ATTACHMENT A17

CATEGORY 3: FULL SERVICE PARTNERSHIP SERVICES

FORENSIC ASSERTIVE COMMUNITY TREATMENT

Scope of Work

Purpose A. The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking statements of qualifications from qualified Offerors interested in providing Forensic, Diversion, and Reintegration (FDR) Forensic Assertive Community Treatment (FACT) program (hereafter referred to as “the program”) for eligible County residents. Services sought may be funded by state and/or federal grants focusing on the treatment of justice involved clients, such as grants by the Department of State Hospital.

B. The program shall provide the highest level of outpatient services including, but not limited to:

1. Mental health services;

2. Medication support;

3. Case management;

4. Crisis intervention;

5. Outreach and engagement;

6. Housing support;

7. Substance abuse treatment for people with co-occurring disorders[footnoteRef:2]; [2: Clients require both mental health and substance use treatment services.]

8. Educational and vocational services; and

9. Rehabilitative services.

C. The program services shall be culturally appropriate and trauma-informed to promote the recovery, stability, and resilience of all clients. Services shall be designed to improve the emotional/behavioral functioning and enhance the abilities for clients to participate in meaningful activities such as recreational, school, employment, social engagement, and independent living activities.

Operational and Logistical Requirements A. 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 on or become certified to provide Medicare reimbursable services on or before the contract start date.

B. Offeror shall strategically operate a Medi-Cal and Medicare certified service delivery site within the identified County catchment areas. The site shall be considered home base for Offeror’s staff. Even with established sites, services shall be offered in the community or wherever the clients are (e.g., work, school, home, homeless shelter, jails, courts, etc.), if appropriate.

C. Offeror shall have current Drug Medi-Cal (DMC) certification or have the ability to become Drug Medi-Cal certified on or before the contract start date.

A. Services shall be situated within the identified County catchment areas. The four (4) primary regions of focus for program services are North, Central, and South County regions:

1. North County: Palo Alto, Los Altos and Los Altos Hills, Mountain View;

2. Central County: San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell;

3. East County: San Jose (Foothills, Berryessa) and Northeast San Jose/Milpitas areas; and

4. South County: Gilroy, Morgan Hill, and the unincorporated area of San Martin.

Background Information B. FACT is an alteration of the Assertive Community Treatment (ACT) model, which shall focus specifically on the treatment of justice-involved individuals. ACT was developed for individuals with severe mental health conditions who do not seek out support, have trouble engaging in traditional office-based programming, and might otherwise be served in an institutional setting.

1. The model is a community-based model that is characterized by:

a. A low client-to-staff ratio;

b. Services provided primarily in a community setting rather than in an office setting;

c. A multi-disciplinary team designed to share caseloads;

d. Twenty-four (24)-hour staff availability;

e. Ability to offer a wide array of in-house services; and

f. Longer lengths of stay.

C. The California Legislature enacted Penal Code (PC) 1001.36 and Welfare and Institutions Code 4361 and amended Penal Code 1370 on June 27, 2018, to authorize courts to divert certain individuals with serious mental illness and allow the Department of State Hospitals (DSH) to contract with counties as a funding mechanism for the establishment of new or expansion of existing pre-trial mental health diversion programs. PC 1001.36 and PC 1370 establish the criteria by which a court can divert an individual to a county pre-trial Felony Mental Health Diversion Program funded by DSH. On July 1, 2020, DSH entered into a grant agreement contract with BHSD FDR to administer a pre-trail jail felony mental health diversion program for individuals charged with felony offenses in the County.

Target Population D. The program shall provide comprehensive, evidence-based behavioral services to justice-involved adult (ages 18 through 59) and older adults (age 60 and over) diagnosed with severe and persistent mental health and/or co-occurring (mental health and substance use) conditions that result in substantial functional impairments or symptoms. A portion of the population to be served shall also require treatment specific to individuals deemed Incompetent to Stand Trial (IST).

E. Offeror shall have the capacity to serve clients with one (1) or more of the following:

1. A primary psychiatric diagnosis of Schizophrenia; Schizoaffective Disorder; Bipolar Disorder; or Major Depressive Disorder with Psychotic Features;

2. Significant functional impairment(s) preventing basic adult functioning without significant assistance from others;

3. High medical and/or mental health service needs with no indication that other available community-based services can more effectively meet;

4. Justice-involved; and/or

5. Deemed IST;

F. Clients served shall have Medi-Cal benefits designated to County 43 (Santa Clara County) or be uninsured. Program staff shall assist individuals with applying and gaining access to Medi-Cal and an income source (e.g., General Assistance [GA], Supplemental Security Income [SSI], etc.).

G. Individuals served shall meet Medi-Cal medical necessity criteria in accordance with all laws and regulations governing Medi-Cal and Medicare programs mandated by federal, state, and local statues, and not limited to California Code of Regulations (CCR) Title 9 and Social Security Act Title XXII Regulations.

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

1. Goals shall include, but not be limited to:

a. Reduce subjective suffering from mental illness and co-occurring substance conditions;

b. Reduce the number of people with mental illness and/or co-occurring conditions who are booked into correctional facilities;

c. Decrease incarceration rates among justice-involved adults and older adults;

d. Reduce experiences of homelessness, crisis, hospitalization, substance use, violence, and victimization;

e. Reduce experiences of crisis, violence, and victimization;

f. Strengthen recovery, self-sufficiency, and other psychosocial outcomes, including housing, education, employment/income, and access to entitlement benefits;

g. Increase reintegration into community life with a focus on stability, particularly in the area of symptom management and reduction of harmful behaviors and suicide; and

h. Reduce inadequate mental health services for clients waiting in custody for hospital placement.

2. Objectives shall be achieved by:

a. Providing services that meet timeliness requirements set forth by the BHSD;

b. Increasing the number of successful discharges;

c. Reducing the number of clients receiving inpatient hospital services who are readmitted;

d. Ensuring that clients remain engaged in treatment after being released from custody;

e. Incorporating the principles of “wellness and recovery,” in which all services are client-centered, strength-based, and promote recovery and resiliency;

f. Assisting justice-involved individuals in developing life skills that will improve their ability to live and thrive in the community following incarceration;

g. Identifying the risk to reoffend;

h. Helping clients address substance/alcohol use and related risky behaviors (e.g., unsafe sex, criminal behaviors) as applicable;

i. Enhancing client understanding of medication adherence and its effectiveness, if appropriate;

j. Encouraging clients to actively participate in their recovery and self-monitor their milestones and goals toward self-determination, family, education, and vocational services;

k. Engaging underserved clients who have not benefited from traditional outpatient mental health services due to complex risk factors including substance use, community violence, interpersonal family violence, general neglect, and exposure to trauma;

l. Increasing clients’ understanding of the importance of their medication and its effectiveness;

m. Providing access to peer support staff who will assist clients in modeling personal recovery; and

n. Providing culturally and linguistically proficient client-centered services that integrate the full range of treatment and rehabilitation modalities.

Reporting and Data Collection Requirements A. Offeror shall comply with the reporting requirements reflected in Division 5 of the California Welfare and Institutions Code, Division 1, and Title 9 of the California Code of Regulations.

B. Offeror shall submit the following assessment data into the State Data Collection and Reporting (DCR) system through an online interface:

1. The Partnership Assessment Form (PAF);

2. The Key Event Tracking (KET); and

3. Quarterly Assessment (3M).

C. Offeror shall adhere to DCR policies and data collection procedures established by the BHSD.

D. Offeror shall have a current Electronic Healthcare Record (EHR) system with the capability to exchange data with County systems and the State’s DCR system, or plan to implement one by the contract start date.

E. Offeror shall attend a DCR training as required by the BHSD for all FSP providers.

F. Offeror shall complete the following requirements:

1. Enter a weekly capacity report that includes recent referrals, current enrollment, and recent discharges that reflect current and accurate program capacity;

2. Enter client demographic information, direct and outreach services information, Sexual Orientation and Gender Identity and Expression (SOGIE) information, and other appropriate data into the BHSD’s data information system;

3. Enter client data into the State Client and Service Information (CSI) system;

4. Complete and submit the MHSA reporting template to the BHSD on a quarterly basis;

5. Collect treatment and service data for outcomes data reporting;

6. Collect and track client Milestones of Recovery Scales (MORS) scores to determine treatment effectiveness;

7. Collect, document, track and report on data related to community outreach, education, and training services;

8. Measure client outcomes to for justice involved adults and older adults served to assist in determining areas of improvement;

9. When applicable, administer assessment tool(s) as part of the program requirement(s) and collect and report on assessment tool data; and

10. Utilize the Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition (DSM-5) and/or the International Classification of Diseases, Tenth Edition (ICD-10) for diagnoses and coding purposes.

G. Offeror shall be responsible for the completion and submission of data, including the following as appropriate for the program:

1. CSI data;

2. MORS scores;

3. Active Caseload/Length of Stay (LOS);

4. Network Adequacy Certification Tool (NACT);

5. Units of Service (UOS);

6. Client to staff ratio;

7. Reports on client readmission to the program;

8. Post-discharge placement/service(s) type, frequency, etc. report;

9. MHSA reports;

10. Outreach and Engagement Process report;

11. Ninety Plus (90+) Days Without Service Report shall consist of a status update for each client listed; include the disposition for each client listed, an explanation the client has not been closed, and submit to the BHSD Program Monitor; and

12. Other data reporting requirements as requested by the BHSD.

H. Offeror shall analyze collected data to identify trends, verify goal achievement, and measure service quality. The analysis shall be used to make decisions to help improve organizational performance.

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

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

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

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

Outcomes and Measurements A. Offeror shall develop a process to systematically monitor, analyze, and improve the performance of the program in order to better assist clients in achieving their treatment outcomes.

1. Offeror shall collect data relevant to specific treatment outcomes which may include, but not be limited to:

a. Improved client stability and decreased incarceration and psychiatric hospitalization;

b. Demonstration of a positive client service experience;

c. Number of clients referred;

d. Number of clients who were successfully outreached/engaged into treatment;

e. Number of clients enrolled who were retained in services and for what duration;

f. Number of clients who obtained medical benefits;

g. Number of clients who obtained a steady source of income;

h. Number of clients who maintained stable housing;

i. Number of clients enrolled in educational/vocational programs;

j. Number of clients who graduated to less intensive services;

k. Number of clients not re-incarcerated;

l. Number of clients who regained daily life functions;

m. Duration of time for client to achieve restoration of adjudicative competence;

n. Number of clients who are on the Jail Assessment Coordination (JAC) list due to lack of residential and outpatient services;

o. Percentage of clients diverted from jail into appropriate levels of care;

p. Improved emotional and behavioral functioning, and ability to participate in meaningful activities; and

q. Other categories as deemed necessary by the BHSD FDR Division.

B. Offeror shall achieve the following outcome measurement methods:

1. Offeror shall provide monthly, quarterly, and annual reviews from the following data sources:

a. MORS scores;

b. DLA-20;

c. CSI system;

d. Vulnerability Index – Service Prioritization Decision Assistance Tool (VI-SPDAT) data;

e. County data system; and

f. NACT.

2. Offeror shall implement individualized assessments using standardized tools[footnoteRef:3], including, but not limited to, Functional Assessment Scale (FAS) and American Society for Addiction Medicine (ASAM) Six-Dimension Scale. [3: The BHSD shall offer training through the Learning Partnership Division, as needed.]

3. Offeror shall track the practice fidelity and client outcomes of all Evidence-Based Practices (EBPs) utilized in the program’s services.

4. Offeror shall administer the client feedback tool (Client Satisfaction Survey) bi-annually.

5. Offeror shall initiate any other monthly, quarterly, and annual measurement tools and documents, which may include, but shall not be limited to Microsoft Excel and other formats as requested by the BHSD.

6. 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.

7. Offeror shall have a current behavioral health electronic health record (EHR) system with capability that meets the County’s standards or shall have a behavioral health EHR system in place upon start of contract. Offeror shall utilize the County-operated EHR for billing/reimbursement purposes.

Program Description A. Service Description

1. The program shall provide services as outlined by the Dartmouth Assertive Community Treatment Scale (DACTS).

2. Clients shall be eligible to receive services on a no-time-limit basis twenty-four (24) hours per day, seven (7) days per week. Service intensity shall be dependent on need and can vary from once weekly to several contacts per day.

3. Services shall be provided in a variety of settings, including outpatient clinics, the clients’ place of residence, and in the community, as appropriate. Services may include, but not be limited to, the following:

a. Care plans;

b. Individual, family, and group therapy;

c. Rehabilitation services;

d. Collateral services;

e. Medication support services;

f. Case management/brokerage services;

g. Crisis intervention services;

h. Outreach services; and

i. Other services that assist clients in establishing a stable community living environment.

4. Offeror shall collaborate with clients to formulate individualized treatment plans that meet their specific needs.

5. For clients in correctional or restricted facilities, outreach and engagement efforts shall be provided prior to their release from these facilities.

6. Offeror shall utilize EBPs, Promising Practices (PPs), and trauma informed practices whenever clinical indicated and based on each client’s diagnosis. EBPs and PPs recommended for FDR programs may include the following:

a. Motivational Interviewing;

b. Cognitive Behavioral Therapy (CBT);

c. Trauma-Focused CBT (TF-CBT);

d. Solution-Focused Brief Therapy;

e. Dialectical Behavioral Therapy;

f. Trauma-informed approaches; and

g. Integrated co-occurring disorder practices; and

h. Peer supports such as Wellness Recovery Action Planning.

7. Offeror shall incorporate modalities for the justice-involved population, including but not limited to:

a. Thinking for a Change;

b. Moral Reconation Therapy; and

c. Risk and Responsivity.

8. Offeror shall provide integrated behavioral health services, including high-frequency and intensive community-based services, intensive care coordination, intensive home-based services, time-limited services, WRAP services, family/peer support, and 24/7 clinical crisis support.

a. Offeror shall render these services based on clinical care and treatment needs.

9. Offeror shall provide injection(s) and related medication management services as necessary in the outpatient clinics.

10. Integrated services shall be evidence-based and may include, but shall not be limited to:

a. Comprehensive, individualized mental health treatment;

b. Risk assessments that assess the likelihood for re-offending/re-arrest;

c. Chemical dependency/substance abuse treatment (individual and group treatment);

d. Medication management and education;

e. 24-hour crisis intervention services and immediate support;

f. Assertive community-based outreach and engagement services;

g. Support and advocacy while incarcerated or hospitalized;

h. Self-management and skills training;

i. Immediate linkage to necessary basic needs, such as food and clothing;

j. Immediate assistance with securing appropriate supported housing arrangements;

k. Assistance with applying and gaining access to Medi-Cal and an income source (i.e., GA, SSI, etc.);

l. Vocational/educational support and linkages;

m. Community integration through social activities;

n. Peer support services;

o. Transportation assistance;

p. Assistance in obtaining personal identification and Social Security cards;

q. Assistance with activities of daily living and linkage to natural support networks, including family; and

r. Flex funds to assist with housing costs and other treatment plan needs.

11. Offeror shall provide the following justice-specific services:

a. Provide transportation for clients from custody to their assigned community placements, and to/from their scheduled appointments;

b. Visiting clients who are in custody to provide outreach and engagement efforts prior to their scheduled release to determine if the assigned level of care is appropriate for each outreached client;

c. Be present clients’ scheduled court hearings to provide treatment updates and support;

12. Offeror shall provide the following services specific to IST clients:

a. Accept clients released into the program for community treatment by the Court.

b. Accompany the client to scheduled court hearings at intervals set by the Court.

c. Submit client treatment status updates to the Court when:

i. A client is admitted;

ii. A client is discharged;

iii. A client is re-hospitalized;

iv. A client is incarcerated;

v. Assault occurs;

vi. Drug related incidents occur; and/or

vii. A client does not adhere to treatment/medication.

d. Complete an evaluation on clients who are restored to competency under the program, to be used by the Court to determine the next steps for the client within the justice system.

e. Master lease properties to secure housing placements for IST clients.

B. Service Expectations

1. Offeror shall work collaboratively with community navigators, community providers, other mental health agencies, substance use treatment services providers, physical health providers, educational systems, other groups that provide supportive services, and justice partners such as, but not limited to probation, the courts, the district attorneys, and public defenders.

2. 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.

3. Offeror shall maintain fidelity to the requirements for MHSA CSS as set forth in the CCR CSS Title 9, Chapter 14, Article 6, Sections 3610-3620.10 and 3640.

4. Offeror shall ensure that Network Adequacy standards are met by ensuring that each of the outpatient services under the program shall be available within fifteen (15) miles or thirty (30) minutes from the clients’ established residency. Clients may opt to receive services from another provider outside the specified distance and time restrictions upon providing the BHSD with written authorization.

5. Offeror shall ensure that their organization’s service plan shall meet 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.

6. Offeror shall not subcontract for any Medi-Cal or non-Medi-Cal services.

D. Staffing Requirements

1. Staff are expected to be persistent and utilize a variety of methods to engage clients who may initially refuse or be reluctant to receiving services.

2. Staff shall demonstrate basic core competencies in designated areas of practice, including FACT core processes, integrated mental health, and substance abuse treatment, supported employment, family psychoeducation, and wellness self-management.

3. Offeror’s staff shall comprise of staff who are appropriately trained and meet the qualifications as Licensed Professionals of the Healing Arts, as well as their respective discipline requirements.

4. Staff shall meet the BHSD Co-Occurring Standards. This includes, at minimum, training staff to meet the following core skill levels:

a. Co-occurring Informed: This level of practice identifies the core skills needed to support treatment. The identified domains for this level are screening, engagement, readiness and retention, education, advocacy, and collaboration.

b. Co-occurring Capable: This level of practice identifies the core skills needed to provide an integrated assessment and provide treatment to clients and families facing mild to moderate co-occurring disorders. The identified domains for this level are screening, assessment, diagnosis, and co-occurring capable treatment.

c. Co-occurring Enhanced: This level of practice identifies the expertise needed to provide fully integrated treatment to clients and families challenged with moderate to severe co-occurring disorders. The identified domains are assessment, diagnosis, and integrated treatment.

5. The program shall be Dual Diagnosis Capable (DDC) in which staff:

a. Address the client’s relationship between mental health and substance-related disorders and its effect on the client’s readiness to change;

b. Complete Readiness to Change assessments for both mental health and substance use conditions; and

c. Assess for relapse and recovery environmental issues through individual and group program content.

6. Staff shall have knowledge in working with the target population, including trauma exposed clients.

7. Staff shall be well-versed in recognized symptoms of mental health issues.

8. Staff shall participate in trainings related to the MHSA CSS required data collection and reporting.

9. Staff shall participate in the Sexual Orientation and Gender Identify and Expression (SOGIE) 101 Training.

10. Staff shall attend all systemwide BHSD trainings and participate in all required trainings specific to the needs of the program.

11. Staff shall be trained and proficient in the following:

a. Knowledge and skills in the principles of psychosocial rehabilitation and recovery process;

b. Confidentiality;

c. Crisis Intervention;

d. Knowledge of community resources, including self-help centers and ethnic community resources;

e. Understanding of the justice system;

f. Capacity to collaborate and coordinate with local providers of health and human services;

g. Knowledge of IST;

h. Understanding of the behavioral health system of care;

i. Knowledge of the grievance and complaint policies and procedures; and

j. Knowledge of informed consent to medication and treatment.

12. Offeror’s staff shall contain the following professionals for the purposes of the program:

a. Psychiatrists;

b. Psychiatric Nurses;

c. Clinicians/Therapists;

d. Substance abuse specialists;

e. Vocational/Educational sepcialists;

f. Housing specialists;

g. Benefits specialists;

h. Forensic peer support specialists; and

i. Program administrative assistants.

13. Offeror shall maintain practices related to recruiting, hiring, and promoting multi-lingual staff and/or a culturally or ethnically diverse workforce. Offeror 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).

E. Cultural Competency

1. Offeror 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 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.

3. Offeror shall provide outreach activities focused on reaching underserved, underrepresented, and/or multicultural populations.

F. Clinical Supervision

1. Offeror shall meet reflective supervision, reflective practice, and clinical supervision requirements as follows:

a. Submission of a clinical supervision plan that includes fidelity to the chosen EBPs or PPs;

b. Provision of a consistent schedule and structured weekly reflective supervision of staff;

c. Maintain a workflow that is manageable for supervisors and attending to the ratio of no more than one to eight (1:8) supervisors to supervisees; and

d. Provision of clinical supervision activities for review during monthly or bi-monthly meetings.

G. Referrals and Admissions

1. The program shall accept referrals that are generated through the BHSD Collaborative Court Staff, BHSD Reentry Resource Center staff, and various Justice-related departments.

2. Offeror shall initiate contact with the client after receiving referral.

3. Offeror shall visit potential clients in custody prior to release to screen and determine the appropriateness of the referral, engage the client in mental health treatment, and develop a therapeutic alliance.

4. Offeror shall provide a detailed policy and plan to monitor and review the initial contacts with clients to ensure quality assurance.

5. Offeror shall ensure compliance with Department of Health Care Services (DHCS) Network Adequacy Requirements in ensuring timely access to services.

6. When Offeror denies an admission, Offeror shall notify the referring agency and the BHSD Program Monitor of the following:

a. The reason(s) for not admitting;

b. The disposition of the case; and

c. Any referrals or recommendations made to the referring agency, as appropriate.

7. Based on the severity of mental illness and functional impairment of clients who qualify for services, the final decision to admit a referral shall rest jointly with the BHSD and Offeror.

8. If a client has or is suspected to have Autism Spectrum Disorder/Intellectual Developmental Disability but is not connected to San Andrea Regional Center (SARC), Offeror’s staff shall request collateral information from school, attorney, and/or doctor upon obtaining a signed Release of Information (ROI) to provide linkage to SARC and/or additional community resources.

9. Offeror shall provide clients with access to medication evaluations and support services in a timely manner once enrolled in services.

10. Offeror shall serve clients as determined by County policies, procedures, directives, and guidelines within the program resources.

H. Assessment

1. Offeror shall conduct client mental health assessments with a comprehensive and coordinated team approach to determine medical necessity, detailing the client’s impairment in important areas of life functioning.

2. Offeror’s assessments shall include a thorough review of clients’ justice involvement history.

3. Upon intake, Offeror shall conduct a housing stability assessment to determine the extent to which housing subsidies are needed.

4. Offeror shall conduct medication evaluations once a client is enrolled in program services.

I. Care Coordination

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

a. Offeror shall provide outreach and engagement services during episodes of incarceration and inpatient hospitalization.

b. Offeror shall establish collaborative working relationships with program-related service providers and organization, including but not limited to:

i. Law enforcement;

ii. Faith communities;

iii. Drop-in centers;

iv. Meal programs;

v. Shelters;

vi. Health clinics;

vii. Local emergency rooms;

viii. Housing providers;

ix. Education and employment service providers;

x. Crisis Responders; and

xi. Mental health professionals.

c. Offeror shall hold multidisciplinary team meetings to ensure comprehensive and consistent care when program services.

d. Offeror shall link clients to community-based resources as well as primary care services.

e. Offeror shall communicate with clients and their families to ensure comprehensive and consistent care.

f. Offeror shall participate in the planning and collaboration of local continuum of care by attending regular meetings as determined by the BHSD.

J. Program Hours of Operations

1. Offeror shall be open for services during regular office hours Monday through Friday, and for forty (40) hours per week, with after-hours services available to accommodate clients requiring evening and weekend appointments as well as crisis outpatient services available twenty-four (24) hours a day, seven (7) days a week.

2. During holidays, Offeror shall maintain a minimum a skeleton crew that shall process referrals, provide crisis coverage, and initiate Lanterman-Petris-Short (LPS) protocols.

K. Evaluations, Transitional Planning, and Discharge

1. Offeror shall utilize the following scales to determine when a client is ready to transition from the program into other BHSD programs:

a. ACT Transition Readiness Scale; and

b. ACT Transition Assessment Scale.

2. Offeror shall conduct regular need assessments and evaluate clients to determine the effectiveness of EBPs and PPs utilized. Offeror shall document any needs for continued stay.

3. Offeror shall provide discharged clients and their families with a written transition plan that discusses the use of community/family supports and their care plan.

4. For clients transitioning to a higher or lower level of care, Offeror shall provide a copy of the client’s care plan to the new care provider in a warm handoff.

5. Offeror shall discharge clients who meet one (1) or more of the following criteria:

a. Clients who do not meet Medi-Cal medical necessity criteria;

b. Clients who demonstrate the ability to function in major life roles with less intensive service;

c. Clients who move outside the geographic area of the program’s service area;

d. Clients who need a medical nursing home placement;

e. Clients who request discharge, despite Offeror’s best, repeated efforts to engage them in service planning;

f. Clients who are not engaged and not responsive to follow-up after persistent efforts to locate them; and

g. Clients who graduate from the justice system.

6. Offeror shall submit an Incident Report to the BHSD whenever an event that causes or has the capacity to cause physical or psychological injury or has the potential for a claim or litigation.

7. Offeror shall review each client’s status and progress towards planned goals annually to determine possible discharge planning and/or step down to a non-justice focused program. Offeror shall re-write clients’ goals as necessary to match the level of care needed.

8. If Offeror is unable to provide co-occurring substance use treatment within their scope, a referral to appropriate services shall be facilitated and collaboration between the Offeror and the new provider shall address any co-occurring treatment needs.

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 B17 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 will 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 A17: Forensic Assertive Community Treatment Scope of Work CATEGORY 3: Full Service Partnership Services