Appendix K.docx

APPENDIX K

County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY23-0225: Behavioral Health Treatment Facility Continuum of Care Proposed Rates Form

Offeror Name:

Offerors shall complete the applicable sections below based upon their proposal for the following scope(s):

☐ Scope A4a ☐ Scope A4b ☐ Scope A4c

Proposed Rates:

Application for Qualification Indicate Programs as applicable Proposed Daily Rate[footnoteRef:1] per Bed [1: All rates listed above include any and all costs associated with providing the stated service categories, including but not limited to staffing, operating expenses, etc. All rates or pricing schedule shall be mutually agreed upon by the County and Offeror.]

A4a: Basic Supplemental Residential Care Services

☐ Level 1: Basic Supplemental Residential Care Services This level of care is for clients with the following:

a. Vulnerability;

b. Yelling and screaming;

c. Destruction of property;

d. Substance and/or alcohol use;

e. Suicidal and/or homicidal behavior; and/or

f. Assaultive behavior to staff and peers.

Level 1: $

☐ Level 2: Basic Supplemental Residential Care Services for clients who are mono-lingual, blind, deaf, or with dual-diagnosis This level of care is for clients with the following:

a. Hearing loss or deaf;

b. Vision loss or legally blind;

c. Developmentally disabled or mental retardation; and/or

d. Monolingual in Spanish, Cantonese, Mandarin, Tagalog, Vietnamese, or Farsi.

Level 2: $

☐ Level 3: Basic Supplemental Residential Care Services for clients with SMI or other minor medical conditions This level of care is for clients with the following:

a. May have secondary medical and/or substance use issues and/or are intellectually disabled in addition to psychiatric conditions;

b. Diagnosed with an intellectual disability on a continuum based on level of severity that includes the following categories: mild, moderate, severe, and profound. Depending on where clients fall on this continuum, they are oftentimes nonverbal and exhibit aggressive and/or self-injurious behaviors;

c. Have been refused for admission at a standard RCF due to aggressive behaviors or history of aggression towards staff and peers; and/or

d. Have a history of recidivism (in and out of psychiatric or medical hospitals) due to aggression or substance use issues.

Level 3: $

☐ Level 3: Basic Supplemental Residential Care Services for clients who are medically frail or require assistance with insulin This level of care is for clients with the following:

a. Medically Frail: these are clients with significant co-morbid conditions such as psychiatric, medical, and health related issues such as Chronic Obstructive Pulmonary Disease (COPD), obesity, renal disease, clients needing daily assistance with hygiene and grooming due to medical conditions;

b. Diabetic/Insulin Dependent: these are clients with a history of diabetes who require finger stick and are unable to manage their disease and/or perform the basic self-care required to stabilize their blood sugar levels (this does not apply to clients who are solely on oral medication for a diabetic condition);

c. High blood pressure or other medical conditions who require assistance with medication management; and/or

d. Limited mobility who have assisted devices such as wheelchairs and canes.

Level 3: $

A4b: Intermediate Supplemental Residential Care Services

☐ Level 4: Intermediate Supplemental Residential Care Services

a. Psychiatric issues and significant co-morbid medical conditions such as COPD, obesity, and renal disease;

b. History of Absence Without Official Leave (AWOL) and require intense supervision or with a Wander Guard provided by the facility;

c. Require daily assistance with hygiene and grooming due to medical conditions;

d. Specialized equipment (e.g., sleep apnea machine, electric wheel chair, colostomy bag, oxygen tank, etc.) that need one-on assistance and/or one-on-one supervision with the equipment;

e. Require temporary medical assistance with transition from release from a medical facility.

f. Require assistance with how to check and monitor their blood sugar levels and administer insulin to treat their diabetic condition;

g. Chronically ill with medical issues that may require one-to-one supervision who require high level of behavioral interventions, support, and/or a high level of nursing interventions;

h. Require hospice of end-of-life care; and/or

i. Significant behavioral challenges, limited social skills, dual diagnoses, impaired or unable to attend to independent living skills, poor self-regulation skills, thought disorders, and/or nursing complexities that prevent them from living in the least restrictive setting.

Level 4: $

A4c: Residential Care Services for Clients with Severe Mental Illness (SMI) and Traumatic Brain Injury (TBI)

☐ Level 5: Supplemental Services for Clients with SMI and Traumatic Brain Injury (TBI)

a. Symptoms including cognitive and judgmental impairments, and a disability that causes significant interference with treatment, but do not present an immediate threat to safety nor prevent independent functioning;

b. Limited cognitive functioning level who require one-on-one assistance with hygiene and grooming due to low cognitive functioning level;

c. Difficulty with their thought process, functioning level, unable to perform basic tasks, which affects concentration, communication, speech, swallowing, vision, and mobility; and/or

d. Severe cognitive and psychiatric impairments who have been denied for admission at a regular RCF.

Level 5: $

If travel by proposer or staff will be required or requested by the County and the County agrees to compensate the Contractor for travel costs, costs must be inclusive of any travel costs. The County will not reimburse itemized travel costs.