HomeMy WebLinkAboutBOARD STANDING COMMITTEES - 12122016 - FHS Cte Agenda Pkt
FAMILY & HUMAN SERVICES
COMMITTEE
December 12, 2016
1:00 P.M.
651 Pine Street, Room 101, Martinez
Supervisor Candace Andersen, Chair
Supervisor Federal D. Glover, Vice Chair
Agenda
Items:
Items may be taken out of order based on the business of the day and preference
of the Committee
1.Introductions
2.Public comment on any item under the jurisdiction of the Committee and not on this
agenda (speakers may be limited to three minutes).
3. CONSIDER recommending to the Board of Supervisors the appointments of Edirle
Menezes and Stacie Cooper-Roundtree on the Local Planning and Advisory Council for
Early Care and Education, as recommended by the County Office of Education.
4. CONSIDER accepting the report from the Health Services Department with an update
on the six month implementation of Laura's Law (Assisted Outpatient Treatment
program), and forward it to the Board of Supervisors their for approval. (Warren Hayes,
MHSA Program Manager)
5. CONSIDER accepting the report from the Health Services Department on the
implementation of Secondhand Smoke Protections Ordinance, and direct staff to forward
it to the Board of Supervisors for their information. (Daniel Peddycord, Public Health
Director)
6. CONSIDER accepting the recommendation from the County Administrator's Office
staff regarding the continuation of referrals to the Family and Human Services
Committee in 2017. (Enid Mendoza, FHS Staff)
7.No additional meetings are scheduled for the 2016 Family and Human Services
Committee.
8.Adjourn
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The Family & Human Services Committee will provide reasonable accommodations for persons
with disabilities planning to attend Family & Human Services Committee meetings. Contact the
staff person listed below at least 72 hours before the meeting.
Any disclosable public records related to an open session item on a regular meeting agenda and
distributed by the County to a majority of members of the Family & Human Services Committee
less than 96 hours prior to that meeting are available for public inspection at 651 Pine Street, 10th
floor, during normal business hours.
Public comment may be submitted via electronic mail on agenda items at least one full work day
prior to the published meeting time.
For Additional Information Contact:
Enid Mendoza, Committee Staff
Phone (925) 335-1039, Fax (925) 646-1353
enid.mendoza@cao.cccounty.us
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FAMILY AND HUMAN SERVICES COMMITTEE 3.
Meeting Date:12/12/2016
Subject:Appointments to the Local Planning Council
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: 25
Referral Name: Appointment to the LPC
Presenter: Ruth Fernandez, LPC
Coordinator/Manager
Contact: Enid Mendoza, (925)
335-1039
Referral History:
The review of applications for appointments to the Contra Costa Local Planning Council for Child
Care and Development was originally referred to the Family and Human Services Committee by
the Board of Supervisors on April 22, 1997.
Referral Update:
Please see the attached request from the Local Planning Council and the council candidate
applications.
Recommendation(s)/Next Step(s):
RECOMMEND the following appointments on the Local Planning and Advisory Council for
Early Care and Education with term expirations as specified below, as recommended by the
County Office of Education:
Public Agency 2 Central/South County Seat with a term expiring April 30, 2017:
Edirle Menezes, Ph.D, resident of San Ramon working for a public agency in Concord
Child Care Provider 4 East County Seat with a term expiring April 30, 2018:
Stacie Cooper-Roundtree, resident of Antioch providing child care services in Antioch
Fiscal Impact (if any):
Not applicable.
Attachments
LPC Memo, Applications and Supporting Docs
Statement from Pamela Comfort, Deputy Superintendent, Educational Services
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10
11
12
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14
15
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17
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25
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FAMILY AND HUMAN SERVICES COMMITTEE 4.
Meeting Date:12/12/2016
Subject:Referral No. 107 Laura's Law - Assisted Outpatient Treatment
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: 107
Referral Name: Laura's Law
Presenter: Warren Hayes, MHSA Program
Manager
Contact: Enid Mendoza, (925)
335-1039
Referral History:
At its June 3, 2013 meeting, the Legislation Committee requested consideration of whether to
develop a program in the Behavioral Health Division of the Health Services Department that
would implement assisted outpatient treatment options here in Contra Costa County be referred to
the Family and Human Services Committee (FHS).
On July 9, 2013, the Board of Supervisors referred the matter to FHS for consideration.
On March 10, 2014, FHS accepted the report and recommendations from the Health Services
Department to pilot an Assisted Outpatient Treatment Program.
On October 7, 2014, the Board of Supervisors considered the report from the Health Services
Assisted Outpatient Treatment (AOT) Workgroup. The Board expressed its intention to
implement an involuntary assisted outpatient treatment program, and instructed the County
Administrator’s Office and Health Services Department to provide additional information at a
later Board meeting to ensure no voluntary programs would be reduced as a result of
implementing Laura’s Law.
On February 3, 2015, the Board of Supervisors adopted the recommendations of the Health
Services Department for a program to be developed with stakeholder participation. Additionally,
the Board directed staff to return to the Board for final approval of the program once funding for
the program implementation had been built into the budget.
On December 15, 2015, the Health Services Department provided the Board of Supervisors with
an update on the progress of the Assisted Outpatient Treatment Program. The Board approved the
department's recommendation to continue with the program's implementation using $2.25 million
per year of Mental Health Services Act funding, which would not impact the County's General
Fund or reduce the existing voluntary mental health program services. The Board asked that the
department return with an update after six months of the full implementation.
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On September 12, 2016, FHS accepted the report from the Health Services Department on the
implementation of the County's AOT program.
On September 27, 2016, the Board accepted the report, as recommended by FHS, from the Health
Services Department on the implementation of the County's AOT program and accepted the
department's proposal to report back to FHS and the Board when data on the 6 month
implementation period was available.
Referral Update:
Please see the attached report from the Health Services Department and Resource Development
Associates containing implementation information and data on the first six months of the
County's Assisted Outpatient Treatment (AOT) program.
Recommendation(s)/Next Step(s):
ACCEPT the report from the Health Services Department on the six month implementation of the
County's Assisted Outpatient Treatment Program, as authorized by the Board of Supervisors and
AB 1421 (Laura's Law), and forward the report to the Board of Supervisor for approval.
Fiscal Impact (if any):
Mental Health Services Act funding to support the program is contained within the Health
Services Department budget. There is no impact to the County General Fund.
Attachments
AOT 6 Month Implementation Report
28
Contra Costa County Assisted Outpatient
Treatment (AOT) Evaluation
2016 Interim Evaluation Report
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Table of Contents
Executive Summary ............................................................................................................................1
Introduction ......................................................................................................................................5
AOT in Contra Costa County ..................................................................................................................... 5
AOT Evaluation .......................................................................................................................................... 8
Methodology .....................................................................................................................................9
ACT Fidelity Assessment ........................................................................................................................... 9
AOT Program Evaluation ......................................................................................................................... 10
Results ............................................................................................................................................. 14
ACT Fidelity ............................................................................................................................................. 14
Pre-AOT Enrollment Outcomes............................................................................................................... 24
Post-AOT Enrollment Outcomes ............................................................................................................. 37
Discussion ........................................................................................................................................ 50
AOT Referrals .......................................................................................................................................... 50
Outreach and Engagement ..................................................................................................................... 51
ACT Fidelity ............................................................................................................................................. 52
Preliminary Outcomes ............................................................................................................................ 54
CCBHS and MHS Data Capacity ............................................................................................................... 54
Appendices ...................................................................................................................................... 55
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Table of Figures
Figure 1. Contra Costa County AOT Program Implementation Timeline ...................................................... 1
Figure 2. Contra Costa County AOT Client Engagement Process Flowchart ................................................. 7
Figure 3. AOT Eligibility Determinations for all Referred Consumers by Month ........................................ 26
Figure 4. Average Investigation Contact Attempts per Consumer ............................................................. 28
Figure 5. Average Duration (in Minutes) of Investigation Contacts per Consumer10 ................................. 29
Figure 6. Locations of CCBHS Investigation Contacts for All Eligible Consumers, ...................................... 30
Figure 7. Type of Outreach and Engagement Contact Attempts for All Consumers .................................. 31
Figure 8. Type and Number of Outreach and Engagement Attempts per Consumer, ................................ 32
Figure 9. Proportion of Successful Outreach Attempts by Provider for All Consumers ............................. 33
Figure 10. Successful Outreach and Engagement Attempts by Provider per Consumer ........................... 34
Figure 11. Average Duration (in Minutes) of Successful Outreach and Engagement Attempts by Provider
for All Eligible Consumers ........................................................................................................................... 35
Figure 12. Average Duration (in Minutes) of Successful Outreach Attempts by Provider per Consumer . 35
Figure 13. Locations of Successful Outreach and Engagement Attempts for All Eligible Consumers ........ 36
Figure 14. Average Days Spent in Each Step by Month for AOT Consumers .............................................. 37
Figure 15. Consumers’ History of Incarceration or Arrest in the 12 Months Prior to AOT Enrollment ...... 40
Figure 16. Episodes of Service Use Other than ACT for AOT Consumers ................................................... 43
Figure 17. Number of Consumers Experiencing Adverse Events Pre-AOT Enrollment .............................. 44
Figure 18. County Hospitalization and Other Service Costs Pre-Enrollment for AOT Consumers .............. 48
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Table of Tables
Table 1. Data Sources and Elements ........................................................................................................... 10
Table 2. ACT Fidelity Assessment Scores .................................................................................................... 14
Table 3. Action Team Monthly Intake January 2016 to July 2016 .............................................................. 17
Table 4. Quartile Ranking of Service Hours Received for July 2016 ........................................................... 20
Table 5. Action Team Face-to-face Contacts with Clients by Week for July 2016 ..................................... 21
Table 6. Summary of Requestor Type ......................................................................................................... 25
Table 7. Status of All AOT-Eligible Consumers at Conclusion of Evaluation Period, ................................... 27
Table 8. Total Number of Investigation Contacts by Consumer Status ...................................................... 28
Table 9. Total Number of Outreach and Engagement Contact Attempts by Consumer Status ................. 31
Table 10. AOT Consumer Demographics .................................................................................................... 38
Table 11. AOT Consumer Primary Diagnosis at Enrollment ........................................................................ 39
Table 12. Average and Median Hospital Episodes and Days in Hospital .................................................... 39
Table 13. Housing Status 12 Months Prior to and at Enrollment for AOT Consumers ............................... 40
Table 14. Sources of Financial Support for AOT Consumers ...................................................................... 41
Table 15. Length of Enrollment in AOT ....................................................................................................... 42
Table 16. Safety SSM Scores for AOT Consumers (n = 16) .......................................................................... 45
Table 17. Social Functioning and Independent Living SSM Scores for AOT Consumers (n = 16) ............... 45
Table 18. MHS Costs ................................................................................................................................... 47
Table 19. Contra Costa County Department Costs ..................................................................................... 47
Table 20. Service Costs Pre-AOT Enrollment .............................................................................................. 48
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Executive Summary
Background
On February 3, 2015, the Contra Costa County Board of Supervisors adopted a resolution to authorize the
implementation of AOT in accordance with the Welfare and Institutions Code, Sections 5345-5349.5.
Figure 1 below shows the implementation timeline of AOT in Contra Costa County.
Figure 1. Contra Costa County AOT Program Implementation Timeline
The County has designed an AOT program model that exceeds AB 1421 requirements and responds to the
needs of its communities. The Care Team (CCBHS and Mental Health Systems) collaborates to conduct
investigation, outreach, and engagement activities. MHS provides Assertive Community Treatment (ACT)
services for individuals enrolled in ACT. When implemented to fidelity, ACT produces reliable results for
consumers, including decreased negative outcomes, such as hospitalization, incarceration, and
homelessness, and improved psychosocial outcomes, such as increased life skills and involvement in
meaningful activities.
This preliminary report captures the first six months of
AOT implementation in Contra Costa County,
specifically addressing the following research
questions:
1. How faithful are Contra Costa County’s ACT
services to the ACT model?
2. What are the outcomes for the people who
participate in AOT, including the DHCS-
required reporting outcomes?
In addition to adopting a new legal mechanism for providing mental health services to individuals with
serious mental illness, the County contracted with a new service provider (MHS) to introduce a new
service model (ACT). Given the number of new elements being introduced in Contra Costa County in the
first six months of starting-up the AOT program, this report’s discussion about the AOT program’s
implementation and preliminary outcomes should be interpreted cautiously until the County’s AOT
program has become more firmly established.
What is ACT?
ACT is an evidence-based behavioral health
program for people with serious mental
illness who are at-risk of or would
otherwise be served in institutional settings
such as a hospital or jail, or experience
homelessness.
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Key Findings
Pre-AOT Enrollment
The Pre-AOT Enrollment period includes the referral process and the investigation and outreach and
engagement conducted by the Care Team. From 108 referrals, investigation of 101 cases resulted in 38
AOT eligible consumers receiving outreach and engagement. As of July 31, 2016, 17 consumers were
enrolled in ACT and 11 were still receiving outreach and engagement services.
Investigation of the referral process suggests that individuals for
whom AOT is appropriate are being identified for services.
Additional key findings regarding referral to AOT include:
Consumers’ family members, spouses, and housemates
made the majority (60%) of referrals to CCBHS, suggesting
that AOT has increased the capacity of this group to seek
help for their loved ones.
There may be an opportunity for the County to increase its
education and outreach to law enforcement officials and
mental health service providers to further inform them
about AOT, their role as qualified requestors, and the
opportunities to refer eligible individuals for service.
The Care Team is intended to work collaboratively to investigate and
engage consumers in order to connect them to long-term services,
either voluntarily or through AOT enrollment. Research on the Care
Team’s efforts suggests that the Care Team is conducting many
activities to connect with consumers and their families in the
community in order to engage them in long-term mental health
services. Findings also suggest that in the final months of the
evaluation period, the program model shifted so that investigation
and outreach and engagement efforts operated consecutively
instead of concurrently.
Post-AOT Enrollment
The County appears to be reaching the target population of consumers who have a history of repetitive
hospitalization, incarceration, and homelessness and are unable or unwilling to engage in voluntary
services. Although consumer enrollment dates span the six-month period, consumers are receiving a high
degree of mental health services through this program.
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Preliminary Outcomes
Given the small sample size and enrollment periods, this evaluation only reports baseline findings. Key
demographic characteristics of the 17 AOT consumers include:
Gender: 47% male, 53% female
Race/Ethnicity: 29% Black/African American,
59% White, 12% Other
Region: 47% Central, 29% East, 24% West
Diagnosis at Enrollment: 30% mood disorders,
65% schizophrenia, 6% other, 65% co-
occurring SUD
At baseline, the 17 AOT consumers reported experiencing a variety of adverse life events prior to
enrollment, including hospitalization (13), incarceration (5), arrest (7), and homelessness (2).
AOT Investments and Costs
Given the preliminary nature of the AOT program at the end of the evaluation period, it is premature to
estimate per person service delivery costs or project potential cost savings. The County has made the
following investments with AOT implementation:
MHS Costs
Cost Type Oct-June 2016
Start-up Costs $242,832 (Oct ’15 - Jan ’16)
Service Delivery
Costs
$661,660 (Feb ’16 - Jun ‘16)
Total $904,492 (Oct ’15 - Jun ’16)
Contra Costa County Department Costs
County Department Feb-July 2016
CCBHS $262,500
County Counsel $22,733
Public Defender’s Office $66,750
Superior Court $64,000
Recommendations
Following the interim six-month evaluation of the new AOT program in Contra Costa County, RDA makes
the following recommendations:
AOT Referrals Increase outreach and education to qualified requestors, including
professional staff (e.g. LEAs and mental health providers)
Monitor “ineligible” consumers for a period of time to determine if re-
referral to AOT is needed
Investigations and
Outreach
Utilize all ACT team members to provide outreach and engagement
Strengthen communication practices during the transition between the
investigation and outreach and engagement phases
AOT Consumers and
Service Participation
There may be a high proportion of AOT consumers who have forensic
needs or are connected with the criminal justice system. MHS should
consider training in forensic ACT and forensic mental health interventions.
ACT Fidelity
The MHS ACTiOn Team received an
overall fidelity score of 4.73, indicating
a high level of fidelity to the ACT Model.
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Data Capacity CCBHS: Track investigation information electronically so that the data is
available for each evaluation period and the County can learn more about
who is and is not referred to MHS for AOT enrollment.
MHS: Consistently input PAT, KET, and 3M data in the County’s DCR
system.
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Introduction
In 2004, stakeholders throughout the mental health system in California joined together in support of
Proposition 63, the Mental Health Services Act (MHSA). The MHSA was intended to “expand and
transform” the public mental health system according to the following principles of 1) Recovery, Wellness,
and Resiliency, 2) Consumer and Family Driven, 3) Community Collaboration, 4) Cultural Competency, and
5) Integrated Services.
MHSA provided an infusion of funds for Full Service Partnership (FSP) programs, among others, to provide
services using a “whatever it takes” model for people with serious mental illness. However, the
implementation of MHSA did not sufficiently address one of the largest issues facing the mental health
community across the nation: the cycle of repetitive psychiatric crises and resulting hospitalizations,
incarcerations, and homelessness of the most seriously mentally ill who struggle to engage in services.
As California counties began recognizing these limitations of the MHSA, some counties began choosing to
implement California Assembly Bill 1421 (AB 1421). Passed in 2002, AB 1421 (also known as “Laura’s Law”)
authorized the provision of Assisted Outpatient Treatment (AOT) in counties that adopt a resolution to
implement AOT. AOT is designed to interrupt the repetitive cycle of hospitalization, incarceration, and
homelessness for people with serious mental illness who have been unable and/or unwilling to engage in
voluntary services through an expanded referral and outreach process which may include civil court
involvement, whereby a judge may order participation in outpatient treatment. The Welfare and
Institutions Code defines the target population, intended goals, and the specific suite of services required
to be available for AOT consumers in California.
AOT in Contra Costa County
On February 3, 2015, the Contra Costa County Board of Supervisors adopted a resolution to authorize the
implementation of AOT in accordance with the Welfare and Institutions Code, Sections 5345-5349.5. On
February 1, 2016, Contra Costa County’s AOT program became operational. In March 2016, the County
accepted their first consumer into AOT. Contra Costa County provides behavioral health services to AOT
consumers through an Assertive Community Treatment (ACT) team operated by Mental Health Systems
(MHS), a contracted provider organization. ACT is an evidence-based behavioral health program for
people with serious mental illness who are at-risk of or would otherwise be served in institutional settings
or experience homelessness. ACT has the strongest evidence base of any mental health practice for people
with serious mental illness and, when implemented to fidelity, ACT produces reliable results for
consumers, including decreased negative outcomes, such as hospitalization, incarceration, and
homelessness and improved psychosocial outcomes, such as improved life skills and increased
involvement in meaningful activities.
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It is important to note that in adopting a resolution to implement AOT, Contra Costa County not only
adopted a new legal mechanism to connect individuals with serious mental illness to mental health
services, they also contracted a new service provider, MHS, to implement the County’s first ACT program
in order to ensure they are providing the highest quality of care for individuals enrolled in AOT. Because
there are a number of new components coming together at once, it is natural to expect programmatic
modifications to be implemented over the course of the evaluation period (February 2016 - July 2016),
and beyond.
Contra Costa County’s AOT Program Model
Contra Costa County has designed an AOT program model that exceeds the requirements set forth in the
legislation and responds to the needs of its communities. The Contra Costa County AOT program includes
a Care Team comprised of CCBHS and MHS staff, including a County clinician, family advocate, and peer
counselor, as well as an ACT team operated by MHS.
The first stage of engagement with Contra Costa County’s AOT program is through a telephone referral
whereby any “qualified requestor”1 can make an AOT referral. Within five business days, a CCBHS mental
health clinician connects with the requester to gather additional information on the referral, as well as
reach-out to the individual referred to begin to identify whether he/she meets AOT eligibility criteria (see
Appendix I. AOT Eligibility Requirements).
If the person appears to initially meet eligibility criteria, a CCBHS investigation from the Care Team staff
facilitates a face-to-face meeting with the family and/or consumer to gather information, attempt to
engage the consumer, and develops an initial care plan. If the consumer continues to appear to meet
eligibility criteria, the Care Team provides a period of outreach and engagement while furthering the
investigation to determine eligibility. If at any time the consumer accepts voluntary services and continues
to meet eligibility criteria, he/she is immediately connected to and enrolled in ACT services.
However, if after a period of outreach and engagement, the consumer does not accept voluntary services
and continues to meet criteria, the County mental health director or designee may choose to file a petition
with the court. Utilizing a collaborative court model that combines judicial supervision with community
mental health treatment and other support services, Contra Costa County then holds 1-2 court hearings
to determine if criteria for AOT are met. At this time, the individual may enter into a voluntary settlement
agreement to receive ACT services, or be ordered to AOT for a period of no longer than six months. After
six months, if the judge deems that the person continues to meet AOT criteria, they may authorize an
additional six-month period. At every stage of the process, CCBHS and MHS staff continue to offer the
individual opportunities to voluntary engage in services and may recommend a 72-hour hold, at any stage
of the process, if they meet existing involuntary criteria. Figure 2 depicts this process.
1 Qualified requestors include: An adult who lives with the individual; Parent, spouse, adult sibling, or adult child of
the individual; Director of an institution or facility where the individual resides; Director of the hospital where the
person is hospitalized; Treating or supervising mental health provider; Probation, parole, or peace officer.
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Figure 2. Contra Costa County AOT Client Engagement Process Flowchart
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AOT Evaluation
The AOT program in Contra Costa County presents three main areas of interest to both the program’s
implementation as well as its evaluation. The issues include:
1. There is little evidence that indicates who may be best served in a voluntary program and who
may be most likely to require and subsequently benefit from AOT services.
2. In order to determine how to best target outreach efforts, it is necessary to understand how
people with serious mental illness become engaged in outpatient mental health services,
particularly the AOT program.
3. As consumers receive Contra Costa County’s AOT services, understanding the factors that affect
their service participation, retention, and outcomes, specifically as it pertains to the AOT
intervention, will allow Contra Costa County to best identify individuals with serious mental illness
who are most likely to benefit from AOT.
In order to assess these issues, CCBHS contracted with Resource Development Associates (RDA) to provide
external evaluation services to better understand the role of ACT and AOT in Contra Costa County’s system
of care, as well as to inform the required annual report to DHCS. This initial report addresses the following
evaluation research questions:
1. How faithful are Contra Costa County’s ACT services to the ACT model?
2. What are preliminary outcomes for the people who participate in AOT, including the DHCS-
required reporting outcomes?
This report is intended to provide information to the Board of Supervisors, Contra Costa Behavioral Health
Services, stakeholders, and the public about how AOT implementation is progressing, with special
attention paid to the referral and outreach and engagement process, as well as preliminary findings as
they relate to consumers enrolled in AOT. Each section begins with a short list of highlighted key findings
for quick reference. Future reports will include comparisons of consumers who participate in AOT with
and without court involvement, as well as comparisons of consumers who engage in existing FSP services
and those who participate in AOT without court involvement.
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Methodology
ACT Fidelity Assessment
The intention of the fidelity assessment process is to measure the extent to which MHS’ ACT team is in
alignment with the ACT model and identify opportunities to strengthen ACT/AOT services. For this
component of the evaluation, RDA applied the ACT Fidelity Scale, developed at Dartmouth University2
and codified in a SAMHSA toolkit.3 This established assessment process sets forth a set of data collection
activities and scoring process in order to determine a fidelity rating as well as qualifications of assessors.
The fidelity assessment began with a series of project launch activities. This included:
1. Project launch call with CCBHS to confirm desired outcomes for the fidelity assessment and
identify contact persons for each of the activities.
2. Project launch call with CCBHS and MHS to introduce the fidelity assessment and desired
outcomes, describe the assessment process, and confirm logistics for the assessment site visit.
3. Data request to CCBHS and MHS in advance of the site visit to obtain descriptive data about
consumers enrolled in ACT since program inception.
The assessors conducted a full-day site visit at MHS’ ACT team office in Concord, CA on August 26, 2016.
During the site visit, the assessors engaged in the following activities:
ACT program meeting observation
Interviews with eight (8) ACT team members including the Team Leader, Clinical Director,
Clinician, Nurse, Family and Peer Partners, and Housing and Vocational Specialists.
Review of available documentation
Consumer focus group (11 of 17 enrolled consumers in attendance)
Family member focus group (13 family members of 9 enrolled consumers in attendance)
Debrief with the Team Leader and Clinical Director
Concurrently, RDA obtained data from CCBHS and MHS and conducted descriptive analyses of the
demographics and service utilization patterns of consumers enrolled in ACT.
Following the site visit and data analysis, the assessors each independently completed the fidelity rating
scale and then met to seek consensus on each individual rating as well as identify recommendations to
strengthen MHS’ ACT program fidelity rating. The results of that discussion and the fidelity assessment
are presented in the proceeding Results and Discussion sections.
2 http://www.dartmouth.edu/~implementation/page15/page4/files/dacts_protocol_1-16-03.pdf
3 Substance Abuse and Mental Health Services Administration. Assertive Community Treatment: Evaluating Your Program. DHHS
Pub. No. SMA-08-4344, Rockville, MD: Center for Mental Health Services Administration, U.S Department of Health and Human
Services, 2008.
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AOT Program Evaluation
RDA worked with CCBHS and MHS staff to obtain the data necessary for addressing the second research
question about AOT consumers’ outcomes since the program’s implementation, from February 1, 2016
through July 31, 2016. Table 1 below presents the data sources utilized for this evaluation, as well as the
data elements captured by each data source, and the questionnaires and/or forms that were used to
measure each data element. Appendix II. Description of Evaluation Data Sources provides a description of
each data source.
Table 1. Data Sources and Elements
Data Source Data elements Questionnaires/Forms
CCC Referral Log AOT Referrals
Demographics
Referral Log
CCC Blue Notes Outreach and Engagement
Encounters
Blue Notes for each Outreach and
Engagement Encounter
CCC PSP Billing System Behavioral Health services
Hospitalizations
Diagnoses
Service Claims
MHS Outreach and
Engagement Log
Outreach and Engagement
Encounters
Outreach and Engagement Log
Data Collection &
Reporting (DCR) Files
Arrests
Incarceration
Homelessness
Employment
Partnership Assessment Form
(PAF)
Key Event Tracking Form (KET)
Quarterly Assessment (3M)
MHS Outcomes
Spreadsheet
Social Functioning
Independent Living
Violent Behavior
Victimization
Recovery
High Risk Assessment (HRA)
Brief Psychiatric Rating Scale
(BPRS)
Self Sufficiency Matrix (SSM)
CCBHS Financial Data Costs associated with AOT CCBHS Expenditures to MHS
Staffing Expenditures: County
Counsel, Public Defender’s Office,
and Civil Court
Data Analysis
RDA worked closely with CCBHS and MHS staff throughout the data collection and analysis processes.
Upon receiving each data set, RDA performed a review of its contents and collaborated with CCBHS and
MHS staff to ensure the evaluation team understood each data element and could seek additional data
as needed.
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Given that data for this evaluation came from multiple sources, RDA first ensured that identifying
information for consumers was consistent and could be matched across sources so that each consumer
could be tracked throughout his or her involvement in AOT. For example, data from MHS regarding
consumers’ enrollment into AOT was matched with County billing data to establish enrollment dates and
create a variable indicating whether or not County services occurred before or after AOT enrollment. RDA
consulted with CCBHS and MHS on any consumers where their timeline was unclear.
After verifying our understanding of the data with the Care Team and matching consumers across data
sources, RDA began the analysis. Throughout this process, several key analytic decisions were made:
Though some data sources provided consumer data through August, the evaluation team decided
to use July 31, 2016 as a cut-off date for data collection and analysis in order to consistently report
on all consumer outcomes. For example, episodes open beyond July 31, 2016 were given an end
date of July 31 for this interim report’s analyses.
RDA decided to categorize consumers based on their four disposition or status categories as of
July 31, 2016 (i.e., Ongoing Outreach and Engagement, Accepted ACT Services Voluntarily,
Accepted ACT Services with a Settlement Agreement, and Closed).
RDA also created several variables for analysis based on multiple data sources, which were used
to describe the average duration of time consumers spent moving through the AOT process,
depending on what month they were referred:
o Length of time (in days) from referral to first CCBHS contact
o Length of time (in days) from first CCBHS contact to last (or July 31, 2016 if investigation
still ongoing) CCBHS contact
o Length of time (in days) from first CCBHS contact to first MHS contact
o Length of time (in days) from first MHS contact to AOT enrollment
o Length of time (in days) from referral to enrollment
Given the different sample sizes in the above-mentioned four disposition groups (11, 14, 3, and
10, respectively) and variability in length of enrollment for those in AOT, findings were reported
per month and per consumer when possible. This allowed RDA to standardize results and account
for differences in sample size and length of enrollment.
For this report, RDA used self-reported data for all outcomes except hospitalization and billable
services. The majority of this data captured consumers’ experiences for 12 months prior to their
enrollment in AOT; however, RDA was able to use three years of pre-data for hospitalizations and
other billable CCBHS services. RDA chose to use all years of available PSP billing data, standardized
by month, when reporting on hospitalization costs and the consumer profile, but used only the
year prior to enrollment when reporting on pre-AOT hospitalizations in the “AOT Consumer
Outcomes” section.
RDA chose not to report on any data at an individual level in order to ensure confidentiality.
For all analyses in this report, RDA used descriptive statistics (e.g., frequencies, mean, median, and mode)
to describe the data in meaningful ways. In future reports with larger sample sizes and longer enrollment
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periods for consumers, RDA will look to employ both descriptive and inferential statistics to answer the
evaluation’s research questions.
Limitations
As is the case with all real-world evaluations, there are limitations to consider. One major limitation is the
preliminary nature of this evaluation. Given that the County’s AOT program became operational on
February 1, 2016, and that the County embarked on implementing its first ACT program with a new service
provider at this time, there are natural programmatic developments and modifications that took place
over the course of the evaluation period. It is important to note that program modifications are to be
expected, and results should be interpreted cautiously until the County’s AOT program has become more
firmly established.
It is also important to note that from February 1, 2016 - July 31, 2016 Contra Costa County’s AOT program
enrolled only 17 AOT consumers, six of which enrolled in June or July. Moreover, AOT consumers had only
spent, on average, 77 days enrolled in the AOT program, with participation ranging from two weeks to
five months through July 31, 2016. Because relatively few individuals enrolled in AOT during the
evaluation period, and they only spent, on average, short periods in AOT, this report does not assess
changes in DHCS outcomes, including costs, pre- and post-AOT enrollment. Instead pre-AOT criminal
justice involvement and histories of hospitalization and homelessness are reported, while baseline
psychosocial assessment data from MHS are reported. Future reports will analyze changes over time as
greater numbers of AOT participants have been enrolled for longer periods of time.
For this report, RDA also relied on AOT consumer self-reported measures of criminal justice involvement
to identify pre-AOT criminal justice involvement. While self-report measures may serve as an accurate
proxy, they are not ideal measures and limit the precision of the analyses. In order to produce more robust
analyses for future reports, RDA has established agreements with the Superior Court and Sheriff’s Office
to collect arrest and sentencing data to measure criminal justice involvement pre- and post-AOT
enrollment.
MHS has been operational for a short time period and thus there is a relatively small number of AOT
consumers enrolled in the program. In order to the average monthly cost of providing MHS services for
AOT consumers, RDA utilized the most recent month’s (June 2016) financial data from MHS. While this
measure is not ideal, RDA made the assumption that the costs incurred during the most recent month of
AOT implementation would be the most reflective of the current costs. Once the program has matured
and greater number of consumers are enrolled, RDA will be able to calculate a more usable average
monthly MHS costs.
A final limitation is the County’s data capacity for tracking AOT services. CCBHS has no electronic records
of their investigation process; instead, all of this information exists in hard copy, hand-written notes. RDA
spent one day working with CCBHS staff to collect pertinent information on all individuals eventually
referred to MHS; moving forward, in order to better describe and compare the consumer profiles of those
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who are and are not referred to MHS for AOT enrollment, it is imperative that CCBHS begin to transfer
data from field notes into an electronic platform.
MHS also has data limitations, as large numbers of PAF, KET, and 3M data were not available via the
County’s DCR data system. It appears that PAF data is only available for consumers’ first assessment, so if
AOT consumers have already had assessments entered into the system there was no way to retrieve this
data. Moreover, large numbers of KET and 3M data were missing from the DCR. As a result, RDA staff
spent one day working with MHS to transfer hard copies of PAF, KET, and 3M assessments into Excel
spreadsheets for evaluation. Moving forward, RDA will work with MHS to streamline this process.
Despite these limitations, the following evaluation will help CCBHS and MHS better understand how AOT
implementation is progressing, as well as some of the individual, program, and systems-level processes
that have resulted from the implementation of AOT. This evaluation will help CCBHS and MHS develop
program improvements, and also help the County begin to answer critical questions that will assist them
as they continue to improve their capacity to meet the needs of those with the most serious mental
illnesses. This evaluation would not be able to answer such questions if AOT implementation took place
under the constraints of a randomized control trial.
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Results
RDA’s evaluation of Contra Costa County’s AOT program is structured to explore specific research
questions. This initial report addresses the following to evaluation research questions:
1. How faithful are Contra Costa County’s ACT services to the ACT model?
2. What are the outcomes for the people who participate in AOT, including the DHCS-required
reporting outcomes?
In this Results section, RDA first presents its findings addressing the first research question of assessing
Contra Costa County’s implementation fidelity of ACT services. Following the presentation of RDA’s ACT
Fidelity Assessment findings, RDA then presents its findings of outcomes exhibited and experienced by
AOT participants, broken down by pre- and post-AOT enrollment related outcomes.
ACT Fidelity
The ACT program was rated on the three domains set forth in the ACT Fidelity Scale, including:
Human Resources: Structure and Composition
Organizational Boundaries
Nature of Services
Each domain has specific criterion rated on a five-point Likert scale with clearly defined descriptions for
each rating. The following chart provides an overview of the domains, criterion, and ACTiOn Team’s
program rating. As shown in the table below, the ACTiOn Team received an overall fidelity score of 4.73
indicating a high level of fidelity to the ACT Model. The proceeding section provides descriptions,
justifications, and data sources for each criterion and rating.
Table 2. ACT Fidelity Assessment Scores
Domain Criterion Rating
Human Resources: Structure
and Composition
Small caseload 5
Team approach 5
Program meeting 5
Practicing ACT leader 4
Continuity of staffing 4
Staff capacity 5
Psychiatrist on team 5
Nurse on team 5
Substance abuse specialist on team 5
Vocational specialist on team 5
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Domain Criterion Rating
Program size 5
Organizational Boundaries
Explicit admission criteria 3
Intake rate 5
Full responsibility for treatment services 5
Responsibility for crisis services 5
Responsibility for hospital admissions N/A
Responsibility for hospital discharge planning N/A
Time-unlimited services 5
Nature of Services
In vivo services 3
No drop-out policy 5
Assertive engagement mechanisms 5
Intensity of services 5
Frequency of contact 4
Work with support system 5
Individualized substance abuse treatment 5
Co-occurring disorder treatment groups 5
Co-occurring disorders model 5
Role of consumers on treatment team 5
ACT Fidelity Score 4.73
Human Resources: Structure and Composition
Small caseload refers to the consumer-to-provider ratio, which is 10:1 for ACT programs. MHS’ ACTiOn
Team received a rating of 5 for this criterion as they have 11.5 FTEs who provide direct services, as well
as 2 administrative staff, for 17 consumers and clearly exceeds the 10:1 ratio. This was assessed through
personnel records and staff interviews.
Team approach refers to the provider group functioning as a team rather than as individual team members
with all ACT team members knowing and working with all consumers. MHS’ ACTiOn Team received a rating
of 5 for this criterion as more than 90% of consumers had face-to-face interactions with more than one
team member in a two-week period. This was assessed through consumer records and further supported
through the morning meeting observation, staff interviews, and consumer and family focus groups.
The Program meeting item measures the frequency with which the ACTiOn team meets to plan and review
services for each consumer. MHS’ ACTiOn Team received a rating of 5 for this criterion as they team meets
at least four times per week and reviews every consumer in each meeting. Assessors observed the
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program meeting during the site visit and observed the team discussion for every consumer as well as
confirmed the frequency of program meeting through available documentation and staff interviews.
Practicing ACT leader refers to the supervisor of frontline staff providing direct service to consumers. Full
fidelity requires that the supervisor provide direct service at least 50% of the time. MHS’ ACTiOn Team
received a rating of 4 because the Team Leader provides direct services about 40% of the time. These
direct services include both formal and informal interactions and may or may not include formal progress
notes. As such, this rating is solely based on staff interviews.
Continuity of staffing measures the program’s level of staff retention. Full fidelity requires less than 20%
turnover within a two-year period, which was adjusted to a 6-month period for MHS’ ACTiOn Team as per
the Dartmouth protocol for evaluating new programs. During the evaluation period, there were four of
20 staff who discontinued employment with MHS’ ACTiOn Team, which is a 20% turnover rate for the first
six months of program operation. This results in a rating of 4 based on the scoring rubric and was assessed
through a review of personnel records and staff interviews.
Staff capacity refers to the ACT program operating at full staff capacity. According to personnel records,
the MHS’ ACTiOn Team has operated at or above full staffing capacity 100% of the time, which exceeds
the 95% benchmark set forth in the scoring rubric.
Fidelity to the ACT model requires 1.0 FTE psychiatrist per 100 consumers. For 17 consumers, the ACT
team would require a 0.17 FTE psychiatrist. Currently, MHS’ ACTiOn Team provides 0.5 FTE psychiatrist,
as reported by staff and personnel records. This results in a rating of 5. Once the program is at full capacity
of 75 enrolled consumers, the team will require a .75 FTE psychiatrist to meet full fidelity to the ACT
model.
The ACT model requires a 1.0 FTE nurse per 100 consumers. Currently, MHS’ ACTiOn Team employs two
full-time nurses, including a registered nurse and licensed vocational nurse, as observed by personnel
records and staff interviews. This exceeds the required ratio and results in a rating of 5.
The ACT model includes a substance abuse specialist position on the ACT team. Currently, MHS’ ACTiOn
Team employs a 1.0 FTE dual recovery specialist as well as a family partner who is a Certified Drug and
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Alcohol Counselor (CADC), as observed by personnel records and staff interviews. This exceeds the
required ratio and results in a rating of 5.
The ACT model includes a vocational specialist position on the ACT team. Currently, MHS’ ACTiOn Team
employs a 1.0 FTE vocational rehabilitation specialist, as observed by personnel records and staff
interviews. This exceeds the required ratio and results in a rating of 5. When at full capacity, the program
will need to ensure that there are 1.5 FTE with the requisite experience in vocational rehabilitation.
Program size refers to the size of the staffing to provide necessary staffing diversity and coverage. MHS’
ACTiOn Team exceeds the staffing ratio, as observed by personnel records and staff interview. This results
in a rating of 5.
Organizational Boundaries
Explicit admission criteria refer to: 1) measureable and operationally defined criteria to determine referral
eligibility, and 2) ability to make independent admission decisions based on explicitly defined criteria.
MHS’ ACTiOn Team, in partnership with CCBHS, has explicit admission criteria for enrollment into ACT.
However, the responsibility for actively identifying and engaging potential ACT consumers lies primarily
with CCBHS as a part of the larger Assisted Outpatient Treatment program. The measureable and
operationally defined criteria clearly meets ACT fidelity while the decision-making authority is not in
alignment with the model. This is not to suggest that a partnership between CCBHS and MHS could not
meet fidelity but more that the partnership must involve both parties working together to determine and
confirm eligibility. For this reason, MHS’ ACTiOn Team received a score of 3, which is the average of a 5
for the clearly defined criteria and a 1 because they take all cases as determined outside of the program.
Intake rate refers to the rate at which consumers are accepted into the program to maintain a stable
service environment. In the past six months, there have been no more than six consumers admitted in
any given month resulting in a rating of 5. This was observed through a review of consumer records.
MHS’ Action Team admitted new clients from March to July for the reporting period. There were no
intakes in the months of January and February. For the five months that the team conducted intakes, they
averaged 3.4 clients per month. The most intakes they had in month was four in March, June, and July
and the lowest intakes was two in the month of April.
Table 3. Action Team Monthly Intake January 2016 to July 2016
Month of Intake Total Intakes
March 4
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Month of Intake Total Intakes
April 2
May 3
June 4
July 4
Total Intakes 17
Monthly Average 3.4
In order to implement ACT with fidelity, a provider should have a monthly intake rate of six or lower. The
Action Team’s highest monthly intake was four and receive a score of 5
for this item.
Fidelity to the ACT model requires that ACT programs not only provide case management services but also
provide psychiatric services, counseling/psychotherapy, housing support, substance abuse treatment, and
employment and rehabilitative services. Currently, MHS’ ACTiOn Team provides the full range of services,
including psychiatric services, counseling/psychotherapy, housing support, substance abuse treatment,
and employment and rehabilitative services. This was observed through program meeting observation,
staff interview, a review of consumer personnel records, and input from a consumer focus group and
results in a rating of 5.
The ACT model includes a 24-hour responsibility for covering psychiatric crises. MHS’ ACTiOn Team
provides 24-hour coverage through a rotating on-call system that is shared by all program staff, with the
exception of administrative staff. The Team Leader and Program Supervisor provide back-up coverage and
support. This was observed through program meeting observation and staff interview as well as a review
of personnel records and results in a rating of 5.
The ACT model includes the ACT program participating in decision-making for psychiatric hospitalization.
Currently, MHS’ ACTiOn Team is willing and available to participate in all decisions to hospitalize ACT
consumers. During the initial six-month period, there were no inpatient psychiatric hospitalizations. It is
important to note that some consumers were hospitalized at the time of referral and/or enrollment into
the program, and those hospitalizations were not considered in this ACT Fidelity Assessment criterion as
the decision to hospitalize occurred either before or as a part of the enrollment process. Some consumers
did access other crisis services post ACT-enrollment, including Psychiatric Emergency Services and Crisis
Residential Treatment, but none were actually hospitalized following enrollment. As such, this criterion
was not scored and removed from the overall fidelity score.
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The ACT model includes the ACT program participating in hospital discharge planning. Currently, MHS’
ACTiOn Team is willing and available to participate in all decisions to hospitalize ACT consumers. During
the initial six-month period, there were no inpatient psychiatric hospitalizations. It is important to note
that some consumers were hospitalized at the time of referral and/or enrollment into the program, and
those hospitalizations were not considered in this criterion as the hospitalization occurred either before
or as a part of the enrollment process. Some consumers did access other crisis services post ACT-
enrollment, including Psychiatric Emergency Services and Crisis Residential Treatment, but none were
actually hospitalized following enrollment. As such, this criterion was not scored and removed from the
overall fidelity score.
The ACT model is designed to be time-unlimited with the expectation that less than 5% of consumers
graduate annually. MHS’ ACTiOn Team did not graduate any consumers during the assessment period,
although any consumer who moved out of the area was removed from the analysis for this criterion. This
was determined through consumer records, staff interview, and via input from family members.
Nature of Services
ACT services are designed to be provided in the community, rather than in an office environment. The
Community-based services item measures the number of MHS’ ACTiOn Team contacts in a client’s natural
settings which refers to location where clients live, work, and interact with other people. To calculate this
measure, we randomly selected 10 of the 17 ACT clients and counted the total number of community
based encounters for each client from January 1, 2016 to July 31, 2016. We calculated a ratio of
community based encounters to the total number of encounters for each client. We then ranked the ten
ratios and determined the median value to score this measure. For this time period, 53% of all encounters
between the Action Team and Clients occurred in the Community-based settings. As this percentage falls
between the range of 40% to 59%, the score for this measure is 3.
This criterion refers to the retention rate of consumers in the ACT program. According to consumer
records and staff report, no consumer dropped out of MHS’ ACTiOn Team in the past 12 months. Any
consumer who moved out of the area was removed from the analysis for this criterion, and this was
determined through consumer records, staff interview, and via input from family members.
As part of ensuring engagement, the ACT model includes using street outreach and legal mechanisms as
indicated and available to the ACT team. The ACT team includes a subsection of consumers who are
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enrolled in Assisted Outpatient Treatment via agreement with the court, a legal mechanism for supporting
engagement, as well as a variety of outreach mechanisms to engage consumers. During the program
meeting observation and staff interviews, team members discussed places where they regularly frequent
to locate and interact with consumers. This results in a rating of 5.
Intensity of services is defined by the face-to-face time service time MHS’ ACTiOn Team staff spend with
clients. Fidelity to the ACT model requires that consumers receive an average of two hours per week of
face-to-face contact. We measured intensity of services by analyzing data from the most recent and up to
date time period, which was July 2016. Following ACT Assessment protocols, we calculated the weekly
mean values of encounter time (converted from minutes to hours) between MHS’ ACTiOn Team staff and
clients over a four-week period. From the mean values over the four-week period we determined the
median number of services hours. We excluded phone contacts and collateral contacts.
For the month of July, 17 ACT clients received a total of 362.7 hours of face-to-face services. The intensity
of service rate was 5.4 hours of services per week per client. In order to be in alignment with the ACT
model, providers are expected to provide more than two hours of services per week. Since the MHS’
ACTiOn Team well exceeds that level, they receive a score of 5.
Across individual clients, we noted some variability in the intensity of services for the month. The range
of intensity was relatively large; from a minimum value of 5.2 hours to 50.7 hours with the median being
17.7. Similarly, when ranking clients in quartiles, as depicted in Table 4, the top quartile of four clients
accounts for 164 hours, or forty-eight percent (45%) of all hours (n = 341) for that month. Similarly, the
second quartile of five clients accounts for 104 hours or 30% of service hours in July. If the first and second
quartiles are combined, nine clients account for 267 or seventy-eight percent (78%) of logged service
hours in July. The remaining eight clients in the third and fourth quartiles account for only a total of 74
services hours or twenty-two percent of services hours.
Table 4. Quartile Ranking of Service Hours Received for July 2016
Quartile Range of Hours # of Clients Total Hours Percent of Total (n = 341)
Quartile 1 51– 27 4 163.8 48%
Quartile 2 26 – 17 5 103.6 30%
Quartile 3 16 – 10 4 52.2 15%
Quartile 4 9 – 0 4 21.8 6%
This variability indicates that while nearly all clients are receiving the appropriate intensity of services, a
small portion of clients receive services at much higher rate of intensity than the rest. Currently, with the
smaller pool of clients, this does not appear to impact MHS’ ACTiOn Team’s capacity to provide services
at a rate that is in alignment with the ACT model. However, as MHS’ ACTiOn Team expands the number
of clients they serve, continuing this trend will likely cause inconsistencies in service delivery across clients
and may result in decreased fidelity to the model.
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Fidelity to the ACT model requires that ACT consumers have an average of at least four (4) face-to-face
contacts per week. We measured frequency of contact by analyzing at data from the most recent and up
to date time period, which was July 2016. Following ACT Assessment protocols, we calculated the mean
values over a four-week period of face-to-face contacts between ACT team member and ACT clients. From
the mean values over the four-week period, we determined the median number of services hours. We
excluded phone contacts and collateral contacts. For the month of July, MHS’ ACTiOn Team conducted a
total of 223 face-to-face contacts with 16 clients. Using the ACT assessment methodology, the frequency
of contact rate was 3.8 face-to-face contacts per week with the Action Team. In order to be in full
alignment with the ACT model, providers must have an average of four contacts per week. As the average
is slightly lower than 4, the ACTiOn team receives a score of 4.
Table 5. Action Team Face-to-face Contacts with Clients by Week for July 2016
Week Weekly Total Contact Weekly Average Contacts
Week 1 (July 1 – 7) 37 2.6
Week 2 (July 8 - 15 64 4.5
Week 3 (July 16- 23) 62 3.9
Week 4 (July 24 – 31) 60 3.7
Looking at face-to-face contacts per client for the entire month, we also noted a large range in face-to-
face contacts. The lowest number of contacts for the month was five while the max number of contacts
was 28 with the median value being 13. Similarly, as depicted in Table 5, there is some variation in the
total number of contact by from Week One to the other three weeks in the month.
The ACT model includes support and skill-building for the consumer’s support network, including family,
landlords, and employers. This criterion measures the extent to which MHS’ ACTiOn Team provides
support and skill-building for the client’s informal support network as a way to further enhance the client’s
integration and functioning. Per the ACT Fidelity Assessment methodology, we identified a subgroup of
11 clients with collateral contacts from January 1, 2016 to July 31, 2016 and calculated the average rate
of contact for this for the subgroup. We then calculated the rate of contact for the entire caseload of 17
clients. The rate of collateral contact for the Action Team for this time period is 4.8 contacts per month
per client. In order to be in full alignment with the model, ACT providers must have 4 or more collateral
contacts per client, per month. As the Action Team’s rate of contact is higher than four, they receive of
score of 5.
When looking at the contact data of clients with collateral contacts, we noticed that there is a wide range
in the number of contacts for each client. Most clients were in a range of 1 to 6 contacts per client, while
one client had 50 contacts. It is important to note, that this individual does skew the rate of contact to
increase substantially. If we exclude this individual from the calculation, the rate of collateral contact
drops from 4.8 to 2 while the median value drops to 3.5.
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The ACT model is based on an interdisciplinary team that provides all of the services a consumer may need
to support their recovery and address their psychosocial needs, including individualized substance abuse
treatment. MHS’ ACTiOn Team provides individualized substance abuse services via the dual recovery
specialist, family partner, and other clinical staff. This was observed through a review of personnel and
consumer records, staff interview, and consumer focus groups and results in a rating of 5.
The ACT model is based on an interdisciplinary team that provides all of the services a consumer may need
to support their recovery and address their psychosocial needs, including co-occurring disorder treatment
groups. MHS’ ACTiOn Team provides co-occurring disorder groups led by the dual recovery specialist,
family partner, and other clinical staff. This was observed through a review of personnel and consumer
records, staff interview, and consumer focus groups and results in a rating of 5.
The ACT model is based on a non-confrontational, stage-wise treatment model that considers the
interactions between mental illness and substance use and has gradual expectations of abstinence. The
assessors were impressed with the implementation of motivational interviewing and stages of change
principles throughout the program meeting and staff interviews and found that MHS’ ACTiOn Team clearly
meets and exceeds the treatment philosophy set forth in the ACT model. This results in a rating of 5.
The ACT model includes the integration of consumers as full-fledged ACT team members, usually in the
provision of peer support and/or peer counseling. MHS’ ACTiOn Team does include consumer
membership as a part of the ACT team staffing. This was observed through a review of personnel records,
team meeting observation, and staff interview and results in a rating of 5.
Other Feedback
ACT consumers and family members were generally appreciative of the ACT program and believed that
participating in ACT had been beneficial. Program strengths included:
Partnership and Responsivity: Consumers commented on the unique qualities of the ACT
program with respect to feeling like a partner and participating in shared decision making with
the team to determine recovery goals and strategies. They specifically highlighted the psychiatrist
as someone who cares about their opinions, asks for their feedback, and considers their
experiences in making medication decisions. One participant also acknowledged that the team
nurse has been willing to administer injections at her home to help her feel more comfortable
because she is afraid of needles. Consumers also acknowledged how responsive staff are.
Consumers shared, “I get assistance right away,” and “you can explain your need and someone
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will come find you.” Another consumer stated, “Someone is always within your reach. Telephone,
stop by, or they come find you.”
Professionalism: Consumers discussed the professionalism of the ACT team and staff. Consumers
specifically mentioned their consistency in returning phone calls and clear communication as well
as the staff training in supporting individuals when in crisis to deescalate the situation and avoid
interaction with the police and/or hospital.
Inclusive approach to services: Participants highlighted that the ACT team is responsive to a
variety of support needs, including:
o Coordinating, reminding, and providing transportation to attend appointments, including
doctor and psychiatry appointments
o Support with medications, specifically injections and delivering prescriptions
o Helping navigate the legal system, either the court component of AOT or because of previous
victimization
o Activity-based and recovery-oriented groups, including the fitness class
Discussion participants also provided suggestions for improving the program, including:
Meaningful Activities: Consumers and family members shared that despite the frequent contact
with members of MHS’ ACTiOn Team, people still have a fair amount of free time. Both consumers
and family members suggested that activity-based groups may be helpful to support consumers
with their recovery goals. Suggestions included more game nights, art groups, barbeques, trips to
the library or other community locales, and volunteering at the local animal shelter.
Family Component: While family members and consumers alike discussed how the program is
supporting them to rebuild relationships, family members also discussed how difficult it can be to
support their loved ones and that it would be useful to have a family support group for ACT family
members as a part of the program. This group could provide support to family members as well
as provide psychoeducation to build additional skills to support their loved one. The assessors
recommend, in addition to a family support group, a multi-family group whereby ACT consumers
and their family members attend a group and participate in recovery-oriented activities together.
Multi-family groups are an evidence based practice and support improved communication within
a family unit as well as develop shared goals and tools to support recovery, provide additional
opportunities for consumers and family members to build positive experiences as the consumer
stabilizes, and encourage community amongst consumer and family members.
Housing and Supervision: While many consumers and family members appreciated that they
received housing as a part of enrolling in MHS’ ACTiOn Team, family members cited both the lack
of available housing in the County, the lack of a diversity of housing options, and supervision
concerns. While there were no ready solutions, some family members wished that there was a
higher degree of supervision within the housing placements for their loved ones as well as more
housing choices.
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Pre-AOT Enrollment Outcomes
As noted above, CCBHS and MHS conduct an extensive set of activities from the time of referral to
enrollment (refer to Figure 2 above for a visual representation of Contra Costa County’s AOT process).
Findings regarding the intended program model indicate that in practice this process has occurred in two
consecutive steps, with some overlap. Given that in adopting AOT the County also implemented its first
ACT program while working with a new service provider (MHS), it is natural for program modifications to
occur. Currently, CCBHS staff conducts investigations to determine whether individuals referred to AOT
meet eligibility criteria. Then, if an individual does meet eligibility criteria, the CCBHS staff in charge of the
investigation connects MHS with the consumer to enroll them in AOT, either voluntarily or with court
involvement. Given the modification to the AOT program implementation, RDA reports separate findings
for CCBHS investigation and MHS outreach and engagement.
Referral for AOT
As previously described, qualified requestors refer individuals who appear to meet AOT eligibility criteria
by calling the County’s AOT referral line. CCBHS staff determine the status of the qualified requestor prior
to beginning their investigation of the referred consumer. CCBHS received 108 total referrals during the
evaluation period. Of these 108 referrals for AOT, 105 were for unique individuals.4 Seven of the 108 total
referrals were from unqualified requestors or requestors labeled as “other.” The majority of unqualified
requestors were individuals referring themselves for AOT.
Table 6 depicts the percentage of referrals by each category of qualified requestor. The majority of
qualified requestors who referred consumers to CCBHS for investigation were family members or
housemates of consumers, which suggests that the implementation of AOT in Contra Costa County
provides an opportunity for non-professionals to refer their loved ones for services. It also suggests that
the County may need to increase its educational efforts with law enforcement and mental health
providers to further inform them about the program and their role as qualified requestors. No referrals
were made by the Director of the institution where a referred individual resides. It is unlikely that any
4 None of the three individuals referred multiple times met AOT eligibility criteria.
KEY FINDINGS
Individuals for whom AOT is appropriate are being identified for services.
Consumers’ family members, spouses, and housemates made the majority (60%) of referrals to
CCBHS, suggesting that AOT has increased the capacity of this group to seek help for their loved
ones.
There may be an opportunity for the County to increase its education and outreach to law
enforcement officials and mental health service providers to further inform them about AOT,
their role as qualified requestors, and the opportunities to refer eligible individuals for service.
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referrals would be made by this type of requestor because Contra Costa County does not have any in-
county mental health institutions. Given the large proportion of referrals from non-professionals, it is
possible that the County may need to implement more targeted recruitment of eligible consumers who
may not have loved ones advocating for them.
Table 6. Summary of Requestor Type5
Requestor Percent of Total Referrals (N = 108)
Parent, spouse, adult sibling, or adult child 58.3%
Treating or supervising mental health provider 16.7%
Probation, parole, or peace officer 14.8%
Adult who lives with individual 1.9%
Director of hospital where individual is hospitalized 1.9%
Director of institution where individual resides 0.0%
Not a qualified requestor or “other” 6.5%
Care Team
Contra Costa County’s Care Team consists of CCBHS and MHS staff. As previously described, the AOT
program is designed so that the County’s investigation and MHS’s outreach and engagement efforts occur
concurrently; however, quantitative and qualitative findings from the six-month evaluation period
indicate that program implementation has modified over time. At the conclusion of the evaluation period,
investigation efforts and outreach and engagement services were operating as a consecutive process.
Therefore, this section reports findings from the different Care Team processes separately and concludes
with findings from the time of referral to enrollment.
5 Source: CCBHS Care Team Referral Log
KEY FINDINGS
Members of the Care Team (CCBHS and MHS) are conducting many activities to connect with
consumers and their families in the community in order to get them engaged in long-term
mental health services.
In the final months of the evaluation period, investigation and outreach and engagement
efforts operated consecutively instead of concurrently.
At the conclusion of the evaluation period (July 31, 2016), eligible consumers could be
grouped into four different dispositions:
o Ongoing Outreach and Engagement (29%)
o Accepted ACT Services Voluntarily (26%)
o Accepted ACT Services with a Settlement Agreement (8%)
o Closed (26%)
57
Following referral by a qualified requestor, CCBHS staff conduct a screening of the client’s information
and face sheet. If the client appears to meet AOT eligibility criteria, CCBHS meets with the qualified
requestor. If the client continues to appear to meet eligibility criteria following a meeting with the
qualified requestor, CCBHS begins a four- to six-week investigation to determine eligibility. Investigation
consists of attempts to contact consumers via phone and in-person at various locations to determine if
referred consumers meet the criteria for AOT. Consumers’ family members are also included in this
process, when appropriate and as permitted by law.
Figure 3 depicts CCBHS’s eligibility determination for each referred consumer, by month. Individuals were
either considered eligible for AOT, ineligible, or no determination had been made at the time of the
evaluation. For the first three months of the program’s implementation, an eligibility determination was
made for all consumers. Qualitative data from focus groups with the County’s investigation team suggest
that the increase in consumers without an eligibility determination in May, June, and July may be partially
due to a program modification requiring CCBHS to sign a document verifying that a referred consumer
meets eligibility criteria before connecting them to MHS. This modification may have increased the
duration of investigation periods. Additionally, the increase in consumers without a determination in
more recent months may also be reflective of investigations that are still ongoing because consumers are
difficult to connect or with locate. Future evaluation reports capturing a greater implementation period
are expected to help explain these patterns.
Figure 3. AOT Eligibility Determinations for all Referred Consumers by Month6
During the evaluation period of February-July 2016, CCBHS’s investigation identified and connected 38
individuals to MHS for outreach and engagement services. The remaining 67 consumers who were
6 Source: CCBHS Care Team Referral Log
7
7
15
7
5
1
6
12
12
1 6
11
18
0 5 10 15 20 25 30
Feb.
March
April
May
June
July
Number of Consumers
Eligible for AOT Not Eligible for AOT No Determination
58
referred either had an unqualified requester, were considered ineligible, were unable to be located, were
connected to other services, or still have an ongoing investigation.
For the purposes of this evaluation, RDA established the following four eligibility status categories to
reflect the disposition of consumers at the conclusion of the evaluation period (July 31, 2016):
Ongoing Outreach and Engagement: Consumers connected by the County to MHS for intensive
outreach and engagement services who are still being engaged with the goal of connecting them
to long-term services
Accepted ACT Services Voluntarily: Consumers connected to MHS who enrolled in AOT and are
receiving ACT services without court involvement
Accepted ACT Services with a Settlement Agreement: Consumers connected to MHS who
needed court involvement to enroll in AOT and receive ACT services
Closed: Eligible consumers who were connected to MHS but closed in collaboration with the
County for reasons including no longer meeting eligibility requirements, revocation of referral
from the qualified requestor, or if consumers could not be located
Table 7 depicts the disposition of the 38 consumers considered eligible for AOT by CCBHS at the conclusion
of the evaluation period. As of July 31, 2016, 45% of referred consumers who were considered eligible for
AOT and connected to MHS enrolled in AOT, 29% were still receiving outreach services, and 26% were
closed to investigation and outreach and engagement.
Table 7. Status of All AOT-Eligible Consumers at Conclusion of Evaluation Period7,8
Consumer
Status
Number of
Consumers
% of Total Eligible
Consumers
Ongoing Outreach and
Engagement
11 29%
Accepted ACT Services
Voluntarily
14 37%
Accepted ACT Services with
Settlement Agreement
3 8%
Closed 10 26%
During the evaluation period, CCBHS’s investigation team made a total of 420 investigation contact
attempts with consumers who appeared to meet AOT eligibility criteria (N = 38).9 The proportion of total
investigation contacts made with each consumer group is reported in Table 8. The majority of contacts
were made with either consumers who were still receiving outreach and engagement services (32%) or
who voluntarily enrolled in AOT (31%).
7 Three individuals who were receiving outreach at the time of the evaluation have since been enrolled in AOT.
8 Sources: CCBHS Care Referral Log; MHS Outreach and Engagement Log
9 Data determining the outcome of each investigation contact is currently unavailable.
59
Table 8. Total Number of Investigation Contacts by Consumer Status
Consumer Status Number of Contact Attempts
Ongoing Outreach and Engagement 135
Accepted ACT Services Voluntarily 131
Accepted ACT Services with
Settlement Agreement
62
Closed 92
Figure 4 shows the average number of contacts per consumer by each disposition category. Though
consumers who eventually accepted ACT services with a settlement agreement received the fewest total
investigation contacts, they experienced the most contacts per consumer compared to any other group.
This likely reflects: 1) the small size of this group (n = 3), and 2) the challenges associated with finding and
engaging this group of consumers, which requires more attempts at contact to determine eligibility and
successfully connect them with MHS for outreach and engagement.
Figure 4. Average Investigation Contact Attempts per Consumer10
The median duration of time spent with all eligible consumers (N = 38) at every contact was 20 minutes.
Figure 5 shows the average duration of contacts per consumer by disposition. As with the number of
contacts per consumer (see Figure 4), CCHBS staff spent more time per contact with consumers who
eventually enrolled in AOT through a settlement agreement, likely for similar reasons.
10 Source: CCCBHS Care Team Referral Log
9
21
9
12
Closed
Accepted ACT Services with Settlement Agreement
Accepted ACT Services Voluntarily
Ongoing Outreach and Engagement
0 10 20 30
Contacts per Consumer
60
Figure 5. Average Duration (in Minutes) of Investigation Contacts per Consumer10
A key component of the investigation process is CCBHS’s ability to meet consumers and their families at
whatever location is necessary to find consumers and determine their eligibility for AOT. During the
evaluation period, CCBHS connected with consumers and their family members in several locations and
through both in-person and phone contacts. Figure 6 shows that 38% of contacts with all consumers
occurred in a clinic setting in the County, including CCBHS’ network of clinics, while 25% of contact
attempts occurred in the field. Visits to correctional or inpatient facilities comprised 15% of investigation
contacts and 21% of contacts occurred over the phone. Healthcare and licensed care facility visits
accounted for two percent of contacts and the remaining four percent were at other locations or
unknown. It is interesting that most contacts are occurring in clinic settings; future evaluations will explore
the outcomes of these contacts to see if there are any differences in the success of contacts based on
their location.11
11 The total investigation contacts (N = 420) is lower than the total locations of contacts (N = 438) because some
contacts occurred at multiple locations. Percentages of contact locations are reported for the total number of
contacts.
3.4
10.5
2.5
2.4
0.0 2.0 4.0 6.0 8.0 10.0 12.0
Closed
Accepted ACT Services with Settlement Agreement
Accepted ACT Services Voluntarily
Ongoing Outreach and Engagement
Minutes per Contact
61
Figure 6. Locations of CCBHS Investigation Contacts for All Eligible Consumers12, 13
In sum, the CCBHS investigation team identified and connected 38 eligible consumers for AOT outreach
and engagement services. The majority of their contact attempts during the investigation were with those
for whom outreach and engagement was still ongoing at the conclusion of the evaluation and with
consumers who accepted ACT services voluntarily. However, they engaged in more contacts per consumer
and had longer contacts on average with consumers who enrolled in ACT with a settlement agreement.
Most of their total contacts occurred in their office (38%) or the field (25%). Given data constraints, RDA
was unable to determine how many contacts were successful or the nature of the contact (e.g., in-person,
collateral).
The CCBHS investigation team connects all consumers who appear to meet AOT eligibility requirements
to MHS for outreach and engagement services. MHS conducts intensive outreach and engagement
services to collect information about and build rapport with consumers and their families so that
consumers ultimately agree to enroll in AOT and accept ACT services voluntarily.
As previously reported, CCBHS identified 38 eligible consumers and connected them to MHS. From
February-July 2016, MHS attempted to provide outreach and engagement services 252 times to those
consumers. RDA could not determine the outcomes of six of the 252 attempts and therefore removed
them from the analysis. Contacts were considered unsuccessful if the consumer did not show, if MHS staff
were unable to locate the consumer, or if MHS left a message for the consumer or family member. Figure
12 Source: CCBHS Care Team Referral Log
13 In order to protect consumers’ confidentiality, correctional and inpatient facility categories were condensed to
“Institutional Setting” and healthcare and licensed care facilities were condensed to “Community -Based Programs
and Facilities.”
158
105
87
63
7
18
0%
5%
10%
15%
20%
25%
30%
35%
40%
Office Field Phone Institutional
Setting
Community
Programs &
Facilities
Other or
UnknownContact Attempts62
7 shows that of the remaining 246 attempts at contact, 74% were successful and resulted in either an in-
person contact; a telephone, email, or mail contact; or a collateral contact (e.g., contact with a family
member, friend, clinician, etc.). This indicates that MHS’s contact strategy is working effectively, as they
were able to reach consumers or their loved ones the majority of the time.
Figure 7. Type of Outreach and Engagement Contact Attempts for All Consumers14
The proportion of total outreach and engagement contacts made with each consumer group is reported
in Table 9. The majority of contact attempts were made with consumers who were still receiving outreach
and engagement services (44%) or those who voluntarily enrolled in AOT (37%).
Table 9. Total Number of Outreach and Engagement Contact Attempts by Consumer Status
Consumer Status Number of Contact Attempts
Ongoing Outreach and Engagement 109
Accepted ACT Services Voluntarily 90
Accepted ACT Services with
Settlement Agreement
18
Closed 29
Figure 8 depicts the type and number of outreach and engagement attempts by MHS per consumer by
consumer groups. Consumers who were still receiving outreach and engagement services at the
conclusion of the evaluation period had the most successful in-person contacts per consumer. They also
had the most unsuccessful contacts per person, which could reflect the higher number of total contact
attempts for this group. Consumers for whom outreach and engagement was closed received the fewest
total contact attempts (12%) and more unsuccessful attempts per consumer than either group of
consumers enrolled in AOT. Interestingly, though consumers who voluntarily enrolled in AOT had five
14 Source: MHS Outreach and Engagement Log
57%
2%
15%
26%
In-Person Contact (n = 139)
Phone/Email/Mail Contact (n = 4)
Collateral Contact (n = 38)
Unsuccessful Contact (n = 65)
63
times as many total contact attempts than those who enrolled with a settlement agreement, the two
groups had comparable outreach attempts per person. This is likely due to the difference in group size,
with only three consumers enrolling in AOT through a settlement agreement.
Figure 8. Type and Number of Outreach and Engagement Attempts per Consumer15,16
As previously mentioned, MHS’s outreach and engagement team consists of MHS clinicians and staff,
family partners, and peer partners. Family partners are individuals with the lived experience of having a
loved one with a serious mental illness. Peer partners are individuals with lived experience as consumers
of the mental health system. Figure 9 shows the proportion of successful outreach and engagement
attempts by provider for all consumers (N = 38). Family partners made almost half of the successful
outreach contacts with all consumers, while peer partners made about one third.
15 Source: MHS Outreach and Engagement Log
16 There were 0.3 Phone/Email/Mail contacts for Ongoing Outreach and Engagement Consumers and 0.2 for Closed
Consumers
0.7
4.3
4.0
5.6
0.4
0.3
1.2
1.5
1.6
1.3
1.2
2.5
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
Closed
Accepted ACT Services with Settlement Agreement
Accepted ACT Services Voluntarily
Ongoing Outreach and Engagement
Outreach Attempts per Consumer
In-Person Contact
Phone/Email/Mail Contact
Collateral Contact
Unsuccessful Contact
64
Figure 9. Proportion of Successful Outreach Attempts by Provider for All Consumers17
Figure 10 depicts the rate of outreach and engagement attempts by provider per consumer by disposition.
Clinicians and MHS staff had zero successful contacts with consumers who were eventually closed in
collaboration with the County. They had the most contacts per consumer with those who were still
receiving outreach and engagement services. Compared to other providers, family partners had the
highest rates of contact per consumer with those who accepted ACT services voluntarily and with those
who still receiving outreach and engagement services at the conclusion of the evaluation period. Peer and
family partners had equal contact with those who accepted ACT services with a settlement agreement.
17 Source: MHS Outreach and Engagement Log
22%of successful
attempts
46%of successful
attempts
32%of successful
attempts
Clinician/MHS/Other Staff
Family Partner
Peer Partner
65
Figure 10. Successful Outreach and Engagement Attempts by Provider per Consumer18
The average duration of successful outreach and engagement attempts for all eligible consumers (N = 38)
for the evaluation period was 44 minutes. Figure 11 shows the average length of successful attempts
across all consumers by provider. Though peer partners had fewer contacts than family providers, their
contacts lasted longer than family partners or clinicians and MHS staff, on average.
18 Source: MHS Outreach and Engagement Log
1.3
1.0
2.0
0.5
1.7
2.4
3.5
0.8
1.7
1.8
1.7
0 2 4 6 8
Closed
Accepted ACT Services with Settlement Agreement
Accepted ACT Services Voluntarily
Ongoing Outreach and Engagement
Successful Outreach Attempts per Consumer
Clinician/MHS/Other Staff
Family Partner
Peer Partner
66
Figure 11. Average Duration (in Minutes) of Successful Outreach and Engagement Attempts by
Provider for All Eligible Consumers19
Figure 12 shows the average length of providers’ successful outreach and engagement attempts per
consumer. Interestingly, though there were fewer overall contacts between providers and consumers
who eventually enrolled in ACT with a settlement agreement, the contacts that were made lasted longer
per consumer than for any other consumer group.
Figure 12. Average Duration (in Minutes) of Successful Outreach Attempts by Provider per Consumer20
19 Source: MHS Outreach and Engagement Log
20 Source: MHS Outreach and Engagement Log
54 minutes per
consumer
68 minutes per
consumer
88 minutes
per consumer
Clinician/MHS/Other Staff
Family Partner
Peer Partner
23
5
3
2
12
4
3
5
16
4
3
0 10 20 30 40 50 60
Closed
Accepted ACT Services with Settlement Agreement
Accepted ACT Services Voluntarily
Ongoing Outreach and Engagement
Minutes per Successful Outreach Attempt
Clinician/MHS/Other Staff
Family Partner
Peer Partner
67
As with the investigation process, MHS’ outreach and engagement services are characterized by a
willingness to engage with consumers and their families in the community and other settings. Figure 13
shows the various locations of MHS’ successful contacts with consumers and their families. Most contacts
occurred in hospitals or psychiatric emergency facilities (PES; 25%) or the community (21%).
Figure 13. Locations of Successful Outreach and Engagement Attempts for All Eligible Consumers21
In summary, the MHS outreach and engagement team made most of their successful contacts with
consumers who were still receiving outreach services at the conclusion of the evaluation period (44%) or
who voluntarily enrolled in ACT (37%). Though they made fewer total contact attempts with consumers
who enrolled in AOT with a settlement agreement, the rate of contacts per consumer was similar acros s
the two AOT groups. MHS family partners made the most successful contacts (46%) and had the highest
rate of contacts with consumers still receiving outreach and engagement services; however, peer partners
tended to have longer-lasting contacts. The longest contacts for all MHS providers were with consumers
who enrolled in AOT with a settlement agreement.
Throughout the evaluation period, there was variability in the time it takes from initial referral to AOT
enrollment. Figure 14 depicts the timeline from referral through enrollment by each month of program
implementation. Each month consists of all AOT consumers who were referred that month. The chart
captures the average length in days of each stage of contact for consumers who enrolled in AOT during
the evaluation period:
Referral to first CCBHS contact
First CCBHS contact to first MHS contact
21 Source: MHS Outreach and Engagement Log
41
24
34
48
13
19
0%
5%
10%
15%
20%
25%
30%
68
First MHS contact to AOT enrollment
First CCBHS contact to last CCBHS contact
Figure 14 suggests that individuals are getting from referral to enrollment more quickly as the AOT
program model matures. In the program’s first month of operation the average number of days from
referral to enrollment was 70 days; by June the average number of days had dropped to approximately
22 days from referral to enrollment. Figure 14 also shows that there is less overlap between the
investigation and the outreach and engagement services in the more recent months of program
implementation. This represents the aforementioned modifications to the program implementation that
occurred in more recent months and suggests that in the final months of the evaluation period, efforts at
finding and engaging consumers are happening consecutively, as opposed to concurrently.
Figure 14. Average Days Spent in Each Step by Month for AOT Consumers22
Post-AOT Enrollment Outcomes
During the evaluation period, 17 of the 38 consumers identified by the Care Team as eligible for AOT
enrolled in AOT and accepted ACT services. Of those 17 consumers, three enrolled following a petition to
the court and a settlement agreement and 14 enrolled voluntarily.
This section reports the consumer profile of these 17 individuals, including their diagnosis and past service
history, as well as a description of the intensity, frequency, and type of services they received.
22 Sources: CCBHS Forensic Mental Health Referral Log; MHS Outreach and Engagement Log
69
AOT Consumer Profile
This section reports the demographic information and characteristics of consumers enrolled in AOT,
including their diagnosis at enrollment and service utilization history.
The CCBHS Care Team collected demographic information for every consumer referred for AOT. Table 10
depicts the demographic characteristics of the 17 individuals enrolled in AOT at the conclusion of the
evaluation period. The majority of AOT consumers were female, white, and from the Central region of
Contra Costa County.
Table 10. AOT Consumer Demographics23
Category Percent
Gender
Male 47%
Female 53%
Race/Ethnicity
Black/African American 29%
White 59%
Other 12%
Region
Central 47%
East 29%
West 24%
MHS staff documents the primary diagnosis of AOT consumers at every encounter. For descriptive
purposes in this evaluation, we report diagnosis at enrollment into the AOT program. Table 11 shows that
the majority of consumers had a primary diagnosis of either schizophrenia (65%) or a mood disorder
(30%), which includes bipolar and depressive disorders. Secondary diagnosis information will be included
in future reports.
23 Source: CCBHS Forensic Mental Health Referral Log
KEY FINDINGS
The County is reaching the target population of consumers who have a history of repetitive
hospitalization, incarceration, and homelessness.
Sixty-five percent of AOT consumers self-report having co-occurring mental health and
substance use disorders.
70
Table 11. AOT Consumer Primary Diagnosis at Enrollment24
Diagnosis Percent
Mood Disorder, Including Bipolar and Depressive Disorders 30%
Schizophrenia 65%
Other 6%
According to County billing data, 12% of consumers had at least one episode of substance use treatment
prior to enrollment; however, 65% of AOT consumers had a self-reported co-occurring substance use
disorder at some point in their life and 59% had a self-reported co-occurring substance use disorder at
enrollment.
MHS clinicians administered the Brief Psychiatric Rating Scale (BPRS) for 16 of the 17 consumers at
enrollment. The BPRS measures psychiatric symptoms in 18 domains, including hostility, suspiciousness,
and hallucination. For each question, the clinician rated the participant’s observed symptomology over
the previous days from 1 (not present) to 7 (extremely severe). The total rating scale ranges from 24 to
160. The average BPRS score of the 16 AOT consumers assessed at enrollment was 65, with scores ranging
from 29 to 118 and a median score of 59.
County PSP data was used to track consumers’ history of psychiatric hospitalization in the three years
prior to the implementation of AOT in Contra Costa County. During that time, 13 consumers had at least
one inpatient psychiatric hospitalization at the Contra Costa Regional Medical Center, Mount Diablo
Medical Pavilion, or Napa State Hospital. As shown in Table 12, of those consumers with at least one
hospital stay, there was an average of five hospitalizations per consumer. Their prior hospital stays lasted
an average of 23 days. On average, all 17 AOT consumers had about 3.8 hospitalizations per consumer.
Table 12. Average and Median Hospital Episodes and Days in Hospital
Average Median
Hospital Episodes 5 5
Hospital Days 23 21
Consumers reported their history of justice system involvement for the 12 months prior to AOT
enrollment. As show in Figure 15, 29% of consumers were in jail and 41% were arrested at some point in
the 12 months prior to enrollment. The 41% of consumers with a history of arrest were arrested an
average of five times during that period. Qualitative data from CCBHS and MHS suggests there is greater
proportion of consumers referred to AOT who have forensic involvement than is currently reflected in
self-report data.
24 Source: PSP Data
25 RDA currently only has self-report criminal justice data. Data from the criminal justice system will be accessible
and included in future reports.
71
Figure 15. Consumers’ History of Incarceration or Arrest in the 12 Months Prior to AOT Enrollment26
In addition to incarceration and arrest history, 24% of consumers were on probation and had been on
probation at some point in the previous 12 months.
According to self-report data, among 17 AOT consumers enrolled during the evaluation period, 35% (n=6)
were homeless when they enrolled in AOT and 12% (n=2) were living in an emergency shelter. Another
29% (n=5) of consumers were either living with their parents; an adult family member; or in a house or
apartment with a spouse or partner, minor children, dependents, or a roommate while either holding the
lease or contributing to the rent or mortgage at enrollment. Additionally, in the year prior to enrollment,
88% (n=15) of AOT consumers self-reported having spent time in an acute medical or psychiatric hospital,
community care center, or residential treatment facility.
Table 13 depicts the housing status of AOT consumers at enrollment and, during the 12 months prior to
enrollment, and the average number of days they had a given housing status during that 12-month period.
Table 13. Housing Status 12 Months Prior to and at Enrollment for AOT Consumers27
Housing Status Status at
Enrollment
Status in the
Last 12 Months
Average Number of Days
in the Last 12 Months
Lives in the Community 29% 18% 340
Homeless 35% 12% 257.5
Jail 0% 29% 50.5
26 Sources: PAF and PSP Data
27 Source: PAF
5
7
0%
10%
20%
30%
40%
50%
60%
70%
80%
Incarcerations ArrestsPercent of AOT Consumers (n = 17)72
Housing Status Status at
Enrollment
Status in the
Last 12 Months
Average Number of Days
in the Last 12 Months
Acute Medical or Psychiatric Hospital,
Community Care Center, or Residential
Treatment
18% 88% 55
Emergency Shelter 12% 12% 15.5
Other 6% 6% 177
Unknown 0% 6% 365
Consumers reported their different sources of financial report at enrollment and in the 12 months prior
to enrollment. As shown in Table 14 consumers received financial support from a variety of sources both
prior to and at enrollment. The majority of consumers received support from Supplemental Security
Income (SSI) in the 12 months prior to enrollment and continued to receive SSI support at enrollment.
Additionally, 24% had a representative payee at enrollment, and 29% had a payee in the 12 months prior
to enrollment.
Table 14. Sources of Financial Support for AOT Consumers28
Source of Financial Support Received in the 12 Months
Prior to Enrollment
Receiving at
Enrollment
Supplemental Security Income 59% 53%
Social Security Disability Insurance 12% 18%
Support from family or friends 18% 18%
Retirement/Social Security 12% 12%
Other (including Housing Subsidy, General Relief/
Assistance, and Food Stamps)
24% 12%
AOT Consumers’ Service Participation
AOT consumers in Contra Costa County receive ACT services from a multidisciplinary team who provide
direct services in the community and are available 24-hours a day to provide time-unlimited services. This
section reports the intensity and frequency of ACT services for the 17 AOT consumers, as well as the types
of services they experienced in addition to ACT.
28 Source: PAF
KEY FINDINGS
The length of participation varies across AOT consumers.
Consumers are receiving substantial service provision from the ACT team.
In addition to ACT, consumers receive services from other County and contracted providers.
73
There was variability in the length of time spent receiving ACT services, depending on consumers’ initial
referral and enrollment dates. AOT enrollment dates ranged from March to July and consumers were
enrolled for an average of 77 days through the end of the evaluation period on July 31, 2016 (see Table
15). There was an average of 24 ACT service encounters per month with an average duration of 156
minutes per contact.
Table 15. Length of Enrollment in AOT
Average Minimum Maximum Median
77 days 13 149 72
ACT is intended to provide 100% of services, including providing opportunities for participation in
recovery-oriented activities such as game nights, art groups, barbecues, and other activities that support
life skills development. MHS only recently started to track the participation of AOT consumers in
significant meaningful activities; future reports will report on changes in rates of participation in these
activities during program participation.
Though ACT is designed to provide comprehensive FSP services, some consumers receive additional
services while enrolled in AOT. During the evaluation period, AOT Consumers in Contra Costa County
engaged in the following additional services:
Crisis: This includes services received at the CCRMC Psychiatric Emergency Services, Miller
Wellness Center, and clinical services provided by the CCBHS forensic unit in partnership with
local law enforcement agencies.
Crisis residential treatment: A 24-hour unlocked facility that provides an alternative to inpatient
hospitalization, including admissions at Hope House and Neireka House.
Inpatient: Any psychiatric hospitalization in a locked setting, including services at Contra Costa
Regional Medical Center Unit 4C and Mt Diablo Psychiatric Hospital. Any out of county
hospitalization billed to Medi-Cal or reimbursed by CCBHS are included. Hospitalizations covered
by private insurance or Medicare only may not be included.
Outpatient: Any non-residential outpatient specialty mental health service, including Full Service
Partnership, case management, medication, and other outpatient services.
Jail mental health: Mental health services provided by CCBHS to consumers while incarcerated in
a Contra Costa County jail facility. Mental health services received while consumers were
incarcerated in other county or state prisons are not included.
As shown in Figure 16, the majority of consumers’ non-ACT service episodes were either for crisis services
(48%) or crisis residential treatment stays (32%). Notably, six of the 17 AOT consumers had not engaged
in any services other than those provided by MHS at the conclusion of the evaluation period.
74
Figure 16. Episodes of Service Use Other than ACT for AOT Consumers29
Data on AOT consumers’ adherence to treatment plans was not available for this report. Retention is a
proxy of adherence, and all participants who enrolled in ACT remained engaged with the program through
the evaluation period. RDA is exploring the possibility of receiving pharmacy data to assess medication
possession ratios as a proxy for adherence to medication plans in future reports.
AOT Consumer Outcomes
One key objective of AOT is to interrupt the cycle of repeated psychiatric hospitalizations, incarcerations,
and homelessness among individuals with serious mental illness who are unwilling or unable to engage in
voluntary specialty mental health services. Given the preliminary nature of the AOT program at the end
of the evaluation period, this section reports only on pre-enrollment and baseline measures of these
outcomes. Future reports will report on changes in outcomes during AOT participation.
29 Source: PSP Data
15
10
1
2
3
0
2
4
6
8
10
12
14
16
Crisis CRT Inpatient Jail MH OutpatientEpisodes
KEY FINDINGS
Given the preliminary nature of the AOT program at the end of the evaluation period, it is
premature to evaluate AOT consumer outcomes.
This section reports on pre-enrollment and baseline measures of DHCS outcomes.
75
Figure 17 indicates consumers’ hospitalization, incarceration, arrests, and homelessness from the 12
months prior to enrollment. The chart depicts the number of AOT consumers who experienced an adverse
life event or hospitalization at least once in the 12 months prior to their enrollment in AOT. As noted in
the consumer profile section, the findings below indicate that the County is reaching the target population
of consumers who have a history of hospitalization, incarceration, and homelessness.
Figure 17. Number of Consumers Experiencing Adverse Events Pre-AOT Enrollment30
At the time of this report, substance use data was only available for pre-enrollment and at enrollment. As
previously reported, 12% of consumers had at least one episode of substance use treatment prior to
enrollment, while 65% of AOT consumers self-reported having a co-occurring substance at some point in
their lives and 59% reported a substance problem at enrollment. Changes in consumers’ substance use
will be reported in the next evaluation report.
The primary enforcement mechanism in AOT occurs when a judge issues a mental health evaluation order
at a designated facility for a consumer who does not meet 5150 criteria established in the WIC. No
enforcement mechanisms were used in the first six months of the program.
30 Sources: PAF and PSP Data
13
5
7
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
Hospitalizations Incarcerations Arrests HomelessnessAOT Consumers76
At the time of this report, data on violent behavior was only available for AOT consumers at enrollment.
Baseline data from the High Risk Assessment (HRA) indicates that all consumers had a history of violent
impulses and/or homicidal ideation toward a reasonably identified victim. Changes in consumers’ violent
behavior will be reported in the next evaluation report.
For this report, data from the “safety” domain of the Self Sufficiency Matrix (SSM) at enrollment was used
to indicate consumers’ victimization experience. The “safety” domain is scored from 1 (in crisis) to 5
(thriving) and captures the extent to which consumers’ environment is stable and safe. Table 16 reports
consumers’ scores on the SSM for safety. On average, the 16 consumers who were given the assessment
reported feeling stable regarding safety in their community. For future reports, additional data will be
collected to report the victimization of consumers with greater specificity.
Table 16. Safety SSM Scores for AOT Consumers (n = 16)31
Domain Average Median Mode
Safety 2.5 3 4
For this report, the majority of social functioning and independent living data is only available for pre-
enrollment and at enrollment to AOT. MHS clinicians completed the SSM for all but one consumer at
enrollment to gauge consumers’ baseline social functioning and independent living. Table 17 depicts
consumers’ baseline scores for the life skills, family/social relations, and community involvement domains
of the SSM.
Table 17. Social Functioning and Independent Living SSM Scores for AOT Consumers (n = 16)32
Domain Average Median Mode
Life Skills 2.7 2.5 2
Family/Social Relations 2.1 2 2
Community Involvement 2.3 2 2
On average, consumers were rated between being able to meet between a few and most of the needs of
daily living without assistance. On average their family/friends may be supportive but lack the resources
or ability to help and there is some potential for abuse or neglect. Additionally, consumers are socially
isolated and/or lack social skills and/or the motivation to become socially involved, on average.
According to self-report data, in the 12 months prior to AOT enrollment all AOT consumers were
unemployed, none were in school, and 29% had a primary care physician. At enrollment, 18% of
consumers were employed and 53% of consumers included employment in their recovery goals. No
31 Source: SSM
32 Source: SSM
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consumers were in school at enrollment, but 47% included education in their recovery goals and one
consumer enrolled in a community college or four-year college while receiving ACT services. Eighteen
percent of consumers had a primary care physician at enrollment.
Consumer satisfaction surveys will be administered further into the four-year evaluation; therefore, data
is not currently available but will be included in future reports.
AOT Costs and Cost Savings
There are a number of expenses associated with the implementation of Contra Costa County’s AOT
program. RDA collected cost related information from the CCBHS Finance Department, as well as from
County Departments involved in AOT who outlined their costs associated with the program. These costs
are discussed in greater detail below.
While there are expenses associated with implementing the County’s AOT program, ideally there are also
costs savings generated through program implementation. For instance, if AOT consumers have reduced
numbers of hospitalizations, arrests, and incarcerations after enrolling in AOT this saves the County money
they would be spending on these events. Additionally, the County generates revenue when MHS provides
Medi-Cal eligible services for AOT consumers. The sections below provide a preliminary look at costs
associated with AOT program implementation, as well as the extent to which AOT has generated revenue
through Medi-Cal billing. Future reports will assess the extent to which AOT has produced cost savings, if
at all, through reduced numbers of hospitalizations and reduced criminal justice involvement post-
enrollment in AOT.
The County contracted with MHS to provide ACT services as part of the AOT program in October 2015.
The costs paid to MHS during the fiscal year 2015-2016 (October 2015 – June 201633) were $904,492.
Approximately $242,832 went towards start-up costs (October 2015 – January 2016) while approximately
$661,660 went towards service delivery (February 2016 – June 2016).
33 RDA does not include MHS cost data for the month of July because financial data was only available for fiscal year
2015 – 2016.
KEY FINDINGS
Given the preliminary nature of the AOT program at the end of the evaluation period, it is
premature to project MHS service delivery costs or project potential cost savings.
Because there are only 17 AOT consumers during the evaluation period, MHS per person service
costs are higher than they will be once AOT reaches its capacity of 75 consumers.
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Table 18. MHS Costs
MHS Costs October - June 2016
Start-up Costs $242,832 (Oct ’15 - Jan ’16)
Service Delivery Costs $661,660 (Feb ’16 - Jun ‘16)
Total $904,492 (Oct ’15 - Jun ’16)
Of the costs paid to MHS for service delivery during the February through June 2016 time period, the
County estimated they would receive approximately 35% (accounting for a 15% disallowance rate) in
revenue from Medi-Cal billing, or $231,581.07. In actuality, MHS provided approximately $30,413.44
worth of Medi-Cal eligible services during this time period, and the County estimates they will receive
approximately $10,644.70. While this figure is much below the amount the County anticipated they would
generate through ACT service provision, it is important to remember that the County’s AOT program is in
its early stages; only 17 consumers had enrolled in AOT during the evaluation period, and none of these
individuals were enrolled for the full time. With this in mind, it is important to note that the amount of
revenue generated through ACT service provision will grow as the AOT program enrolls more individuals.
Contra Costa County reported AOT-related expenses for the following public agencies: CCBHS, County
Counsel, the Office of the Public Defender, and the Superior Court. Table 19 shows the approximate dollar
amount each department spent on AOT related services from February-July 2016. To calculate costs
associated with CCBHS, the Public Defender’s Office, and the Superior Court, RDA assumed approved
budgets were expended on a 1/12 basis. For costs associated with County Counsel, RDA received actual
monthly costs for the time period.
Table 19. Contra Costa County Department Costs34
County Department February - July 2016 Cost
CCBHS $262,500
County Counsel $22,733
Public Defender’s Office $66,750
Superior Court $64,000
Costs associated with CCBHS are for CCBHS Care Team operations that include managing the AOT referral
line and conducting investigation and outreach for all individual referred to AOT by qualified requestors.
County Counsel provides consultation services for CCBHS, and also prepares and files all petitions to Court
and represents the County in Court hearings. Finally, the Office of the Public Defender has one full-time
employee who represents all AOT clients, and the Superior Court is responsible for holding AOT court
hearings each week.
34 Source: County AOT Financial Data
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Pre-AOT Enrollment Service Costs
RDA utilized PSP billing data to determine the total costs of services for the 17 enrolled AOT consumers in
the three years prior to AOT enrollment. The total cost of services for the 17 AOT consumers during this
time period was $2,856,712 or $952,237 annually. Figure 18 shows that psychiatric inpatient
hospitalizations accounted for 28% of those total costs.
Figure 18. County Hospitalization and Other Service Costs Pre-Enrollment for AOT Consumers
Table 20 shows the breakdown of these costs per month and per consumer. Though RDA had access to
three years of billing data from PSP, eight of the 17 consumers had less than three years’ worth of data.
Of those eight consumers, five had between two and three years of data, two had less than one year of
data, and one had no pre-data. On average, in the three years prior to enrolling in AOT, hospitalization
costs were $1,853 per consumer per month; all other service costs were approximately $3,954. This
indicates that the average monthly service cost was approximately $5,806 for AOT consumers in the three
years prior to their enrollment in AOT.
Table 20. Service Costs Pre-AOT Enrollment
Services Average Annual
Cost
Average Cost
per Month
Average Annual
Cost Per Consumer
Average Cost per
Month per
Consumer
Hospitalization $285,420 $23,785 $22,544 $1,853
Other Services $872,652 $72,721 $48,094 $3,953
Total $1,158,072 $96,506 $70,638 $5,806
$893,486
69%
$1,963,226
Hospitalizations All Other Services
31%
69%
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Post-AOT Enrollment Service Costs
Given the preliminary nature of the AOT program at the end of this evaluation period, it is premature to
estimate per person service delivery costs or project potential cost savings. RDA will report these types of
post-AOT enrollment service costs in future evaluation reports after the AOT program has been in
existence for a longer period of time.
Because 17 AOT consumers had spent, on average, only 77 days enrolled in the County’s AOT program
during the evaluation period RDA does not report on cost savings at this time; it is imperative to monitor
greater numbers of individuals for longer periods of time before suggesting an association between
enrollment in AOT and reduced hospitalizations and/or criminal justice involvement for AOT consumers
in Contra Costa County.
Future reports will assess potential costs savings associated with reduced hospitalizations and criminal
justice involvement once greater number of AOT consumers have been enrolled for longer periods.
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Discussion
AOT Referrals
Since program inception, there have been 108 referrals concerning 105 individuals, suggesting that people
who meet criteria as qualified requestors are knowledgeable about how to refer eligible individuals to
the program. However, more than half of referrals are coming from family. While a consistent number of
referrals have been made to AOT since the start of the program, only approximately one-third have been
made by Mental Health providers and/or Law Enforcement Partners. The County may wish to consider
how to continue to educate these partners about the County’s AOT program. Intervening while individuals
are in secure settings where County staff can locate them is often ideal; in these cases, individuals who
are referred to AOT while in a secure setting may be more likely to voluntarily accept ACT services.
Additionally, CCBHS and/or MHS staff will be more able to locate these individuals to begin the
investigation and outreach and engagement process. It is ideal for providers from psychiatric hospitals,
PES, and/or jail staff to make referrals to AOT for eligible individuals as close to intake as possible so that
CCBHS and/or MHS staff have an opportunity to engage them prior to their release to help link them to
appropriate services. This may also ensure that eligible individuals without involved family members also
gain access to the program. Suggestions to promote access for all County residents who may benefit from
this program include:
Outreach and engagement presentations and other communications strategies throughout the
County to promote access and ensure that all communities have the knowledge to refer eligible
individuals; and
Continued outreach efforts to professionals who meet criteria as qualified requestors, including
CCRMC, jail, and law enforcement staff who are likely to come into contact with eligible
individuals who may not have involved family.
The CCBHS Care Team conducts an investigation to determine eligibility and need for all consumers
referred. Their approach includes reviewing the consumer’s service history and diagnosis, gathering
collateral information from the qualified requestor and/or family, and conducting an assessment with the
consumer referred. Thirty-one of the consumers referred were unable to be located or were otherwise
connected to services. The CCBHS Care Team described that for the “ineligible consumers,” they had a
history of participating in mental health services on a voluntary basis but had some sort of disruption in
services. For these individuals, the CCBHS Care Team has been able to determine if it is more beneficial to
re-connect the individual to services where they had previously been successful or refer the person to
AOT, if eligible. This may be an unexpected benefit of AOT implementation in that the CCBHS Care Team
has established a safety net whereby they are able to assess and link consumers in need to the most
appropriate service, which may include AOT but also may include other services, as clinically indicated.
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The majority of the consumers referred to AOT who needed mental health services agreed to participate
in mental health services on a voluntary basis. This includes 82% of consumers who enrolled in ACT
services with MHS on a voluntary basis as well as the consumers previously discussed who were re-
connected to other CCBHS mental health services (e.g., FSP or other outpatient services). Additionally,
there was a percentage of referrals who were unable to be located. For referred consumers who either
cannot be located or agree to participate in voluntary services:
The County may wish to consider monitoring the hospitalization and/or incarceration of these
individuals for a set period of time to
o Contact those who are unable to be located when in secure settings (e.g. hospital, jail);
and
o Ensure that those who agree to voluntary services sustain service participation and
achieve certain outcomes as expected in ACT (e.g., reduced hospitalization and
incarceration) or can be proactively identified and re-referred, if clinically indicated.
CCBHS and MHS may also wish to monitor those who enroll in ACT services on a voluntary basis
for service participation and progress, such as hospitalization and/or incarceration, to determine
if an agreement with the court, such as AOT court order or voluntary settlement agreement,
would further support the consumer.
Outreach and Engagement
In adopting a resolution to implement AOT, Contra Costa County not only adopted a new legal mechanism
to connect individuals with severe mental illness to mental health services, they also contracted a new
service provider, MHS, to implement the County’s first ACT program in order to ensure they are providing
the highest quality of care for individuals enrolled in AOT. The program model, as designed, included a
Care Team consisting of CCBHS clinical staff and MHS peer and family staff. The original intent was that
the Care Team, including CCBHS and MHS staff, would work together to concurrently conduct the referral
investigation and outreach and engagement efforts. In practice, the program model has changed in that
1) CCBHS clinical staff conduct the referral investigation first to determine eligibi lity, and then 2) refer
only eligible consumers to MHS for outreach and engagement by the peer and family partners. Because
there are a number of new components coming together at once, it is natural to expect programmatic
modifications to occur. While it is normal and expected that any program will make modifications during
initial implementation as a response to unexpected challenges and to ensure that the program is able to
meet its intended goals, it is important that any modifications are explicit and that any implications of
program adaption are planned for and addressed. Changing the Care Team from a concurrent to
consecutive approach to investigation and outreach has implications, including:
Currently, the de facto care transition from AOT referral to ACT enrollment occurs between
CCBHS clinicians and the MHS family partner. Moving forward, it may be important to schedule
an in-person transition between CCBHS and MHS staff that includes the consumer, and family as
permitted, as well as clinical staff from MHS. In alignment with the ACT model, all team members
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provide services to all consumers, so that the “warm handoff” could also occur with a clinical case
manager, nurse, dual recovery specialist, or other ACT team member and not be limited to the
family partner, as originally suggested in the program design.
While the original design suggested concurrent approaches to investigation and outreach,
separating these activities into two discrete phases may create ambiguity in terms of roles and
responsibilities. In order to ensure that each phase of the process is successful and that eligible
consumers are able to efficiently and effectively move through the process and enroll in ACT, it
may be important to clarify roles and responsibilities as well as establish set communication
procedures to ensure that MHS receives all relevant information from the CCBHS clinical staff to
engage and serve the person, and CCBHS is notified when someone is at risk of or experiencing
hospitalization and/or incarceration so that they can re-evaluate if a petition or other legal
mechanism is appropriate to support the person.
This change may also shorten the length of time that MHS engages in pre-admission “outreach
and engagement” and move outreach and engagement activities post-enrollment. While
outreach and engagement for an ACT team can happen pre or post formal enrollment, this change
may:
o Reduce MHS’ staff ability to work with parents/family in advance of ACT enrollment if the
consumer does not provide express written consent upon enrollment; and
o Increase the likelihood that MHS staff sign people up while in secure settings (e.g.
hospital, jail) rather than wait until release back into the community.
If the County continues this program modification, which would be expected, it may be important to
“complete” the modification and make the modified design as explicit as the planned design. This includes
documenting the modified process, clarifying roles and responsibilities, and establishing set
communication procedures that promote bi-directional communication beginning at referral and
extending throughout ACT service participation. It may also be useful to set shared expectations about
enrolling consumers while in secure settings and the role of family engagement at each phase of the
process.
ACT Fidelity
Overall, MHS’ ACTiOn Team received an average fidelity rating of 4.73 and scored in the “high fidelity”
range. The assessors were impressed with a variety of elements of MHS’ ACTiOn Team and observed that
many of the program elements were present and met or exceeded fidelity measures. The program was
robustly staffed with more team members than required with staff who are clearly committed to the
success of the program and consumers. Staff demonstrated their familiarity with motivational
interviewing and the recovery model in conversations with assessors and are working as a cohesive team.
The program is structured to provide adequate staffing that can do “whatever it takes” to support
consumers and meet them “wherever they’re at,” literally and figuratively. Team members appeared to
work together throughout the day to ensure that all consumers receive individualized support to achieve
their goals. Both consumers and family members expressed gratitude to MHS’ ACTiOn Team and staff for
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the accomplishments that ACT consumers have achieved during program participation. Throughout the
focus groups, assessors heard consumer and family member accounts of increasing stability and finding
hope, as well as a number of tangible successes, including:
Obtaining housing and income
Reducing hospitalizations
Feeling safe
Improving and repairing family relationships
Believing that recovery is possible
While the fidelity assessment revealed a high degree of alignment with the ACT model, this is a relatively
new program that is not yet operating at full capacity. MHS’ ACTiOn Team is contracted to provide services
to 75 individuals, is currently serving 17 individuals, and is fully staffed with 13.5 direct service staff and
two administrative staff. As admissions increase, the team may need to consider how to scale their
operations to maintain a high degree of fidelity with the model. For example, the assessors noted the
following areas that may require more focused attention:
In the team meeting, staff discussed all 17 consumers. When at full capacity, their meetings will
need to include 75 consumers.
Staff are currently delivering medication to some consumers on a daily basis. While this is a
common practice for ACT teams, MHS’ ACTiOn Team may need to consider how to structure
medication delivery to more consumers as the program grows.
Groups are currently held at the MHS’ ACTiOn Team office in Concord, CA, and staff provide
transportation to consumers who live in East and West County. With a larger group of consumers
throughout the County, it may be more feasible to hold activities in other locations to minimize
travel time while still providing the same level of support. This may also improve the ratio of
community-based services provided in-vivo.
Currently, the psychiatrist works half-time. When at full capacity, the team will need a ¾ time
psychiatrist to remain in fidelity with the model.
As noted previously, there is a high variability in the frequency and intensity of services consumers
receive. As the program grows, MHS’ ACTiOn Team may need to consider how to ensure that all
consumers receive the appropriate level of service.
In order to meet the needs of the community, MHS’ ACTiOn Team may need to accept more than
six consumers per month until at capacity. The specific enrollment numbers should be determined
in partnership with the County.
Given that the ACT model is new to Contra Costa County and is a part of the AOT pilot project, the
assessors acknowledge that there is a need to continue to attend to the partnership between CCBHS and
MHS’ ACTiOn Team. While this currently shows up around admissions in this fidelity assessment, it may
also play a role in how CCBHS and MHS work together around hospital admission and discharge. While
there were was only one hospitalizations in the first six months of implementation, it is likely that more
hospitalizations will occur at some point, and the partnership between CCBHS and MHS is key to both
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supporting consumers to avoid unnecessary hospitalizations as well as transition back into the community
upon discharge.
Preliminary Outcomes
While the County’s AOT program is in its early stages, it appears that the program is enrolling people who
are eligible and have a high degree of need.
Thirteen of 17 AOT consumers (76%) had at least one psychiatric hospitalization in the three years prior
to their AOT enrollment. Among these 13 individuals, each had an average of three hospitalizations in the
three years prior to their AOT enrollment. The majority of AOT consumers (59%) also self-reported
experiencing a mental health or substance abuse related emergency intervention in the 12 months prior
to enrollment, and approximately 59% also self-reported having a co-occurring substance use disorder at
the time of their AOT enrollment. Moreover, approximately 41% (n=7) of AOT consumers reported being
arrested and 24% (n=5) reported being incarcerated in the 12 months prior to AOT enrollment.
Approximately 41% of AOT consumers also reported being homeless or living in an emergency shelter at
the time of their enrollment.
Additionally, it appears that there may be a high proportion of AOT consumers who have forensic needs
or are also connected with the criminal justice system. While ACT is an appropriate service intervention
for consumers with forensic needs and AOT is a less restrictive intervention than incarceration and
criminal court involvement, this may require additional preparation and/or training to appropriately
respond to the emerging needs.
CCBHS and MHS Data Capacity
CCBHS does not currently track their AOT referral investigation process electronically or in a spreadsheet
format; this information only exists as hard copies of their field notes. In order to analyze the investigation
and outreach and engagement process more robustly in future reports so that we can learn more about
the consumer profiles of who is and is not referred to MHS for AOT enrollment, it is imperative that, at a
minimum, CCBHS begin to transfer data from field notes into an electronic platform.
A large amount of PAF, KET, and 3M data were also not available via the County’s DCR data system for
this evaluation. It appears that PAF data is only available for consumers’ first assessment, so for AOT
consumers who have already had assessments entered into the system there is no way to pull this data
from the DCR. Significant amounts of KET and 3M data were also missing from the DCR. Moving forward,
MHS should enter PAF, KET, and 3M data into the DCR on a daily, weekly, and/or monthly basis to ensure
these data are up-to-date and available for each evaluation period. RDA will work with MHS to develop a
process for collecting PAF data in a usable format for each evaluation period moving forward.
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Append ices
Appendix I. AOT Eligibility Requirements35
In order to be eligible, the person must be referred by a qualified requestor and meet the defined criteria:
The person is 18 years of age or older.
The person is suffering from a mental illness
There has been a clinical determination that the person is unlikely to survive safely in the
community without supervision.
The person has a history of lack of compliance with treatment for his or her mental illness, in that
at least one of the following is true:
a. At least 2 hospitalizations within the last 36 months, including mental health services in a
forensic environment.
b. One or more acts of serious and violent behavior toward himself or herself or another, or
threats, or attempts to cause serious physical harm to himself or herself or another within
the last 48 months.
The person has been offered an opportunity to participate in a treatment plan by the director of
the local mental health department, or his or her designee, provided the treatment plan includes
all of the services described in Section 5348, and the person continues to fail to engage in
treatment.
The person's condition is substantially deteriorating.
Participation in the assisted outpatient treatment program would be the least restrictive
placement necessary to ensure the person's recovery and stability.
In view of the person's treatment history and current behavior, the person is in need of assisted
outpatient treatment in order to prevent a relapse or deterioration that would be likely to result
in grave disability or serious harm to himself or herself, or to others, as defined in Section 5150.
It is likely that the person will benefit from assisted outpatient treatment.
35 Welfare and Institutions Code, Section 5346
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Appendix II. Description of Evaluation Data Sources
CCBHS Referral Log: This spreadsheet includes the date of each AOT referral, as well as the demographic
characteristics of each individual referred to AOT and the disposition of each referral upon CCBHS’ last
contact with the individual referred (e.g., unqualified requestor, open AOT investigation, voluntarily
accept MHS services, court involved MHS participation).
Using these data RDA identified the total number of referrals to the County’s AOT program from February
1, 2016 – July 31, 2016, as well as the number of referrals made to AOT each month, and the number of
individuals who have received more than one AOT referral.
CCBHS Blue Notes: RDA staff converted CCBHS’s Blue Notes (i.e., field notes from successful outreach
events) into a spreadsheet tracking the date, location and length of each CCBHS Investigation Team
outreach encounter. RDA used these data to assess the average length of time (i.e., days) between AOT
referrals and the County Investigation Team’s first contact with referrals, as well as the average length
(i.e., days and encounters) of outreach and engagement provided by the CCBHS Investigation Team per
referral.
MHS Outreach and Engagement Log: This spreadsheet tracks the date and outcome of each MHS
outreach encounter, including information on who provided outreach (e.g., family partner, peer partner,
clinician) to whom (consumer or collateral contact such as friend, family, or physician), and the location
and length of each outreach encounter.
RDA used these data to calculate the average number of outreach encounters per month the MHS team
provided each referral, as well as the average length of each outreach encounter, the type (who provided
outreach and who received outreach) and location (e.g., community, secure setting, telephone) of
outreach provided, and the average number of days of outreach provided for reach referral.
Contra Costa County PSP Billing System (PSP): These data track all services provided to AOT participants,
as well as diagnoses at the time of each service. Using PSP service claims data RDA identified the clinical
diagnoses of AOT participants at enrollment, as well as the types and costs of services consumers received
pre- and post-AOT enrollment (e.g., outpatient, inpatient, residential, and crises), the average frequency
with which consumers received AOT FSP services, and the average duration of each service encounter.
Data Collection & Reporting (DCR) Files: RDA attempted to and was unable to collect reliable Partnership
Assessment Form (PAF), Key Event Tracking (KET) and Quarterly Assessment (3M) data from the DCR.
Instead RDA staff converted MHS’ paper forms into excel spreadsheets to include all PAF, KET, and 3M
data utilized in this report to generate consumer profile measures and self-reported changes in outcome
measures such as homelessness, arrests, and incarcerations pre- and post-AOT enrollment.
MHS Outcomes Files: These files include assessment data for a number of clinical assessments MHS
conducts on AOT participants. For the purposes of this evaluation, RDA utilized information from the Brief
Psychiatric Rating Scale (BPRS), High Risk Assessment (HRA), and Self Sufficiency Matrix (SSM) to calculate
88
baseline measures to serve as proxies for symptomology (BRPS), violent behaviors (HRA), and social
functioning, independent living, and victimization (SSM). RDA did not assess changes in assessment
measures over time because the majority of participants had only been enrolled in AOT long enough to
conduct baseline assessments.
CCBHS Financial Data: Financial data provided by CCBHS indicate the County’s allocated AOT budget, as
well as actual expenses paid for MHS ACT services, County Counsel, Civil Court, and Public Defender
services. RDA used these data to calculate the AOT costs incurred by the County, as well as revenue
generated through Medi-Cal billing.
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90
FAMILY AND HUMAN SERVICES COMMITTEE 5.
Meeting Date:12/12/2016
Subject:Update on the Implementation of the Secondhand Smoke Ordinance
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: 82
Referral Name: Secondhand Smoke Ordinance
Presenter: Daniel Peddycord, Public Health
Director
Contact: Enid Mendoza, (925)
335-1039
Referral History:
The issue of secondhand smoke and the associated health implications was first referred to the
Family and Human Services Committee by the Board of Supervisors on March 1, 2006. Since
that time the Health Services Department has provided annual reports to update the Committee
and the Board of Supervisors on the problem and progress made to address it.
The Board of Supervisors adopted a comprehensive Secondhand Smoke Protections Ordinance in
2006 on the heels of the California Air Resources Board report which designated secondhand
smoke as a toxic air contaminant based on a review of the research linking secondhand smoke
with numerous adverse health effects. The Board strengthened these protections in October 2009,
October 2010 and April 2013 in response to community complaints regarding drifting smoke in
multi-unit housing and the need for additional policies to protect public health.
On June 17, 2014 the Board of Supervisors adopted Ordinance 2014-06 which prohibits smoking
on property owned or leased by the County.
Referral Update:
Please see the attached report provided by the Health Services Department on the progress made
in implementing the new ordinance and the challenges associated with it.
Recommendation(s)/Next Step(s):
ACCEPT the report from the Health Services Department on the implementation of the
Secondhand Smoke Protections Ordinance, and direct staff to forward it to the Board of
Supervisors for their information.
Fiscal Impact (if any):
No fiscal impact; this is an informational report.
91
Attachments
Update Report on Secondhand Smoke Protections Ordinance
Secondhand Smoke Brochure - English
Secondhand Smoke Brochure - Spanish
Secondhand Smoke Brochure for Landlords, Property Managers and Developers
92
• Contra Costa Behavioral Health Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health •
• Contra Costa Hazardous Materials • Contra Costa Health Plan • Contra Costa Public Health • Contra Costa Regional Medical Ce nter and Health Centers •
WILLIAM B. WALKER, M.D.
HEALTH SERVICES DIRECTOR
DANIEL PEDDYCORD, RN, MHA/MPA
DIRECTOR OF PUBLIC HEALTH
C ONTRA C OSTA
P UBLIC H EALTH
597 CENTER AVENUE, SUITE 200
MARTINEZ, CALIFORNIA 94553
PH (925) 313-6712
FAX (925) 313-6721
DANIEL.PEDDYCORD@HSD.CCCOUNTY.US
To: Family and Human Services Committee, Contra Costa Board of Supervisors
From: Daniel Peddycord, Director of Public Health
Re: Annual Report on Implementation of Secondhand Smoke Protections Ordinance
Date: December 12, 2016
Background
The Board of Supervisors adopted a comprehensive Secondhand Smoke Protections Ordinance in 2006.
This decision came on the heels of the California Air Resources Board report designating secondhand
smoke as a toxic air contaminant based on a review of the research linking secondhand smoke with
numerous adverse health effects. The Board strengthened these protections in October 2009, October
2010, April 2013 and June 2014 in response to community complaints regarding drifting smoke and the
need for additional policies to protect public health.
In April 2014, the Committee voted to send to the full Board of Supervisors a revision to the County
Health and Safety Code that would expand secondhand smoke protections to make all County properties
100% smoke-free. As a result of the Board’s adoption of the new protections in June, 2014, all County
owned and leased properties were designated 100% smoke-free beginning March 1, 2015.
At our last annual report on the Implementation of the Secondhand Smoke Protections Ordinance on
April 13, 2015, Family and Human Services Committee accepted the report on Implementation of the
Smokefree Campuses provision and staff recommendations for strengthening the ordinance. The
Committee directed staff to work with County Counsel to draft ordinance language that would create
100% smoke-free multi-unit housing and revise and strengthen the regulation of electronic smoking
devices under County Law, and to bring the draft ordinance language back to the Full Board of
Supervisors for consideration.
Implementation of the Smoke-free County Properties, (Smoke-Free County Campuses), and
other Secondhand Smoke Protections Ordinance Provisions Over the Past Year
Smoke-Free County Campuses Provision:
Since our last report, Facilities Services has posted signage at various county campuses, including the following
properties:
4545 Delta Fair Boulevard, Antioch
4549 Delta Fair Boulevard, Antioch
3105 Willow Pass Road, Bay Point
4191 Appian Way, El Sobrante
30 Douglas Drive, Martinez
40 Douglas Drive, Martinez
50 Douglas Drive, Martinez
1220 Morello Avenue, Martinez
2530 Arnold Drive, Martinez
303 41st Street, Richmond
2523 El Portal Drive, San Pablo
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∎ Contra Costa Community Substance Abuse Services ∎ Contra Costa Emergency Medical Services ∎ Contra Costa Environmental Health ∎ Contra Costa Health Plan ∎
∎ Contra Costa Hazardous Materials Programs ∎ Contra Costa Mental Health ∎ Contra Costa Public Health ∎ Contra Costa Regional Medical Center ∎ Contra Costa Health Centers ∎
Facilities Services’ original plan was to continue posting outdoor signage and to remove cigarette waste receptacles
in the areas of highest County campus concentration, beginning in Central County, moving to West County, and
finally to East County. Facilities Services has reported to us that understaffing in their department over the past
year has required them to prioritize the work on a complaint-basis, and Tobacco Prevention Project Staff have
been in communication with Facilities Services when complaints are received by our department. With the
retirement of the Facilities Services Director, Tobacco Prevention Project staff will be working with the new
director on a plan for completing the signage and removal of waste receptacles on all County Campuses once the
staffing issue has been resolved.
Tobacco Prevention Project Staff will be conducting another presentation to County Building Safety
Coordinators at Risk Management’s Countywide Safety Coordinators Meeting in January 2017. Updated
“Smokefree Contra Costa” smokefree campus paper flyers and the staff version of the “Frequently Asked
Questions” document will be distributed for internal posting.
Tobacco Prevention Project staff continue to maintain the Contra Costa Smoke-Free Campus web pages
on the Health Services website (www.smokefreecc.org) This includes information on the ordinance, and
the “Frequently Asked Questions” document for the public.
Other Ordinance Provisions:
The Tobacco Prevention Project continues to educate the public and businesses on provisions of the
ordinance through community presentations, distributing educational brochures, responding to
complaints and inquiries, and incorporating educational materials into County business license mailings.
There have been only two complaints from the public over the past year regarding existing outdoor
secondhand smoke protection provisions and no complaints about the use of electronic smoking devices
(ESDs) in areas where smoking is permitted.
Report back on Smokefree Multi-Unit Housing Draft Ordinance and Electronic Smoking Device
Definition
Multi-Unit Housing Protections: As directed by the Committee, Public Health staff are working with County Counsel
on a draft ordinance that would revise the County’s Secondhand Smoke Protections Ordinance to create 100%
Smokefree Multi-unit housing in the unincorporated County, including all multi-family housing complexes of two
or more units. Public Health staff hopes to bring this to the Board of Supervisors shortly after the New Year.
The majority of the secondhand smoke complaints received by the Tobacco Prevention Project continue to be
from multi-family housing residents regarding unit-to-unit and outside-to-unit drifting smoke. For residents of the
unincorporated county, staff follows up with landlords and property owners regarding compliance with the
County’s current laws. However, since the County’s ordinance does not include protections that address unit-to-
unit drifting smoke, many of these residents are still exposed to secondhand smoke in their homes.
Electronic Smoking Devices: The new definition of Electronic Smoking Devices, which would prohibit the use of any
electronic smoking device that can be used to deliver nicotine, regardless of whether or not the device contains
nicotine, was approved by the full Board on May 24, 2016 to be included in the revisions to the Tobacco Retailer
Licensing and Zoning Ordinances, and is expected to be on the Board agenda in late December.
Provision of Technical Assistance to Contra Costa Cities
Since our last report, Tobacco Prevention Project staff provided technical assistance to the cities of El
Cerrito and Orinda regarding outdoor secondhand smoke protections and electronic smoking device
policy and implementation. The City of Orinda adopted an ordinance (4/16) that did not include
electronic smoking devices, however prohibits smoking of conventional tobacco within 20 feet of doors,
windows, air ducts and ventilation systems of enclosed places open to the public; in outdoor dining areas;
in public parks and trails; and on city property when being used for an outdoor event. The City of El
94
∎ Contra Costa Community Substance Abuse Services ∎ Contra Costa Emergency Medical Services ∎ Contra Costa Environmental Health ∎ Contra Costa Health Plan ∎
∎ Contra Costa Hazardous Materials Programs ∎ Contra Costa Mental Health ∎ Contra Costa Public Health ∎ Contra Costa Regional Medical Center ∎ Contra Costa Health Centers ∎
Cerrito adopted a strong, comprehensive secondhand smoke protections ordinance in October, 2014, and
staff has continued to provide technical assistance on implementation issues.
On 11/30/16, the US Housing and Urban Development (HUD) adopted rules requiring public housing
developments in the U.S. to provide a smoke-free environment for their residents, including in all living
units, indoor common areas, administrative offices and all outdoor areas within 25 feet of housing and
administrative office buildings, within the next 18 months. Staff will be offering technical assistance to
the County’s Housing Authority in implementing these rules.
Attachments:
1. “A Guide to Contra Costa County’s Secondhand Smoke Protections Ordinance” brochure and “For
Property Managers, Developers and Landlords in unincorporated Contra Costa: Information on Contra
Costa County’s Secondhand Smoke Protections Ordinance” brochure.
95
A Guide to Contra Costa County’s
Secondhand Smoke
Protections Ordinance
Contra Costa Public Health
Tobacco Prevention Project
597 Center Ave, Suite 125
Martinez, CA 94553
888-877-4202 Complaint line
925-313-6214 Office
925-313-6864 Fax
http://www.cchealth.org/topics/tobacco
Who do I call to make a complaint?
Any person may call the Contra Costa Health
Services Tobacco Prevention Project at
888-877-4202.
What happens after a complaint is made?
A warning letter will be sent to the business
owner about a possible violation of the ordinance.
Failure to comply with the ordinance may result
in fines.
Are there other remedies under the law?
Under the Americans with Disabilities Act,
violators may be sued for $50,000 for the first
violation and $100,000 for the second violation,
plus attorney’s fees, if a member of the public
experiences damage to their health due to
secondhand smoke exposure.
For more information or to order signage for your
business, contact the Tobacco Prevention Project
or visit our website.
If you or someone you know would like to
quit smoking, call
1-800-NO BUTTS
for free cessation services and
more information.
Why is this Ordinance Important?
There is no safe level of exposure to secondhand
smoke. This ordinance helps to protect everyone
who lives and works in the unincorporated
communities of Contra Costa County from the
harmful effects of secondhand smoke.
Secondhand smoke causes as many as 53,000 deaths
each year in the Unites States, approximately
6,000 of which occur in California. Health impacts
of Secondhand Smoke (SHS) in California each
year include:
• Over 400 lung cancer deaths
• Over 3,600 cardiac deaths
• About 31,000 episodes of asthma
• About 1,600 cases of low birth weights in
newborns
• Over 4,700 cases of premature births
In 2006, the California Air Resources Board
(CARB) designated secondhand smoke as
a toxic air contaminant that may cause or
contribute to an increase in deaths or in
serious illness or pose a hazard to human
health, particularly in children.
April 2015
Many services are covered by Medi-Cal. If you
would like to receive information regarding
Medi-Cal eligibility call the Social Services office:
1-800-709-8348.96
About the Ordinance
New laws in Contra Costa County reduce
secondhand smoke exposure among residents,
visitors and workers in all unincorporated
communities of Contra Costa County (County
Ordinance Code Chapter 445-4).
Where Smoking is Prohibited
Smoking of any tobacco product or plant
(including the use of a hookah pipe, medical
marijuana or electronic smoking device such as an
e-cigarette) is prohibited in the following areas:
Indoor Areas
All workplaces and indoor areas open to the
public, including tobacco shops, owner- or
volunteer-operated businesses and hotel lobbies.
Outdoor Areas
• All areas within 20 feet of the doors, operable
windows, air ducts, and ventilation systems of
any enclosed worksite or enclosed places open
to the public, except while passing on the way
to another destination;
• Outdoor dining areas at bars and restaurants
and outdoor lounges and dining areas at
places of employment;
• Public parks and on public trails;
• Outdoor public service areas (e.g., ATMs,
ticket lines, and bus stops); and
• Outdoor public events (e.g., fairs, festivals,
concerts, and farmers’ markets).
County Owned or Leased Properties
• Smoking is prohibited on the campus of
County-owned or leased properties.
Multi-Unit Housing (two or more units)
• Common indoor and outdoor areas;
• Within 20 feet of doors, windows, air ducts
and ventilation systems of multi-unit housing
residences, except while walking from one
destination to another;
• On all balconies, patios, decks and in carports;
and
• In 100% of all dwelling units of multi-unit
housing residences that received a building
permit after January 1, 2011.
Multi-unit Housing Landlord Requirements
Under the law, landlords are required to:
• Maintain and keep on file at the premises: (1)
a list of all designated non-smoking units at
the residence; (2) a floor plan of the residence
that identifies the location of all designated
non-smoking units, any units where smoking
is permitted and any designated outdoor
smoking areas;
• Provide a copy of the list and floor plan, and
a copy of any policy for addressing smoking
complaints to each prospective tenant along
with every new lease or rental agreement
for the occupancy of a unit in a multi-unit
residence; and
• Include lease terms with a clause stating it is
a material breach of the lease to smoke in a
non-smoking unit or in any indoor or outdoor
common area where smoking is prohibited.
Landlord, Owner and Manager Requirements
In every building or other place where smoking is
prohibited by law, the owner, operator or manager
must:
• Post “No smoking” signs with letters of not
less than one inch in height, or the use of
the international “No Smoking” symbol
(consisting of a burning cigarette in a red
circle with a red bar across it), visibly in every
building or other place where smoking is
regulated by the owner, operator, manager or
other person having control of the building or
other place.
• Not allow ashtrays or other receptacles for
disposing of smoking material where smoking
is prohibited; and
• Not knowingly allow smoking in smoking
prohibited areas. The owner, operator or
manager must request that the person stop
smoking and if the person fails to stop, ask
them to leave the premises.
97
Abril de 2015
Una guía sobre el decreto
de protecciones contra el
humo de segunda mano
del Condado Contra Costa
Contra Costa Public Health
Tobacco Prevention Project
597 Center Ave, Suite 125
Martinez, CA 94553
Línea de quejas: 888-877-4202
Oficina: 925-313-6214
Fax: 925-313-6864
http://www.cchealth.org/topics/tobacco
¿A quién llamo para presentar una queja?
Cualquier persona puede llamar al Proyecto de
Prevención de uso del tabaco, Servicios de salud
de Contra Costa al número 888-877-4202.
¿Qué sucede después de presentar una queja?
Se le enviará una carta de advertencia al
propietario del negocio sobre una posible
violación del decreto. No cumplir con el decreto
puede provocar que se imponga una multa.
¿Hay otros recursos de acuerdo con la ley?
Según la Ley de Americanos con Discapacidades
(Americans with Disabilities Act), las personas
que cometan la infracción serán demandadas por
$50,000 por la primera infracción y $100,000 por la
segunda infracción, además de los honorarios de
abogados, si un miembro del público experimenta
daños a su salud debido a la exposición al humo de
segunda mano.
Para obtener más información o para ordenar rótulos
para su negocio, comuníquese con el Proyecto de
Prevención del uso del tabaco o visite nuestro
sitio web.
Si usted o alguien a quien usted conoce
quiere dejar de fumar, llame al
1-800-NO BUTTS
para recibir los servicios gratuitos para dejar
de fumar y para recibir más información.
¿Por qué es importante este decreto?
No existe un nivel seguro de exposición al humo
de segunda mano. Este decreto ayuda a proteger
a todos los que viven y trabajan en comunidades
no incorporadas del Condado Contra Costa de los
efectos nocivos del humo de segunda mano.
El humo de segunda mano causa hasta 53,000 muertes
cada año en Estados Unidos, aproximadamente
6,000 de ellas ocurren en California. Los impactos a
la salud del humo de segunda mano (Secondhand
Smoke, SHS) cada año en California incluyen:
• Más de 400 muertes por cáncer de pulmón
• Más de 3,600 muertes por problemas cardíacos
• Aproximadamente 31,000 episodios de asma
• Aproximadamente 1,600 casos de recién
nacidos con bajo peso al nacer
• Más de 4,700 casos de nacimientos prematuros
En 2006, la Junta de Recursos del Aire de
California (California Air Resources Board,
CARB) designó el humo de segunda
mano como un contaminante tóxico del
aire que puede causar o contribuir a
un aumento en el número de muertes
o enfermerdades graves o representar
un peligro para la salud humana,
particularmente los niños.
Muchos servicios están cubiertos por Medi-Cal.
Si desea recibir información sobre la elegibilidad
para Medi-Cal, llame a la oficina de Servicios
Sociales al: 1-800-709-8348.98
Acerca del Decreto
Las nuevas leyes del Condado Contra Costa
restringen la exposición al humo de segunda mano
entre los residentes, visitantes y trabajadores
de todas las comunidades no incorporadas del
Condado Contra Costa (Capítulo 445-4 del Código de
Ordenanzas del Condado).
En dónde se prohíbe fumar
Se prohíbe fumar cualquier producto o planta de
tabaco (incluyendo el uso de un narguile, mariguana
medicinal o un aparto electrónico para fumar como
un cigarrillo electrónico) en las áreas siguientes:
Áreas en el interior
Todos los lugares de trabajo y áreas en el interior
que estén abiertos al público, incluyendo tiendas de
venta de productos de tabaco, negocios operados
por el propietario o un voluntario y vestíbulos de
los hoteles.
Áreas al aire libre
• Todas las áreas a una distancia de 20 pies de las
puertas, ventanas que se puedan abrir, ductos de
aire y sistemas de ventilación de cualquier sitio
de trabajo cerrado o lugares cerrados que estén
abiertos al público, salvo cuando pasan en su
camino a otro destino;
• Áreas para comer al aire libre en bares y
restaurantes y salones al aire libre y áreas para
comer en los lugares de trabajo;
• Parques públicos y senderos públicos;
• Áreas de servicio público al aire libre (por
ejemplo, cajeros automáticos, colas para
comprar boletos y paradas de bus); y
• Eventos públicos al aire libre (por ejemplo,
ferias, festivales, conciertos y mercados
agrícolas).
Propiedades arrendadas o que sean propiedad del
condado
• Está prohibido fumar en los campos de
propiedades arrendadas o que sean propiedad
del condado.
Viviendas multifamiliares (dos o más unidades)
• Áreas comunes en el interior y al aire libre;
• A una distancia de 20 pies de puertas, ventanas,
ductos de aire y sistemas de ventilación de
viviendas con varias unidades, excepto cuando
camina de un lugar a otro;
• En todos los balcones, patios, terrazas y en garajes
abiertos; y
• En el 100% de todas las unidades habitacionales
de residencias multifamiliares que recibieron una
licencia para construir después del 1 de enero de 2011.
Requisitos para los propietarios de viviendas
multifamiliares
De acuerdo con la ley, a los propietarios se les exige:
• Mantener y guardar en el archivo en las
instalaciones: (1) una lista de todas las áreas
designadas para no fumar de la residencia; (2) un
plano de planta de la residencia que identifique
la ubicación de todas las unidades designadas
para no fumar, cualquier unidad en donde esté
permitido fumar y cualquier área designada para
fumar al aire libre;
• Proporcionar una copia de la lista y del plano de
planta, así como una copia de cualquier política
sobre cómo tratar las quejas por fumar a cada
posible inquilino junto con cada nuevo contrato
de arrendamiento o contrato de alquiler para
la ocupación de una unidad en una residencia
multifamiliar; y
• Incluir en los términos del contrato una cláusula
que indique que es una violación material al
contrato de arrendamiento fumar en una unidad
en donde no se permite o en cualquier área
común en el interior o al aire libre en donde esté
prohibido fumar.
Requisitos del propietario, arrendador y
administrador
En todos los edificios o en cualquier otro lugar
en donde esté prohibido fumar según la ley, el
propietario, el operador o el administrador deben:
• Colocar rótulos de "No fumar" con letras de no
menos de una pulgada de altura o el símbolo
de uso internacional "No fumar" (un cigarrillo
encendido dentro de un círculo rojo con una
barra roja que lo atraviesa), visiblemente en
todos los edificios o en cualquier otro lugar en
donde fumar esté regulado por el propietario,
el operador, el administrador u otra persona
que tenga el control del edificio o de otro lugar.
• No permitir que haya ceniceros u otros
recipientes para desechar el material que
se haya utilizado para fumar en donde esté
prohibido fumar; y
• No permitir deliberadamente, fumar en áreas
en donde está prohibido fumar. El propietario,
el operador o el administrador debe solicitar
que la persona deje de fumar y si la persona no
lo hace, pedirle que abandone las instalaciones.
99
For Property Managers,
Developers and Landlords
in unincorporated
Contra Costa
Information on
Contra Costa County’s
Landlord Liability
Landlords are not liable for a tenant’s
breach of the smoking regulations if
(1) the landlord has fully complied
with all provisions of the law; and (2)
upon receiving a signed written com-
plaint regarding prohibited smoking,
the landlord provides warning to the
offending tenant. Upon receiving a
second signed, written complaint
against the offending tenant, the land-
lord may evict but is not liable for the
failure to do so.
Penalties for Non-compliance with the Ordinance
Failure to comply with the ordinance can
result in administrative fines of $100 for the
first violation, $200 for the second violation
within a year and $500 for each additional
violation within a year. Landlords who fail
to comply with this ordinance may be sub-
ject to other legal claims by tenants.
Tobacco Prevention Project
Community Wellness and Prevention Programs
Contra Costa Public Health
597 Center Avenue, Suite 125 Martinez, CA 94553
888-877-4202 Complaint line 925-313-6214 Office
925-313-6864 Fax
http://www.cchealth.org/tobacco
For more information or to order signage
(available as supplies last) for your multi-unit
housing residence, contact the Tobacco Preven-
tion Project or visit our website.
Why is this Ordinance Important?
In 2006, the California Air Resources Board
(CARB) designated secondhand smoke as a toxic
air contaminant that may cause or contribute to
an increase in deaths or in serious illness or pose a
hazard to human health, particularly in children.
The U.S. Surgeon General has declared that there
is no safe level of exposure to secondhand smoke.
Secondhand smoke causes as many as 53,000
deaths each year in the Unites States, approxi-
mately 6,000 of which occur in California.
Secondhand smoke has been shown to move
through light fixtures, through ceiling crawl
spaces, and into and out of doorways and win-
dows. This ordinance helps to protect people who
live in multi-unit housing in the unincorporated
communities of Contra Costa County from the
harmful effects of secondhand smoke.
This is a
smoke-free building
August 2013
Many services are covered by Medi-Cal. If you would like to receive
information regarding Medi-Cal eligibility call the Social Services office:
1-800-709-8348
100
Lease/Rental Agreement Requirements
Under the law, the Owner and Man-
ager of a multi-unit housing building
must:
Maintain and keep on file at the
premises: (1) a list of all designated
nonsmoking units at the residence; (2)
a floor plan of the residence that
identifies the location of all desig-
nated non-smoking units, any units
where smoking is permitted and any
designated outdoor smoking areas;
and
With every new lease or rental agree-
ment for the occupancy of a unit in a
multi-unit residence, include:
A copy of the list of nonsmoking
units;
A copy of the floor plan;
Information indicating whether a
policy for handling smoking com-
plaints is in effect at the multi-unit
residence, and if so, the terms of
the policy; and
A clause stating it is a material
breach of the lease to a) violate
any law regarding smoking while
on the premises; b) smoke in a
non-smoking unit; or c) smoke in
any multi-unit residence common
area where smoking is prohibited.
(The California Apartment Asso-
ciation’s form 34.0 may be used
for this purpose).
Under certain conditions, landlords may
designate a common outdoor area of a
multi-unit housing residence as a smoking
area. For more information contact the
Tobacco Prevention Project at 888-877-
4202.
New Law in Effect
In March 2013, the Contra Costa County
Board of Supervisors amended the County’s
Secondhand Smoke Protections Ordinance
to include more protections for residents of
multi-unit housing in unincorporated Contra
Costa.
Smoking of any tobacco product or other
plant (including the use of a hookah
pipe, medical marijuana or Electronic
Nicotine Delivery System (ENDS) such
as an e-cigarette) is prohibited in the fol-
lowing areas of multi-unit housing with 2
or more units:
Common indoor and outdoor areas;
Within 20 feet of doors, windows, air
ducts and ventilation systems, except
while walking from one destination to
another;
On all balconies, patios, decks and in
carports; and
In 100% of all dwelling units of multi-
unit housing residences that receive a
building permit after January 1, 2011.
Landlord Responsibilities
Under the law, the Owner and Manager of
a multi-unit housing building must:
Post “No smoking” signs with letters of
not less than one inch in height, or the
international “No Smoking” symbol
(consisting of a burning cigarette in a red
circle with a red bar across it). The sign
must be visibly posted in every building
or other place where smoking is prohib-
ited by law;
Not allow ashtrays or other receptacles
for disposing of smoking material where
smoking is prohibited;
Not knowingly allow smoking in smoking
prohibited areas; and
Comply with lease/rental agreement
requirements outlined in the next section.
101
102
FAMILY AND HUMAN SERVICES COMMITTEE 6.
Meeting Date:12/12/2016
Subject:2017 Year End Report on FHS Referral Items
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: N/A
Referral Name: N/A
Presenter: Enid Mendoza, Senior Deputy County
Administrator
Contact: Enid Mendoza, (925)
335-1039
Referral History:
At the end of each calendar year, the staff person to the Family and Human Services Committee
reports to the Committee on the activities during the year and makes recommendations regarding
the closure of referrals and the carryover of other referrals to the next year.
Referral Update:
Recommendation(s)/Next Step(s):
ACCEPT the recommendations as outlined in the attached memo, which requests to carry forward
twenty-two referrals and add one new referral to the 2017 Family and Human Services
Committee.
Attachments
Year End Memo on FHS Referrals for 2017
103
County of Contra Costa
OFFICE OF THE COUNTY ADMINISTRATOR
MEMORANDUM
DATE: December 12, 2016
TO: Family and Human Services Committee
Supervisor Candace Andersen, Chair
Supervisor Federal D. Glover, Vice Chair
FROM: Enid Mendoza, Senior Deputy County Administrator
SUBJECT: 2016 YEAR-END REPORT ON FAMILY AND HUMAN SERVICES
COMMITTEE REFERRAL ITEMS
_________________________________________________________________________
RECOMMENDATION(S):
I. ACKNOWLEDGE that the Board of Supervisors carried over twenty-one referrals
from the prior year into the 2016 calendar year.
II. ACKNOWLEDGE that on June 7, 2016, the Board of Supervisors accepted and
approved the Employment and Human Services Director’s recommendation to
change the following referrals:
a. Eliminate the “Office of the Future” report from Referral #44 - Challenges
for EHSD and expand the referral to include the “Continuum of Care
Reform (Foster Care)” report; and
b. Reduce the frequency of Referral #108 – Call Center Oversight and the
Health Care Reform Update from biannual to annual and eliminate the
referral after June 30, 2017; and
c. Expand Referral #93 – Independent Living Skills Program to include
additional youth services updates and retitle the referral to “Youth Services
Report”; and
d. Refer a new report regarding the “impacts of technology on access to
public benefits” to the Employment and Human Services Department so
that the Family and Human Services Committee and the Board of
Supervisors can receive annual updates on the department’s reworking of
its business processes and development of technologies to make remote
access of public benefits more common; and
e. Expand Referral #110 – Innovative Community Partnerships to include
a report on “Whole Family Services”.
104
Page 2 of 2
III. ACKNOWLEDGE that at the April 26, 2016 Board of Supervisors meeting the
topic of child and teen psychiatric services and the utilization planning of the 4-D
Unit was referred to the Family and Human Services Committee for follow up.
IV. ACKNOWLEDGE that at the September 13, 2016 Board of Supervisors meeting,
the issues brought forward by the Mental Health Commission on the County’s
public mental health care system was referred to the Family and Human Services
Committee for follow up.
V. ACCEPT the recommendation to carry forward the following twenty-four referrals
from the 2016 Family and Human Services Committee to the 2017 Committee:
a. Referral #5 – Continuum of Care Plan for the Homeless/Healthcare for the
Homeless
b. Referral #20 – Public Service Portion of the CDBG
c. Referral #25 – Child Care Planning/Development Council Membership
d. Referral #44 – Challenges for EHSD (Continuum of Care Reform)
e. Referral #45 – Adult Protective Services and Challenges for Aged & Disabled
Populations
f. Referral #56 – East Bay Stand Downs for Homeless Veterans / Stand Down on
the Delta
g. Referral #61 – HIV Prevention/Needle Exchange Program
h. Referral #78 – Community Services Bureau/Head Start Oversight
i. Referral #81 – Local Child Care & Development Planning Council Activities
j. Referral #82 – Secondhand Smoke Ordinance
k. Referral #92 – Local Planning Council – Child Care Needs Assessment
l. Referral #93 – Youth Services Report (formerly Independent Living Skills
Program)
m. Referral #101 – FACT Committee At-Large Appointments
n. Referral #103 – SNAP/CalFresh (Food Stamp) Program
o. Referral #107 – Laura’s Law
p. Referral #108 – Call Center Oversight and the Health Care Reform Update
(to be eliminated June 30, 2017, or after final report in 2017)
q. Referral #109 – Workforce Innovation and Opportunity Act
r. Referral #110 – Innovative Community Partnerships
s. Referral #111 – Human Trafficking – Update on Commercial Sexual
Exploitation of Children and Update on the Family Justice Center
t. Referral #112 – Policy Options to Protect Youth from Tobacco Influences in the
Retail Environment
u. Referral #113 – Built Environment and Health in All Policies
v. Referral #114 – Impacts of Technology on Access to Public Benefits
w. Referral #115 – Child and Teen Psychiatric Services
x. Referral #116 – Public Mental Health Care System
105