Attachment A1b.pdf

ATTACHMENT A1b

CATEGORY 1: CRISIS

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 1 of 8 ATTACHMENT A1b: Post Crisis Stabilization Services Scope of Work CATEGORY 1: Crisis

POST CRISIS STABILIZATION SERVICES

SCOPE OF WORK

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

I. Purpose

A. The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking statements of qualifications from qualified Offerors interested in operating Children, Youth, and Family System of Care (CYF) Post Crisis Stabilization Services (PCSS) Program (hereafter referred to as “the program”).

B. Offeror shall provide comprehensive, appropriate, and trauma-informed behavioral health services for youth (ages 4 through 17) and their families, and significant supports that combine components of recovery-oriented, evidence-based practices (EBPs), promising practice (PPs), and trauma-informed practices to stabilize youth transitioning from psychiatric hospitalization and reduce hospitalization admissions.

I. The program has been designed to ensure that children, youth, and their families (hereafter referred to as “clients”) receive the necessary mental health services when discharging from psychiatric hospitalization and/or experiencing crisis. Services shall be designed to improve the emotional /behavioral functioning and enhance the abilities of clients who may experience significant emotional and psychological distress following a crisis event.

II. Background Information

A. The implementation of an outpatient Post-Crisis Stabilization program for clients recognizes the need for specialized mental health outpatient services for young individuals who have experienced a crisis. This recognition stems from the understanding that crises can have a profound impact on the mental well-being of youth and that timely and appropriate intervention is crucial for their recovery. The program aims to address their immediate emotional and psychological needs while equipping them with the necessary skills and resources to prevent future crises and promote long-term mental health and resilience.

B. The general plan for the program involves an outpatient provider specifically designed to cater to the unique needs of youth post-crisis. Offeror shall provide a safe and welcoming environment where youth can access therapeutic services, including individual counseling, safety planning, family support, Intensive Home-Based Services (IHBS), Intensive Care Coordination (ICC), and psychiatric consultations.

C. This program's approach shall be multidisciplinary and collaborative. It will involve a team of mental health professionals, including Psychologists, Psychiatrists, Clinicians/Intensive Care Coordinators, Family Specialists, and Family Partners, who will work together to develop individualized treatment plans for each youth. These plans will

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 2 of 8 ATTACHMENT A1b: Post Crisis Stabilization Services Scope of Work CATEGORY 1: Crisis incorporate evidence-based interventions and therapeutic modalities that are best suited to address the specific needs of the youth with a goal of reducing the need for psychiatric hospitalization.

III. Target Population

A. The program shall serve clients (ages 4 through 17) with full-scope Medi-Cal who are residents of Santa Clara County. All clients shall meet medical necessity and criteria for Medi-Cal reimbursable primary Mental Health Diagnosis.

B. The program is designed to provide intensive, short-term services to clients who recently experienced an acute crisis and/or discharge from psychiatric care. Services, including dosage and intensity, may be adjusted depending on the clinical needs of the client.

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

1. Youth clients who may exhibit profound difficulties in family interactions, peer relationships, and academic or vocational settings. They may display severe emotional dysregulation, necessitating intensive external support for effective management. Client may present with danger to self, others, or grave disability;

2. Common diagnoses may include, but not limited to, major depressive disorder, bipolar disorder, psychotic disorders, Post-traumatic stress disorder (PTSD), and others, necessitating crisis intervention due to acute symptoms or exacerbations.

Behaviors may include suicidal ideation, self-harm, psychosis, severe agitation, and more;

3. Support System: Ability to utilize a support system may be minimal, underscoring the critical role of available and effective support networks—comprising family, friends, caregivers, and community resources—to provide immediate and ongoing assistance;

4. Treatment Timeline: Typically involves immediate interactions, through multiple engagements over time. Clients typically require intensive support for 90 days. Step-down care is likely needed once initial crisis-oriented needs are stabilized;

5. Crisis Intervention: Due to the high level of need, crises are likely to occur, necessitating a robust crisis management plan to effectively manage potential exacerbations of symptoms. Crisis supports should be available 24/7; or

6. Care Coordination: Critical need for intensive care coordination, often requiring Multi-Disciplinary Teams (MDT) and Child and Family Team (CFT) meetings. Care plans must be regularly adjusted based on evolving needs.

IV. Program Goals and Objectives

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

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

a. Ensure clients experiencing crisis and/or psychiatric hospitalization are provided coordinated service delivery to stabilize symptoms and transition client back into their familial/community setting;

b. Reduce psychiatric hospitalization admissions;

c. Increase clients’ ability to develop and implement safety plans to reduce crisis/ prevent suicide risk;

d. Prevent and reduce placement disruptions and out of home placements (e.g., child welfare involvement, residential care due to legal or behavioral concerns, and incarceration); and

e. Engage 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; and

f. Reduce clients’ distress and trauma symptoms with the crisis they have experienced. Through counseling and other therapeutic interventions, alleviate the psychological distress related to crisis and promote healing.

2. Objectives shall be achieved by:

a. Demonstrate the practice and principles of the Integrated Core Practice Model (ICPM) to provide culturally appropriate and trauma informed services;

b. Utilize the CFT meetings as a strategy to identify needs, implement care coordination, assess progress and support transition to long term services and resources;

c. Provide prompt access and engagement to mental health services for clients experiencing crisis by offering an intake within forty-eight hours (48) upon receiving the referral;

d. Promote cohesive, coordinated transition plans, linkage to services and appropriate levels of care to support the ongoing needs of client (e.g. outpatient mental health services, substance use treatment services, education, medical, etc.);

e. Prevent further crisis or relapse post-crisis by equipping clients with necessary tools and strategies to manager their emotions, make healthy choices and seek help when needed;

f. Provide immediate support and intervention to clients who have experienced a crisis. This includes addressing their emotional and psychological needs and ensuring their safety and well-being; and

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g. Support clients in developing effective skills to manage the aftereffects of a crisis. This includes teaching clients healthy ways to regulate emotions, problem-solve and adapt to challenging situations.

V. Reporting and Data Collection Requirements

A. Offeror shall collect and report required data to BHSD quarterly, including but not limited to:

1. Report the number of clients the program serves, including demographic information such as age, gender, language, and ethnicity.

2. Measure and report the program's clinical outcomes, including changes in mental health symptoms, improvements in functioning and coping skills, and reductions in crisis incidents. Utilize validated assessment tools and surveys to gather this data and track progress over time by use of functional assessment tool(s), such as the Crisis Assessment Tool (CAT).

3. Notify BHSD program monitor on a monthly basis of clients needing to extend services beyond 90 days.

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

VI. Outcomes and Measurements

A. Key Outcomes:

1. Restore client and family to a prior level of stabilization.

2. Every client will have a safety plan upon discharge.

3. Support client’s ability to remain in the community, attend school, and prevent hospitalization.

4. Decrease incidents of re-hospitalization.

5. Reduce client’s risk-taking behaviors.

6. Improve care coordination and positive community engagement to ensure appropriate and timely transition of care.

B. Offeror shall initiate quarterly measurement tools and documents, which may include Microsoft Excel and other formats as requested by the BHSD. Offeror shall supplement reviews using the following data sources:

1. CAT

a. For crisis programs with an average length of stay up to 90 days, the CAT

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 5 of 8 ATTACHMENT A1b: Post Crisis Stabilization Services Scope of Work CATEGORY 1: Crisis assessment shall be administered to clients, rather than utilizing the Child and Adolescent Needs and Strengths (CANS) tool. This supports decision-making, treatment planning, quality improvement, and service outcome monitoring. The Offeror shall abide by the CATs Operational Guideline developed by the Praed Foundation.

b. The Offeror shall be responsible for training, certifying and annually re-certifying their staff on the appropriate CAT tool(s).

c. The Offeror shall maintain a minimum of two (2) staff that are the Offerors CATs trainers to ensure sustainability and that CAT principles and philosophy are integrated into clinical practice.

d. The Offeror shall establish and/or maintain an online account with Praed Foundation to access online CATs training and certification.

2. County data systems or assessment tools as required by the BHSD.

VII. Program Description

A. Service Description

1. Program will provide intensive and individualized services, both therapeutic and rehabilitative modes of services as defined by Specialty Mental Health Services (SMHS), to effectively stabilize the client and family system to the level of functioning prior to the crisis.

2. Services will be client centered and tailored to the needs of the client based upon age, developmental functioning, history of trauma, culture, and family environment.

3. Services will encompass coordination of care using the ICPM for the delivery of services (https://theacademy.sdsu.edu/wp-content/uploads/2018/05/california-children-youth-and-families-integrated-core-practice-model-icpm-2018.pdf).

4. Coordination of care will use the ICPM for the delivery of services.

5. Services will be provided at a location that is most convenient for the client and may occur at the client’s residence, school, clinic, agency or other locations in the community as necessary and needed by the clients served.

6. Services will be provided to client in their preferred language.

7. Service average length of stay is 90 days and could be extended as needed to support linkage and warm handoff.

8. Services may include the following:

a. Assessment of the client and family’s needs and strengths;

b. Crisis intervention and stabilization;

c. Safety planning;

https://theacademy.sdsu.edu/wp-content/uploads/2018/05/california-children-youth-and-families-integrated-core-practice-model-icpm-2018.pdf https://theacademy.sdsu.edu/wp-content/uploads/2018/05/california-children-youth-and-families-integrated-core-practice-model-icpm-2018.pdf

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d. Individual and family therapy;

e. Medication evaluation and support services;

f. Collateral;

g. Case management/brokerage services;

h. IHBS;

i. ICC;

j. CFT; and

k. Transition planning and referral linkage to support warm handoff to other service providers

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

B. Staffing Requirements

1. Staffing generally will consist of a treatment team, which may include:

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

i. Licensed or Associate Marriage and Therapist (LMFT/AMFT)

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

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

b. Psychiatrist;

c. Mental Health Rehab Specialist (MHRS);

d. Mental Health Peer Support Specialist; or

e. Other qualified providers

2. Staff shall possess and maintain appropriate licenses and certificates in accordance with applicable statutes and regulations. Background checks, criminal record reviews, and Department of Justice (DOJ) clearances shall be obtained and maintained in accordance with County rules and regulations.

C. Referrals and Admissions

1. Offeror shall create a referral template to be used by providers, hospitals, and BHSD in collaboration with BHSD.

2. Offeror shall accept referrals for the Post Crisis Stabilization Services from the Mobile Response Stabilization Services (MRSS) program, the Crisis Stabilization Unit (CSU), psychiatric hospitals, or from BHSD for Medi-Cal beneficiaries only. Priority shall be given to referrals from the BHSD, Child Welfare, and Juvenile Probation Department.

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3. Offeror agrees to accept urgent referrals, including discharges from in-patient hospitals, emergency psychiatric services, or crisis stabilization units and similar facilities. Offeror shall ensure that all referrals are triaged, and intakes are offered within 48 hours of receipt of referral.

4. Offeror will provide education and outreach to local crisis programs and psychiatric hospitals about the program, admission criteria and services offered.

D. Care Coordination

1. Care coordination is a crucial component of the program given the high acuity needs of the client and average 90-day length of stay. Coordination with other team members and providers needs to occur as soon as possible.

2. Offeror shall coordinate and communicate with other providers (e.g. psychiatric hospitals, crisis programs, social workers, probation officers, school staff, medical professionals, psychiatry, etc.) and facilitate MDT meetings to promote care coordination, case consultation, information sharing, and a feedback loop process with treatment team providers. This shall occur at least once per month.

3. If clients are in the crisis stabilization unit, psychiatric hospital or other inpatient facilities, Offeror shall communicate and be part of discharge planning prior to the client’s release.

4. Offeror will support client with developing and utilizing safety plan for supports that may occur after hours.

5. Offeror shall participate and facilitate as needed, in CFT meetings to promote care coordination, information sharing, client and family voice and choice, and a feedback loop to the client and family. This shall occur as often as client and family requests.

6. Upon discharge, program will coordinate a warm hand off with the new provider to ensure minimal disruptions in care.

E. Program Hours of Operation

1. The program is part of the crisis continuum of services and as such should ensure access to crisis intervention and support from 8am-7pm. The program shall work in tangent with the MRSS program to provide after-hours support, thus having the ability to provide immediate and effective response to any crisis situation, 24 hours a day, 7 days a week.

F. Evaluations, Transitional Planning, and Discharge

1. Offeror shall monitor the client’s stabilization and needs through the CFT process.

2. Offeror shall demonstrate knowledge of the different levels of care within the BHSD system to determine appropriate transition planning with the client.

3. Offeror shall partner and collaborate within internal agency and external agencies to

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Internal Notes/Additional info:

Post Crisis Stabilization Services

HOURS LEVEL OF CARE PROJECTED #

CLIENTS/YR

8am - 7pm

Ninety (90) day of twenty (20) hours of Specialty Mental Health Services (SMHS) monthly, with use of Integrated Core Practice Model- Family Team Process

Total Number of Projected Clients to be Served: 360