BILL ANALYSIS Ó
SB 614
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Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
614 (Leno) - As Amended July 6, 2015
SENATE VOTE: 40-0
SUBJECT: Medi-Cal: mental health services: peer, parent, and
family support specialist certification.
SUMMARY: Requires the Department of Health Care Services (DHCS)
to establish a program for certifying peer and family support
specialists (PFSS) and to collaborate with interested
stakeholders and allows DHCS to seek any federal waivers or
state plan amendments to implement the certification program.
Specifically, this bill:
1)Establishes numerous definitions in furtherance of this bill
including adult peer support specialist, family peer support
specialists, and parent peer support specialist.
1)Requires peer support specialist services to provide support,
coaching, facilitation, and education to Medi-Cal
beneficiaries that is individualized to the beneficiary and is
conducted by a certified peer support specialist.
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2)Requires DHCS to establish a peer, parent, and family support
specialist certification program by July 1, 2017. that must do
the following:
a) Establish a certifying body, either within DHCS, through
contract, or through an interagency agreement, to provide
for the certification of peer, parent, and family support
specialists;
b) Provide for a statewide certification for each of the
following categories of peer support specialists, as
contained in federal guidance issued by the Centers for
Medicare and Medicaid Services:
i) Adult peer support specialists, who may serve
individuals across the lifespan;
ii) Transition-age youth peer support specialists;
iii) Family peer support specialists; and,
iv) Parent peer support specialists.
c) Define the range of responsibilities and practice
guidelines for the categories of peer support specialists;
d) Determine curriculum and core competencies, including
curriculum that may be offered in areas of specialization,
such as older adults, veterans, family support, forensics,
whole health, juvenile justice, youth in foster care,
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sexual orientation, gender identity, and any other areas of
specialization identified by DHCS;
e) Requires specialized curriculum to be determined for
each of the categories of peer support specialist and
requires that core competencies-based curriculum include,
at a minimum, all of the following elements:
i) The concepts of hope, recovery, and wellness;
ii) The role of advocacy;
iii) The role of consumers and family members;
iv) Psychiatric rehabilitation skills and service
delivery, including defined practices;
v) Cultural competence training;
vi) Trauma-informed care;
vii) Group facilitation skills;
viii) Self-awareness and self-care;
ix) Co-occurring disorders of mental health and
substance use;
x) Conflict resolution;
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xi) Professional boundaries and ethics;
xii) Safety and crisis planning;
xiii) Navigation of, and referral to, other services;
xiv) Documentation skills and standards; and,
xv) Study and test-taking skills.
f) Specify training requirements and requiring training to
include people with lived experience as consumers and
family members;
g) Specify required continuing education requirements for
certification;
h) Determine clinical supervision requirements for
certified personnel that require, at a minimum, certified
personnel to work under the direction of a mental health
rehabilitation specialist or substance use disorder
professional;
i) Establish a code of ethics;
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j) Determine the process for certification renewal;
aa) Determine a process for revocation of certification;
and,
bb) Determine a process for allowing existing personnel
employed in the peer support field to obtain certification
under this article, at their option.
3)Establishes minimum requirements to be certified as an adult
peer support specialists, a transition-age youth peer support
specialist, a family peer support specialist, or a parent peer
support specialist that must include the following:
a) Be at least 18 years of age;
b) Have or have had a primary diagnosis of mental illness,
substance use disorder, or both, which is self-disclosed;
c) Have received or is receiving mental health services,
substance use disorder services, or both;
d) Be willing to share his or her experience of recovery;
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e) Demonstrate leadership and advocacy skills;
f) Have a strong dedication to recovery;
g) Agree to uphold and abide by a code of ethics. A copy of
the code of ethics shall be signed by the applicant;
h) Successful completion of the curriculum and training
requirements for the appropriate peer support specialist
classification;
i) Pass a certification examination approved by the
department for the appropriate peer support specialist
classification; and,
j) Successful completion of any required continuing
education, training, and recertification requirements.
4)Specifies that peer support specialists are not qualified or
authorized to diagnose an illness, prescribe medication, or
provide clinical services.
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5)Requires DHCS to closely collaborate with the Office of
Statewide Health Planning and Development and its associated
workforce collaborative, and regularly consult with interested
stakeholders in developing, implementing, and administering
the peer, parent, and family support specialist certification
program established pursuant to this article. Requires
consultation to initially include, at a minimum, bimonthly
stakeholder meetings, which may also include technical
workgroup meetings.
6)Requires DHCS to amend the Medicaid state plan to do both of
the following:
a) Include each category of certified peer, parent, and
family support specialists as a provider type; and,
b) Include peer support specialist services as a distinct
service type which may be provided to eligible Medi-Cal
beneficiaries who are enrolled in either a Medi-Cal managed
mental health care plan or a Medi-Cal managed care health
plan.
7)Authorizes DHCS to seek any federal waivers or other state
plan amendments as necessary to implement the certification
program provided for under this article.
8)Requires full federal financial participation (FFP) and all
necessary federal approvals to be obtained before the
provisions of this bill are enacted.
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9)Authorizes DHCS to utilize Mental Health Services Act (MHSA)
funds and any designated Workforce Education and Training
Program resources to develop and administer the peer, parent,
and family support specialist certification program.
10)Authorizes MHSA funding to serve as the state's share of
funding for purposes of claiming FFP.
11)Authorizes DHCS to enter into exclusive or nonexclusive
contracts on a bid or negotiated basis, including contracts
for the purpose of obtaining subject matter expertise or other
technical assistance. Authorizes contracts to be statewide or
on a more limited geographic basis.
12)Authorizes DHCS to implement, interpret, or issue plan
letters, plan or provider bulletins, or similar instructions,
without taking regulatory action, until the time regulations
are adopted.
13)Requires DHCS to adopt regulations by July 1, 2019.
Requires, if regulations have not been adopted, beginning six
months after the effective date of this article, DHCS must
provide semiannual status reports to the Legislature until
regulations have been adopted.
EXISTING LAW:
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1)Establishes the Medi-Cal program, administered by DHCS, under
which qualified low-income individuals receive health care
services.
2)Grants DHCS the sole authority in state government to
determine the qualifications, including the appropriate
skills, education, training, and experience of personnel
working within substance use disorder (SUD) recovery and
treatment programs licensed and/or certified by DHCS.
3)Authorizes DHCS to require an individual providing counseling
services in SUD programs licensed and/or certified by DHCS to
be registered with or certified by a certifying organization
(CO) approved by DHCS to register and certify counselors.
4)Grants DHCS the authority to conduct periodic reviews of COs
to determine compliance with all applicable laws and
regulations and to take actions for non-compliance, including
revocation of DHCS's approval.
5)Requires, through regulations, the certification of SUD
counselors to be based on specific counseling competencies,
training, and education, including understanding addiction,
knowledge of treatment methods, and professional readiness.
FISCAL EFFECT: According to the Senate Appropriations
Committee: one-time costs, likely in the hundreds of thousands
per year for one to three years, to develop program standards
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and seek federal approvals by DHCS; uncertain ongoing costs to
manage the program; uncertain impact on county mental health
plans that provide specialty mental health services in the
Medi-Cal program; and uncertain impact on Medi-Cal managed care
plans that provide mental health services to Medi-Cal
beneficiaries when the mental illness is not severe.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author this bill
provides California the opportunity to receive new federal
Medicaid funds, expand our behavioral health workforce, and
include evidence-based PFSS services into our comprehensive
health and behavioral health care system. A PFSS is a person
who uses lived experience from mental illness plus skills
learned in formal trainings, coupled with a certification
process, to provide guidance in a behavioral health care
setting to promote mind-body recovery and resiliency.
Quantitative, independently assessed research findings support
the efficacy of a PFSS. Peer support services help people
navigate systems of care, remove barriers to recovery, stay
engaged in the recovery process, and live full lives.
More than 30 states have implemented a certification process
under their Medicaid programs. The author argues that
California would benefit from enactment, for we presently have
no standard definition of training or certification process
and could be obtaining a 50% federal match for services, which
are currently supported by local funds. DHCS has included the
PFSS as a workforce expansion strategy in the recent 1115
Waiver Renewal "Medi-Cal 2020", which it submitted to the
federal Centers for Medicare and Medicaid Services (CMS) on
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March 27, 2015. The author concludes that this bill can be
the vehicle for this specific purpose.
2)BACKGROUND.
a) PFSS. According to DHCS, a substantial number of
studies demonstrate that the PFSS improves patient
functioning, increases patient satisfaction, reduces family
burden, alleviates depression and other symptoms, reduces
hospitalizations and hospital days, increases patient
activation, and enhances patient self-advocacy. PFSS are
used in at least 36 states and throughout the Veterans
Health Administration. PFSS participating in SUD treatment
activities are currently a recognized Medicaid service
provider in California for SUD services; however, these
providers are often limited in the services they are able
to provide in traditional health care settings. DHCS states
that expanded use of PFSS in mental health and SUD as part
of a care team can improve care coordination between
behavioral health and physical health care needs of
patients. DHCS included PFSS as a component to the recent
1115 Waiver Renewal.
b) Certification of PFSS. CMS released guidance for
establishing a PFSS certification program to enable FFP in
an effort to more fully incorporate and expand the use of
peers. CMS requires peer support providers to complete
training and certification as defined by each state.
Substantive work has been conducted in California by the
Working Well Together Statewide Technical Assistance
Center, a collaborative of peer and client-oriented
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organizations, which culminated in a final report of
recommendations to proceed with peer certification. This
effort identified key issues for laying the foundation of
certification, including training recommendations and core
components for a statewide certification program;
establishing a standard of practice and core competencies;
defining the level of care and services; integrating
services across physical health, mental health, and SUD
services; and, allowing for portability from one county to
another.
c) DHCS Certification Duties. While DHCS does not
currently have licensing responsibilities, it does ensure
that certified counselors provide quality treatment to
clients by enforcing the Counselor Certification
Regulations for Substance Abuse Disorder (SUD) counselors.
The Department of Alcohol and Drug Programs (DADP),
established to alleviate problems related to inappropriate
alcohol and drug use and abuse, adopted SUD counselor
certification regulations in April 2005. DADP's programs
and duties were transferred to DHCS on July 1, 2013.
d) Community Health Workers (CHWs). CHWs educate and
promote behavioral health prevention and wellness topics,
and provide resources using culturally and linguistically
appropriate methods specific to the communities they serve.
While CHWs are not defined in current law, CHWs are
recruited at the county level and are individuals who have
received services or are family members of persons who have
received behavioral health services and interested
community members who have general knowledge of the local
county system. CHWs conduct educational presentations and
perform community outreach activities addressing prevention
and early intervention needs to groups and individuals
within community organizations countywide such as schools,
churches, etc. In Filipino and Latino communities, CHWs
are widely known as "promotoras".
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For example, in San Bernardino County, CHW undergo forty
hours of extensive training on various behavioral health
topics and learn how to identify and recognize early signs
and symptoms of substance abuse and mental health
conditions and carry resource manuals and brochures to
disseminate health care information in several ways that
include:
i) Educational presentations to faith based groups,
community groups, and school groups (such as Parent
Teacher Associations);
ii) "Knock and Talk" sessions where they target relevant
neighborhoods to provide outreach, education and support;
iii) Conduct one-on-one educational sessions in homes or
smaller groups;
iv) Provide information at community cultural events and
fairs; and,
v) Meet with local agencies to advocate for policy
change that include primary care facilities, government
agencies, and local businesses.
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3)SUPPORT. The sponsor of the bill, the County Behavioral
Health Directors Association (CBHDA), states in support of the
bill that peer providers who use their lived experience with
mental illness and recovery, coupled with skills learned
through formal training, are valuable additions to service
delivery in behavioral health settings. CBHDA states that
this bill will offer training and certification for peers,
parents, and family support specialists and enable California
to receive federal funds for this purpose.
Supporters of the bill, including the California Coalition for
Mental Health, Children Now, Disability Rights California, and
Western Center on Law & Poverty, write that the state's
underutilization of the PFSS at a time when the Medi-Cal
program has been expanded and the health care system needs to
ensure that the appropriate workforce meets demand, including
culturally and linguistically appropriate care. Supporters
cite research that the PFSS helps clients hone life
functioning skills, alleviate depression and other symptoms,
enhance clients' advocacy and navigation abilities, reduce
hospitalizations, and improve client satisfaction. Supporters
further cite the lack of statewide training and supervision
standards for the PFSS and state that CMS, the U.S. Department
of Veteran's Affairs, and more than 30 states have already
recognized the importance and value of PFSS certification.
4)CONCERNS. The Committee notes that multiple letters of
concern have been submitted stating that in order to ensure
underserved communities receive equitable services that are
culturally and linguistically appropriate, language for the
bill should be considered that would simply allow Counties to
utilize "Community Health Workers" in lieu of "Peer Support
Specialists" when appropriate to serve racial, ethnic, and
cultural communities.
5)OPPOSE UNLESS AMENDED. The California Consortium of Addiction
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Professionals (CCAPP) states in opposition to the bill that
the regulatory framework presented in the bill is not
practical and that the bill lacks standards of education, a
code of ethics, a defined scope of practice, among other
things. Additionally, CCAPP states with concern that DHCS
does not currently have licensing responsibilities.
6)PREVIOUS LEGISLATION. AB 2374 (Mansoor), Chapter 815,
Statutes of 2014, requires DHCS to, among other things,
conduct periodic reviews of COs and require COs to contact
other COs before registering or certifying a person as an SUD
counselor to determine if the person's registration or
certification had ever been revoked.
7)POLICY COMMENTS.
a) Transitional-Age Peer Specialists. The bill as
currently drafted inconsistently references three
certification categories in some sections, and four
certification categories in others. The Committee
recommends amendments defining "Transitional-Age Peer
Specialist" and conforming amendments that consistently
refer to the four defined certification categories
throughout the bill.
b) Community Health Workers. As previously discussed, CHWs
play a vital role in promoting prevention and wellness
within local communities. The Committee received numerous
letters of concern, requesting an amendment that would
allow counties to utilize CHWs or PFSSs to provide peer
mental health support services. The certification
requirements for PFSSs have been carefully crafted pursuant
to CMS guidance, and the inclusion of CHWs that have not
met the certification requirements set forth in this bill
may jeopardize FFP. The Committee may wish to amend this
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bill to encourage CHW cooperation in facilitating early
intervention for mental health services by partnering with
PFSSs for engagement, outreach and education services.
c) Technical Amendments. The Committee recommends
technical language clarifying that core competencies-based
curriculum should also include elements regarding addiction
recovery principles.
REGISTERED SUPPORT / OPPOSITION:
Support
County Behavioral Health Directors Association of California
(sponsor)
American Federation of State, County and Municipal Employees
Association of California Healthcare Districts
California Alliance of Child and Family Services
California Association of Alcohol and Drug Program Executives
California Association of Social Rehabilitation Agencies
California Coalition for Mental Health
California Council of Community Mental Health Agencies
California State Association of Counties
California Youth Empowerment Network
Children NOW
Common Sense Kids Action
Disability Rights California
Los Angeles County Board of Supervisors
Mental Health America of California
Mental Health America of Los Angeles
NAMI Alameda County South
NAMI California
San Bernardino County
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Service Employees International Union
Steinberg Institute
Telecare Corporation
Urban Counties Caucus
Western Center on Law & Poverty
Women's Policy Foundation of California
Women's Policy Institute
Concerns
African-American Health Institute of San Bernardino County
Connections: a Counseling Center Affirming Spirituality and
Diversity
Council of Sacramento Valley Islamic Organizations
Cyrus Urban Inter-Church Sustainability Network
Diversity in Health Training Institute
Hmong Health Collaborative
La Familia
MAS Social Services Foundation
Multi-Ethnic Collaborative of Community Agencies
Muslim Wellness Foundation-Atlanta
National Association of Social Workers, California Chapter
Native American Health Center
Native Directions, Inc.
Racial and Ethnic Mental Health Disparities Coalition
Tarbiya Institute
Village Project, Inc.
4 Individuals
Oppose Unless Amended
California Consortium of Addiction Programs and Professionals
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097
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