Copyright © 2022 Albuquerque Journal

Part two of a two-day series

Seven years ago, Bernalillo County raised taxes on the sale of nearly every good and service.

The goal of the one-eighth of 1 percent gross receipts tax hike, according to the county website, was to “develop a comprehensive, well-networked and accessible continuum of care for children, youth, and adults in need of behavioral health services” in partnership with federal, state and local government partners, plus the nonprofit and private sector.

It has yielded nearly $161 million in its first seven years. It moved $80 million out the door in that time, and has some of the balance committed to major projects.

But whether it has been effective remains an ongoing question.

Critics say the county’s “Behavioral Health Initiative,” or BHI, has suffered from disorganization, waning engagement with the community and a lack of clear-cut performance standards.

Results are typically reported in terms of “clients seen” or “hours of treatment given,” but big-picture shifts are hard to find.

Suicide rates in Bernalillo County are higher than they were before the tax, according to the most recent state data, and drug overdose deaths have soared. The number of people who are homeless in Albuquerque – which represents the vast majority of Bernalillo County – is higher today than in 2015, according to official counts.

And while the tax has been described as a mechanism for working alongside others to develop a “continuum of care” in the community, the county and its most logical partner – the city of Albuquerque – showed “no effective collaboration at all levels to improve the lives of citizens,” according to a 2021 analysis the city and county ordered to identify local needs.

“Both the City (of Albuquerque) and the County recognize that the behavioral health care system is fragmented, difficult to navigate, and lacking a full complement of care options, at times leading to no or insufficient treatment,” the analysis states. “Stakeholders, especially clients, report a system that sounds good in PowerPoint presentations and on City and County websites but are inaccessible, with several interviewees indicating it was a ‘fantasy system.’”

Bernalillo County Manager Julie Morgas Baca acknowledges the need for improvement. She said the county is now partnering with the city on multiple projects – including the city’s Gateway Center homeless shelter and services hub – reengaging community members in its BHI decision-making and developing a plan to better inform the public about available resources.

“It’s a huge undertaking,” Morgas Baca said of launching the tax-funded BHI. “And we’ve learned – we’ve learned about what to do and what not to do. We’re starting to know more about our strengths and our weaknesses; we’re starting to understand … how important the data is and for us to be able to have our goals and to be able to demonstrate that we meet those goals.”

Haphazard patchwork

The county at some point abandoned the 2015 behavioral health business plan it paid a contractor $325,000 to develop. Officials say they used the document as a guide but that it was written by an Arizona firm and therefore did not completely align with the New Mexico behavioral health landscape.

“It’s not necessarily something that we say, ‘OK, we check this piece of the plan, we check this piece of the plan,’” said county Behavioral Health Services Director Margarita Chavez-Sanchez, who oversaw the BHI for years until a recent restructuring. “But it was the road map that helped to build kind of the structure of the BHI.”

County officials say individual programs have goals, though they are still gathering data to show if what they are funding is working.

All of it feels “haphazard,” said Peter Cubra. A retired Albuquerque attorney and behavioral health advocate who pushed the county to initiate the tax, Cubra said ill-defined goals and poor planning have hurt the execution.

“It is true that inevitably some dollars are being spent in ways that are doing us good – thank God for that – but it is still being done in a haphazard way and patching together bits and pieces of a system does not constitute having a system of care,” Cubra said. “And until we have a vision of a system of care and skillful implementation of a strategic plan to build it, it will continue to be a patchwork that’s ineffective and not efficiently using the funds.”

Cubra currently sits on the steering committee of Coalition for a Safer ABQ, a consortium that includes behavioral health professionals and those with experience using – or trying to access – such services.

The group – composed of people Cubra says “have been trying to improve our systems for many years” – in 2020 began writing city and county officials asking them to create a strategic plan showing how they intended to “establish a genuine continuum of care” for the metro area, coordinating behavioral health and social service programming.

The city and county have since released a draft document that identifies eight strategic goals like “support efforts to increase access and housing stability of individuals with behavioral health needs” and “improve services in the community that will stabilize the need for behavioral health supports and prevent crisis.” Each goal has associated action steps, but there are few measurement standards and no timelines for meeting the objectives.

Cubra characterized the document as “distressingly unprofessional.”

County leaders say they are presently working to make a more detailed strategic plan.

The coalition raised concerns about limited community input in the strategic planning process and urged city and county leaders to maintain an ongoing dialogue with providers, advocates and other stakeholders as they carry out any final strategic plan.

The community was supposed to be part of the BHI.

The county has turned to subject-matter experts from the community to serve on the committees established to help guide BHI spending, but some of those committees convened only sparingly in recent years. Morgas Baca said the county “underutilized” those groups and that she is actively working to reengage community stakeholders.

“I just consider them a tremendous resource. I think that they needed the acknowledgement from me that they are valued,” Morgas Baca said.

Program results

The BHI currently funds 40 contracts throughout the community.

The four primary focus areas are:

⋄ Crisis services, including the law enforcement and clinical support teams that respond to 911 calls for nonviolent incidents involving someone with a behavioral health issue;

⋄ Community supports, such as peer-to-peer services for those with behavioral health concerns;

⋄ Housing; and

⋄ Prevention, Intervention and Harm Reduction, such as suicide prevention programs and initiatives aimed at reducing “adverse childhood experiences.”

The county says the BHI programs have served at least 131,732 individuals in just over seven years. County officials say they are confident the programs are making a difference in people’s lives.

“Now that I’ve worked with these providers for so long, they’re doing amazing stuff,” said Charlie Verploegh, who led the BHI before recently leaving the county for a new position. “When I go, when I listen to the stories about clients, it’s amazing.”

Officials say they build performance metrics into each contract and that staff – including six special projects and program coordinators – oversee the contracts, though they acknowledge they could use more personnel.

But the numbers publicly reported are often encounter- or engagement-based – the number of service hours provided, counseling sessions conducted or referrals made. Cubra said that is of limited use.

“It’s just bean-counting to say we had 1,752 case management encounters paid for. What does that tell us? What if 100% of the case managers don’t know what they’re doing or if people who have the highest needs never get any case management, but the easy-to-serve do?” he said. “They haven’t done any efficacy measures of any kind.”

Since the tax’s inception, the county has prioritized “process” evaluations, Chavez-Sanchez said. Those evaluations, she said, “were really helpful in gleaning more insight into the gaps both in oversight and contract compliance.”

But outcomes are a different, and mostly unstudied, subject.

County leaders say they now have contracted two new firms that will start looking closer at program results will also help with contract review and improvement.

Findings made so far by the Institute for Social Research at the University of New Mexico run the gamut, according to Paul Guerin.

Guerin, director of the ISR’s Center for Applied Research and Analysis, has authored many of the reports on BHI programs. He said some of the BHI’s contract providers have worked to document changes between a client’s intake and discharge that indicated their programming had a positive impact. But in other cases, researchers found that the providers could provide little such data or were not even performing the services the BHI wanted.

In one evaluation, ISR wrote that “fuzziness exists around” the provider’s understanding of the programs and services it was contracted to provide. In addition, “data collection on service provision and short-term goals or outcomes was also entirely absent. To that point, identified outcomes were equally broad, which left confusion about what specific goals and objectives (they) hoped to achieve with clients.”

In evaluating a different provider, ISR found “no empirical evidence” that most of the clients the provider was serving were from the target population and that “services were not implemented as designed.”

Guerin said he could understand people questioning if the county’s behavioral health tax had made an impact.

“If they were to read some of our reports,” he said, “they would get a mixed answer.”

But the criteria used for evaluation was sometimes so rigid, Verploegh said, that it might have discounted the work of providers whose programs did not fit nicely inside certain models.

Cory Lee of Crossroads for Women, a BHI contractor that provides housing and support services to formerly incarcerated women, said the BHI contracting did not always account for variations across programs.

“I want to believe what they were trying to do was provide a sense of structure, but in that there was a little bit of maybe just a tad too much of trying to encourage people to fit into a certain box,” Crossroad’s executive director said.

Reorganization

Bernalillo County Commissioner Debbie O’Malley is the only current commissioner who was part of the 2015 vote to impose the tax. It was clear the community had behavioral health needs, she said, and she was glad to support a new revenue stream to support them.

But she said she has heard – and understands – many of the public criticisms of the BHI and believes that there are structural problems with the management and oversight. Many complaints have come from the county’s contracted providers, who feel unsupported.

Even what she considers the county’s earliest and most concrete goal for the tax – opening a “crisis triage center” for people in the throes of a mental health or substance use crisis who might otherwise end up in jail or the emergency room – has yet to be realized, though it’s on the way.

She said the BHI seems to operate “project by project” instead of in a comprehensive fashion.

As a commissioner who is not a mental health specialist, O’Malley said she has consistently relied on county staff to handle the day-to-day details or bring forward vetted projects that need funding. But she said she believes the elected officials need to start digging into the situation.

“I think we need a better handle on it,” O’Malley said.

Chief among her concerns is the amount of tax money still sitting on the sidelines. Even after this year and some major planned expenditures, finance officials anticipate the county will have $32 million sitting in the bank on top of the customary reserves, though Morgas Baca said she aims to spend $4 million helping with a new medical “sobering center” at the city’s planned Gateway Center.

Morgas Baca said the accruing balances caught her attention and prompted her to reorganize earlier this year, saying she felt the situation needed more intensive monitoring. She extracted the special tax-funded BHI – which includes many contracts with outside providers – from the Department of Behavioral Health Services, which manages county-run services like the detoxification and public inebriation programs at the CARE Campus.

“I think it was just a lot for one director,” she said.

Morgas Baca merged the BHI with the county’s criminal justice reform efforts to create a new office that “represents the county’s critical non-law enforcement response to help reduce crime, lower recidivism, and improve outcomes for those needing treatment and support for behavioral health disorders,” according to the county’s website.

Lee of Crossroads for Women said she’s noticed positive changes at the BHI over the last year, including better communication and collaboration.

“I have seen a lot of amazing things in the last year – them really fine-tuning what their focus is, and so it’s been nice to watch that happen considering in the beginning it was difficult.”

Morgas Baca said the BHI has many success stories, but that the county needs to be able to demonstrate its larger impact with data.

“The public deserves to know that their money is being well-spent because the goals are being met,” Morgas Baca said. “And if they’re not, then we need to be doing something else.”