Attachment A19.docx

ATTACHMENT A19

CATEGORY 4: COMMUNITY REINTEGRATION SERVICES

FORENSIC, DIVERSION, AND REINTEGRATION AFTERCARE SERVICES

Scope of Work

Purpose The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking proposals from qualified Offerors interested in Forensic, Diversion, and Reintegration (FDR) Aftercare Program (hereafter referred to “the program”) services for eligible County residents.

The purpose of the program is to extend community reintegration services available to clients involved in the justice system, who are nearing graduation or have graduated from the justice system but continue to need mental health services to prevent re-incarceration.

The program shall serve justice-involved adults (ages 18 through 59) and older adults (age 60 and over) diagnosed with severe mental illness (SMI) and include co-occurring[footnoteRef:2] substance use disorders that require outpatient services and other related needs. [2: Clients require both mental health and substance use treatment services.]

The program shall provide comprehensive behavioral health services for clients that combine components of recovery-oriented, evidence-based practices (EBPs), promising practices (PPs), and trauma-informed practices.

Operational and Logistical Requirements

1. 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.

1. Offeror shall strategically operate and 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 can be offered in the community or wherever the clients are (e.g., work, school, home, homeless shelter, jails, courts, etc.), if appropriate.

1. Services shall strategically 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, and Sunnyvale;

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.

Target Population A. Offeror shall serve justice-involved adults and older adults who experience the following:

5. Were released or are in the process of being released from a County correctional facility into a community setting;

6. Have been arrested, charged with, or convicted of a criminal offense and have a history of mental illness or substance use disorders;

7. Diagnosed with severe and persistent mental health and/or co-occurring conditions that result in functional impairments or symptoms, and without treatment shall be at imminent risk of decompensation, resulting in hospitalizations and/or incarceration;

8. Are from underserved cultural populations;

9. Are trauma-exposed and/or are from distressed families;

10. Identify with Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, and Plus (LGBTQ+) communities;

11. Are at risk for suicide, homelessness, incarceration, or hospitalization;

12. Poorly adhere to treatment with medication management;

13. Require public assistance services or benefits due to mental functioning impairments and circumstances.

C. Clients served are residents of County that may be uninsured, have full-scope Medi-Cal, Medicare, or both Medi-Cal and Medicare (Medi-Medi).

D. All individuals served through this program must meet Medi-Cal medical necessity criteria pursuant to Title 9, California Code of Regulations (CCR), Chapter 11, Sections 1820.205, 1830 .205, and 1830.210 in order to receive Medi-Cal specialty mental health services.

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

Goals shall include, but not be limited to:

Reduce subjective suffering from mental illness and/or co-occurring conditions;

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

Prevent/decrease incarceration rates among justice-involved adults and older adults;

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

Strengthen recovery, self-sufficiency, and other psychosocial outcomes; and Encourage clients to actively participate in their recovery and self-monitor milestones and goals towards self-determination, family, vocational, and recreational services.

Objectives shall be achieved by the following:

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

b. Increase the percentage of admitted clients who are successfully discharged;

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

d. Reduce the percentage of admitted clients receiving inpatient hospital services who are readmitted;

e. Engage clients in treatment after being released from custody;

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

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

h. Provide behavioral health and co-occurring substance use services;

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

j. Enhance client understanding of medication adherence and its effectiveness, if appropriate;

k. Initiate coordination and linkage with naturally occurring resources and other providers that serve adults and older adults in the County.

l. Encourage clients to actively participate in their recovery and self-monitor their milestones;

m. Provide time-limited services for each client through the care coordinator as the single point of responsibility for services based on clinical care and treatment needs; and

n. Improve client self-sufficiency through the development of a recovery plan.

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

B. Offeror shall complete the following requirements:

1. Provide a weekly program capacity report;

2. Enter client demographic information, direct and outreach services information, and other appropriate data into the BHSD’s data information system;

3. Enter Sexual Orientation and Gender Identity and Expression (SOGIE) information;

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

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

6. Complete and submit the MHSA reporting template to the BHSD;

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

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

9. Measure client outcomes of justice-involved clients to assist in determining areas of improvement;

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

C. The BHSD may request status update(s) on particular clients to coordinate care and service linkages between County clinics, County-contracted providers, and other Health System resources. Offeror shall designate primary and alternate management positions to coordinate all referrals and discharges.

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

1. CSI data;

2. MORS;

3. Daily Living Activities (DLA-20);

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

5. Network Adequacy Certification Tool (NACT);

6. Units of Service (UOS) report;

7. Client to staff ratio;

8. Reports on client readmission to the program;

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

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.

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

1. PCE with 837 billing;

2. PCNX with 837 billing;

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

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

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

1. Services that meet the fidelity of the program:

a. Key outcomes (timeliness access, engagement in services, successful discharge, acute care readmission, recidivism);

b. Services to the identified target population;

c. Services to the number of clients/caseloads agreed upon by the BHSD and Offeror;

d. The number of unit of services agreed upon in the budget;

e. Staffing specifics;

f. Number of clients who have successfully graduated from the FDR;

g. Number of clients who have obtained benefits;

h. Number of clients who were linked to a primary care physician;

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

j. Number of clients who became employed;

k. Number of clients who were not re-incarcerated; and

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

B. Offeror shall achieve the following outcome measurement methods:

1. Provide monthly, quarterly, and annual reviews from the following data sources:

a. MORS scores;

b. DLA-20;

c. CSI system

d. County data system; and

e. NACT.

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

D. 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.

E. 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.

III. Program Description A. Service Description

1. Offeror shall provide the following services:

a. Individualized assessments using standardized tools[footnoteRef:3], including, but not limited to: [3: The BHSD shall offer training through the Learning Partnership Division, as needed.]

i. Functional Assessment Scale (FAS); and

ii. American Society for Addiction Medicine (ASAM) Six-Dimension Scale.

b. Care plans;

c. Individual, family, and group therapy;

d. Rehabilitation services;

e. Collateral services;

f. Medication support services;

g. Housing and transportation services, including flex funds for housing assistance;

h. Crisis intervention services;

i. Outreach services; and

j. A variety of other services that assist clients in establishing a stable community living environment.

2. Offeror shall collaborate with clients to formulate individualized treatment plans that meet the specific needs of the individuals.

3. Offeror shall utilize EBPs, PPs, and trauma-informed practices as appropriate, including but not limited to the following:

a. Cognitive Behavioral Therapy (CBT);

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

c. Solution-Focused Brief Therapy (SFBT);

d. Dialectical Behavior Therapy; and

e. Motivational Interviewing (MI).

f. Integrated co-occurring disorder practices; and

g. Peer supports.

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

a. Criminal Thinking;

b. Thinking for a Change;

c. Moral Reconation Therapy; and

d. Risk and Responsivity.

5. Offeror shall coordinate and secure safe housing for clients released from custody. Designated staff shall transport clients to safe community placements upon their release from custody.

6. Offeror shall be responsible for transporting clients to and from scheduled appointments, including, but not limited to, medical appointments, and social security appointments.

7. Offeror shall be present during clients’ court hearings to provide treatment updates and gather information on clients’ justice status.

8. Offeror shall ensure that the clients have access to medically required medication upon release from custody.

9. Offeror shall provide a weekly status report on CAPS clients who have been released into the community to the BHSD FDR Division.

10. Offeror shall provide a client status report (CSR) to the BHSD FDR Division for clients that are justice-involved who have been released into the community.

11. Offeror shall abide by the CSR Policy and Procedure established by the BHSD.

12. Offeror shall immediately submit an incident report to the BHSD when an event that causes or has the capacity to cause physical or psychological injury or has the potential for a claim or litigation to occur.

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, directors, 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 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.

4. Offeror shall ensure that their organization’s service plans hall 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.

C. Staffing Requirements

1. Staffing shall include a multidisciplinary team that includes the following:

a. Psychiatrist;

b. Direct service staff, such as:

i. Licensed or associate social workers;

ii. Marriage and family therapists and interns;

iii. Social workers;

iv. California Association of Alcoholism and Drug Abuse Counselor (CAADAC)

v. Peer mentors;

vi. Rehabilitation counselors; and

vii. Other direct service staff, as appropriate.

b. Nursing staff and/or psychiatric nurse; and

c. Quality assurance staff.

2. Offeror shall have staff who are appropriate trained and meet the qualifications of Licensed Practitioner of the Healing Arts (LPHA) as well as meet specific discipline requirements.

3. Staff shall at least meet the licensing requirements as set forth in Title 9, Title 19, Title 22, and Medi-Cal Regulations.

4. Staff shall be specialized and experienced in working with justice-involved clients.

5. Staff shall meet the BHSD Co-occurring Standards, including having all paraprofessional and professional practitioners trained in the following three minimal core skills 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.

6. Staff shall participate in the SOGIE 101 Training.

7. Offeror shall ensure that appropriate staff attend all system wide BHSD trainings and shall participate in all required trainings specific to the needs of the program.

8. 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;

e. Sensitivity and awareness of language and cultural influences on clients;

f. Understanding of the behavioral health system of care;

g. Understanding of the justice system; and

h. Capacity to collaborate and coordinate with local providers of healthcare services.

9. Staff shall be required to obtain jail clearance to conduct outreach to clients who are in custody.

10. Offeror shall maintain practices related to recruiting, hiring, and promoting bi/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, plus [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 inclusivity and tools and support to improve their organization’s ability to identify and mitigate bias, respect differences, build empathetic relationships, and manage conflict.

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

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

4. Offeror shall provide outreach activities focused on reaching underserved, underrepresented, and/or multicultural populations. Furthermore, the outreach process may take place in custody settings, psychiatric hospitals, or in the community.

E. Clinical Supervision

1. Offeror shall conduct weekly reflective supervision of all staff, regardless of licensure, to ensure fidelity to the chosen EBPs or PPs implemented by the program.

F. Referrals and Admissions

1. Offeror shall accept referrals that are generated through the BHSD Collaborative Court Staff, BHSD Reentry Resource Center staff, and other FDR providers. These may include, but are not limited to:

a. Step downs from higher level of care;

b. Step ups from lower level of care;

c. Referrals from other Counties for clients that have benefits with Santa Clara County; and/or

d. Referrals from Adult Custody Health, the Probation Department, the Parole Department, the Pretrial Department, and other justice partners.

2. Offeror shall accept referrals five (5) days per week, during regular scheduled business hours.

3. Offeror shall ensure that referrals which do not meet the criteria for behavioral health services or that need a different level of care, shall be linked by Offeror to appropriate alternative resources or another provider.

4. 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.

G. Care Coordination

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

a. 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 rewrite clients’ goals as necessary to match the level of care needed.

b. Provide client injection(s) and related medication management services as necessary in the outpatient clinics.

c. Link clients to community-based resources as well as primary care services.

d. Communicate with clients and their families to ensure comprehensive and consistent care, good communication with system partners and other serving agencies.

e. Co-occurring substance use treatment shall be based on harm reduction principles. If Offeror is unable to provide this treatment specialty within their scope, a referral to appropriate services shall be facilitated and collaboration between the two providers shall address any co-occurring treatment needs.

H. Program Hours of Operations

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

2. During holidays, Offeror shall maintain a minimum a skeleton crew that shall facilitate the processing of referrals coming from the BHSD Reentry Center or the Collaborative Courts, provide crisis coverage, initiate Lanterman-Petris-Short (LPS) protocols.

I. Evaluations, Transitional Planning, and Discharge

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

2. Clients shall be discharged by Offeror when a client meets at least one (1) of the following criteria:

a. Upon successful graduation from the justice system;

b. Upon mutual agreement between the client and their treatment team that the goals of treatment have been met;

c. Upon a good faith determination by Offeror that the client cannot be effectively served by the program;

d. Upon transfer out of the County to another mental health program or region, and appropriate follow-up or other service linkage have been made;

e. Long-term incarceration;

f. Upon the client’s unilateral decision to terminate treatment against medical advice;

g. Upon transfer to a lower level of care or another mental health provider;

h. Upon transfer to another County health program, in which Offeror shall comply with a Feedback Loop Process to ensure that referral sources are notified of the status of the referral, provided the appropriate sections of the assessment, and informed of outcomes and/or next steps;

i. Upon notification of client admission into an institutionalized setting (e.g., Institute of Mental Disorder [IMD], Mental Health Rehabilitation Center [MHRC], or locked Skilled Nursing Facility [SNF]) with the BHSD 24-hour Care Team re-assigning the client to outpatient services as appropriate;

j. When the client no longer meets Medi-Cal medical necessity criteria; and/or

k. When the client is not engaged and not responsive after persistent efforts to locate them and following all County policies and procedures.

3. Offeror shall transfer clients who have graduated from the program to lower level care, such as non-justice focused programs or Primary Care Behavioral Health.

4. Offeror shall facilitate transitions to other agencies for additional or specialized support for clients requiring higher levels of care, such as Full-Service Partnership (FSP) or Forensic Assertive Community Treatment (FACT).

5. Offeror shall take all reasonable steps to avoid unnecessary discharges.

6. All discharges shall be accompanied with a discharge summary.

IV. 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 B19 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 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 A19: Forensic, Diversion, and Reintegration Aftercare Services Scope of Work CATEGORY 4: Community Reintegration Services