San Diego supervisors receive plan to expand substance use treatment; county cites Medicaid funding risk

Vice Chair Terra Lawson-Remer called a March 4 San Diego County Board of Supervisors special board conference to review the county's Substance Use Disorder Optimal Care Pathways model and broader behavioral health strategy.

The plan, presented by Deputy Chief Administrative Officer for Health and Human Services Kim Giardina with presentations from Dr. Luke Bergman, director of Behavioral Health Services, and Dr. Nicole Esposito, chief population health officer for Behavioral Health Services, maps service capacity goals across crisis diversion, residential treatment, outpatient care and housing supports and sets multi-year benchmarks for expanding access to care.

Why it matters: San Diego County officials said the model would shift the system from crisis-driven care toward ongoing, community-based treatment that can reduce emergency department visits, hospitalizations and justice system involvement. Vice Chair Lawson-Remer said, "For too long, our system has failed to meet people where they are," and framed the pathway model as part of a five-year vision to grow treatment capacity countywide.

County staff described gains since 2021 and the scale of proposed expansion. Key figures presented include 44 mobile crisis response teams (MCRTs) countywide (grown from a two-team pilot), eight crisis stabilization units (CSUs) with two more planned, and MCRTs having responded to more than 12,500 crises and served over 8,000 unique clients. Staff reported a 28% decrease in monthly admissions to the county psychiatric emergency unit between 2021 and 2024 and a 200% increase in admissions to regional CSUs during the same period.

The SUD Optimal Care Pathways (SUD OCP) model produces targeted capacity increases if fully implemented: an estimated 450 transitional-support slots (a new service type), roughly 3,000 additional residential treatment slots, about 9,000 more outpatient treatment slots, and roughly 2,400 more housing resources over five years. Staff said those targets correspond to modeled percentage increases of roughly 78% for residential care, 97% for outpatient care and 92% for housing resources compared with current capacity.

Dr. Esposito tied the model to state law changes, noting that Senate Bill 43 (effective Jan. 1) broadened the definition of grave disability to include severe substance use disorder and requires more capacity across levels of care. "SB 43's expansion of CSUs and MCRTs was instrumental in our readiness," Esposito said, listing planned openings including the Tri-City psychiatric health facility (expected summer 2025), 49 recuperative care beds coming online early in 2025, and 70 new residential substance-use beds at the CERTS facility by July 2026.

Presenters and public- and private-sector partners emphasized that expanding capacity is necessary but not sufficient: staff said the system needs stronger links between hospitals, emergency departments and community providers so crisis touch points become effective referral opportunities. "If we were able to connect with people during these crisis touch points, we could connect with more people to treatment," Dr. Esposito said, illustrating how emergency-department stabilization without direct referral often fails to bring patients into continuing care.

Board members and criminal justice partners praised the system changes while flagging funding risks. Supervisor comments commended the county's growth in MCRTs, CSUs and treatment slots but repeatedly raised concerns about a heavy reliance on federal Medicaid (Medi-Cal) financing. Staff said Medicaid covered about 70% of costs in the county's substance-use system last year and that the county provides the required local match. Supervisors warned that proposed deep cuts to federal Medicaid funding would jeopardize both future expansion and existing programs.

Sheriff Commander Jim Emmick and Chief Deputy District Attorney Rachel Solove described operational benefits and limits: Emmick said MCRTs and CSUs allow deputies to connect individuals with services and return to other duties, but he added that PERT and co-response teams remain necessary for public-safety incidents. Solove said justice partners must both support upstream diversion and expand treatment for people already involved in the justice system.

Public comments and providers: Hospital and community providers, including UC San Diego Health, Palomar Health, Father Joe's Villages, and MCRT operators, described pilots and operational lessons. UC San Diego Health's ED-based transitional support work and Telecare/Exodus MCRT operations were singled out as components that expand access and divert people from higher levels of care. Multiple members of the public urged stronger prevention for youth and questioned county policy on marijuana licensing; several speakers urged caution about commercialized cannabis and called for stronger youth-prevention strategies.

Board action: After discussion, the board voted unanimously to receive the presentation and directed the County Administrative Officer to return with updates on the Optimal Care Pathways model in August 2025. The motion passed with all supervisors present voting aye; the transcript records the outcome as unanimous among those present but does not list a roll-call tally for individual supervisors.

What's next: Staff will continue planning with managed care plans, hospitals, cities and community providers to pursue the model, subject to county budget constraints and federal/state policy changes. Supervisors asked staff to include additional partners (the public defender's office was specifically requested) in ongoing planning and to return with a progress update in August 2025.

Limitations: Presenters and supervisors warned implementation depends on funding stability, workforce availability and local permitting processes for residential facilities; the county said it currently cannot commit to specific expansion timelines if major federal Medicaid funding reductions occur.