Attachment A7.docx

ATTACHMENT A7

CATEGORY 1: PREVENTION AND EARLY INTERVENTION SERVICES

OLDER ADULT PREVENTION EARLY INTERVENTION SERVICES

Scope of Work

Purpose The County of Santa Clara (County) Behavioral Health Services Department (BHSD) is seeking statements of qualifications from qualified Offerors interested to design and operate the Older Adult (OA) Prevention and Early Intervention (PEI) Services (hereafter referred to as “the program”).

Offeror shall serve Older Adults (ages 60 and over) who have not been diagnosed with severe mental illness (SMI) and/or co-occurring[footnoteRef:2] substance use disorders but may be experiencing early signs of potentially severe and disabling mental illnesses. [2: Clients require both mental health and substance use treatment services.]

Offeror shall provide culturally appropriate and trauma-informed services to promote the recovery, stability, and resilience of all clients. Services shall:

1. Promote recovery and shall increase client quality of life, community connections, self-reliance, and shall decrease negative outcomes, such as hospitalization, isolation, abuse, incarceration, and homelessness;

2. Improve the emotional/behavioral functioning and enhance the abilities for clients to participate in meaningful activities, such as recreational, educational training, employment, and independent living activities; and

3. Build and nurture natural supports, which help clients remain in the communities as emotionally healthy and productive members.

Offeror shall work cooperatively with community navigators, community providers, other mental health agencies, Substance Use Treatment Service providers, physical health providers, educational systems, and any other agencies which provide supportive services.

Background Information A. BHSD Adult and Older Adult System of Care is structured as a continuum of care that serves an ethnically and racially diverse population of Santa Clara County clients. According to the US Census, the population of Santa Clara County in 2016 was one million nine hundred and nineteen thousand and four hundred and two (1,919,402). In Fiscal Year 2015-2016, the Santa Clara County Mental Health Plan served about sixteen thousand and five hundred and ninety-two (16,592) unduplicated clients. Of these clients, over two thousand and four hundred (2,400) were over the age of sixty (60), representing fifteen percent (15%) of the total adult clients served. Additionally, a significant percentage of the older adults served were diagnosed with:

a. Mental health, substance use, or co-occurring diagnoses (e.g., depression, anxiety, and developmental and/or intellectual disabilities);

b. Significant health issues (e.g., difficulties related to mobility).

B. The County’s Older Adult Prevention and Early Intervention Program is funded under the PEI Project 4 (P4) component of the Mental Health Services Act (MHSA).

Target Population A. The program shall serve OA clients who have not previously received specialty BHSD services including:

1. Clients showing early signs of potentially severe or disabling mental illness(es);

2. Clients at risk of entering the AOA System of Care;

3. Underserved cultural populations;

4. Populations who identify as part of the Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, and Plus (LGBTQ+) community;

5. OA clients experiencing early symptoms of depression, anxiety, fear of harm or abandonment, feelings of social isolation, substance use;

6. Caregivers experience stress related to caring for their client(s); and

7. Clients who may be eligible or enrolled in Medi-Cal, Medi-Cal/Medicare, Medicaid, and/or are uninsured.

B. The program shall serve clients who are County residents that may be uninsured, or have full-scope Medi-Cal or Medicare. Clients with Medi-Cal or Medicare shall meet criteria in accordance with all laws and regulations governing Medi-Cal and Medicare programs as mandated by federal, state, and local statues. This includes California Code of Regulations (CCR) Title 9 and Social Security Act Title XXII Regulations.

C. Offeror’s services shall strategically be situated within the identified County catchment areas. The three (3) 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.

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

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:

a. Increase active participation in self-monitoring goals and milestones toward self-help, coping strategies;

b. Psychoeducation for caretakers and family members;

c. Strengthen recovery, self-sufficiency, and other psychosocial outcomes;

d. Reduce disparities in accessing mental health services;

e. Reduce the psychosocial impact of trauma;

f. Reduce and prevent the risk of suicide;

g. Increase clients' access to ongoing supportive community-based services to maintain an active lifestyle.

h. Decrease symptoms with early intervention for low-intensity short term care.

i. Increase access to early intervention behavioral health services for the target population, including timely access to services, high-quality care, and effective treatment using evidence-based practices.

Objectives shall be achieved by:

a. Developing and delivering awareness campaigns to educate the public on mental health issues and reduce stigma associated with mental illness;

b. Psychoeducation to help clients process their experiences using early intervention strategies to increase their sense of self-efficacy and resilience;

c. Case management to ensure that clients have access to appropriate resources; and

d. Linkage to referral networks to connect individuals with local organizations providing additional supportive services such as language support, housing assistance, job training, legal help, etc.

3. Offeror shall implement the program in accordance with the California Welfare and Institutions Code (WIC) Section 5840 to make behavioral health services accessible to County residents with SMI and co-occurring substance use issues in need of treatment.

Reporting and Data Collection Requirements A. Offeror shall comply with the reporting requirements reflected in Division 5 of the California WIC and Division 1 of Title 9 of the CCR when applicable.

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

1. Administer a clinical assessment at intake, follow-up, and discharge;

2. Enter client demographic information, direct and outreach services 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. Collect treatment and service data for outcomes data reporting;

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

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

7. Measure client outcomes to determine areas for improvement;

8. Administer assessment tool(s) per program requirements and collect and report on assessment tool data; and

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

C. Data Submission

1. Offeror shall collect and report on the following data:

a. CSI data;

b. Older Adult relevant assessment tools;

c. Active Caseload/Length of Stay (LOS) Report;

d. Network Adequacy Certification Tool (NACT);

e. Units of Service (UOS) Report;

f. Client to staff ratio;

g. Reports on client readmission to the program;

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

i. MHSA quarterly and annual reports;

j. Outreach and Engagement Process report; and

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

2. Offeror shall implement Countywide client satisfaction/perception surveys to improve service delivery operations. The BHSD Decision Support (DS) team shall oversee the distribution, collection, and results in processing and distribution.

3. 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.

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

1. Ensure clients have timely access to mental health service;

2. Ensure clients are engaged in services;

3. Successfully discharge clients; and

4. Conduct referrals to outpatient services.

B. Offeror shall achieve the following outcome measurement methods:

1. Number of home visits to clients;

2. Referrals given for additional and supportive services;

3. Records of support groups provided for clients and caretakers;

4. Number of clients transferred to Medi-Cal homes, WARMS, Wellness Programs, PCBHs, and/or other related health care programs; and

5. Clinician-completed assessments.

6. Client feedback tool (Client Satisfaction Survey) administered bi-annually.

C. Offeror shall achieve the following data submission:

1. Offeror shall collect treatment data for outcomes data reporting. Offeror shall enter direct services data into the County’s data information system.

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

3. 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.

4. Provide quarterly and annual reviews from the following data sources:

a. Relevant County data systems; and

b. PEI Prevention data report.

Program Description A. Service Description

1. Offeror shall provide PEI behavioral health services to clients.

2. Offeror shall utilize a variety of treatment approaches to resolve problems varying by each client’s unique needs.

3. Offeror shall provide consultation and individual/group health education for clients, caregivers, and service providers.

4. Offeror shall provide short-term supportive counseling and case management and brief individual and group psychotherapy.

5. Offeror shall utilize EBPs, Promising Practices (PPs), and trauma informed practices whenever clinically indicated and based on each client’s diagnoses. EBPs and PPs recommended for the program may include the following:

a. Motivational Interviewing (MI);

b. Stages of Change;

c. Cognitive Behavioral Therapy (CBT);

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

e. Solution-Focused Brief Therapy (SFBT);

f. Trauma-informed approaches;

g. Integrated co-occurring disorder practices; and

h. Peer supports.

6. 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.

7. Offeror shall strategically operate a Medi-Cal and Medicare certified service delivery site within the 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, education setting, home, homeless shelter, etc.), if appropriate.

8. 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.

B. Staffing Requirements

1. Offeror shall provide an updated agency plan for administrative coverage or program-related changes to the BHSD Division Director at the beginning of each new fiscal year, and when any changes to this plan occur.

2. Offeror shall describe the existing staff who shall be providing the services and program components described in this RFSQ. Offeror shall include a staffing table and credentials for those who shall be providing and supporting these services and indicate position title, linguistic and cultural skills, education, experience, licensure, and certifications, including administrative, supervisory, and direct service staff.

3. Offeror shall describe their plan to recruit and maintain appropriate staffing to meet the diverse population of Santa Clara County. Offeror shall provide a personnel retention plan, which includes a current list of staff at the organization, their credentials, bilingual language capacity, and the length of time the employee has been with the organization.

4. Offeror shall provide the approximate percentage turnover of the direct service staff over the past three years. Offeror shall also describe how the organization shall provide continuity of care for families during staff turnover.

5. Staff shall attend regularly scheduled meetings, training sessions, seminars and/or other meetings as scheduled by the BHSD Director and/or their designee. Meetings shall include but are not limited to:

a. AOA System of Care meetings; and

b. Quality Improvement (QI) meetings.

6. Offeror shall maintain adequate staffing for the program, including the following as appropriate for the program:

a. Licensed or license-eligible clinicians;

b. Case managers; and

c. Rehabilitation counselors.

7. Staff shall possess the following education and experience:

a. Knowledge of mental health and psychopathology;

b. Specialized experience working with Older Adult clients in a mental health service agency, and experience addressing issues of aging and substance use issues;

c. Crisis and conflict management training and experience in working with older adults, including knowledge of safety issues that may exist when working with individuals with mental disabilities in a community-based environment;

d. Familiarity with various experiential mental health treatment methods in group and milieu therapy and activity-based programming;

e. Ability to relate effectively with Older Adult clients with disabilities, fellow employees, and the public;

f. Ability to use sound judgment set proper boundary with clients; and

g. Possession of problem-solving skills and tact when working with special needs or difficult clients.

8. Staff shall attend any County training that pertains to providing behavioral health services to Older Adults and all systemwide BHSD trainings.

9. Offeror shall ensure that staff understand the principles of wellness and recovery services and other Evidence-Based Practices (EBPs) as determined by the BHSD.

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 + [LGBTQ+], cultural and linguistic capacity, racial equity).

C. 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 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 Older Adults in underserved, underrepresented, or multicultural populations.

D. Referrals and Admissions

1. Offeror shall serve clients as determined by County policies, procedures, directives, and guidelines that are within Offeror’s resources.

2. Offeror shall accept referrals from:

a. County Agencies;

b. County-contracted agencies; and

c. The Behavioral Services Call Center.

3. Offeror shall screen all referrals and determine appropriateness. If referral does not meet criteria for the program, the referral shall be redirected to alternative resources to resolve the presenting issue(s).

E. Care Coordination

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

a. Offeror shall provide comprehensive assessment, medication review/management, and treatment planning in collaboration with a geriatric psychiatrist or geriatrician and/or a clinical service team member.

b. Offeror shall link clients to a Medi-Cal Home, Wellness Program, Primary Care Behavioral Health (PCBH), and/or other related health care program for continued care, as applicable.

i. To facilitate care coordination, Offeror shall request Health Insurance Portability and Accountability Act (HIPPA) and California law-compliant client authorization to share client information with all other providers involved in the client’s care, in satisfaction of state, and federal privacy laws and regulations.

ii. Offeror shall engage in care coordination activities beginning at client intake and throughout the treatment and discharge planning processes.

iii. Offeror shall discuss in their proposal evaluation criteria for clients needing additional mental health services and other resources, including how they would assist in transitioning the client.

iv. Clients who are open to receiving traditional mental health services shall, as part of their acceptance into this program, sign appropriate Consents for Release of Information so that program staff have authorization to share client information with their primary mental health providers.

v. Offeror shall describe their organization’s willingness, experience, and ability to collaborate with multiple County systems and services.

F. Program Hours of Operations

1. Offeror shall be open for services during regular office hours Monday through Friday, 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 to address the emergency needs of clients.

2. During holidays, Offeror shall maintain at minimum a skeleton crew that shall facilitate the processing of referrals coming from the BHSD Call Center, operate the 24-Hour Care unit, provide crisis coverage, and initiate Lanterman-Petris-Short (LPS) protocols.

G. Evaluations, Transitional Planning, and Discharge

1. Offeror shall discharge clients that meet program goals or transfer clients who require further support from mental health services based on the client's level of care need as determined by relevant screening tool.

2. Offeror shall facilitate transitions to other agencies for additional or more specialized support for clients requiring higher levels of care.

3. Offeror shall review each client’s status and progress towards planned goals to determine discharge planning or connect the client to the County of Santa Clara Call Center for a referral to outpatient service or refer to psychiatry medication evaluation or related medication management services as necessary in the outpatient clinics.

4. Offeror shall discharge clients when they meet at least one (1) of the following criteria:

a. Upon mutual agreement by the client and the treatment team that the client completed the program successfully;

b. Upon a good faith determination by Offeror that the program cannot effectively serve the client;

c. Upon client or guardian's unilateral decision to terminate treatment against medical advice;

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

e. Upon transfer to another County mental 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 next steps;

f. 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;

g. When the client is incarcerated for over thirty (30) days;

h. When the client no longer meets Medi-Cal medical necessity criteria; and

i. When the client is not engaged and responsive after thirty (30) days of persistent efforts to locate them and following all County policies and procedures.

5. Offeror shall provide referral, consultation and advocacy with other local organizations or agencies as appropriate. This includes but is not limited to referral to the following:

a. The BHSD;

b. Crisis and problem resolution;

c. Case management;

d. Client advocacy groups;

e. Health and medication education providers; and

f. Health care and community resources.

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 B7 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 3ATTACHMENT A7: Older Adult Prevention and Early Intervention Services Scope of Work CATEGORY 1: Prevention and Early Intervention Services