Attachment A1.docx

ATTACHMENT A1

CATEGORY 1: PREVENTION AND EARLY INTERVENTION SERVICES

IN-HOME OUTREACH TEAM

Scope of Work

Purpose The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking statements of qualifications from qualified Offerors interested in providing transitional age youth (TAY), adult, and older adult prevention and early intervention (PEI) services in accordance with the In-Home Outreach Team (IHOT).

The IHOT program (hereafter referred to as “the program”) is an outreach and engagement initiative funded by the Mental Health Services Act (MHSA) funds. It is designed to provide intensive outreach and engagement, mental health screening, in-home intervention, family education, and support and linkage to treatment for clients who are not voluntarily engaging in services that connect them with ongoing mental health and/or substance use treatment services.

Offeror shall have current Medi-Cal certification or become certified to provide Medi-Cal reimbursable services on or before the contract start date. In addition, Offeror shall have Medicare certification or become certified to provide Medicare reimbursable services on or before the contract start date.

I. Background Information A. BHSD Adult and Older Adult System of Care is structured as a continuum of care that serves an ethnically and racially diverse population of Santa Clara County clients. According to the US Census, the population of Santa Clara County in 2016 was one million nine hundred and nineteen thousand and four hundred and two (1,919,402). In Fiscal Year 2015-2016, the Santa Clara County Mental Health Plan served about sixteen thousand and five hundred and ninety-two (16,592) unduplicated clients. Of these clients, over two thousand and four hundred (2,400) were over the age of sixty (60), representing fifteen percent (15%) of the total adult clients served. Additionally, a significant percentage of the older adults served were diagnosed with:

1. Mental health, substance use, or co-occurring[footnoteRef:2] diagnoses (e.g., depression, anxiety, and developmental and/or intellectual disabilities); [2: Clients require both mental health and substance use treatment services.]

2. Significant health issues (e.g., difficulties related to mobility).

B. Four thousand and one hundred four (4,104) clients, representing twenty-five (25%) of adult and older adult clients who participate in specialty mental health services, only received services in emergency and crisis settings and never connected to ongoing services that are likely to promote their recovery. Once clients discharge from Emergency Psychiatric Services (EPS), there is little to support them in connecting to ongoing outpatient services. Without support to engage clients in ongoing treatment, it is more likely that these clients will experience further crises and undue suffering.

C. One thousand and four hundred sixty-four (1,464) clients admitted to EPS in Fiscal Year 2015-2016 were TAY ages 18 through 25, with an average age of twenty-two (22). These clients received EPS an average of three (3) times per year, and most did not participate in additional mental health services.

D. The BHSD recognizes the importance of partnering with contract providers to make behavioral health services accessible to Santa Clara County transitional-aged youth, adult, and older adult residents.

Target Population A. The program shall serve the following:

1. High-risk, unserved, and underserved TAY (ages 18 through 25), adults (ages 26 through 59) and older adults (age 60 and above);

2. Diagnosed with severe mental illness (SMI) and/or substance use issues who are not engaging in services and are experiencing repetitive hospitalization, criminal justice system involvement, homelessness, and/or medical issues which impact their behavioral functioning; and

3. Residents of Santa Clara County that may be eligible or enrolled in Medi-Cal, Medi-Cal/Medicare, Medicaid, and/or uninsured.

B. Services shall be provided in all County catchment areas and the unincorporated area of San Martin.

Program Goals and Objectives A. The program shall be aligned to achieve the following goals and objectives:

Offeror shall align its program to achieve the following goals:

a. Identify individual client needs and improve connections to referrals, education, support services, appropriate medical/substance use/behavioral health care and treatment in the community as needed;

b. Provide early intervention services, integrated into community mental health centers with the goal of increasing access to timely services;

c. Reduce the effects of untreated mental illness on illness on clients and their families;

d. Maintain or improve the overall level of functioning and self-sufficiency in the community;

e. Increase the understanding of mental health issues while reducing the effect of untreated mental illness in TAY, adult and older adult clients with SMI and their families;

f. Increase family member satisfaction with the BHSD System of Care;

g. Reducing stigma in populations that are not in need of specialty mental health services;

h. Increase access to care through strategic outreach and engagement services with priority populations;

i. Reduce disparities among specific racial/ethnic communities by providing culturally competent services; and

j. Decrease hospitalization, incarceration, homelessness, substance use, violence, and victimization.

Objectives shall be achieved by offering services designed to:

k. Address and reduce root causes for psychiatric hospitalizations and admissions;

l. Assist with maintaining clients in their community and/or in the least restrictive environment or placement;

m. Promote social adjustment and interpersonal relationship/interaction;

n. Provide ongoing education and supports to assist clients and their families with gaining insight and understanding into mental illness;

o. Strengthen emotional maturity and psychological stability; and

p. Actively connect clients with other supportive services, such as housing, financial and benefits assistance, substance use treatment, legal services, and medical care providers.

II. Reporting and Data Collection Requirements A. Offeror shall comply with the reporting requirements reflected in Division 5 of the California Welfare Institutions Code (WIC) and Division 1 of Title 9 of the California Code of Regulations (CCR) when applicable.

B. Offeror shall administer all assessment tool(s) per County’s program requirement(s).

C. Offeror shall collect and report on assessment tool data.

D. Offeror shall collect treatment data for outcome data reporting. Offeror shall enter direct services data into the County’s data information system.

E. When applicable, other data collection methods may include but are not limited to, entering data into a database as specified by the County using other formats, such as Microsoft Excel.

F. Offeror shall track the behavioral health services received by clients and caretakers that participate in activities and events.

G. Offeror shall track information including, but not limited to, the following:

1. Number of home/community visits to client;

2. Referrals given for additional/supportive services;

3. Records of support groups provided for clients and caretakers; and

4. Number of clients transferred to Medi-Cal homes, WARMS, Wellness Programs, PCBHs, and/or other related health care programs.

H. Offeror shall describe the organization’s ability to use their current electronic health record (EHR) system (including the capability to exchange data with County systems) and/or the ability to implement a new EHR system as listed in Appendix H. Offeror shall provide details on how their organization shall use the County’s myAvatar system using one (1) of the following implementation types:

1. PCE with 837 billing;

2. PCNX with 837 billing;

3. PCNX non-837 billing with fast service entry claims submission; or

4. Solely client information without billing, if no EHR billing is need for the particular program/contract.

III. Outcomes and Measurements A. Offeror shall achieve the following outcomes:

1. Expand access to specialty mental health services for clients with SMI who are experiencing crisis and hospitalization, incarceration, and/or homelessness and are unable and/or unwilling to participate in treatment;

2. Identify clients in need of services, providing outreach and engagement to increase their willingness to participate in specialty mental health services, and connect them with ongoing mental health services; and

3. Improve clients’ experience of mental health services and reduce experiences of crisis/hospitalization, and incarceration.

B. Offeror shall achieve the following outcome measurement methods:

1. Ninety percent (90%) of clients will receive weekly face-to-face services from the team;

2. Eighty percent (80%) of the clients will receive their first face-to-face visit from the team within three (3) days of referral;

3. Eighty percent (80%) of clients will successfully be linked to outpatient services or rehabilitation and recovery services within the first twelve (12) months of referral;

4. Clients will have a twenty-five percent (25%) reduction in the number of EPS and Emergency Department (ED) visits within the first twelve (12) months of referral; and

5. Clients will have a twenty-five percent (25%) reduction in the number of inpatient psychiatry services visits within the first twelve (12) months of referral.

C. Offeror shall achieve the following data submission:

1. Offeror shall collect treatment data for outcomes data reporting. Offeror shall enter direct services data into the County’s data information system.

2. When applicable, other data collection methods may include but are not limited to, entering data into a database as specified by the County using other formats such as Microsoft Excel.

3. Offeror shall track the behavioral health services received by clients and caretakers that participate in activities and events.

4. Offeror shall track information including, but not limited to, the following:

a. Number of home/community visits to a client;

b. Referrals given for additional and supportive services;

c. Records of support groups provided for clients and caretakers; and

d. Number of clients transferred to Medi-Cal homes, Wellness and Recovery Medication Services (WARMS), Wellness Programs, PCBHs, and other related health care programs.

IV. Program Description A. Service Description

1. Offeror shall provide comprehensive mental health assessment for substance use, emotional, behavioral, functional, and social issues affecting health. In addition, Offeror shall utilize a variety of treatment approaches to resolve problems varying by each client's unique needs. This shall optionally include time-limited follow-up and case management.

2. Offeror shall provide comprehensive assessment, medication review/management, and treatment planning in collaboration with the psychiatrist or primary care physician and/or a clinical team member.

3. Offeror shall provide consultation and individual/group health education for clients, caregivers, and service providers.

4. Offeror shall, at minimum, make services available in the six (6) threshold languages: Spanish, Vietnamese, Tagalog, Mandarin, Cantonese, and Farsi. Staffing will reflect the percentage of ethnic and cultural make-up of the target population. If unable to provide services in each client’s primary language, Offeror shall provide the clients with access to interpreters or real-time language translation technology.

5. Offeror shall provide short-term supportive counseling and case management for up to a hundred and twenty (120) days, and/or brief individual and group psychotherapy.

6. Clients shall be linked to a Medi-Cal Home, WARMS, Wellness Program, Primary Care Behavioral Health (PCBH), and/or other related health care program for continued care.

7. Offeror shall provide referral, consultation, and advocacy with other local organizations or agencies as appropriate, including but not limited to the following:

a. Referral to the BHSD;

b. Crisis and problem resolution;

c. Case management in either a home or community-based setting; and

d. Client advocacy, education, and/or linkages to primary/behavioral health/ medication/community resources.

8. Offeror shall utilize wellness and recovery practices to link clients with a variety of services to identify and pursue goals that shall improve quality of life, self-sufficiency and independence by helping clients identify ways to manage their symptoms, health, and recovery.

9. At least once on an annual basis, the Offeror shall conduct a Client Satisfaction Survey, administer it to clients, and provide a summary of the results to the BHSD so that feedback and input can be incorporated as appropriate for ongoing quality improvement efforts.

10. Offeror shall provide program services in accordance with the ordinances and resolutions of the County Board of Supervisors and the applicable policies, procedures, directives, and guidelines of the County, BHSD, and the County of Santa Clara Health System (Health System), including, but not limited to the BHSD Provider Manual and the BHSD policies and procedures.

11. Offeror shall ensure that their organization’s service plan shall meets Medi-Cal/CalAIM behavioral health requirements, including, but not limited to:

a. Medical necessity criteria;

b. Documentation redesigns;

c. Co-occurring treatment;

d. Standardized screening and transition tools;

e. Behavioral Health CPT coding transition; and

f. Payment reform.

B. Staffing Requirements

1. Offeror shall be staffed with a minimum of 1:15 staff during the hours of operation.

2. Staff shall include professionals such as Licensed Clinical Social Workers and/or Marriage and Family Therapists, and paraprofessional Staff.

3. Staff shall possess the following education and experience:

a. A minimum of two (2) years of education in the areas of mental health and/or psychopathology;

b. Specialized experience working with transitional aged youth, adult, and older adult clients in a mental health service agency, and experience addressing substance use issues;

c. Crisis and conflict management training and experience in working with transitional aged youth, adults, and older adults, including knowledge of safety issues that exist when working with clients with mental disabilities in a community-based environment;

d. Familiarity of and/or experience with various experiential treatment methods, group and milieu therapy and activity-based programming with mental health service recipients;

e. Ability to relate and communicate effectively with transitional aged youth, adults and older adult clients with disabilities, fellow employees, and the public;

f. Ability to communicate clearly and concisely, both orally and in writing;

g. Ability to use sound judgment and set clear boundaries in the staff-client relationship; and

h. Display problem-solving skills and tact when working with special needs or challenging clients.

4. Staff shall attend any County training that pertains to providing behavioral health services to transitional-aged youth, adults, and older adults, as required by the BHSD.

5. Offeror’s organization shall maintain practices related to recruiting, hiring, and promoting bi/multi-lingual staff and/or a culturally or ethnically diverse workforce. Offeror’s organization shall have training requirements related to diversity, equity, and/or inclusion (e.g., Lesbian, Gay, Bisexual, Transgender, Queer, Questioning + [LGBTQ+], cultural and linguistic capacity, racial equity).

C. Cultural Competency

1. Offeror’s organization shall be inclusive of promoting behaviors and practices towards a more equitable, diverse, and inclusive organizational mindset. Offeror shall have a leadership model inclusivity and tools and support to improve their organization’s ability to identify and mitigate bias, respect differences, build empathetic relationships, and manage conflict.

2. Offeror shall monitor and evaluate client/family satisfaction and culturally responsive services/practices to continually improve service quality. Data shall be used to improve program satisfaction.

3. Offeror’s organization shall have a plan to address barriers when they do not have staff available to meet the six (6) Santa Clara County threshold languages (Spanish, Vietnamese, Mandarin, Cantonese, Tagalog, and Farsi) and a plan for actions and changes to ensure diversity and inclusion in service delivery.

4. Offeror’s organization shall provide outreach activities focused on reaching underserved, underrepresented, and/or multicultural populations.

D. Referrals and Admissions

1. Offeror shall serve clients as determined by County policies, procedures, directives, and guidelines.

2. Offeror shall accept referrals from contracted agencies, County agencies, and the Behavioral Services Call Center. The clients referred need to meet the diagnostic and functioning levels stated herein. All referrals shall be screened for consistency with the BHSD inclusionary criteria, which shall be determined by guidelines developed with community and provider input and approved by the BHSD Director.

3. Offeror shall screen all referrals for appropriateness. If referral does not meet criteria for the program, the referral shall be redirected to alternative resources to resolve the presenting issue(s). Offeror must be knowledgeable of community resources and have client linkage to alternative services as appropriate.

4. Offeror may refer clients, as appropriate, to other community supports, such as any offsite or onsite co-located BHSD services, substance use/recovery partners, or their organization’s specialty mental health programs and services.

E. Care Coordination

1. Offeror shall adhere to the following care coordination guidelines:

a. Offeror shall provide time-limited[footnoteRef:3] services to each client. [3: Time frame shall be based on clinical care and treatment needs on a case-by-case basis per client.]

b. Each client shall receive age-appropriate direct services, which include assessment, treatment planning, medication support rehabilitation, case management, care coordination, and crisis intervention.

c. Offeror shall provide direct clinical services based on the client’s assessment, evaluation, medication support, plan development, therapy, rehabilitation, case management, collateral services, and crisis intervention needs. Treatment services shall be culturally and linguistically proficient.

F. Program Hours of Operations

1. The program shall be open for services Monday through Friday, 8:00 AM to 6:00 PM.

2. Offeror shall provide an updated agency plan for administrative coverage or program-related changes to the BHSD Division Director at the beginning of each new fiscal year, and whenever any changes to this plan occur. The BHSD Division Director and/or their designee must approve the plan and any changes prior to implementation.

G. Evaluations, Transitional Planning, and Discharge

1. Evaluations:

a. Milestones of Recovery Scale (MORS) Administration and Entry into the County data system:

i. Each month, clinical staff shall complete MORS evaluations for their clients and enter their score into the County data system.

ii. For clients ages sixty (60) and older, the Older Adult MORS shall be administrated monthly.

b. Quarterly Reviews: Offeror shall submit a quarterly report demonstrating performance in engagement in services, successful discharges, and acute care readmissions.

c. Quality Improvement Plan: Offeror shall submit an annual QIP for review and approval by the County.

2. Transitional Planning:

a. Initiate discussion of discharge planning with clients at the start of treatment and continue throughout the client/family’s Length of Stay (LOS).

3. Discharge Planning:

a. Offeror shall follow up with clients to ensure that appropriate service linkage is made before terminating/closing the client from the program.

b. Offeror shall follow the guidelines below when discharging a client to the community:

i. Discuss possible challenges with client/family;

ii. Review strategies, skills, and supports to facilitate continuing treatment;

iii. Discuss using additional supports (e.g., family, peers, parent mentors, etc.) wherever possible;

iv. Provide client/family with a written transition plan which includes the elements above;

v. Confirm linkage of client to a Primary Care Provider (PCP) for continuity of medications and/or physical health; and

vi. Confirm linkage of client to behavioral health provider for continuity of medications, treatment, and services.

V. Public Health Emergency or Other Emergency Disaster Plan A. Offeror shall have policies and procedures to address disaster preparedness during a Public Health Emergency or other emergency disaster. Offeror shall complete Appendix B1 and submit the following supplemental information:

1. Emergency and disaster plan to deliver services during a Public Health Emergency or other emergency disaster that includes at a minimum, evacuation procedures, training for workforce members, and quarterly emergency drills;

2. Emergency and disaster plan to deliver services during a pandemic such as the COVID-19 pandemic.

B. Offeror shall comply with all County requirements relating to COVID-19.

1. If applicable, Offeror shall complete the Attachment E, Contractor Certification of Compliance with COVID-19 Vaccine Requirements (“Certification”) upon successful contract negotiations. For staff who routinely perform services for the County onsite and share airspace with or proximity to other people at a County facility as part of their services for the County, including but not limited to vaccination, as applicable and periodically updated, and available at https://procurement.sccgov.org/doing-business-county/contractor-vaccinations and incorporated herein by this reference.

RFSQ-BHS-FY23-0210: Adult and Older Adult System of Care Services Page 1 of 3 ATTACHMENT A1: In-Home Outreach Team Scope of Work CATEGORY 1: Prevention and Early Intervention Services