SANTA CRUZ >> Providing care to patients who need it the most is not easy or cheap, and given Santa Cruz County’s current fiscal challenges, how can local public health officials do so in a more efficient and effective way, while maintaining a compassionate approach?

The Santa Cruz County Civil Grand Jury attempted to tackle this question in a newly released 25-page report titled “If You Can’t Measure It, You Can’t Manage It,” by identifying and excavating the issue before proposing a series of viable solutions for leaders in county government to consider.

The independent government watchdog, composed of local citizens, found that the county has struggled to adequately track high-cost beneficiaries, or HCBs, which are patients who require an outsized financial footprint due to frequent and repeated interactions with providers and county agencies. This makes an already intractable and costly problem, much worse in a bleak budgetary landscape.

If the county wants to reverse the trend, the jury concluded, it’ll have to collaborate more with partner providers, double down on comprehensive and seamless administrative systems and attempt to address the underlying clinical issues arising from homelessness, as well as physical and mental afflictions.

“They (the county) must be able to quickly identify these clients, understand the critical incidents that lead to any given patient becoming a high-cost client, and provide services that will improve patient outcomes,” the jury wrote. “In the long run, better management will improve outcomes for all patients, control costs, and reduce the number of HCBs.”

Most of the county’s high-cost beneficiaries are insured by Medi-Cal and receive care through the Health Services Agency’s Behavioral Health Division. To help define the scope of the issue, the jury noted that county health centers offer services to about 15,000 Medi-Cal patients annually. Of that total, about 5,700 receive substance use disorder and moderate to severe behavioral health treatments. But about 15% to 20% of that 5,700 — 855 to 1,140 people — draw down about 55% of overall claimed services.

While about 95% of local funding for these behavioral health services comes through Medi-Cal reimbursements, the local operating costs have consistently exceeded the available state and federal funding and the county must pull from its general fund to fill the gap. For the past three years, it has done so to the tune of $40.3 million.

The jury’s report, its sixth this term, arrived just a couple weeks after the county Board of Supervisors navigated a budget cycle that hit the Health Services Agency and behavioral health teams especially hard. Faced with millions in budget reductions, the agency initially recommended cutting 74.4 full-time staff positions, 11.6 of which were currently filled. But after public backlash, the board pivoted at the last minute to temporarily stave off eliminating about seven of those positions and also scrambled to find support for a couple of key behavioral health programs it has financially backed in the past.

All of this happened before Congress passed a recent spending bill that experts warn will further devastate health care funding, especially for Medi-Cal enrollees.

“As an insurer, most healthcare organizations develop a number of tools and business models to manage the underlying risk,” the jury commented.

A good place to start, as recommended by the jury, would be for the county to further deepen its collaboration with the Central California Alliance for Health, a county contractor of nearly 30 years. The alliance insures about 79,000 of the county’s 82,000 Medi-Cal patients and it has a more robust system for defining, identifying, tracking and regularly reporting on local high-cost patients. Based on financial reserve data from late last year, the alliance also appears to be in a more comfortable financial situation compared to the county.

A strengthened collaboration would look like, according to the report, a new interface to track costs, services and outcomes for high-cost beneficiaries known as a “level of care tool.” The alliance already has a tool of its own, but by integrating its data with the county’s, both groups will get a more complete view of the service landscape and, in turn, delivery of services may improve.

The jury complimented the county and the Sheriff’s Office for consistently treating these beneficiaries with “dignity and respect, despite sometimes difficult conditions,” but it knocked the agencies for an approach that breaks its various response efforts into insulated siloes that don’t talk enough to one another. These programs include an integrated housing and recovery team, a 24/7 mobile crisis response team and enhanced care management. However, their failure to adequately communicate and share information with one another has led to fragmented services, finances and administration. They even lack a comprehensive definition for high-cost beneficiaries, according to the report.

“The Jury finds that each program provides critical services to HCBs and, although they have overlapping goals and likely clientele, too, there is little to no coordination for tracking clients that receive services,” the report reads. “The lack of coordination leads to higher costs in an era of shrinking resources.”

To better this system, the jury called for improved administrative integration, monthly data reports posted on the county’s website and more frequent meetings with the county Mental Health Advisory Board and the Serving Communities Health Information Organization.

“The care of individuals with critical mental health and substance use needs is of utmost importance to the Department, and County staff are deeply committed to this work,” Marni Sandoval, Santa Cruz County director of behavioral health, told the Sentinel in a statement Wednesday. “We would like the opportunity to fully review the report and defer further comment until we make a formal response.”

The county Board of Supervisors and the Alliance for Health both have until Sept. 24 to submit responses to the report. The Health Services Agency director and CEO of the alliance both have until Aug. 25 to provide responses of their own.

The full report is online at santacruzcountyca.gov/departments/grandjury.aspx.