the process of that has profoundly changed. … We feel like partners."
That feeling also seemed to extend to staff.
Carlos Olsen, a therapist for CARES in Santa Maria, said "this is an exciting time" for staff and that input is encouraged from staff for the first time.
A chief of compliance position was also established as a result of the audit, and Celeste Anderson has been in that position for nine months, ensuring that the department is in compliance with state and federal statutes as well as their own policies.
Supervisor Peter Adam said that metrics for improvement "were still inadequate," and he pressed staff about how they'll define clinical success.
Camacho-Craft said recovery will happen "when people return to level of functioning that is meaningful to them."
Adam wanted more of an answer, however.
"I want to have some way to measure the success of the program," he said, asking that staff come back with at least two measurements that quantify success for patients.
"I'd like to cut through the clinical jargon stuff and get it into language that regular people can understand," he said, adding that he wanted to know how many people in crisis are diverted from hospital or jail, which was met with applause from the audience in both North and South County meeting rooms.
About 17 people spoke, encouraging the changes, many of whom have been involved in the mental health community for decades.
Annmarie Cameron of the Mental Wellness Center said she's "participated in no less than four times to reform this department."
"This time we have it, and we're going to get it right," she said, because there are hundreds of people involved, the time is right with new resources and the board is supportive.
Accountability and regular check in will be key to success, however.
"Ask us to come back regularly and report where we are," she said. "The more you ask us to stand behind this the more likely we will succeed."
Rich Detty, whose son, Cliff, died in the county's Psychiatric Health Facility in 2010, said he'd like to know what changes have been made in the PHF, which works with the most vulnerable mental health patients.
Detty raised concerns about patient care, how often doctors check on patients after they are given injections at the PHF and the availability of medical staff during evening hours
"I wonder if this situation has been changed," he said. "I'd like answers."
Supervisor Doreen Farr said that when she first took office, she was hearing bad things about the department consistently but that those reports have tapered off.
"One of my major measures of success is that I don't hear about ADMHS anymore," she said. "This is really quite tremendous when we think about where we were a few years ago."