|Budget Issue:||Inmate mental health care staffing.|
|Program:||Department of Corrections and Rehabilitation|
|Finding or Recommendation:||Reject Governor’s 2010-11 budget proposal for authority to establish 45.4 additional mental health positions as well as to appropriate $9.8 million to support some of these positions, because the California Department of Corrections and Rehabilitation has not made a strong enough case to convert to a new staffing ratio model that would further increase the already significant and growing state costs for in-prison mental health care.|
In 2006, the federal court in the Coleman v. Schwarzenegger case pertaining to inmate mental health carerequired the California Department of Corrections and Rehabilitation (CDCR) to develop a new methodology for determining future staffing levels necessary to provide constitutionally adequate mental health care. In response to this court order, the 2006-07 budget package included $750,000 for CDCR to conduct a staffing analysis study along with statutory language that specified that the results of this study would be incorporated in the subsequent budget process. The eventual study, known as the Staffing Analysis Model (SAM), was completed by external consultants and presented to the Legislature in June 2007. In general, SAM takes into account the types of tasks that need to be completed to provide such care, as well as the time it takes and the classification of employees needed to complete these tasks.
Based on the results of this model, the 2008-09 budget authorized 404.7 positions for inmate mental health care—(1) 245.1 mental health positions under the authority of CDCR and (2) 159.6 nursing positions who were under the authority of the Receiver, but intended assigned to provide mental health services. However, the 2008-09 budget did not appropriate additional funding for these positions. This is because CDCR indicated that the positions would be funded temporarily with salary savings. At this time, the department reports that none of the 404.7 positions have been filled. Moreover, the 2009-10 budget included an additional $8 million to support staffing for mental health crisis beds based on the results of SAM.
After further review of the above staffing model, the department now concludes that SAM as developed by the external consultants is unreliable. (We discuss the department’s rationale for this conclusion below.) As a result, the department recently developed a new workload methodology internally in consultation with the Special Master assigned by the Coleman court. According to CDCR, mental health clinicians and managers were asked to estimate the staff necessary to deliver an adequate level of mental health services to inmates. The department then used this data, as well as data collected from several other states, to develop staffing ratios for most mental health position classifications (such as psychologists).
Based on these ratios, the department requests an additional 362.1 positions and funding that will eventually total $77.2 million annually upon full implementation in five years. These positions are in addition to the 245.1 positions authorized for CDCR in the 2008-09 budget, for a total of 607.2 mental health positions. (The 159.6 unfunded nursing positions under the control of the Receiver are not included in this total and would continue.) For 2010-11, the Governor’s budget proposes a $9.8 million General Fund augmentation to support 73 of the 607.2 positions. (After the release of the Governor’s budget, CDCR informed us that the $9.8 million request is over budgeted by $2.2 million, due to a calculation error regarding equipment costs.) As discussed above, under the department’s request this level of funding would eventually increase to $77.2 million in 2014-15.
While we recognize the need and the desire of the federal court to ensure that there is an adequate level of staff available to provide the necessary mental health services to inmates, we have several concerns with the Governor’s proposal, as discussed below.
Need for New Staffing Methodology Not Fully Justified. As mentioned above, CDCR perceives that SAM is now an unreliable model for estimating mental health staffing needs. Specifically, the department suggests that (1) the model is based on flawed assumptions regarding workload requirements, (2) the external consultants did not adequately consult with CDCR staff as the model was being developed, (3) the model is not transparent and is difficult to update for changes in the mental health delivery program and the size of the inmate population. Our analysis indicates, however, that CDCR’s logic for dropping SAM and moving to a new and more costly model is questionable.
Although the Special Master also raised a similar concern that some of the assumptions in SAM are flawed, he did find the model to be completely functional and adaptable. He recommended that the department address the flawed assumptions and then continue using SAM.
Moreover, a report prepared for the department by the consultants that developed SAM appears to contradict some of CDCR’s assertions. According to this report, all workload assumptions were validated against the department’s own data, as well as against industry standards and comparable data from other states, and reviewed by clinical experts, including CDCR staff. The consultants estimate that CDCR invested over 3,500 hours of staff time reviewing and providing feedback on SAM. In addition, the consultants who developed SAM contend that the model was designed specifically to be transparent and to allow CDCR to continually update mental health staffing requirements based on dynamic factors (such as revisions to contemporary correctional mental health standards and changes in the size of the inmate population).
We also note that the department plans to use its staffing-ratio methodology only for determining the need for certain mental health positions (such as psychologists and psychiatrists). For other types of positions (such as nurses), the department intends to continue using SAM. At this time, it is unclear why CDCR believes that two different staffing methodologies are warranted.
Vacancy Rates Remain High for Certain Mental Health Classifications. Our analysis indicates that CDCR may not be able to able to effectively fill all of the requested positions in the timeline outlined by the department, due to the high vacancy rates that currently exist for such positions. More than half of the 607.2 positions that the department is seeking funding for over the next five years are for classifications with vacancy rates of more than 10 percent. For example, 178 positions are for the classification of Licensed Clinical Social Worker, for which the department currently has a vacancy rate of 27 percent. In addition, 39 positions are for the classification of Staff Psychiatrist, for which the department currently has a vacancy rate of 40 percent. Given such high vacancy rates, the requested funding may not be spent as proposed in the budget year to the extent that the requested positions are not filled.
Salary Savings Remain Available. As mentioned previously, the department’s initial plan was to fund the roughly 400 mental health positions authorized in the 2008-09 budget temporarily with salary savings. According to CDCR, none of these positions have been filled and $46 million in salary savings from the vacant mental health positions has instead been spent on nursing registry. However, data provided to us by the department indicate that actual salary savings from the vacancies in mental health staff in 2008-09 totaled about $100 million. At the time of this analysis, the department has yet to fully explain how the remaining salary savings were spent and why the $100 million in savings would not be more than sufficient to temporarily offset the General Fund augmentation proposed in the Governor’s budget.
State Costs for Mental Health Care Have Grown Significantly. The Governor’s budget proposes a total of $385 million from the General Fund for mental health services in 2010-11. This is $219 million more than the amount the state spent on such services in 2005-06 — more than doubling expenditures in this area. The increases in General Fund expenditures on inmate mental health care have largely been drive by the need for additional staff (such as pharmacy technicians) and significant increases in employee compensation for existing staff (such as for psychiatrists).
In view of the above concerns, we recommend that the Legislature reject the Governor’s 2010-11 budget proposal for authority to establish 45.4 additional mental health positions as well as to appropriate $9.8 million to support some of these positions. The CDCR has not made a strong enough case, in our view, to convert to a new staffing ratio model that would further increase the already significant and growing state costs for in-prison mental health care. In addition, we recommend that the Legislature require the department to report at budget hearings on the level of mental health staffing that would be needed in the budget year based on the preexisting SAM, updated as necessary to reflect any new workload requirements.