Executive Summary

Purpose and Methods

The purpose of this report is to inform citizens and policy makers concerning where the San Mateo County Alcohol and Drug Program (ADP) recovery services system is working, point out areas of unmet needs, and discuss how the system can be modified over time to address these needs in the difficult funding environment of the 1990's. In preparing this report, the authors reviewed pertinent county documents and data, and conducted a key informant survey.

Overview of County Recovery Services

The current San Mateo County alcohol and other drug (AOD) recovery system is essentially a lean system of basic treatment types. San Mateo County contracts with twelve agencies to provide AOD recovery services to county residents. These services include a range of modalities: short-term non-medical and methadone detoxification, residential, outpatient counseling, and methadone maintenance. The system has initiated several relatively small new programs to meet some identified needs.

The document review and key informant survey identified a number of needs. Some are being addressed by specific programming but there is need for additional services, other needs are not being addressed by any specific programming. Following are the issues identified and recommendations:

• Waiting lists. Provider waiting lists are an important indicator of the extent of need for increased substance abuse recovery services. Most providers surveyed stated that their waiting lists were about 3 months long, or between 40 to 80 clients per month.
   
• Residential services. An increase in residential services is a strongly perceived need of the county AOD service system. Residential recovery is the service of choice for many clients, because it offers an intensive, structured program, and it removes clients from the environment linked with their AOD abuse.
   
• Medical detox. Another need identified was for a medically supervised detox program. The existing detox provider does not have its own medical supervision, which is required when clients are detox-ing from certain substances, such as Valium and barbiturates.
   
• Relapse prevention and aftercare. Another need identified was for services to help prevent clients from relapsing. A tendency to relapse is part of addiction; preventing it with support groups and individual counseling is more cost-effective than treating relapse when it occurs.
   
• Services for women, pregnant women, and women with children. Respondents identified a need for more residential and detox services for women, especially for women with children. Women with children often cannot participate in programs unless they bring their children with them. Currently, Thea Bowman House is specifically identified as serving women with children, but capacity is not sufficient to meet demand, and women with more than two children cannot be served.
   
• Homelessness. In 1991, the estimated number of homeless persons in the county was 8,665 and this number has certainly increased in the last three years. Only one small program for women with children serves the homeless, although other providers serve this population to some extent. Data should be collected on the homeless now served to assess who is serving them and how, and to determine the unmet needs if any.
   
• African-Americans. The ADP continues to develop services in East Palo Alto that target African-Americans. A new program, Free At Last, opened in January. Services provided include drop-in counseling, assessments, and referrals. The services are already being utilized.
   
• Latino services. A need that was strongly identified by many informants was for additional bilingual/bicultural services for the county's large Latino population, which is the largest ethnic population in the county. There is only one 6-bed residential facility for the Spanish-speaking population, and that is for women (Casa Maria) . The ADP has issued RFP's for a Latino men's residential program and a Latino nonresidential program.
   
• Asian/Pacific Islanders. The proportion of participants in recovery services who are Asian/Pacific Islanders is less than that reported in 1989, while the proportion of Asian/Pacific Islanders in the county population has continued to grow. Filipinos comprise the largest ethnic population within the county's Asian/Pacific Islander population, and the second largest ethnic group in the county. Asians/Pacific Islanders make up 17% of the county's population, but less than 2% of the population in treatment. Providers may have difficulty reaching these groups because they lack staff who are bilingual and bicultural in these cultures. Culturally relevant AOD recovery services for Asian/Pacific Islanders appears to be an increasingly important and unmet need in the county, AOD recovery system.
   
• HIV-positive/persons with AIDS. Current estimates of persons infected with HIV in San Mateo County range from 3,000-5,000 persons; approximately 650 of these are intravenous drug users. The county AIDS program provides testing, HIV education, and counseling at recovery programs. One unresolved issue is that clients' medical needs may be perceived to conflict with other program policies and procedures, limiting access to existing programs. There are no specific facilities for substance abuse clients with HIV or AIDS. The more these clients can be in a AOD free environment, the more their own quality of life is improved, and the less likely they are to spread the virus thorough unsafe behaviors. There is a need for more AOD providers who are skilled and knowledgeable in dealing with these clients. The ADP is exploring the possibilities for providing additional services in this area.
   
• Gays and lesbians. Sexual minorities experience barriers to accessing recovery services. These can include distrust of the system, homophobia, and lack of program staff who are sensitive to sexual orientation issues. There is an added risk of HTV among gay men, relatively high risk of alcoholism among gay men and lesbians, and recent reports suggest that there is once again high amphetamine use (sometimes injected) among gay men. Particularly in light of the AIDS epidemic, it would seem desirable to have AOD recovery programs configured for this population, with identified gay and lesbian staff. This need was identified in a 1989 County study. In 1994, no specific initiatives have been developed to address this population.
   
• Dually diagnosed. Most mental health programs screen out people who have substance abuse problems, and AOD programs generally do not accept people who take psychotropic medications and/or have pronounced symptoms of severe mental illness. These barriers to recovery can leave the dually diagnosed client with no place to go. The county's dual diagnosis project was recently lost to budget cuts. At Project 90, a consulting psychiatrist leads a group for dually diagnosed clients, and Palm Avenue Detox accepts clients who use psychiatric medications. But specific recovery slots and programs are needed for this population, with service protocols developed to address their specific needs.
   
• Children and youth. Some providers feel that services are needed for children of substance-abusing parents. Recent national data indicate that AOD use among youth is once again increasing. The county provides prevention and early intervention services for youth, and has implemented an adolescent residential recovery program for adolescents. Currently, no additional programming is planned for adolescent AOD recovery.
   
• Seniors. The 1992-93 report notes the need for a residential program targeting the elderly, which should be addressed if funding becomes available. Currently, Pyramid Alternatives is the only agency that provides specific AOD programming for the senior population. They receive far more requests for service than they can provide.
   

Prevention and Treatment: A Continuum of Care

Experts in the AOD field recognize the need for a comprehensive continuum of care to effectively address AOD problems. San Mateo County provides the basic elements of a continuum of care for AOD, from prevention programming through outreach, crisis intervention, screening and assessment, referral, detox, recovery services, and limited aftercare. Prevention efforts are important to reduce substance abuse problems in the future. Yet, prevention programs do not address the many people who already have AOD problems. Substance abuse treatment has been extensively evaluated, and has been shown to be effective. Besides helping people achieve and maintain abstinence from alcohol and other drugs, outcome studies have shown that treatment reduces crime and violence. To address our current AOD-related problems, such as crime and family violence, making treatment widely available is imperative. For the foreseeable future, both prevention and treatment will be important elements of a comprehensive continuum of services to address AOD problems.

Funding Planning

Long waiting lists demonstrate that San Mateo County's ADP lacks the capacity to meet the current demand for recovery services. Needs for additional capacity, and additional services for particular populations, have been identified, but funding has been cut due to local, state, and federal budgetary shortfalls. One of the obvious costs of any further reductions in services is that unaddressed needs for substance abuse services will expand to overwhelm the resources of other service systems. Given the limited funding of the system, and the overflow of clients, the providers and administration are to be commended for the successes they have achieved under difficult circumstances. The system has been adjusted and efficiency maximized; without additional funding, it seems unlikely that further substantial improvements can be made. The priorities for meeting identified needs are therefore, 1) prevent additional funding cuts, and 2) proactively seek additional funding.

Data and evaluation. The ADP has identified and responded to the need to have its own database about its AOD services. A consultant was retained to develop a new data collection system, which is being implemented. It includes three new tools-intake, exit, and 6-month follow-up forms-which will be used by all county providers. For both evaluation and funding purposes, it is highly desirable for the County ADP to collect information consistently across all programs. This database will be essential for preparing both "Needs" and "Evaluation" sections of federal grant applications.

State and Federal Funding for AOD Recovery Services

There are several developments at the state and federal level that may affect county budgeting and reimbursement for some AOD recovery services. These include:

State funding. 1) Restructuring. The Governor's proposed budget includes a provision for restructuring of state AOD funds. Restructuring will establish a Community Services Fund in each county to support many services, including substance abuse. 2) Negotiated Net Amount. This new process changes the way the state gives out Community Development Block Grant funds to counties. All services will be subject to a newly developed rate scale, which may lead to re-budgeting for county recovery services.

Managed care and expanded MediCal reimbursement. A new policy initiative underway in California will result in a managed care plan for AOD recovery services. If approved, the plan would allow reimbursement for some AOD services through MediCal, creating a new funding stream for some recovery services.

National health care. It is unclear to what extent any national health care plan will include AOD recovery services. However, state efforts to develop a AOD managed care plan may result in expanded AOD MediCal benefits, which would then be implemented in California in coordination with the national health care legislation that is adopted.

Federal grant funding. Federal grant funding from agencies such as the Center for Substance Abuse Treatment (CSAT) cannot be used to supplant local funding. Furthermore, areas without sufficient basic services often fare poorly in the competition. Funding is primarily for special populations and projects, for limited periods of time. Thus, replacement of the ADP's system-wide cuts will not be possible with existing federal grant funding program. Should the system be cut further, possibilities for federal funding may dwindle. On the positive side, some of the identified gaps in services for particular populations, such as recovery services for Asians and Pacific Islanders, could be filled by federal grants. Pursuing this funding is time-consuming and the process is highly competitive. To be successful, the ADP will have to find the staff time and external resources to prepare a successful application. These emerging policy and funding trends lead to the recommendation that current levels of AOD recovery services should be maintained, and expanded if at all possible, in order to maximize leveraging of these sources of revenue.

Strategic funding planning. Funding agencies' requirements are such that a county  cannot succeed by designing a program and then looking for funding for it, or by trying to find funding to replace cuts in a particular program. However, by clarifying priorities in advance, and doing some planning, the County can position itself to compete for funds successfully.

Recommended proactive steps for the San Mateo County ADP: 1). Identify particular needs to seek funding for. Determine whether the ADP wishes to directly seek funds or assist a contractor to obtain funds. 2). Identify staff who will be responsible for identifying and following through with funding sources. 3). Initiate discussions with any contractors involved. Identify where funding and staff time for grant preparation will come from. Identify any consultants and grant-writers. 4). Assemble data, especially data relevant to statements of need for specific populations. 5). Contact funding agencies; maintain communication with agency staff to identify information on upcoming funding.