Attachment A9.pdf

APPENDIX A9

CATEGORY 3: OUTPATIENT SERVICES

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 1 of 5 APPENDIX A9: Transitional Age Youth Outpatient Continuum Scope of Work CATEGORY 3: Outpatient Services

TRANSITIONAL AGE YOUTH OUTPATIENT CONTINUUM

SCOPE OF WORK

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

I. Purpose A. Transitional aged youth (TAY) Outpatient Continuum (hereafter referred to as “the program”) has been designed to provide culturally appropriate specialty mental health services to the transitional aged youth population of sixteen (16) through twenty-five

(25) years old, that focuses on increasing self-help activities and promoting health and wellbeing that will assist the youth or young adult as they launch into independence of adulthood.

B. The program shall provide a range of service levels that includes Intensive, Outpatient and Wellness Services that shall meet the needs of the youth or young adult when they need it and addresses impacts to transitional life domains including employment, education, living situation, personal wellbeing, interpersonal relationships, and community functioning.

II. Background A. The Outpatient Continuum (OPC) was designed to meet a need for targeted support to the underserved population in Santa Clara County. Services incorporate culturally and developmentally appropriate practices, and community defined evidence practices to serve the various target populations throughout Santa Clara County. In fiscal year (FY) 2023-2024, 509 clients were served with 33% of clients identified as male and 67% of clients were female. The majority of clients served in SOPC were identified as Latinx (44%). 66% were between the ages of twenty-one (21) to twenty-five (25) and 30% between the ages of sixteen (16) through twenty (20). The most common diagnoses include depressive disorders (37%) and trauma/stressor related Disorders (23%).

III. Target Population A. Medi-Cal beneficiaries between the ages of sixteen (16) through twenty-five (25) with serious mental illness who need therapeutic services, crisis intervention, and linkage to community supports.

B. TAY who are homeless or at risk of homelessness, and/or are transitioning out of child-service programs (e.g., child welfare, juvenile justice, and other placement settings).

C. TAY from underserved and unserved ethnic populations including, but not limited to:

Asian, Asian Pacific Islander, African American/African Ancestry, Latino/Latinx, Native/Indigenous American.

D. A typical client in the TAY OPC program may require support for 6-12 months at a varying frequency of one or more times a week and have, but not limited to some of the below characteristics:

1. Functional Impairment: clients experience significant difficulties in family interactions, peer interactions, and school/employment functioning. They

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 2 of 5 APPENDIX A9: Transitional Age Youth Outpatient Continuum Scope of Work CATEGORY 3: Outpatient Services demonstrate moderate to severe emotional regulations needs that require external supports;

2. Common Diagnoses and Presenting Behaviors (not limited to): Typical diagnoses include moderate to severe anxiety disorders, major depressive disorder, trauma-related disorders, and adjustment disorders with co-occurring developmental delays such as, but not limited to expressive and/or receptive language disorder, global developmental delay disorder, autism spectrum disorder, etc. These conditions result in marked impairment in daily functioning. Internalizing or externalizing behavioral issues contribute to moderate to severe disruptions in relationships and overall functioning;

3. Support System: Clients have access to some social and environmental support, there is a critical need for substantial strengthening and buffering of these supports to adequately meet their complex needs. Involvement with the child welfare system may also be present; typical Clients who experience difficulties in family interactions, peer interactions, and school or vocational functioning.

Moderate to severe emotional regulations needs require occasional or consistent external support.

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

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

a. Increase abilities to address impacts of transitional life domains.

b. Increase knowledge of the needs of transitional aged youth to caregivers and/or natural supports

2. Objectives shall be achieved by:

a. Engage and educate youth/young adults and their caregiver and/or natural supports in the treatment process to ensure voice and choice in services.

b. Increase partnership and coordination of services for the youth/young adult between system partners such as, but not limited to Department of Family and Children’s Services (DFCS), the Behavioral Health Services Department (BHSD), the Juvenile Probation Department (JPD), medical home (Primary Care Physician), educational, regional, and other community organizations.

V. Reporting and Data Collection Requirements

A. Offeror shall track the clients served in the TAY Outpatient Continuum program and the level of service that is being provided (Intensive, Outpatient, or Wellness) and have the ability to provide this information to BHSD upon request.

VI. Outcomes and Measurements

A. Offeror shall achieve the following outcomes:

1. Increase access to regular jobs, mainstream education and/or technical training for young adults living with behavioral health conditions.

2. Increase identification of youth that may be clinically high risk for psychosis and

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 3 of 5 APPENDIX A9: Transitional Age Youth Outpatient Continuum Scope of Work CATEGORY 3: Outpatient Services link to appropriate interventions.

B. Offeror shall use the following measurements:

1. Employment Status documentation

2. Prodromal Questionnaire-Brief (PQ-B)

VII. Program Description

A. Service Description

1. Offeror shall provide a range of services from Intensive, Outpatient to Wellness level of service to youth and young adults who need medically necessary specialty mental health services.

a. Intensive services shall be provided to Youth and Young Adults who demonstrate higher acuity of needs and may require higher frequency of support to address symptoms, conditions, and/or risk factors that are impacting their ability to maintain themselves in community settings.

Services shall include crisis response services, as needed.

b. Outpatient services shall be provided to Youth and Young adults who may need support to address behavioral health challenges that impact transitional life domains including employment, education, living situation, personal wellbeing, interpersonal relationships, and community functioning.

c. Wellness services shall be provided to Youth and Young Adults who may need medication management, and light case management short term support to sustain their wellness and recovery, as the program is actively working on linking to longer term medication management with Primary Care Physician (PCP), Managed Care Plan (MCP), or other long-term provider to ensure a warm handoff.

2. Offeror shall provide primarily community-based services, which may occur in the youth/youth adult’s residence, and/or other locations in the community as appropriate to meet the needs of the individual served.

3. Services shall focus on wellness and recovery goals that include preparing and facilitating self-sufficiency and successful achievement of Youth and Young Adults’ transition goals.

4. Services shall include the following:

a. Provide Individual Placement and Support (IPS) services for young adults ages 18 -25, who have expressed interest and motivation in pursuing competitive employment, regardless of their employment readiness, diagnosis, symptoms, substance us history, psychiatric hospitalization, homelessness.

Level of disability, or legal system involvement.

i. Designated IPS staff shall provide the evidence-based practice of IPS Supported Employment in line with the eight Practice Principles and the

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 4 of 5 APPENDIX A9: Transitional Age Youth Outpatient Continuum Scope of Work CATEGORY 3: Outpatient Services

25 Fidelity Standards (https://ipsworks.org/wp-content/uploads/2017/08/IPS-Fidelity-Scale-Eng1.pdf;

https://ipsworks.org/)

5. Offeror shall ensure that all clients who are identified as needing psychiatry, medication management, or other adjunct SMH service will be provided and/or linked to services within the required network adequacy timeline determined by the Department of Health Care Services (DHCS).

6. Treatment for individuals who have a mild to moderate substance use disorder such that services are integrated into their mental health services.

B. Staffing Requirements

1. Offeror shall maintain adequate staffing for the program, including the following:

C. Care Coordination

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

a. Ensure feedback loop, as listed in Attachment J, is provided to all relevant parties to support client care. This may include but not limited to, medical home (Primary Care Physician), Juvenile Probation, Child Welfare, school placement.

i. Feedback loop shall be inclusive of but not limited to, outcome of referral, changes to treatment, and other needed information for client care.

D. Program Hours of Operations

1. Offeror shall provide hours of operations that ensure accessibility for Transitional Aged Youth receiving services. Services shall be available between 8:00am to 8:00pm at minimum four (4) days a week. After hours, including weekend, supports shall be established to support urgent needs, as appropriate.

VIII. Staffing Requirements

A. Offeror shall provide a multidisciplinary team inclusive of a diverse group of professionals and paraprofessionals with comprehensive knowledge of and capability to deliver high quality comprehensive services to the target population. Team members include, but not limited to:

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 children in the program.

https://ipsworks.org/wp-content/uploads/2017/08/IPS-Fidelity-Scale-Eng1.pdf https://ipsworks.org/wp-content/uploads/2017/08/IPS-Fidelity-Scale-Eng1.pdf https://ipsworks.org/

RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services Page 5 of 5 APPENDIX A9: Transitional Age Youth Outpatient Continuum Scope of Work CATEGORY 3: Outpatient Services

Peer Specialist Provide case management, assistance with predictable behavioral routines/interventions, access community resources, and referrals and linkages to additional service needs. (MHRS/paraprofessional)

Peer Partner Plays a critical role in understanding young adults needs, serves as a liaison and advocate to formal and natural supports/resources and has knowledge through lived experience either in being a beneficiary who has utilized behavioral health services or been involved with other youth serving programs (e.g., child welfare and/or juvenile justice).

(Peer Support Specialist)

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.

Other Staffing according to EBP, best practices or promising practices:

IPS Staff:

Employment/Educational Specialist and IPS Supervisor

Employment/Educational Specialist support all phases of supported employment including intake, engagement, assessment, career profile, employment plan, job development, job placement, and job shadowing. Specialist offers specialized benefits planning to clients referred to the program, when starting a new job, and when there are changes to the work hours and/or pay. Specialist will also assist accessing additional support and benefits, as appropriate.