Behavioral Health Housing and Treatment Resources:The community feedback period for this idea began on 6/6/2019 and ended on 8/5/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
The South Planning Area (SPA) for Continuums of Care lacks the desire for building housing and hospitals. Although evidence suggests that children of parents making $160,000 or more annually are at greater risk for depression, anxiety, eating disorders, psychosomatic illnesses, stealing and substance abuse (https://www.psychologytoday.com/us/articles/201311/the-problem-rich-kids https://www.nytimes.com/2015/01/10/business/growing-up-on-easy-street-has-its-own-dangers.html https://www.cnn.com/2016/01/08/health/affluenza-parenting-challenges-wealthy-households/index.html https://www.apa.org/research/action/speaking-of-psychology/affluence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948879/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1950124/). Anecdotal evidence suggests that the mental health outcomes for children of wealthy parents are worse than other socioeconomic demographics. A valid hypothesis is that South Orange County residents “exile” their mental health cases to the Central Planning Area (CPA) and North Planning Area (NPA) – both for housing and mental healthcare.

 

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County is currently under litigation and the South Planning Area is reluctant to build housing and previously has made the choice to not build hospitals/healthcare within their jurisdiction.

 

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Wealthy jurisdictions, as cited above by “The Problem with Rich Kids” body of research, tend to reject investments in resources for mental health and low-income housing. Yet, these same jurisdictions are likely exiling their members to other places. Venice, CA residents are suing to prevent such resources in their community (https://la.curbed.com/2019/4/16/18410698/venice-homeless-shelter-lawsuit-fundraising). Yet, Venice has no inpatient psychiatric ward.

 

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Respecting the local desires for resource allocation is important for maintaining civility. NPA and CPA have made choices to invest in healthcare/housing infrastructure across the socioeconomic spectrum. SPA has made choices to invest in other goods and services. SPA can bring the money, NPA and SPA can bring the infrastructure.

 

What is the project idea? Please describe how this project will operate.
Implement a “user fee” billed to South Planning Area jurisdictions for use of North Planning Area and Central Planning Area resources, including hospitals, shelters, sober living homes, and other similar resources. Anyone utilizing resources in the NPA and CPA, but can show evidence of previous SPA residency would qualify for quantifying the user fee. SPA residents utilizing hospitals in NPA and CPA can also be billed the user fee since they are utilizing resources outside of their jurisdiction, disproportionately placing a burden on NPA and CPA resources. The user fee can provide an incentive for SPA jurisdictions to implement their own resources and reward NPA and CPA for their disproportionate investment in resources.

 

Additional Information:
http://ochmis.org/documents/10YrPlan.pdf https://www.ocps.org/education-resources/resources-for-the-public/hospitals-and-county-services/ https://www.zillow.com/orange-county-ca/home-values/ http://www.city-data.com/nbmaps/neigh-Orange-California.html

 

 

May 21, 2019

4 comments

This is not my first choice of study, but…

Accept the things you cannot change, have courage to change the things you can and have the wisdom to know the difference.

I would prefer the title of this project to be “A Study on Downward Drift” or something similar (https://en.wikipedia.org/wiki/Drift_hypothesis). The first choice of study I would have is take the data sets of medical records, credit records and tax returns and understand how downward drift occurs. Such a study would emphasize critical points when interventions of various types may slow, prevent or reverse downward drift (i.e. keep people in housing, keep people in a job, etc). A large corporate employer with significant numbers of employees aged 16-30 would be a good corporate partner to assist in such a study. For Orange County, this would be Disneyland or a similar employer. For California, this would be Facebook, Uber, or similar employer. Such a study would have significant learning in how various public policies – specifically employment, ethics, privacy law, HIPPA and others – may help or hurt a person with first onset mental illness. A valid hypothesis is that first onset mental illness is a time when significant downward drift occurs with possible treatment delay due to inability to recognize the onset or inability to share the recognition of onset with those who can help.

Such a study would require significant legal counsel to identify all the laws/contracts in place that may prevent the study.

The structure of Orange County enables a much less ambitious initial attempt at a downward drift study for the population that has the greatest distance to drift down, a theoretically higher risk of experiencing downward drift, and an apparent lack of regional resources. This trifecta isn’t likely to exist in other places. The hypothesis of some leaders is that there is no problem in certain communities and thus downward drift does not occur. Just having the conversation is an opportunity for learning. Conducting the study is a very visible and quantifiable method with feedback incentive to reach an agreement that downward drift does or does not exist in Orange County.

If we can agree that the theory does in fact exist in reality in Orange County then, perhaps, we can move on to the more ambitious study described above. The likelihood that downward drift does, in fact, exist in Orange County is quite high, however disagreement exists on this particular phenomena. This is the motivation for submitting this study.

Innovations Team

Thank you for your submission. The Innovation team needs additional information, please elaborate on your responses as best as possible so that we may work through our review process.

•This idea proposes the imposition of a user fee on South Planning Area jurisdictions and residents that utilize North and Central Planning area behavioral health and housing resources. Would these fees go to the Central and South Planning areas?

•What would be the learning objectives for this project?

•How would the success of this project be measured?

It is acknowledged that this is more of a wild idea than most Innovation proposals. The goal is a downward drift study with feedback to SPA jurisdictions. A user fee is the least disruptive to a homeless/mentally ill person’s life (i.e. relocating the homeless/mentally ill person back to SPA is highly invasive). However, upon reconsideration, a choice should be offered to the individual to be reunited with a more familiar community/more familiar people based upon the each person designs their own recovery ideal. Maintaining contact with family/community is a goal referenced since at least 1957 Short Doyle, so it is anticipated that this wouldn’t be controversial. Patricide/Matricide among mentally ill individuals seems anecdotally to be more common among the wealthy, but I am not familiar with any study that breaks down this risk across the socioeconomic spectrum sliced & diced by treatment naive or treatment experienced patients (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889623/ https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201200484). If reunification is a choice then this open question would need to be addressed. The process might only be a highly controlled, brief contact for the purpose of forgiveness/moving on. If money is involved then the existing policy/laws/contracts would likely make the decision on where the money goes (or if this is even possible). I am open to other feedback interventions, but the goal is a downward drift study with feedback to SPA jurisdictions. A user fee is one way to quantify downward drift in a published record, but there are likely other methodologies to achieve the same goal.

Quality mental health interventions for the wealthy are somewhat of a black box conducted in private. A valid hypothesis is that quite a bit of money is spent prior to downward drift in an attempt to return to normalcy. A valid hypothesis is that the money spent on those that have downward drifted doesn’t achieve treatment goals nor have quality measures to enable rational choice of superior products/services. Anecdotally, these treatments may fall into the wilderness intervention, military intervention camps, alcoholic re-hydration protocols, cash-pay TMS, patient identified drug therapy etc. Possibly there are other hidden actors offering various options for a hefty price. Going beyond the user fee/reunification methodology, it is also possible to inquire about the interventions attempted in private, the costs and the outcomes based upon the cases found and do some learning about trends in this cohort. Mental/Medical Morbidity and mortality associated with these black box interventions would be highly interesting. It is also likely that some abandoned dependents relocated to Orange County for alcohol/drug rehab from nationwide locations may be found. Some data collection safe harbors may be needed to obtain truthful answers as Innovation projects are intended for learning, not compliance.

The ideal outcome for this project would be evidence based interventions for people of high socioeconomic status that can compete in an open market with whatever black box options currently exist. Hypothesized interventions might include a payee with high integrity to help manage monthly allowance, education about the limits of money (i.e. can’t buy happiness), talk therapy surrounding self-created ideas of prestige/success, self-care, etc.

Minimal success would be counting the number of people who downward drifted from SPA to NPA & CPA and estimating the annual rate or population rate.

These answers are based upon learning about a cohort aged approximately 16-35 years old who have downward drifted into poverty likely because of serious mental illness or substance abuse. These answers may be different if later onset serious mental illness is a phenomena in high socioeconomic status demographics.

Based upon the August 2 and August 15 correspondence between cities in Orange County and Orange County (https://www.ocregister.com/2019/08/16/south-orange-county-mayors-contend-there-are-empty-beds-in-north-county-to-help-their-homeless-population/ https://www.sanclementetimes.com/south-county-cities-urge-bartlett-end-countys-regional-approach-homelessness/ https://www.san-clemente.org/home/showdocument?id=53333) there is a fundamental ignorance in leadership about homelessness interventions.

1) Point in Time Counts are snapshots for one to ten days only and are publicly available data easily referenced, but shall mislead when used for any other days. PITs are for Federal goals, not local goals (https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/point-time-counts-are-crucial-data).
2) Vulnerability Index – Service Prioritization Decision Assistance Tool (VISPDAT) data is proprietary data that no one seems to have access, but will give very detailed metrics for currently homeless and the wave of future homeless who are currently at risk. From anecdotal experience, filing a VISPDAT is a protected activity and not highlighted to a homeless individual as a must-do. VISPDAT is geared towards meeting local goals.
3) Section 8 wait-lists are a poor metric for homelessness as, in Anaheim’s case, the wait-list is capped at 10,000 and a lottery is conducted to get onto the wait-list. Thus the true demand is not truly measured. Last asked, Anaheim had about 27,000 on their Section 8 wait-list.
4) Getting into a homeless shelter isn’t the sophomoric vision of South County city leadership. The unwritten, or at least proprietary, policies and procedures of getting into a homeless shelter are quite extensive (Courtyard is an exception, but one that dramatically drives down life-expectancy from loss of hope, lack of sanitation, lack of security, risk of rabies, mosquito vector disease, community stigma, anticholinergic overdose symptoms, etc). That is assuming one avoids all of the look-alike resources that don’t actually have beds nor services. I have grown a collection of business cards for people representing housing “resources”, but don’t actually have housing available.
5) Getting into a homeless shelter also requires the homeless person to conduct their own patient hand-off (see Mental Health Participant Hand-off idea). This doesn’t work well when someone is experiencing confabulation, lack of short-term/long-term memory, hx of traumatic brain injury, psychosis, catatonia, dementia, delirium, etc.
6) The coming evictions from mobile home parks in North Orange County will likely exceed all available shelter space (https://www.ocregister.com/2019/03/26/residents-of-a-mobile-home-park-in-fullerton-and-anaheim-fear-affect-of-rent-increase-on-their-limited-incomes/). This mobile home park investment strategy will likely cross through all of Orange County (https://time.com/5565832/john-oliver-mobile-homes-last-week-tonight/). Perhaps a strategy to keep mobile home owners in their home would be a better use of South County resources.
7) Retaliatory relocation is quite easy and inexpensive. SPA ships north, CPA and NPA can ship south. Offering cash/liquor/food to homeless and contracting with a transportation companies for such a short distance isn’t that expensive. Governments need not be involved as private citizens can make contracts, invest in operations and advocate for their very local community. This is a tremendous waste of resources, but if that is the SPA strategy then it can be the strategy of Central and North Orange County residents as well.

I don’t know how to turn Marie Antoinette from dreams of sweet pastries to find reality. Helping South Orange County leaders find reality would be nice.

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