Attachment A11.pdf

ATTACHMENT A11

CATEGORY 3: OUTPATIENT SERVICES

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CROSS-SYSTEMS CHILD AND YOUTH OUTPATIENT CONTINUUM

SCOPE OF WORK

In addition to Attachment B – Standardized Scope of Work Language, the following applies:

I. Purpose:

A. The County of Santa Clara (County) Behavioral Health Service Department (BHSD) is seeking statement of qualifications from qualified Offerors interested in designing and operating the Cross-Systems Child and Youth Outpatient Continuum (hereafter referred to as “the program”).

B. The program provides Specialty Mental Health Services (SMHS), including but not limited to therapy, medication support, rehabilitation services, Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS), for children and youth with significant behavioral, emotional, or mental health needs. The primary goals are to enhance access to various child-serving system services (e.g., mental health, medical and health services, educational support, child welfare, juvenile justice, substance use treatment, crisis intervention, and family support), facilitate teamwork, and coordinate mental health care. The program focuses on improving access, quality, and coordination of mental health services, leading to better mental health outcomes and overall well-being.

C. Offeror shall provide individualized mental health services for children and youth ages five (5) through 20, along with their family and support systems, with a key focus on Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS). This program is distinct from the Outpatient Continuum (OPC) Program and the Specialty Outpatient Continuum (SOPC) by integrating ICC and IHBS to offer comprehensive, strength-based care tailored to each child’s and family’s needs and to support the child’s progress through treatment phases and enhance over all well-being. Services shall span the continuum of intensive, outpatient, and wellness care, that respects child and family’s values and culture. Services shall be delivered with the Child and Family team (CFT) framework, prioritizing family voice and choice to support the child’s progress through the phases of treatment to improve well-being.

II. Background Information:

A. The program formerly known as Katie A. Intensive Services, resulted from a class action settlement which sought to improve the behavioral health of children and youth who need coordinated and intensive community based mental health services.

Among other outcomes, the settlement resulted in two new Medi-Cal reimbursable services known as ICC and IHBS which are available within this program.

B. Additionally, new practice behaviors and standardized principles and values for integrated care was developed because of the settlement, drawn from the principles of Wraparound. This framework of care, now known as the Integrated Core Practice

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Model (ICPM) ICPM Guide and ACIN 1-21-18:

https://www.cdss.ca.gov/Portals/9/ACIN/2018/I-21_18.pdf, centers the work of supporting the youth’s mental health care around the CFT, and seeks to align services to be integrated and seamless by using a teaming approach.

III. Target Population:

A. The population to be served shall be Medi-Cal eligible children, youth, and young adults (hereafter referred to as “clients”) from age five (5) through 20, who are residents of Santa Clara County and in need of community-based mental health services. The program is target towards three groups:

B. All children with an open case in the child welfare system or the juvenile probation system should be referred to the program within (3) business days of case opening.

Referrals may also be submitted as the needs and circumstances of children and youth change. Youth with an identified need for Intensive Care Coordination may also be referred. The program accepts referrals for:

1. Children and youth involved with the child welfare system, including family maintenance, family reunification, permanent placement, and voluntary services.

2. Children and youth involved with the juvenile probation system who are receiving formal probation services with an assigned probation officer.

3. Children and youth referred from a Specialty Mental Health Services program that does not provide Intensive Care Coordination.

C. The program is designed to be generally less intensive than the Full Services Partnership continuum services program and/or Wraparound services. Services including dosage and intensity may be adjusted depending on the clinical needs of client.

D. A typical client in the program may have, but not limited to some of the below characteristics:

1. Functional impairment: Clients experience significant difficulties in family interactions, peer interactions, and school or vocational functioning. They demonstrate moderate to severe emotional regulation needs that require external supports;

2. Common Diagnoses and Presenting Behaviors (not limited to): Typical diagnoses include moderate to severe anxiety disorders, major depressive disorder, co-occurring disorders such as bipolar disorder, trauma-related disorders, and adjustment disorders. These conditions result in marked impairment in daily functioning. Internalizing or externalizing behavioral issues contribute to moderate to severe disruptions in relationships and overall functioning;

3. Support System: While clients have access to some social and environmental support, there is a critical need for substantial strengthening and buffering of these supports to adequately meet their complex needs.

https://www.cdss.ca.gov/Portals/9/ACIN/2018/I-21_18.pdf https://www.cdss.ca.gov/Portals/9/ACIN/2018/I-21_18.pdf

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4. Therapy Timeline: Initially, clients and their families typically require intensive support for 6-12 months, with sessions scheduled 1-2 times per week. As treatment progresses and stabilization occurs, session frequency may decrease;

5. Crisis Intervention: Crises may occur occasionally; therefore, all clients should have a comprehensive plan in place to address potential exacerbations of symptoms effectively; and

6. Care Coordination: Clients and families typically have moderate care coordination needs, often necessitating CFT meetings to coordinate comprehensive treatment plans and ensure holistic care delivery.

IV. Program Goals and Objectives:

A. The program shall be aligned to achieve the CYF Scope of Work and the following program specific goals and objectives:

1. Goals shall include, but not limited to:

a. Ensuring clients involved in child serving systems experience aligned and coordinated service delivery for complex needs, with strong engagement and participation of the youth and their support network; and

b. Increased stability in the living environment and family functioning.

2. Objectives shall be achieved by:

a. Utilization of the CFT members and CFT meetings as a strategy to identify needs and resources, assess progress, and to adapt interventions to fit client needs;

b. Promote teaming across formal and informal support systems;

c. Clients and their families will be the drivers of the services that are identified and have equity in the decision making;

d. Utilize the CFT to assess, engage, monitor, and transition the youth in alignment with the ICPM, and to scaffold the client and family with increased engagement of natural supports and resources;

e. For clients in out-of-home placement, supports the client, caregiver, future caregiver, and family through transitions in care, preparation for reunification and support after reunification occurs, when clinically indicated;

f. Increase partnership and coordination of services for the client between child serving systems, including Department of Family and Children’s Services (DFCS), the Behavioral Health Services Department (BHSD), the Juvenile Probation Department (JPD), medical, educational, regional, and other community organizations, consistent with the ICPM;

g. Place special emphasis on family and caregiver involvement in treatment;

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h. Engage underserved clients and families who have not benefited from traditional outpatient mental health services or need additional teaming strategies due to complex risk factors including substance use, community or interpersonal family violence, cross-system involvement, or history;

i. Ensure that services are individualized, trauma-informed, culturally, and linguistically responsive, utilizing modalities in accordance with the ICPM and Medi-Cal Manual for ICC, IHBS, and Therapeutic Foster Care (TFC): Medi-Cal Manual Third Edition ADA;

j. Educate the client and/or the client’s significant support person(s) on how to manage the client’s mental health disorder; and teach skills or replacement behaviors that allow the client to fully participate in the CFT process and meetings and other meaningful community activities;

k. Implement a positive behavioral plan and/or modeling interventions for the client’s significant support person(s) and assisting them to implement strategies to improve family functioning and skill-based training;

l. Develop safety plans in collaboration with the child/ youth, and their support system; and

m. Increase client accessibility to mental health and substance use treatment services by providing community based mental health services.

V. Reporting and Data Collection Requirements

A. Offeror shall maintain and provide comprehensive staffing and training records to be reviewed quarterly in a format approved by BHSD. These records demonstrate compliance with contractual requirements. Training records shall include, names of training, dates of trainings, and any certifications obtained as a result. Staffing records shall include, employee’s name, date of hire, job title, language capacity, qualifications, and certifications. Vacancies shall be noted on the staffing records.

B. Offeror shall track the clients serviced in the program and the level of service that is being provided (Intensive, Outpatient, or Wellness) and have the ability to provide this information to BHSD upon request.

VI. Outcomes and Measurements

Offeror shall achieve the following outcomes:

1. The Program uses the CFT model to assess, monitor, adapt and transition the youth from services. When the youth’s CFT comes to consensus that the primary goals of the child and youth have been met, and/or the youth no longer meets ongoing medical necessity for services delivered within the Program, the youth can graduate treatment or transition to a lower level of care as a successful outcome.

VII. Program Description:

https://www.dhcs.ca.gov/Documents/ChildrensMHContentFlaggedForRemoval/Manuals/Medi-Cal_Manual_Third_Edition.pdf https://www.dhcs.ca.gov/Documents/ChildrensMHContentFlaggedForRemoval/Manuals/Medi-Cal_Manual_Third_Edition.pdf

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A. Service Description

1. Offeror shall provide a range of non-stigmatizing services from Intensive, Outpatient to Wellness level of service to children, youth and their family and/or caregivers.

a. Intensive services shall be provided to clients who demonstrate higher acuity of needs and may require higher frequency of support to address symptoms, conditions, and/or risk factors that are impacting their ability to maintain themselves in community settings. Services shall include crisis response services, as needed.

b. Outpatient services shall be provided to clients who may need support to address behavioral health challenges that impact life domains including employment, education, living situation, personal wellbeing, interpersonal relationships, and community functioning.

c. Wellness services shall be provided to clients who may need medication management and light case management short term support to sustain their wellness and recovery as the program is actively working on linking to longer term medication support with Primary Care Physician (PCP), Managed Care Plan (MCP), or another long-term provider to ensure a warm handoff.

2. Services shall be primarily community-based, and may occur at the client’s residence, clinic or agency, school, and other locations in the community, as necessary and as needed by the clients served.

3. Available services shall typically include assessment, therapy (individual, family, and collateral) IHBS, and ICC. Clients may also need, medication evaluation and support services, crisis intervention, and case management/brokerage services.

While not common, group therapy can also be provided. ICC and IHBS shall be provided in accordance with the Medi-Cal Manual for ICC, IHBS, and TFC.

4. All clients referred to the program are eligible for ICC services. ICC services are similar to traditional Targeted Case Management (TCM) but must utilize a CFT process to develop and guide the planning and service delivery process for ICC services and incorporate the phases of treatment as guided by the ICPM.

5. Offeror shall ensure that all clients who are identified as needing psychiatry, medication management, or other adjunct SMH service will be provided and/or linked to services within the required network adequacy timeline determined by the Department of Health Care Services (DHCS).

6. Services shall be individualized and tailored to the needs of the client based upon age, developmental functioning level, history of trauma, cultural values, family environment, and physical health.

7. ICC Services may include:

a. Assessing the client and family’s needs and strengths;

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b. Identifying interventions and/or course of action targets at the client/family’s assessed needs;

c. Assessing the adequacy and availability of formal and informal resources and working with the child and family team to increase natural resources and supports

d. Reviewing information from family and other sources;

e. Ensuring that plans from any of the system partners are integrated to comprehensively address identified goals and objectives.

f. Evaluating the effectiveness of previous interventions and activities;

g. Monitoring and adapting the plan in partnership with the CFT;

h. Preparing the youth for transition in partnership with the CFT;

i. Facilitation of CFT meetings as often as desired or clinically appropriate, and at least every 90 days, and sharing notes with the team with action plans.

8. Clients receiving ICC are also eligible for IHBS. IHBS are similar to traditional individual rehabilitation and collateral Mental Health services but must be delivered at a significant intensity to meet the mental health needs of the client, be predominantly delivered outside of an office setting (e.g., in the home, school, or community), and incorporate the principles of the ICPM. IHBS are intensive, individualized, and strength-based interventions to assist the client and their significant support person(s) to develop skills to achieve the goals and objectives of the client’s treatment plan. Clients in the program shall not automatically receive IHBS. Clients must receive ICC services to access IHBS. IHBS services must be pre-authorized by the County Utilization Review Department, after discussion and agreement with members of the client’s CFT.

9. IHBS services may include:

a. Implementation of a positive behavioral plan and/or modeling interventions for the clients’ significant support person(s) and assisting them to implement strategies;

b. Educating the client and/or the client’s significant support person(s) on how to effectively manage the client’s mental health disorder to improve functioning; and

c. Teaching skills or replacement behaviors that allow the client to fully participate in meaningful activities.

C. Staffing Requirements

1. Clinicians

a. Licensed Practitioner of the Healing Arts (LPHA), including waivered staff;

b. Licensed or Associate Marriage and Family Therapist (LMFT/AMFT);

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c. Licensed or Associate Clinical Social Worker (LCSW/ASW);

d. Licensed or Associate Professional Clinical Counselors (LPCC/APCC).

i. The Clinician provides high-quality, client-centered assessment and treatment which may include assessment, diagnosing of mental health conditions, providing therapeutic interventions, supporting care planning, and family therapy.

ii. The Clinician collaborates with ICC facilitators, IHBS Providers and community-based supports.

iii. Youth who would benefit from having a clinician assigned to provide primary therapeutic interventions (in addition to services described by ICC and IHBS) may be assigned a separate clinician within the program to provide this service.

iv. It is preferable for this role to be filled by a separate staff member to ensure distinct and dedicated attention to the role of the Clinician. The clinician should be embedded as part of the CFT.

v. The role of the Clinician is central to the client’s healing and progress. The role is vital in addressing the immediate mental health needs of clients, supporting healthy family interactions, and supporting long-term well-being.

2. The Intensive Care Coordinator (ICC Facilitator):

a. A highly skilled facilitator, with a strong clinical background, who coordinates and develops the Child and Family Team, and serves as the single point of accountability for the care plan for the youth. Provides ICC services as described in Section 7 (A).

b. Able to navigate complex team and family dynamics to ensure equity, psychological and physical safety of all participants, and full participation, by lifting the voices of the child and family to center the work, setting clear expectations, and using advanced skills in team facilitation to help reach consensus on next steps and mitigate barriers to support the child/youth.

c. Serves in a distinct capacity separate from individual treating clinician or service provider delivering IHBS. If the ICC facilitator is combined with another role, the Offeror must consider the benefits and drawbacks to this dual role.

d. Staff shall have knowledge of the child welfare system, including basic knowledge related mandated reporting, court procedures, and rights of children and families, an understanding of the developmental stages of children, the impact of trauma, abuse, and neglect on their emotional well-being.

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For youth who need services from the program above and beyond ICC, additional staffing may be added to the treatment team as determined by the CFT:

3. The Intensive Home-Based Services Worker(s):

a. Provides medically necessary, skill-based interventions known as IHBS for the remediation of behaviors or improvement of symptoms, including, but not limited to, the implementation of a positive behavioral plan, and/or modeling interventions for the child’s/youth’s family and/or significant others, as described in Section 7 (A).

b. IHBS services may be provided by credentialed paraprofessional staff, Mental Health Rehab Specialists, Clinicians, and other mental health professionals.

c. Serves in a distinct capacity from the ICC facilitator.

4. Psychiatrists Other Licensed Prescribing Practitioners:

a. Service activities may include but are not limited to evaluation of clinical effectiveness and side effects of psychotropic medication; obtaining informed consent; instruction in the use, risks, and benefits of, and alternatives for, medication.

b. Services may include assessment, collateral and plan development related to the delivery of service and/or psychiatric assessment for the client;

prescribing, administering, dispensing, and monitoring of psychiatric medications, and medication education.

5. Parent/Family Partners:

a. As determined by the CFT, a parent partner may be assigned as part of the team to provide direct services, advocacy, and support, to the youth or their caregiver.

i. Parent partners are key individuals who work with children, youth, and families within the public child welfare, juvenile probation, or mental health systems.

ii. Parent partners have lived experience and can convey information on how systems and programs can instill the family-centered and family-driven philosophy and principles necessary to engage children, youth, and families.

iii. The parent partner shall be part of the CFT.

D. Referrals and Admissions

1. The primary source of referrals will be child welfare social workers and juvenile probation officers. Other community partners may also make referrals if the client meets the target population criteria. So

E. Care Coordination

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1. Care coordination is an important component of the Program, which involves various professionals (providers) such as therapist, social workers, Primary Care Providers, public health nurses, school counselor, and family members. This is further specified in the Integrated Core Practice Model manual.

2. A central component of ICC services is ensuring that the holistic needs of the youth, including physical health care needs, are addressed. Care coordination involves communicating with Primary Care Physician or other health professional. By including Primary Care Physician (PCP) or other health care providers in care coordination and planning, it may help in developing a more holistic care plan and help reduce fragmented care. If the youth is receiving Enhanced Care Management (ECM) from the Managed Care Plan, the ICC facilitator communicates planning with the ECM provider to avoid duplication and address any gaps in services.

3. The CFT meeting, held minimally every 90 days, and as often as is clinically indicated, is essential in maintaining a feedback loop and providing regular updates to support care coordination. By collaborating and sharing needed information, the team is optimally supported to help their child, youth, and their family to achieve positive outcomes.

F. Evaluations, Transitional Planning, and Discharge

1. Offeror shall monitor the client progress and goals throughout the CFT process.

Achievements should be acknowledged and celebrated.

2. Offeror shall discharge clients upon mutual agreement by the CFT when the client completes the program successfully as specified in the Integrated Core Practice Manual.

3. Offeror shall transfer clients who have graduated from the program to lower levels of care, such as outpatient care or their managed care plan, based on the client's level of care need as determined by the CFT and any relevant screening tool. The Offeror shall follow the following guidelines when there is a program transfer:

a. Coordinate with the new provider to assure an understanding of client’s strengths, needs, supports, and goals; and

b. Provide copies of Care Plan, Child and Adolescent Needs and Strengths (CANS) assessment tool, Narrative Summary, and Assessment information to the new provider.