Attachment A13.pdf

ATTACHMENT A13

CATEGORY 4: PREVENTION AND EARLY INTERVENTION

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 1 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

COMMUNITY YOUTH WELLNESS CENTER - PEER SUPPORT AND ENGAGEMENT PROGRAM

SCOPE OF WORK

I. Purpose

A. The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking statements of qualifications from qualified Offerors interested in designing and operating Peer Support and Engagement Services in one or both Community Youth Wellness Center (CYWC) locations – allcove Palo Alto and/or Downtown Youth Wellness Center (DYWC) – serving youth ages 12-25. Offerors may propose services for either or both locations. The centers provide integrated services to support mental health, physical health, education, employment, peer, and family support, with a strong focus on community engagement and fidelity to program models.

II. Background Information

A. The CYWC integrates two (2) existing centers:

1. allcove Palo Alto: Established in partnership with Stanford University’s Center for Youth Mental Health and Wellbeing in 2021, allcove uses the Australian headspace model, emphasizing holistic, integrated early intervention for mental and physical health. FY24 Peer Support and Engagement Services included:

a. Peer Support Services – 594

b. Supported Education and Employment Services – 152

c. Outreach (Tours, Tabling, Networking, Engagement, Workshops)- 560

2. DYWC: Launched in 2022, DYWC operates as a community-based, low-barrier center providing drop-in services that includes but not limited to social, education, employment, resource linking, life skill building, wellness, recreational, and supportive services. FY24 Peer Support and Engagement Services included:

a. Peer Support Services - 1089

b. Outreach (Tours, Tabling, Networking, Engagement, Workshops) - 603

B. Both centers offer services aimed at reducing stigma and barriers to care, particularly for vulnerable populations, and maintaining fidelity to the integrated service models they are built upon.

II. Target Population

A. The CYWC serves all youth ages 12-25, including indigenous, LGBTQIA+, homeless, and disconnected youth (not engaged in school or work). The centers prioritize accessibility and offer inclusive, non-stigmatizing environments. Services are designed to meet the needs of youth with moderate emotional or behavioral challenges. Peer Support and Engagement services are provided to all youth regardless of their ability to pay or insurance status.

III. Program Goals and Objectives

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 2 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

A. The CYWC aims to foster positive social-emotional and physical well-being, reduce stigma, and provide accessible, comprehensive services for vulnerable populations.

The following goals and objectives are aligned with the specific requirements of each center:

1. Create a welcoming and safe space for youth to engage in services on their own terms.

2. Decrease stigma surrounding mental health services among young people.

3. Provide access to integrated services, including mental health, physical health, education, employment, and peer/family support.

4. Increase positive social-emotional and physical well-being and life functioning.

5. Engage natural support systems (family and peers) to nurture sustained wellness and social connections.

6. Reduce disparities in access to wellness services among underserved populations.

7. Maintain fidelity to the drop-in, low-barrier service model, allowing youth to access services without appointments.

8. Focus on peer-led recreational and psychoeducational workshops to promote emotional regulation, socialization, and connection.

9. Provide mentorship and leadership development opportunities to empower youth and engage them in shaping services.

10. Manage and facilitate key stakeholder forums, Community Consortium (allcove) and Advisory Group (DYWC), to ensure community voice shapes program design, policies, outreach, and evaluation.

B. allcove Palo Alto-Specific Objectives:

1. Maintain fidelity to the allcove integrated care model, ensuring seamless access to mental and physical health services.

2. Engage the Youth Advisory Group (YAG) to ensure youth voice shapes program design, policies, outreach, and evaluation.

IV. Reporting and Data Collection Requirements

A. Offerors shall comply with County reporting requirements, ensuring fidelity to evidence-based practices (EBPs) and maintaining high-quality service delivery. The following data must be collected and submitted quarterly:

1. Client demographic information, service utilization data, and outreach activities.

2. Client and service information (CSI), treatment and outcome data.

3. Satisfaction surveys, intake assessments, and follow-up assessments to track client progress and satisfaction.

4. Adherence to fidelity requirements, including tracking EBPs, peer support outcomes, and outreach effectiveness.

5. Utilization of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Classification of Diseases (ICD-10) for diagnostic and coding

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 3 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention purposes.

6. Track usage of drop-in services, peer support sessions, and social/recreational activities.

7. Report on outreach efforts to vulnerable youth (e.g., homeless, disconnected youth) and engagement outcomes.

8. Track mentorship and leadership program participation and outcomes.

9. Offeror shall detail 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’s Electronic Health Record (EHR) Status. Offeror shall indicate current and future County EHR system needs in Appendix H, using one (1) of the following myAvatar implementation types:

a. Provider Connect Enterprise (PCE) with 837 billing;

b. Provider Connect NX (PCNX) with 837 billing;

c. PCNX non-837 billing with fast service entry claims submission, or

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

B. allcove Palo Alto-Specific Reporting:

1. Track outcomes related to integrated care services (mental health, physical health, substance use prevention).

2. Report YAG involvement in program decisions, space design, and service delivery.

3. Provide data on the effectiveness of early intervention strategies and substance use prevention outcomes.

4. Ensure timely submission of data related to service utilization, client outcomes, and adherence to program models through BHSD-approve systems (e.g.

Datacove)

C. Data Submission:

1. Submit reports quarterly through the BHSD-approved systems and ensure timely submission of data related to service utilization, client outcomes, and adherence to program models.

V. Outcomes and Measurements

A. Offeror shall achieve the following outcomes, ensuring fidelity to each center's specific service model:

1. Timely access to services.

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 4 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

2. Increased social-emotional well-being and overall life functioning.

3. Positive youth satisfaction with services.

4. Increased engagement in educational and employment opportunities.

5. Strengthened peer and family support systems.

6. High engagement in drop-in services, peer-led workshops, and recreational activities.

7. Improved social connections and reduction of social isolation among youth.

8. Increased youth participation in leadership development and peer mentorship opportunities.

9. High client satisfaction with the confidentiality and holistic nature of services.

B. allcove Palo Alto-Specific Outcomes:

1. Successful integration of mental and physical health services, resulting in improved social-emotional well-being and reduced substance use risk.

2. Increased engagement of youth in leadership roles through the YAG.

VI. Program Description

A. Service Description

1. CYWC offers a range of comprehensive peer support and engagement services designed to support the mental, emotional, and physical health of youth ages 12-25. Services vary by site but share a core focus on early intervention, peer support, educational assistance, and family/community engagement.

2. Peer Support Services:

a. Trained Peer Support Specialists provide one-on-one support, empowering youth to navigate mental health challenges, educational barriers, and employment difficulties.

b. Peer support sessions focus on empowerment, goal-setting, and linking youth to appropriate community resources.

3. Educational and Employment Assistance:

a. Offer educational and vocational support, including assistance with resumes, job searches, interview preparation, and connections to vocational training programs.

b. Academic support, including tutoring, school enrollment help, and pathways to mainstream education or technical training.

4. Social and Psychoeducational Workshops:

a. Psychoeducational workshops cover mental health awareness, coping skills, RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 5 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention emotional regulation, substance use prevention, and life skills.

b. Social activities promote engagement and help reduce stigma surrounding mental health.

5. Family and Community Engagement:

a. Involve family members and community stakeholders in the youth’s wellness journey through family support services and outreach.

b. Ensure the program reflects local community needs by facilitating collaborative discussions with the allcove Community Consortium, DYWC Advisory Group, and other stakeholders to gain insight on community needs from the community.

6. Compliance with County and State Requirements:

a. 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/or the BHSD policies and procedures.

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

c. Medical necessity criteria;

d. Documentation redesigns;

e. Co-occurring treatment;

f. Standardized screening and transition tools;

g. Behavioral health CPT coding transition; and

h. Payment reform.

i. Drop-In Model: Provide low-barrier, flexible access to services without the need for appointments. Centers focus on creating a welcoming space for socialization, recreation, and peer-led support.

j. Mentorship and Leadership Development: Centers emphasizes opportunities for mentorship and leadership through participation in activities and workshops designed to build personal growth and community engagement.

7. allcove Palo Alto-Specific Services:

a. Integrated Care Model: Provide holistic care integrating mental health, physical health, substance use prevention, peer and family support, and education/employment services.

b. YAG Participation: Ensure youth voices are integral to program design, RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 6 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention policies, outreach, and evaluation. YAG also supports leadership and decision-making opportunities for youth.

B. Staffing Requirements

1. Offerors shall ensure that both centers are adequately staffed to meet the program requirements and maintain fidelity to service models.

a. Program Coordinator: Shall work collaboratively with Center Manager and be responsible for day-to-day operations, coordinating Peer Support Specialist staff, and ensuring adherence to program guidelines and fidelity requirements.

b. Peer Support Specialists (PSS): Provide one-on-one peer support, facilitate workshops, and engage in outreach activities. PSS must meet certification and training requirements set by the County and BHSD.

c. Administrative Support: Receptionist or administrative assistant to support the management of day-to-day administrative functions, client intake, data entry, and scheduling.

d. Quality Assurance Staff: Ensure compliance with reporting, data collection, and service quality standards.

e. Offeror shall identify the ability to ensure oversight by a licensed behavioral health clinician to support peer support services billing deliverables.

2. Offeror’s organization shall maintain practices related to recruiting, hiring, and promoting 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).

3. allcove Palo Alto-Specific Staffing:

a. As part of PSS staffing, Offeror will identify staff(s) to support the YAG and ensure youth input is integrated into service delivery.

b. Supported Education and Employment Specialist: Provide one-on-one educational and employment support, facilitate education and employment related workshops, and engage in outreach activities. The SEES must meet certification and training requirements set by the County and BHSD.

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 leadership that models inclusivity and provides tools and support to improve the organization’s ability to identify and mitigate bias, respect differences, build empathetic relationships, and manage conflict.

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 7 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

2. The program shall be reflective of the ethnic, cultural, and linguistically diverse populations of the County and preferences of each client. 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. The program shall be composed of staff proficient in the seven (7) County of Santa Clara threshold languages (Spanish, Vietnamese, Mandarin, Cantonese, Tagalog, Farsi, and Russian). Offeror’s organization shall have a plan to address barriers when they do not have staff available to meet the County threshold languages 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. The referral and admissions process shall ensure seamless entry into CYWC services and adherence to a general workflow that promotes accessibility and continuity of care.

a. Referral Sources: Accept referrals from internal and external sources, including community providers, educational institutions, child welfare and juvenile justice systems, and walk-ins from the community.

2. Admissions Process:

a. Collect basic demographic information (e.g., name, DOB, address, school, grade) and complete intake assessments to identify service needs.

b. Conduct outreach to underserved populations to ensure equitable access to services.

3. Feedback Loop: Offerors shall ensure referral sources, including primary care physicians (PCP) and community partners, are informed of the referral status and next steps to facilitate care coordination.

4. Emphasize integrated care referrals, particularly for youth needing both mental and physical health services. Ensure coordination with external healthcare providers when higher levels of care are required.

5. Utilize a low-barrier admissions process, allowing youth to access drop-in services without appointments. Focus on outreach to engage marginalized youth populations, such as homeless youth and those disconnected from school or work.

E. Care Coordination

1. Offerors shall coordinate care across multiple systems and providers to ensure

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 8 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention comprehensive service delivery for youth.

a. HIPAA-Compliant Authorization: Request client authorization to share information with all relevant providers, ensuring compliance with state and federal privacy laws.

b. Ongoing Coordination: Care coordination should begin at intake and continue throughout treatment, discharge planning, and aftercare.

c. Multi-Agency Collaboration: Offerors must establish partnerships with local providers, educational systems, and social service agencies to support youth in accessing a full continuum of care.

d. Review and Discharge Planning: Regularly review each client’s progress toward their planned goals and adjust care as needed, ensuring smooth transitions to lower levels of care or external providers.

e. Emphasize care coordination with external healthcare providers for youth receiving integrated mental and physical health services. Warm handoffs to specialized care providers for youth requiring higher levels of intervention.

f. Coordinate with community-based organizations to connect youth to housing, educational, and vocational services as needed, with a focus on ensuring continuity of care for homeless or disconnected youth.

F. Program Hours of Operations

1. Both centers’ staffing shall maintain accessible hours to meet the needs of youth while offering flexibility for extended or after-hours programming to support outreach activities and meet the needs of the community.

a. Core Hours: Monday through Friday, 10:00 AM to 7:00 PM.

b. Extended Hours: As opportunities are presented Offeror shall participate in evening or weekend services, such as workshops, tabling or recreational activities, to promote center services and activities, when opportunities are provided for such events

c. Holiday Closures: Offerors must ensure adequate staffing during all operational hours of the centers.

G. Evaluations, Transitional Planning, and Discharge

1. Offerors shall ensure that all clients are appropriately evaluated upon intake, receive regular progress assessments, and have smooth transitions and discharges, as required by County and program guidelines. Both centers must tailor their processes to fit the unique service models while maintaining continuity of care for all clients.

a. Evaluations

i. Initial Intake Assessments:

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 9 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

1) All youth entering services at either center must undergo a comprehensive intake assessment to gather baseline data on mental health, emotional well-being, physical health (where applicable), educational needs, and vocational goals.

2) Assessments should include standardized tools, such as PHQ-2, GAD-2, CRAFFT, and the Prodromal Questionnaire-Brief (PQ-B), to identify areas of need and determine service eligibility.

ii. Ongoing Progress Evaluations:

1) Regular progress evaluations must be conducted every three months, at a minimum, to assess clients' mental health, social-emotional well-being, and overall functioning. These evaluations should be used to modify service plans and goals as needed and include the following:

a) Measure outcomes related to peer support, educational progress, employment support, and recreational activities.

b) Assess youth’s involvement in leadership and mentorship programs.

iii. Transitional Planning

1) Offerors shall develop and implement individualized transitional plans for youth who require more intensive services or need to move to a different level of care.

2) Warm Hand-offs and Transitions:

a) All youth transitioning out of services or requiring a higher level of care shall be provided with warm hand-offs to external providers or appropriate County services. This includes facilitating smooth transitions to housing support, educational programs, healthcare providers, or specialized mental health treatment.

b) Transitional planning should begin early, ensuring that youth and their families are engaged in the decision-making process.

3) Coordination with External Providers:

a) When youth need services beyond the scope of CYWC (e.g., long-term counseling, psychiatric care, housing services), Offerors must coordinate with external providers and facilitate timely referrals to ensure continuity of care.

b) External agencies involved in transitional care planning may include mental health providers, primary care physicians, RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 10 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention educational/vocational training programs, housing services, and community-based organizations.

4) Family and Peer Involvement:

a) Where applicable, family members and natural supports should be involved in the transitional planning process to help sustain the youth’s wellness beyond CYWC services.

b) Youth who have formed peer connections at the centers should be encouraged to maintain these relationships during their transition.

c) Ensure youth receiving early intervention substance use services are transitioned to specialized addiction treatment services, as appropriate.

d) For youth requiring more structured services (e.g., housing, employment assistance), warm handoffs should be made to community-based programs.

5) Discharge

a) Offerors shall follow the County’s discharge criteria, ensuring that all youth exiting the program receive appropriate follow-up and referrals when needed. Discharge Criteria:

b) Youth shall be discharged from the program when they meet one of the following criteria:

c) The youth has successfully completed the program and met their service goals.

d) The youth voluntarily withdraw from the program or does not wish to engage in services any longer.

e) The youth require services that exceed the scope of CYWC and has been successfully transitioned to a more appropriate provider.

f) The youth has not engaged with services for over 30 days, despite multiple attempts to re-engage, following County policies and procedures.

g) Discharge Process:

a. Written Discharge Plan: A comprehensive written discharge plan must be provided to youth upon exiting the program. The plan should summarize services received, progress made, and any recommendations for ongoing support.

RFSQ-BHSD-FY25-0066: Children, Youth, and Family System of Care Services Page 11 of 11 ATTACHMENT A13: Community Youth Wellness Center - Peer Support and Engagement Program Scope of Work CATEGORY 4: Prevention and Early Intervention

b. Exit Survey: An exit survey must be conducted to gather feedback on the youth’s experience with CYWC services, including satisfaction with services and recommendations for improvement.

c. Post-Discharge Follow-Up: A follow-up contact must be made within 30 days post-discharge to ensure the youth has transitioned smoothly and is connected to the necessary services.

d. Re-Entry: Youth who have been discharged may re-enter the program if their circumstances change and they require further support. Offerors shall have a process in place for re-enrollment, where applicable.

h) Link youth, where appropriate, to community-based recreational programs or peer support groups to maintain social engagement and well-being after discharge.

VII. 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 B, Evaluation Criteria and Qualifications 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; and

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 in effect relating to COVID-19 for persons who routinely perform services for County onsite and share airspace with or proximity to other people at a County facility as part of their services for County as set forth in a County Health Order (or similar directives).