DATE: April 7, 2026
TO: Board of Supervisors
SUBMITTED BY: Paul Nerland, County Administrative Officer
SUBJECT: Jail Medical Care Feasibility Study Memorandum of Understanding
RECOMMENDED ACTION(S):
TITLE
Approve and authorize the Chairman to execute a Memorandum of Understanding (MOU) with Golden State Finance Authority (GSFA) to provide cost reimbursement for participation in a regional Jail Medical Care Feasibility Study focused on evaluating long-term, sustainable alternative for jail medical service delivery, effective upon execution and remaining in effect until completion of services or June 30, 2028, total not to exceed $201,523.
REPORT
There is no increase in Net County Cost (NCC) associated with the recommended action. Approval of the recommended action will authorize the County’s participation in a regional feasibility study administered by the GSFA to evaluate long-term sustainable alternatives for the delivery of jail medical services. The study will analyze current service delivery models, assess operational and fiscal considerations, and identify potential alternative approaches that could improve efficiency, service quality, and long-term sustainability utilizing cost saving measures. This item is countywide.
ALTERNATIVE ACTION(S):
Your Board may choose not to approve the recommended action. If the recommended action is not approved, the County will not participate in the regional feasibility study evaluating long-term sustainable alternatives for jail medical services and will not receive the analysis and findings developed through the study that could inform future services delivery decisions.
FISCAL IMPACT:
The NCC associated with this agreement is $51,000 for FY 2025-26. Participation in the feasibility study includes a total regional cost of $320,000 for the Central Valley region, with the County’s proportional share estimated at $201,523 (62.98%) for the entire term of the agreement. Sufficient appropriations and estimated revenues are in County Administrative Office Org 2540 FY 2025-26 Adopted Budget and will be included in subsequent budget requests during the duration of the term.
DISCUSSION:
Counties throughout California are increasingly challenged by the rising cost and complexity of providing legally required medical care to individuals housed in county detention facilities. Many face persistent staffing shortages, escalating contract and litigation costs, and increasing difficulty maintaining compliance with state and national care standards. These challenges are particularly pronounced in rural and mid-sized counties, where limited scale, geographic constraints, and workforce availability create additional barriers to service delivery.
Providing medical and behavioral health care services in county detention facilities represents a significant operational responsibility and financial commitment for counties. The County currently contracts with a private provider, California Forensic Medical Group, Incorporated, to deliver these services to incarcerated individuals housed within its detention facilities, and the agreement has required multiple amendments over time to address evolving service needs, operational requirements, and associated cost increases. As these services continue to grow in complexity and cost, it is prudent for counties to evaluate whether alternative or regional service delivery approaches could improve operational efficiency, maintain compliance with applicable standards of care, and support long-term fiscal sustainability.
The County’s agreement for jail medical and behavioral health care services represents one of the County’s largest contracts and has required multiple amendments to address increasing costs and service demands. Most recently, the Board approved Amendment XII on December 3, 2024, increasing the contract maximum to approximately $394 million and extending the term through June 30, 2029.
These continued cost increases and operational complexities highlight the need to evaluate alternative service delivery models, including potential regional approaches, to improve efficiency and manage long-term costs.
Publicly available data and County experience indicate that contract costs for jail medical services have increased significantly from one contract period to the next, often alongside expanded regulatory requirements and heightened expectations for specialty and behavioral health care. At the same time, chronic workforce shortages have contributed to increased reliance on contract-based service models and temporary staffing arrangements, which can create operational instability and additional fiscal pressure. Limited service provider options amplify the counties’ concerns should one partner no longer be available.
In parallel, counties have observed increased litigation and liability exposure related to jail medical care, underscoring the financial and risk management implications of existing delivery models. In discussions with regional working groups, PRISM, a member-directed risk management joint powers authority, noted recent cases involving in-custody deaths and medical care claims that resulted in multimillion-dollar settlement demands and increased counties costs.
In response to these shared challenges, the Rural County Representatives of California (RCRC), in partnership with PRISM, convened five regional task forces in early 2025 composed of County Executive and Administrative Officers (CEOs and CAOs). The purpose of these task forces was to explore long-term strategies for improving the delivery, quality, cost-effectiveness, and risk management of jail medical care, including the potential for regional collaboration.
The County is participating in the Central Valley regional cohort, which includes Madera, Merced, and Kings Counties.
Following a series of working group meetings with each region, the Golden State Finance Authority (GSFA), RCRC’s affiliated public agency, issued Request for Proposals (RFP No. 2025-GSFA-001) on October 13, 2025. The purpose of the RFP is to procure a qualified consultant, or team of consultants, to conduct a feasibility study evaluating alternative models for jail medical care delivery across five defined regions of California, encompassing a total of 26 participating counties (EXHIBIT A). The feasibility study is intended to support counties in assessing regional collaboration opportunities, cost-effective service delivery approaches, quality-of-care considerations, and compliance with applicable state and national standards.
The RFP submission period closed on December 12, 2025, resulting in two qualifying proposals:
NCCHC Resources, Inc. $1,802,000
Health Management Associates, Inc. $2,881,995
Proposals were evaluated using a structured scoring framework that considered the proposer’s organizational qualifications and experience, technical approach to conducting the feasibility study, ability to assess regional needs and evaluate alternative jail medical service delivery models, and cost and overall fiscal reasonableness. The internal review was conducted by GSFA staff, including the Economic Development Officer, Deputy General Counsel, and Policy Advocate. In addition, all proposals were distributed to CAO/CEO-led regional working groups for review, and GSFA facilitated evaluation meetings with each regional group in early January 2026 to discuss proposals, consider regional priorities, and support the selection process.
For the Central Valley region, this included County Administrators/Executives and additional county staff from Fresno, Madera, Merced, and Kings Counties. Final consultant selection reflected the consensus of participating counties. NCCHC Resources, Inc. (Consultant) was selected based on its demonstrated cost-effectiveness, depth of experience in correctional healthcare and jail medical systems, and strong alignment with the feasibility study scope and regional objectives.
The total cost for the Central Valley regional feasibility study is $320,000, which is allocated among participating counties based on a population-based methodology. Fresno County’s share represents approximately 62.98% of the total cost, or approximately $201,523, with the remaining costs allocated to Madera, Merced, and Kings Counties.
Through the proposed MOU, the County would partner with the GSFA to fund and participate in a coordinated, data-driven evaluation of long-term jail medical care alternative alongside similarly situated counties. Under the anticipated structure, GSFA will serve as the contracting entity and program facilitator, convene coordination meetings between County staff and the selected Consultant, and act as the fiscal intermediary responsible for processing and paying Consultant invoices using funds contributed by participating counties. The feasibility study will be performed exclusively by the selected Consultant.
This agreement differs from the County’s standard contract in that it contains a mutual indemnification clause and includes insurance coverage limits of $1,000,000 for Commercial General Liability, which deviates from the County’s standard agreement requirements. The mutual indemnification clause has been reviewed by Risk Management and deemed acceptable for this agreement between public entities. The County Administrative Office has determined that the inclusion of the $1,000,000 coverage level is reasonable given the nature and scope of the services provided. Additionally, the requirement for additional insureds under the Commercial General Liability coverage is being waived due to GSFA serving as an intermediary between the County and the Consultant; the County Administrative Office deems this acceptable and considers it a business decision.
REFERENCE MATERIAL:
BAI #8, December 3, 2024
ATTACHMENTS INCLUDED AND/OR ON FILE:
Exhibit A - Map of Regions and Participating Counties
On file with Clerk - MOU
CAO ANALYST:
Mary Lu Valencia