A communication transmitted from Yi-An Huang, City Manager, relative to Awaiting Report Item Number 23-11, regarding a review of the current state of mental health resources, particularly for underserved communities, within the CHA

TO: Yi-An Huang, City Manager FROM: Derrick Neal, Chief Public Health Officer, Cambridge Public Health Department DATE: April 5, 2023 SUBJECT: Response to Policy Order #12, adopted February 6, 2023 Excerpt of Order: That the City Manager be and hereby is requested to work with staff in the Cambridge Public Health Department to review the current state of mental health resources, particularly for underserved communities, within the CHA; and be it further ordered that the City Manager be and hereby is requested to report back to the City Council with recommendations for improving the Cambridge Health Alliance system including, but not limited to, information pertaining to the mental health support programs offered, spreading awareness about the 988 hotline, how easy it is to access emergency psychiatric care, and how we can support the CHA with more funding if necessary. OVERVIEW Long before COVID-19, many people in Massachusetts struggled to get care for mental health and substance use disorders. Since the pandemic began, it has become even harder to access treatment, especially for people in crisis. The state estimates that only 50% of people in Massachusetts who have a mental illness receive treatment despite significant improvements to treatment capacity made over the past five years. The reality is that many people only find mental health or substance use treatment when they experience an emergency, and end up “boarding” at a hospital emergency department, sometimes for days or even weeks until they can be placed in inpatient psychiatric care. Expanding access to behavioral health care and improving quality of services has been a longstanding priority of the Governor’s Office, state agencies, and health care systems such as Cambridge Health Alliance. The following section describes some recent Commonwealth of Massachusetts and Cambridge Health Alliance initiatives to improve behavioral health care and promote new programs, including help lines.

MASSACHUSETTS INITIATIVES Since 2015, the Commonwealth of Massachusetts has invested more than $26 billion in behavioral health care across multiple initiatives and state agencies. Behavioral health encompasses mental health and substance use disorders, as well as overall psychological well-being. During the pandemic, the state developed the “Roadmap for Behavioral Health Reform,” an ambitious plan to make it easier for children, teens, and adults to get help for mental health conditions and substance use disorders. Two significant Roadmap programs launched in January 2023 that are part of the state’s larger strategy to reimagine urgent care and expand treatment options: a statewide behavioral health help line and a network of Community Behavioral Health Centers. “The Community Behavioral Health Centers are a major marker for families trying to access care as early as possible,” said Marylou Sudders, outgoing Massachusetts Health and Human Services Secretary, in a radio interview in December 2022. “I have hope that [the CBHCs] will open up the ambulatory front door that so many people can't find their way in.” About the programs: ● A 24/7 Behavioral Health Help Line ([phone removed] or masshelpline.com/chat). Through this free service, anyone in Massachusetts can call, text, or chat at any time to receive individualized support, clinical assessment, and personalized treatment referrals for mental health or substance use issues. Help Line staff remain on the line until callers are connected to their next step. ● Community Behavioral Health Centers. Everyone in Massachusetts now has access to a state-funded network of 29 Community Behavioral Health Centers (CBHCs), including a Cambridge CBHC operated by Cambridge Health Alliance, physically located at Cambridge Hospital. . CBHCs offer immediate care for mental health and substance use needs. Crisis services are available around the clock for anyone in Massachusetts experiencing a potential mental health emergency and are entirely insurance-blind, meaning anyone can access services, regardless of insurance coverage. Routine outpatient services are available for all MassHealth members and may also be covered by some commercial insurers. For more information about CBHC services, see the Cambridge Health Alliance section. In addition, the state legislature enacted legislation in 2022 to fund and implement the new congressionally mandated three-digit calling code for 988 Suicide and Crisis Lifeline services in Massachusetts: ● The national 988 Suicide and Crisis Lifeline (formerly the National Suicide Prevention Lifeline) is for anyone in emotional distress or suicidal crisis, as well as for people worried about a loved one and not sure how to support that person or where to get them help. Trained counselors provide free, confidential emotional support and compassionate, 2

non-judgmental listening to all callers. They also offer assistance with de-escalation and safety planning to help individuals through the least restrictive means possible. The state anticipates that increased collaboration between 988, 911, and the Community Behavioral Health Centers will provide more options for those in crisis, such as dispatching mobile crisis teams to individuals in mental health, substance use, or suicidal crisis rather than police, fire, or EMS. ● There is 988 accessibility and services available for specific groups: People who are deaf or hard of hearing may use the online chat function or TTY users may use their preferred relay service or dial 711 then 988. Language translation services are also available to all callers, specifically the Spanish Language Line can be accessed by pressing 2 after dialing. Service members, veterans, and their families may reach the Veterans Crisis Line by pressing 1 after dialing 988, as well as by chatting online at veteranscrisisline.net or texting 838255. LGBTQ youth may also use the Trevor Lifeline by calling [phone removed] or texting 678-678 to access information and support for LGBTQ youth. CAMBRIDGE HEALTH ALLIANCE INITIATIVES & SERVICES Cambridge Health Alliance (CHA) is one of the region’s leading providers of behavioral and mental health care. CHA is deeply committed to providing a safety net for underserved populations facing barriers to care. To this end, CHA has invested in a multi-year effort to expand its inpatient, outpatient and crisis services for residents of its service area, including the diverse community in Cambridge. Since 2020, CHA has increased behavioral health capacity through two major initiatives: (1) creating a regional Community Behavioral Health Center that provides a wide range of services and (2) expanding inpatient psychiatric care for both children and adults to help address the acute shortage of treatment beds in the region. CHA Community Behavioral Health Center Cambridge Health Alliance serves as one of the state’s 29 designated Community Behavioral Health Centers. The Cambridge CBHC, based at Cambridge Hospital, opened in January 2023. Services include: ● A free 24-hour CHA Access and Crisis Line: [phone removed]. Trained staff support people in crisis and connect them to behavioral health care. Staff also help people who are not in crisis situations. ● 24-hour Mobile Crisis Services: [phone removed]. At any time of day, CHA behavioral health clinicians talk to people by phone, or meet them in their homes, schools or other community 3

locations. Typical response time for mobile crisis services is one hour. This service is available to all Massachusetts residents regardless of insurance plan or ability to pay. ● Behavioral Health Urgent Care: Walk-in evaluation and treatment services are available on the first floor of Cambridge Hospital located at 1493 Cambridge Street. The center is open Monday-Friday from 8 a.m.–8 p.m., and Saturday and Sunday from 9 a.m.–5 p.m. (Closed major holidays.) Once people are evaluated, they are connected to care based on their needs. Expansion of Child Inpatient Psychiatric Care In December 2020, CHA announced a multi-year initiative to expand inpatient psychiatry capacity at Somerville Hospital. U.S. Senators Edward Markey and Elizabeth Warren helped to secure $4.6 million in federal funding for this effort. In June 2022, CHA opened the Center for Inpatient Child & Adolescent Psychiatry at Somerville Hospital. The center added 42 new beds (for a total of 69 beds) for children and teens. The center includes a Neurodevelopmental Unit designed for pediatric patients with a primary diagnosis of autism spectrum disorder, intellectual disability, or a related neurodevelopmental disorder, who are also experiencing serious behavioral or mental health concerns. Significantly, with the introduction of the new center, CHA became the state's largest provider of child and adolescent inpatient mental health services. In recognition of CHA’s critical role in supporting children and youth at a time of enormous demand for services, Senator Markey remarked a the opening ceremony: “The Center for Inpatient Child & Adolescent Psychiatry will provide indispensable behavioral health services in moments when our young people need it most, and help address a critical shortage of inpatient psychiatric care across our Commonwealth.” Expansion of Adult Inpatient Psychiatric Care In January 2023, in acknowledgement of ongoing demand for behavioral health services, CHA completed the conversion of two units at Cambridge Hospital to adult inpatient psychiatry units, creating 25 new beds. Despite staffing challenges in hospitals across the U.S., CHA has been highly successful in recruiting new providers. CHA Behavioral Health Services Cambridge Health Alliance serves all ages with therapy, group programs, medication management and crisis care, including behavioral health urgent care and overnight hospital care. Service areas include: ● Adult Psychiatry ● Behavioral Health Integration with Primary Care ● Child and Adolescent Psychiatry ● Crisis & Emergency Services 4

● Geriatric Psychiatry ● Substance Use & Addiction ● Trauma and Violence Services Mental Health First Aid Training CHA's Community Health Improvement Department continues to offer the nationally recognized Mental Health First Aid (MHFA) training to people who live and work in Cambridge and seven other communities served by CHA. The training is offered in English and Spanish. In the past four years, CHA has trained and certified over 1,800 people in mental health first aid, a program of the National Council for Mental Wellbeing. Trainees learn about risk factors, warning signs, and how to guide someone to helpful resources. Cambridge participants have included city employees, public school personnel, and staff from various community agencies, as well as people who live and volunteer in the city. This year, CHA is piloting Teen Mental Health First Aid (tMHFA), which teaches high school-age teens how to identify, understand and respond to signs of mental health and substance use challenges among their friends and peers. PROMOTING BEHAVIORAL HEALTH HELP LINES & SERVICES Here is a brief summary of state and local promotion efforts currently underway: Massachusetts Behavioral Health Help Line ● The state has created brochures, posters, wallet cards, and FAQs promoting the statewide Behavioral Health Help Line. ● The state’s media outreach plans will be finalized later in March. ● The plans to promote CBHCs on public transit, billboards, and in locations near each CBHC. Specific advertising in Cambridge has not been determined yet. CHA Community Behavioral Health Center Cambridge Health Alliance has promoted its Community Behavioral Health Center as follows: ● Email blast to over 95,000 CHA primary care patients. ● CHA website. The CBHC web page had 2,743 unique visitors from January 1 through March 31, with 18% of users coming from Cambridge. ● FAQ flyers and crisis cards distributed in clinics and to community partners, including the Cambridge Police Department. The materials have been translated into multiple languages, including Spanish, Portuguese, Haitian Creole, Mandarin, Russian, and Nepali. ● Flyers for schools and parents, distributed through the CHA teen health centers. ● Emails/ letters to current CHA psychiatry patients, including nearly 2,000 Cambridge residents. ● Press releases. Stories ran in the Boston Business Journal and the Harvard Crimson. ● Social media. 5

● Presentations at community meetings. NEXT STEPS As noted, CHA and the state have made significant investments in the behavioral health infrastructure in Cambridge and the broader region. The challenge now is to educate residents about the availability of resources and encourage them to access support when necessary. The Cambridge Public Health Department (CPHD) will collaborate with Cambridge Health Alliance, the City of Cambridge, and a range of city partners to help promote the behavioral health help lines, the Cambridge CBHC, and other community and clinical resources. Our focus will be tailoring messages and materials to specific audiences in Cambridge. CPHD proposes undertaking a community outreach campaign to educate nonprofit leaders, Community Engagement Teams, faith-based leaders, representatives from the housing authority, and other community partners about the various resources available to the residents they serve, including CHA’s Community Behavioral Health Center services. In recognition of the particular access barriers faced by non-English speaking individuals and families and other more vulnerable populations in the community, efforts would be oriented toward equipping service providers and others with ties to so-called “hard-to-reach”populations with an understanding of the behavioral health service landscape and materials that equip them to help residents navigate the system. This campaign would involve recruiting a community member trained in mental health (ideally a social worker or therapist) to partner with CPHD’s team to develop and deliver training sessions to staff at settlement houses, programs serving seniors, the out-of-school time network, faith-based organizations, and other groups. Participants would learn about the range of behavioral health resources available at the local, state, and national levels and how to access them. They would also learn which resources would best meet their needs, as well as services available to non-English speakers. Staff would use the initial sessions with community leaders to identify opportunities for hosting educational events for residents, with a focus on youth mental health. A collaboration with the social work staff at the Cambridge Public Library is one example. CPHD staff anticipate working with the Community Engagement Teams (CETs) at the Department of Human Service Programs and Community Development Department, the Cambridge Community Corps, and the CPHD literacy ambassadors to help reach non-English speaking communities. We would coordinate closely with these outreach teams to identify the materials they need to raise awareness of behavioral health resources and be available to attend community gatherings. CPHD behavioral health staff will work with our school health team to identify information needs they have in working with students and families facing behavioral health challenges and will create educational opportunities and materials to address identified needs. We will also coordinate with the department’s Health Equity and Social Justice Resource Specialist, a CPHD staffer in the schools whose focus is identifying and addressing access barriers. CPHD would supplement in-person community sessions with print and digital materials designed to help residents—particularly those in underserved communities—access crisis and routine behavioral 6

health resources. Specifically, we would aim to consolidate the information from various sources to make navigating the information more manageable. CPHD would also coordinate with Cambridge Health Alliance and Commonwealth of Massachusetts campaigns that are already in the works, augmenting their resources with materials, translations, and placement tailored to Cambridge-specific audiences. CPHD’s “home” under the CHA umbrella positions us well to work closely with Community Behavioral Health Center staff to align efforts. As an example, CHA currently provides fact sheets about its CBHC in English, Spanish, Arabic, Amharic, Haitian Kreyol, Mandarin, Nepali and Portuguese. According to CDD and CPS data Bengali and Korean are additional languages that could help make information more accessible to relatively large communities in Cambridge. Evaluation is at the heart of effective public health initiatives. CPHD behavioral health staff propose working with CPHD’s internal program evaluation team to devise an evaluation strategy prior to initiating the campaign. CPHD estimates a budget of $26,500 to implement the proposed behavioral health outreach initiative. This assumes 30 community education sessions, with approximately half the sessions offering interpretation ($12,500); design, translation and printing costs of approximately $6,000 for targeted educational materials; and $8,000 earmarked for design and placement of advertising (social media, transit, radio and/or billboards) in multiple languages. 7