ATTACHMENT A18

CATEGORY 3: FULL SERVICE PARTNERSHIP SERVICES

ASSISTED OUTPATIENT 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 operating an Assisted Outpatient Treatment (AOT) program (hereafter referred to as “the program”) for eligible Santa Clara County residents. The program intent is to provide comprehensive, evidence-based behavioral health services to clients diagnosed with severe and persistent mental health and/or co-occurring conditions[footnoteRef:2], who are struggling to engage in services despite multiple opportunities, and as a result, are at risk of further deterioration and grave disability. The program shall serve voluntary and involuntary clients. [2: Clients require both mental health and substance use treatment services.]

B. The program shall provide the highest level of outpatient services including but limited to mental health services; medication support; case management; crisis intervention; outreach and engagement; housing support; substance abuse treatment for people with co-occurring disorders; educational and vocational services, and rehabilitative services with the intent of promoting recovery, reintegrating clients into the community, and reducing incarceration and hospitalization. The program shall participate in civil court proceedings to petition clients to engage with services as needed.

The program shall be Dual Diagnosis Capable (DDC) in which Offeror can address the relationship between mental health and substance-related disorders and its effect on a client’s readiness to change, as well as relapse and recovery environmental issues through individual and group program content. Readiness to change shall be assessed for both mental health and substance abuse conditions.

Medi-Cal Certification

1. The program shall have current Medi-Cal certification or become Medi-Cal certified to provide Medi-Cal reimbursable services on or before the contract start date.

Background Information

1. AOT was developed for clients with severe mental health conditions who do not seek support, have trouble engaging in traditional office-based programming, and might otherwise be served in an institutional setting.

E. AOT adopts the Assertive Community Treatment (ACT) model, which is a community-based model characterized by the following:

1. A low client-to-staff ratio;

2. Services are provided primarily in the community rather than in an office setting;

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

4. 24-hour staff availability;

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

6. Longer lengths of stay.

Target Population

1. The program shall serve adult (ages 18 through 59) and older adult (age 60 and over) clients with severe and persistent mental health and/or co-occurring conditions that result in substantial functional impairments or symptoms and who meet AOT criteria. Due to the recalcitrant nature of their symptoms, clients are more likely to experience a high utilization and repetitive cycle of incarceration, homelessness, substance use, crisis, and/or hospitalization. Clients shall meet the following prerequisites, including but not limited to:

1. Have Medi-Cal benefits designated to County 43 (Santa Clara County), be uninsured, or otherwise be deemed eligible per the BHSD policy.

2. 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 statutes, including but not limited to California Code of Regulations (CCR) Title 9 and Social Security Act Title XXII Regulations.

1. Clients served in the program shall meet the following criteria:

1. 18 years of age or older and has a severe mental illness.

2. Clinically determined that, in view of the client’s treatment history and current behavior, at least one (1) of the following is true:

a. Is unlikely to survive safely in the community without supervision and the condition is substantially deteriorating.

b. Is in need of AOT in order to prevent relapse or deterioration that would likely to result in grave disability or serious harm to the client or to others, as defined in Section 5150 of the California Welfare and Institutions Code (WIC).

3. Has historical lack of compliance with voluntary treatment and at least one (1) of the following is true:

a. Within the last thirty-six (36) months has been hospitalized at least twice due to mental illness including mental health unit of a correctional facility.

b. Within the last forty-eight (48) months has had one (1) or more acts of serious and violent behaviors or threats or attempts to cause serious physical harm to self or others.

4. Has been offered an opportunity to participate in a treatment plan but continued to fail to engage.

5. Participation in the program is the least restrictive placement necessary to ensure recovery and stability.

6. Clients would benefit from receiving AOT services.

Program Goals and Objectives

1. The program shall be aligned to achieve the following goals and objectives:

Goals shall include, but not be limited to:

a. Decrease symptoms of mental illness and co-occurring substance use;

b. Increase access to primary health care services;

c. Meet basic needs and the enhance quality of life in daily living activities;

d. Improve socialization and development of natural supports;

e. Reduce incarceration, acute inpatient hospitalization, homelessness, and institutionalized care;

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

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

h. Increase reintegration into community life with a focus on stability, particularly involving symptom management and reduction of harmful behaviors and suicide.

Objectives shall be achieved by:

a. Using assertive and extended community-based outreach strategies to engage clients in services;

b. Identifying issues including, but not limited to mental health, co-occurring disorders, and physical conditions/disabilities;

c. Increasing mental health and/or substance abuse treatment retention through outreach and engagement efforts;

d. Decreasing service fragmentation;

e. Utilizing results of client/family satisfaction surveys;

f. Identifying and assisting clients with housing needs;

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

h. Increasing educational and employment opportunities;

i. Identifying suicide risk and impact of trauma;

j. Identifying the risk of recidivism; and

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

Reporting and Data Collection Requirements

1. Offeror shall comply with the reporting requirements, including but not limited to:

1. Division 5 of the California WIC, Division 1, and Title 9 of the CCR;

2. Mental Health Service Act regulations require counties to collect outcome data per CCR Title 9 § 3620.10 and submit it to the State within ninety (90) days per CCR Title 9 § 3530.30. Counties submit data for three (3) different types of assessments into the State Data Collection and Reporting (DCR) system through an online interface:

a. The Partnership Assessment Form (PAF);

b. The Key Event Tracking (KET); and

c. Quarterly Assessment (3M).

J. Offeror shall develop a process to systematically monitor, analyze, and improve program performance to assist clients in achieving their treatment outcomes.

1. The data collection process will provide information relevant to specific treatment outcomes, including but not limited to:

a. Number of clients referred to the program;

b. Number of clients who were successfully outreached/engaged in treatment;

c. Number of clients enrolled who retained services and service duration;

d. Number of clients adhered to prescribed treatment;

e. Number of clients who obtained medical benefits;

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

g. Number of clients who obtained and maintained stable housing;

h. Number of clients enrolled in educational/vocational programs, including competitive employment;

i. Number of clients who improved social functioning and independent living skills;

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

k. Number of clients who reduced the length of their hospital stays due to participation in the program;

l. Number of clients who avoided reincarceration, and the extent to which contacts with local law enforcement and incarceration of persons in the program have been reduced or avoided; and

m. Other categories deemed necessary by BHSD.

1. As part of the data collection process, Offeror shall complete forms provided by BHSD for a baseline assessment, to begin within thirty (30) days of receiving the referral and updated in six (6) month intervals and at discharge. These forms will be part of the program’s regular assessment and service planning process.

1. Offeror shall analyze data to identify trends, verify goal achievement and service quality, and the impact of corrective actions at six (6) month intervals (consistent with the required assessment and service planning process). The analysis shall also be used as a benchmark for Offeror to review their progress in achieving outcomes and to make decisions regarding the improvement of organizational performance.

K. 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

1. Offeror shall achieve the following outcomes:

1. Improved adult stability and decreased incarceration and psychiatric hospitalization;

2. Improved Milestones of Recovery Scale (MORS) and/or Daily Living Activities Functional Assessment (DLA-20) scores for all clients; and

3. Facilitate a positive client service experience.

M. Offeror shall achieve the following outcome measurement methods:

1. Evaluate client/family satisfaction toward the quality of care/services and use data collected to continually improve services.

2. Reports shall be utilized to collect and track client progress. Offeror shall have electronic health record capabilities that meet the County's standards prior to the start of service delivery and provide monthly, quarterly, and annual reports from the following data sources:

a. Client and Service Information (CSI) system;

b. County Data System (myAvatar);

c. DCR system;

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

e. DLA-20;

f. Other data reporting requirements as requested by BHSD.

Program Description

1. Program Operations

1. The program shall provide services using the Assertive Community Treatment (ACT) model, enhanced and modified as needed, to meet the complex needs of AOT clients.

2. The physical program location shall be considered the home base for program staff, and the majority of outreach and services shall be delivered in the community (e.g., jail, school, home, homeless shelter, etc.), wherever clients are.

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

4. Offeror shall participate in the planning and collaboration of local continuum of care by attending quarterly, bi-monthly, or monthly meetings, as determined by the BHSD and Offeror shall provide clinical supervision activities for review during these meetings.

5. Offeror shall submit an Incident Report to BHSD when an event causes or has the capacity to cause physical or psychological.

O. Program Services

1. Program services shall include the use of Evidence-Based Practices (EBPs), Promising Practices (PPs), and Trauma-Informed Practices. EBPs that are expected to be effective for the target population may include, but are not limited to:

a. Cognitive Behavioral Therapy (CBT);

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

c. Family Therapy;

d. Motivational Enhancement Therapy (MET);

e. Motivational Interviewing; and

f. Wellness and Recovery Action Plan (WRAP).

2. Offeror shall integrate Intensive Case Management (ICM) into their execution of the ACT model for service delivery.

3. In accordance with CalAIM implementation, a Problem List will be used to guide individualized and integrated care. The development of the Problem List shall include input from the client and all members of the Team as appropriate for their scope of practice.

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

a. Mental health treatment, including comprehensive and individualized assessments and care/treatment plans, individual and group therapy, and psychiatric services);

b. Substance use treatment, such as:

i. Individual treatment;

ii. Group treatment; and

iii. Twelve (12)-step programs.

c. Medication management and education;

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

e. Assertive community-based outreach and engagement services;

f. Support and advocacy while incarcerated or hospitalized;

g. Self-management and skills training, including symptom management;

h. Physical health screenings and care coordination for other medical needs;

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

j. Immediate assistance with securing appropriate supported housing arrangements, including linking to safe and permanent housing upon graduation from AOT;

k. Assistance with applying and gaining access to Medi-Cal and an income source;

l. Vocational/educational support and linkages that contribute to long-term employment and community stability;

m. Community integration through social activities and outings;

n. Peer support services;

o. Assistance with transportation and accessing transportation benefits;

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;

r. Transition planning begins at assessment with step down planning as part of the client’s overall plan; and

s. Flex funds to help clients pay for housing, medication, food, and other needs identified in the recovery planning process and the client’s individualized treatment plan.

5. Offeror shall implement a commitment process to motivate clients to engage with services and adhere to care plan when necessary.

6. Offeror shall initiate the petition process with submittal of a petition request and supporting documentation to BHSD, as appropriate.

7. Offeror shall support petition-related court process by supporting clients’ court attendance and providing BHSD with the information necessary to facilitate petition-related assessments and subsequent court processes.

8. Offeror shall provide all services outlined in the AOT court order and update the BHSD and the court regularly.

B. Service Description

1. 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).

C. Staffing Requirements

1. Offeror's treatment team shall collectively possess, at minimum, the following paraprofessional/professional practitioners:

a. Psychiatrists;

b. Psychiatric nurses;

c. Clinicians;

d. Paraprofessionals;

e. Substance abuse specialists;

f. Employment/Vocational specialists;

g. Housing specialists;

h. Peer support specialists; and

i. Program administrator(s).

2. Offeror’s treatment team shall comprise staff who are appropriately trained and meet the qualifications as Licensed Professionals of the Healing Arts, as well as their respective discipline requirements. Minimally, staff must meet the licensing requirements as outlined in Title 9, Title 19, and Title 22 of the Medi-Cal Regulations. Additionally, all staff members must have a valid driver’s license.

3. All paraprofessional and professional practitioners shall have competency in the following three (3) core co-occurring areas: co-occurring informed, co-occurring capable, and co-occurring enhanced.

4. Program staff with clinical expertise shall assist in the cross-training of other staff.

5. Staff shall have competency in the following areas:

a. Medi-Cal regulations;

b. Confidentiality laws;

c. Crisis assessment and intervention;

d. Local community resources available to clients;

e. Justice system and its impact on clients;

f. Behavioral Health System of Care;

g. Grievance and complaint policies and procedures; and

h. Informed consent to medication and treatment.

6. Program staff shall assist clients with applying and gaining access to Medi-Cal and an income source (e.g., General Assistance [GA], Supplemental Security Income [SSI], etc.).

7. Staff are expected to be persistent and utilize a variety of methods to engage clients who may initially refuse or be reluctant to receive services. Clients referred to the program shall receive outreach services in order to assess their desire and readiness to enter the program, and willingness to continue receiving assistance.

8. The program shall utilize a multidisciplinary team approach by which clients are the responsibility of the staff comprising this team, and all members are expected to work effectively with all AOT clients.

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

10. 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).

D. 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 of 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. The program shall be reflective of the ethnic, cultural, and linguistically diverse populations of the County and preferences of each client.

3. 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.

4. 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.

E. Referrals and Admissions

1. 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.

2. Referrals to the program shall be managed through the BHSD AOT Triage team and AOT Contract Monitor.

3. Upon the decision to accept a referral into the program, a screening assessment shall be performed to assess the referred client’s individual medical needs.

4. Offeror shall provide access to medication evaluations and support services to clients once enrolled in services.

F. Care Coordination

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

a. Offeror shall outreach and engage clients during episodes of incarceration and inpatient hospitalization to ensure those clients’ smooth transition back into the community.

b. Offeror shall collaborate with the BHSD AOT triage team to conduct joint outreach, quickly respond to identified needs of referred clients, and support the AOT petition process.

c. Offeror shall collaborate with the following organizations to deliver appropriate client care:

i. Law enforcement;

ii. Community-based organizations;

iii. Faith communities;

iv. Drop-in centers;

v. Housing providers;

vi. Education and employment services providers;

vii. Meal programs;

viii. Shelters;

ix. Health clinics;

x. Local emergency rooms;

xi. Crisis Responders; and

xii. Mental health centers.

G. Program Hours of Operations

1. Offeror shall be open for services twenty-four (24) hours a day, seven (7) days a week, and shall provide a coverage plan.

H. Evaluations, Transitional Planning, and Discharge

1. Offeror shall conduct regular need assessments and evaluate clients to determine the effectiveness of services offered.

2. Upon transitioning a client out of the program, Offeror shall coordinate with the new provider/caretaker, including providing copies of the client’s assessment results and care plan, to ensure an understanding of the client’s needs, goals, strengths, and support system.

3. Offeror shall discharge clients who meet any of the following criteria from the AOT program:

a. Clients who, upon mutual agreement by the client and their treatment team, complete the program successfully;

b. Clients who do not meet Medi-Cal medical necessity and AOT criteria;

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

d. Clients who need a medical nursing home placement, as determined by a qualified physician;

e. Clients who are hospitalized or locally incarcerated for an extended period;

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

g. Clients who are not engaged and not responsive to follow-up after Offeror’s persistent efforts to locate them;

h. Clients whom the program cannot effectively serve, as decided by a good faith determination by the AOT team;

i. Clients who are transferred to a lower level of care or another mental health provider; and

j. Clients who are transferred to another County’s mental health services.

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 B18, 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).

RFSQ-BHS-FY23-0210: Adult and Older Adult System of Care Services Page 1 of 3 ATTACHMENT A18: Assisted Outpatient Treatment Scope of Work CATEGORY 3: Full Service Partnership Services