Attachment A2.pdf

ATTACHMENT A2

CATEGORY 2: FULL SERVICE PARTNERSHIP

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 1 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

YOUTH FULL SERVICE PARTNERSHIP CONTINUUM

SCOPE OF WORK

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

I. Purpose

A. Youth Full-Service Partnership Continuum (FSPC) program (hereafter referred to as “the program”) has been designed to serve youth ages six (6) through fifteen (15) with serious emotional disorder (SED) (hereafter referred to as “client”) and ensure youth are supported through formal and natural supports to support remaining in the community, with their families or caregivers and reduce functional impairments, involvement in the juvenile justice and child welfare systems.

B. The program philosophy is to do “whatever it takes” to help individuals achieve their goals, including recovery, by providing a full spectrum of community services and supports, as determined collaboratively with the youth and their caregivers. The services provided may include, but are not limited to, mental health treatment, housing, medical care, educational/employment training, and crisis support.

C. The program services provided may include, but are not limited to, mental health treatment, medication supports, employment/educational/vocational training, and crisis support to engage the youth through formal and informal supports and ensure the youth can remain in the community, with their families or independently and reduce functional impairments, involvement in the juvenile justice and child welfare systems.

D. The FSP team shall have access to “flex” funds that can be used for client supports that would otherwise not be covered by Medi-Cal to achieve successful outcomes of their treatment goals. The services and/or supports identified shall be low cost or no cost and directly tied to the youth’s problem list and/or treatment goals.

II. Background

A. In 2006, BHSD launched the FSPC programs with the goal to assist highest risk youth to remain in the community, with their families or caregivers, while attending school and reducing adverse experiences such as hospitalizations, juvenile justice and/or child welfare involvement. FSP programming utilized a team approach to provide an array of services beyond the scope of traditional outpatient programming to meet needs of the population.

III. Target Population

A. The program shall serve high-risk youth ages of 6 through 15, living in Santa Clara County identified as seriously emotionally disturbed (SED) who have a major psychiatric condition and demonstrate a need for intensive services that meet FSPC eligibility criteria set forth in California Welfare and Institutions Code (WIC), Division 5, RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 2 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

Community Mental Health Services, Section 5600.3.

B. Youth who are difficult to engage in services and stepping down from acute and long-term institutional levels of care (e.g., locked facilities), but have the ability to succeed in the community with sufficient structure and support.

C. Youth that are from underserved and unserved ethnic and cultural populations, including young adults who are identified as Commercially Sexually Exploited Children (CSEC), have been marginalized due to their Sexual Orientation and Gender Identity and Expression (SOGIE), and involved with Child Welfare or Juvenile Justice Systems.

D. Youth that meet the criteria for co-occurring disorders, who have experienced multiple EPS or crisis stabilization unit (CSU) episodes, and/or frequent or extended hospitalizations.

E. Youth who are at risk of, or returned from, out-of-home placements, including those on formal Juvenile Probation and/or Child Welfare, who are experiencing a first episode of serious mental illness with symptoms for more than twenty-four (24) months.

F. Youth who are exiting child service systems (Juvenile Probation and/or Department of Family & Children Services) and meet FSPC criteria.

G. Youth who may be Medi-Cal eligible and/or uninsured.

H. The following groups shall receive targeted and rigorous outreach and engagement services, this includes, but not limited to:

1. Youth who are at risk of involuntary placements or have been released from inpatient settings;

2. Youth who have previously refused or struggled with treatment access;

3. Youth who have symptoms so severe that they are unable to leave home;

4. Youth who are homeless or at risk of being homeless;

5. Youth who are involved in the criminal justice system; and

6. Youth who have experienced a first episode of serious mental illness.

I. A typical client in the Youth FSPC program may require support for 10-12 months with higher frequency (two [2] or more sessions a week) with various team members and have, but not limited to some of the below characteristics:

1. Functional Impairment: youth who exhibit profound difficulties in family interactions, peer relationships, and academic or vocational settings. They display severe emotional dysregulations, necessitating intensive external support for effective management;

2. Common Diagnoses and Presenting Behaviors: Diagnoses include, but not limited to, severe anxiety disorders, major depressive disorder, bipolar disorder, psychotic disorders (untreated psychosis), and trauma-related disorders. These

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 3 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership conditions result in severe impairment in daily functioning. Internalizing or externalizing behavioral issues severely disrupt relationships and overall functioning. Youth may have co-occurring developmental diagnosis/challenges and substance use;

3. Support System: Youths have some access to social and environmental support with an urgent need for extensive strengthening and buffering of these supports to adequately address their complex needs. Youth may be involved with other child serving systems such as child welfare, juvenile justice, and/or San Andreas Regional Center.

IV. Program Goals and Objectives

A. The program shall be aligned to achieve the following goals shall include, but not be limited to:

1. Reflect the core values of Wraparound such as: recognition of the families’ unique cultural values as strength, family voice and choice, team-based decision making, use of natural supports, collaboration, and strength-based intervention;

2. Attain permanent placement in stable community environment;

3. Improved knowledge of effects of substance abuse;

4. Improve youth and family understanding of SED signs and symptoms to regain stability and function to safely remain in least restrictive settings; and

5. Educate youth, youth’s family, and significant caregivers about mental health and co-occurring disorders and how to manage/cope with their illness(es) using the principles of recovery and wellness.

B. Objectives shall include, but not limited to:

1. Engage and encourage youths’ participation in therapeutic activities, assessments, and/or linkage to services that would facilitate a reduction in emergency services;

2. Increase youths’ ability to utilize internal resources/strengths and competencies to assist them to achieve greater self-sufficiency;

3. Increase sense of belonging and connection to their social, community, and culture group/identity;

4. Utilize the Wraparound teaming approach inclusive of formal and natural supports and key figures in youth’s life who actively participate in the development, implementation, and monitoring of the youth’s plan of support;

and

5. Utilize comprehensive age-specific, evidenced-based, and informed/promising practices that address the behavioral health, substance abuse, and physical health issues effective with beneficiaries from ethnic communities and cultures.

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 4 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

V. Reporting and Data Collection Requirements

A. The Department of Health Care Services (DHCS) requires data and reporting into their Data Collection & Reporting System (DCR) for all individuals receiving FSP programming to evaluate the effectiveness of FSP services.

1. Offeror shall collect and report the following:

a. The Partnership Assessment (PAF):

i. Completed upon initial admission to the Youth FSPC; or

ii. Re-establishing Youth FSPC services, if more than one (1) year of discontinued FSP services.

iii. A PAF shall be completed before completing a Key Event Tracking Form (KET) and Quarterly Assessment Form (3M).

b. Key Event Tracking Form (KET):

i. Completed when a key event occurs in the beneficiary's life.

ii. There is no limit to the number of KET forms that can be completed.

c. Quarterly Assessment Form (3M)

i. Shall be completed every three (3) to provide updates to data collected in the PAF.

2. In addition, for youth ages 12 through 15, the Offeror shall administer, collect, and report on the following program specific measures:

a. Prodromal Questionnaire – Brief Version (PQ-B)

i. Completed prior to admission, to determine need for early psychosis services.

b. Mini-Structured Interview for Prodromal Syndromes (Mini SIPS)

i. Administered for young adults who have scored between early psychosis parameters on the PQ-B and have symptoms for twenty-four

(24) months or longer.

B. Data submission

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

2. FSPC Outcome Assessments shall be entered directly into the state's Data and Collection Reporting (DCR) database, on the following timelines.

a. PAF: thirty (30) days upon admit date;

b. KET: within five (5) days after a key event has occurred; and

c. 3M: two (2) weeks before the due date and no more than thirty(30) days after the due date.

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 5 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

3. PB-Q shall be entered into the QUALO system, or other system as identified by

BHSD.

4. Additional outcomes measure identified by BHSD.

VI. Outcomes and Measurements

A. Offeror shall achieve the following outcomes:

1. Increase the number of clients maintaining housing stability to decrease homelessness;

B. Offeror shall be responsible for the completion and submission of the following FSPC program specific data:

1. DCR required tools;

2. PQ-B;

3. Outreach and engagement services data; and

4. Other data or reporting requirements as determined by BHSD.

VII. Program Description

A. Service Description

1. Provide a continuum of services that includes full-service partnership (FSP) to intensive full-service partnership (IFSP) levels of service to meet the needs of youth ages 6 through 15. Full Service Partnership services shall include, but not limited to:

a. Ensure FSP continuum from least to more intensive service based on the assessed functional ability and adjusting the level of serves as needs change by tailoring the frequency and duration of sessions, expanding on youth’s current team to include additional staff, and adding/leveraging adjunct services.

b. Duration of services shall be dependent on service needs and may range from 12 to 18 months at varying degrees of frequency.

c. Offeror shall provide primarily in-home/community-based services, which may occur in the community, youth residence, and/or other locations in the community as appropriate to meet the needs of the individual and their caregivers.

d. Engagement and outreach interventions and strategies to increase readiness and utilization of the program services, ensure smooth transition of care, and continuity of care during inpatient episodes and incarcerations should they occur, including acute care and after-care planning.

e. The program shall provide a full range of the mental health, non-mental health services and supports necessary to address the needs of the youth

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 6 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership and address the “whole” family. Supports shall be provided to parents or adult caregivers when they have their own mental health or substance use needs, in order to advance the client’s goals and achieve outcomes that support the client’s recovery, wellness and resilience.

f. Develop and conduct person-centered action planning which shall identify the highest priority of needs in the life domains applicable to the beneficiary with goals established by the client. Action steps shall be created and responsibility for completing steps shall be established within the individualized Personal Service Plans (PSP) developed for each client and their families.

g. Utilize PSP that is consistent with the principles of wellness and recovery, is developed with the philosophy of client desired goals, with caregiver voice and includes but not limited to: individual steps in relation to education, medication, peer relations, social activities, and relapse prevention, cultivate, and sustain relationships with peers, family members, neighbors, teachers, the community, and others to create a network of support.

h. Peer supports and supportive services shall be provided to assist the client and family in obtaining and maintaining employment, housing assistance, and/or educational opportunities utilizing evidence-based practices.

2. All clients shall be screened and offered, as eligible, Intensive Care Coordination (ICC) services to support wellness, recovery, and improvement in functioning.

a. Upon meeting services criteria, Child and Family Team (CFT) process shall be utilized to develop and guide the planning and service delivery process for ICC services and incorporate the phases of treatment as guided by the Integrated Core Practice Model (ICPM) ICPM Guide and ACIN 1-21-18.

b. ICC Services may include:

i. Assessing the client and family’s needs and strengths;

ii. Identifying interventions and/or course of action targets at the client/family’s assessed needs;

iii. Assessing the adequacy and availability of formal and informal resources and working with the child and family team to increase natural resources and supports;

iv. Reviewing information from family and other sources;

v. Ensuring that plans from any of the system partners are integrated to comprehensively address identified goals and objectives;

vi. Evaluating the effectiveness of previous interventions and activities;

vii. Monitoring and adapting the plan in partnership with the CFT;

viii. Preparing the youth for transition in partnership with the CFT; and https://www.cdss.ca.gov/Portals/9/ACIN/2018/I-21_18.pdf

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 7 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

ix. Facilitation of CFT meetings as clinically appropriate, and at least every ninety (90) days, and sharing notes with the team with action plans.

c. Clients receiving ICC may also be eligible for Intensive Home-Based Services (IHBS). IHBS services must be discussed with members of the client’s CFT and confirmed prior to requesting the required authorization from the County Utilization Management (UM) Division.

d. IHBS are intensive, individualized, and strength-based interventions to assist the client and their significant support person(s) to develop skills to achieve the goals and objectives of the client’s treatment plan and predominantly be delivered outside of an office setting (e.g., in the home, school, or community), and incorporate the principles of the ICPM.

e. IHBS services may include:

i. Implementation of a positive behavioral plan and/or modeling interventions for the clients’ significant support person(s) and assisting them to implement strategies;

ii. Educating the client and/or the client’s significant support person(s) on how to effectively manage the client’s mental health disorder to improve functioning; and

iii. Teaching skills or replacement behaviors that allow the client to fully participate in meaningful activities.

f. ICC and IHBS shall be provided in accordance with the Medi-Cal Manual for ICC, IHBS, and Therapeutic Foster Care (TFC) Medi-Cal Manual Third Edition

ADA.

3. Any youth ages 12 through 15 shall be administered the PQ-B. For scores between early psychosis parameters on the PQ-B, youth shall receive a comprehensive screening utilizing the Mini SIPS, if psychosis symptoms have been present for twenty-four (24) months or longer and engaged in treatment supports. For youth with symptoms less than twenty-four (24) months, youth shall be supported with linkage to appropriate early psychosis program.

B. Care Coordination

1. Offeror shall adhere to feedback loop procedure, as listed Attachment J, and notify referring party, especially primary care providers, upon initiating services and any ongoing treatment changes.

2. Promote coordination and collaboration in care planning efforts with other child-serving agencies and institutions involved in delivering services to the child and family, to ensure comprehensive and consistent care, including Primary Care Providers, Medical Homes, etc.

C. Staffing Requirements https://www.dhcs.ca.gov/Documents/ChildrensMHContentFlaggedForRemoval/Manuals/Medi-Cal_Manual_Third_Edition.pdf https://www.dhcs.ca.gov/Documents/ChildrensMHContentFlaggedForRemoval/Manuals/Medi-Cal_Manual_Third_Edition.pdf

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 8 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

1. Offeror shall provide a clinical team that is a diverse group of professionals and paraprofessionals capable of delivering high quality comprehensive services to the target population. The clinical team includes:

Clinical Team Member

Description

Clinician Co-occurring Enhanced Licensed Practitioner of the Healing Arts (LPHA), including waivered staff, that provides therapeutic interventions utilizing evidence-based practices to support the wellness and recovery of youth in the program.

Personal Service Coordinator (PSC)

Serves as the single point of responsibility for the youth and family. Continuously evaluates care planning.

Coordinates key services for the youth, including adding in clinical team members when appropriate and connecting to additional community resources, to ensure necessary services are provided to the youth and family when they need it.

Rehabilitation Counselor/Case Manager

Assists youth and their family with offering solutions to address practical problems and coordinating social services across multiple areas of need. This role shall have training and knowledge to support housing needs for the youth and their family.

Family Partner Plays a critical role in understanding youth and family’s needs, serves as a liaison to formal and natural supports/ resources and has knowledge through lived experience either in being a beneficiary or parent of a youth who has utilized behavioral health, child welfare/ juvenile justice/ SUT services

Psychiatrists/ Other Licensed prescribing practitioners

Prescribing, administering, dispensing, and monitoring of psychiatric medications, and medication education evaluation of clinical effectiveness and side effects of psychotropic medication; obtaining informed consent;

instruction in the use, risks, and benefits of, and alternatives for, medication.

Occupational Therapist

Support building routine, Sensory integration to support trauma triggers in the environment, Educational/vocational support

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 9 of 9 ATTACHMENT A2: Youth Full Service Partnership Continuum Scope of Work CATEGORY 2: Full Service Partnership

Other staffing according to EBP, best practice or promising treatment models

Can include but not limited to: Employment and Education Specialist, peers support/mentors, faith-based or spiritual leaders, ICC Coordinator, IHBS worker.

Considerations of dual role of credentialed paraprofessional staff, Mental Health Rehab Specialists, and clinicians as appropriate and applicable

2. In addition to licensing requirements the following experience, training, and skills shall be required of Offeror’s staff:

a. A highly skilled facilitator, with a strong background in navigating complex team and family dynamic to ensure equity, psychological and physical safety of all participants, and support full participation for each participant.

b. Knowledge of multicultural experience, local community resources available to the beneficiary population, trauma-informed practice, clinical issues related to child abuse, substance abuse, domestic violence, communication, behavioral management, parenting skills, and parent engagement strategies.

c. Knowledge and trainings of highly researched, evidenced-based practiced designed to assist young people with managing challenging emotions such as, but not limited to:

i. Motivational Interviewing, Solution Focused Therapy, Trauma Informed Cognitive Behavioral Health (TI-CBT), Coordinated Specialty Care (CSC), Wrap-around teaming approach, etc.