Fighting staff shortages with scholarships, California bill aims to boost mental health courts

A seemingly innocuous proposal to offer scholarships for mental health workers in California's new court-ordered treatment program has sparked debate over whether the state should prioritize that program or tackle a wider labor shortage in behavioral health services.

Nine counties have begun rolling out the Community Assistance, Recovery, and Empowerment Act, which Gov. Gavin Newsom (D) signed into law in 2022 to get people with untreated schizophrenia or other psychotic disorders, many of them incarcerated or homeless, into treatment. But often those skilled clinicians have been pulled by counties from other understaffed behavioral health programs.

"There’s just so much change coming with a limited workforce, limited treatment resources, and high expectations for counties to solve things like homelessness," said Scott Kennelly, director of the Butte County Behavioral Health Department. "It's like I'm turning on a fire hose and saying, 'Start drinking.'"

The bill by state Sen. Tom Umberg would create an annual scholarship fund for students who pursue a mental health profession provided they work for three years with CARE Court. Umberg had requested $10 million for the program, but it's unclear how many students would receive the scholarship, said Jackie Koenig, a spokesperson for the senator. The bill sailed through the legislature without a single lawmaker voting against it.

Umberg, a Democrat from Orange County, said CARE Court deserves targeted funding because it’s a new program, and he noted other state scholarships are available for students pursuing a behavioral health degree. For instance, the state announced in March 2023 that it would issue $118 million in grants to support behavioral health providers at 134 nonprofit community-based organizations.

"CARE Court is new, and it is in a unique space that requires unique behavioral health skills, dealing with schizophrenics," Umberg said. "So, we want to encourage folks to go into that space, because it is a challenge."

But local behavioral health administrators say shifting experts into CARE Court may create shortages in other programs or thrust mental health specialists into multiple demanding programs.

The CARE Act allows patients or others, such as their relatives, behavioral health care providers, or roommates, to petition their county court for help. Individuals who agree to participate can receive up to 24 months of treatment, which can include outpatient substance use disorder treatment, stabilization medication, connection to social services, and housing. It is one of Newsom's experimental initiatives intended to get some of the state's 181,000 homeless people off the streets and into housing without resorting to mandatory conservatorships.

Only 7,000 to 12,000 Californians are estimated to be eligible for treatment, according to the Judicial Council, which helps oversee the program.

The state has allocated $251 million to staff and launch the CARE program through the current budget year, including $122 million in grants to counties, according to the state Legislative Analyst's Office. At the same time, counties have been directed to implement a host of other behavioral health programs, such as mobile crisis teams, and boost mental health services for Medi-Cal patients. Last year, Newsom also signed legislation that broadened the number of Californians who could be involuntarily committed.

"As a high-profile mandate, counties are largely moving existing, skilled, experienced staff over to launch and staff the CARE Court teams," said Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, which supports the bill.

It's why critics, including ACLU California Action, Mental Health America of California, and some counties, say a CARE Court scholarship should also support other county programs that treat individuals with serious mental illness and housing instability.

"Restricting workforce development initiatives solely to one of the many new behavioral health initiatives will not solve the issues of staffing across the continuum of behavioral health services," said Alexandra Pierce, an assistant director at the Merced County Behavioral Health and Recovery Services Department.

County behavioral health departments are in the midst of a massive behavioral health workforce shortage — running 25% to 30% below full staff capacity, on average, according to an internal 2023 survey conducted by the county behavioral health director association and the University of California-San Francisco's Healthforce Center, Cabrera said.

More than a dozen rural and urban county behavioral health directors told KFF Health News that hiring challenges are widespread and not unique to CARE Court, pointing to burnout since the start of the covid-19 pandemic and steep competition from schools, correctional facilities, and the private sector, which can offer skilled clinicians higher pay, work-from-home telehealth jobs, and generous vacation.

Michelle Funez, division director of Marin County Behavioral Health and Recovery Services, said a CARE Court scholarship could incentivize students to pursue county jobs that support vulnerable individuals in the community.

Finding the right clinician for CARE Court can be tricky because the job requires skilled individuals to work in homeless encampments and other nontraditional environments, Funez said.

"It can feel like we're looking for the needle in the haystack," Funez said, drawing from "an already smaller body of staff who have the requisite skills for this type of work, who are also up for the challenge."

The nine counties that have launched the specialized courts have received more than 600 petitions in the first 10 months of the program, said Leah Myers, a spokesperson for the state Department of Health Care Services, which helps oversee the program. The remaining 49 counties are slated to launch their programs by Dec. 1.

There have been early successes with the program. A year in, San Diego County is already beginning to "graduate" patients, meaning they have received treatment and have made enough progress to transition out of the court system.

As more counties roll out CARE Courts, they will need more clinicians. A scholarship program, some counties said, could help. But the bill's price tag could be its downfall. In June, Newsom signed a state budget closing an estimated $46.8 billion deficit, and last year he vetoed hundreds of bills, many of them over cost. Newsom spokesperson Elana Ross declined to comment on the measure.

Newsom has until the end of the month to sign or veto the bill.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.