HomeMy WebLinkAboutBOARD STANDING COMMITTEES - 09252017 - FHS Cte Agenda Pkt
FAMILY & HUMAN SERVICES
COMMITTEE
September 25, 2017
10:30 A.M.
651 Pine Street, Room 101, Martinez
Supervisor John Gioia, Chair
Supervisor Candace Andersen, 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. RECOMMEND to the Board of Supervisors the appointment of G.Vittoria Abbate to the
Adult Education & Literacy #1 seat on the Workforce Development Board with a term
expiring June 30, 2020, as recommended by the Workforce Development Board.
4. CONSIDER accepting the Assisted Outpatient Treatment evaluation reports for fiscal
year 2016-17 as provided by the Health Services Department and Resource
Development Associates and forwarding the attached reports to the Board of Supervisors
for their information. (Warren Hayes, MHSA Program Manager)
5. CONSIDER accepting the report from the Employment and Human Services
Department on the foster care Continuum of Care Reform implementation efforts and
forwarding it to the Board of Supervisors for their information. (Kathy Gallagher,
Employment and Human Services Director)
6.The next meeting is currently scheduled for November 6, 2017 at 9:00 am.
7.Adjourn
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.
F&HS Agenda Packet Page 1
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
F&HS Agenda Packet Page 2
FAMILY AND HUMAN SERVICES COMMITTEE 3.
Meeting Date:09/25/2017
Subject:Appointments to the Workforce Development Board
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: N/A
Referral Name: Appointments to Advisory Bodies
Presenter: N/A Contact: Enid Mendoza, (925) 335-1039
Referral History:
On December 13, 2011, The Board of Supervisors adopted Resolution No. 2011/498 adopting policy governing appointments to
independent boards, committees, and commissions, and special districts. Included in this resolution was a requirement that
independent bodies initially conducting interviews for At Large/Countywide seats provide appointment recommendations to a
Board Committee for further review.
The Workforce Development Board implements federal requirements for programs to address the education, skills, and
employment needs for a skilled workforce, and that lead to an increase in the skills and earnings of Contra Costa residents.
On March 14, 2016, the Family and Human Services Committee (F&HS) accepted the Employment and Human Services
Department's recommendation to decertify the then current Workforce Investment Act local Board and recertify a new board
structure in compliance with the new Workforce Innovation and Opportunity Act (WIOA). F&HS approved these
recommendations, and the Board did the same at their March 29, 2016 meeting.
Under new standards in WIOA (2016) and as adopted by the Board on March 29, 2016, the new Workforce Development Board
structure is: a total of 23 required seats and 2 "optional seats", consisting of: 13 Business representatives, 5 Workforce
representatives, and 5 Education and Training representatives as follows: (1) Adult Education/Literacy; (2) Higher Education;
(3) Economic & Community Devl; (4) Wagner Peyser representative; (5) Vocational Rehabilitation. Also two additional/
"optional" seats that may be filled from any of the 3 categories above.
Referral Update:
The Workforce Development Board currently has 19 filled seats and 13 vacancies. Below is the current roster:
Seat Title
Term
Expiration
Date
Current
Incumbent
Incumbent
Supervisor
District
BOS
Appointment
Date
Number of
Meetings
Attended
Since
Appointment
Date
Total
Number of
Meeting
Since
Appointment
(Full Board)
Total
Number
of
Absences
Allowable
in By-laws
Business 1 6/30/2020 McGill Michael II 3/29/2016 5 5 0
Business 2 6/30/2020 VACANT
Business 2 6/30/2020 VACANT
Business 3 6/30/2020 VACANT
Business 3 6/30/2020 Mahoney,
William
V 5/23/2017 0 0 0
Business 4 6/30/2020 Carrillo
Maggie
III 3/29/2016 2 5 3
Business 5 6/30/2020 Amin Bhuphen
B.
IV 3/29/2016 5 5 0
Business 6 6/30/2020 Carrascal Jose III 3/29/2016 4 5 1
F&HS Agenda Packet Page 3
Business 7 6/30/2020 Cox Jason IV 3/29/2016 4 5 1
Business 8 6/30/2020 Georgian
Ashley
II 3/29/2016 4 5 1
Business 9 6/30/2020 VACANT
Business 9 6/30/2020 Robert Lilley V 7/11/2017 0 0 0
Business 10 6/30/2020 Rivera Robert IV 3/29/2016 5 5 0
Business 11 6/30/2020 Steele Justin I 3/29/2016 5 5 0
Business 12 6/30/2020 Adler Paul V 3/29/2016 3 5 2
Business 13 6/30/2020 VACANT
Workforce Representative
1 6/30/2020 VACANT
Workforce Representative
1 6/30/2020 VACANT
Workforce Representative
2 6/30/2020 Williams III
Robert
I 3/29/2016 4 5 1
Workforce Representative
3 6/30/2020 Older Steve IV 3/29/2016 5 5 0
Workforce Representative
4 6/30/2020 Hanlon
Margaret
I 3/29/2016 4 5 1
Workforce Representative
5 6/30/2020 VACANT
Workforce Representative
5 6/30/2020 VACANT
Education 1: Adult
Ed/Literacy 6/30/2020 VACANT
Education 1: Adult
Ed/Literacy 6/30/2020 VACANT
Education 2: Higher
Education 6/30/2020 VACANT
Education 2: Higher
Education 6/30/2020 VACANT
Education 3:
Economic/Community
Dev.
6/30/2020
Connelly
Kristin
II
3/29/2016 4 5 1
Education 4: Employment
Development 6/30/2020 Johnson
Richard
IV 3/29/2016 4 5 1
Additional/Optional #1 6/30/2020 Vega Yolanda II 3/29/2016 5 5 0
Additional/Optional #2 6/30/2020 Montagh, John IV 6/6/2017 0 0 0
Education 5: Vocational
Rehabilitation 6/30/2020 Asch Carol IV 3/29/2016 5 5 0
On June 29, 2017, Ms. G.Vittoria Abbate was interviewed for the Adult Education & Literacy #1 seat vacancy and was
approved by the Workforce Development Board Executive Committee at their July 12, 2017 meeting. There were no other
candidates competing for this seat.
Recommendation(s)/Next Step(s):
RECOMMEND to the Board of Supervisors the appointment of G.Vittoria Abbate to the Adult Education & Literacy #1 seat on
the Workforce Development Board with a term expiring June 30, 2020, as recommended by the Workforce Development Board.
Fiscal Impact (if any):
There is no fiscal impact.
Attachments
WDB Memo to F&HS
G.V.Abbate Application
F&HS Agenda Packet Page 4
MEMORANDUM
DATE: July 18, 2017
TO: Family and Human Services Committee
CC: Kevin Corrigan, CAO Senior Management Analyst
Enid Mendoza, CAO Sr. Deputy County Administrator
FROM: Donna Van Wert, Interim Executive Director
SUBJECT: Appointment to Workforce Development Board
This memorandum requests the Family and Human Services Committee recommend to the Contra Costa County
Board of Supervisors the appointment of the following candidates to the new WIOA compliant Workforce
Development Board of Contra Costa County.
Background:
Local board structure and size:
Compared to predecessor legislation, the Workforce Innovation and Opportunity Act (WIOA) substantially
changes Local Board composition by reducing local workforce development board size while maintaining a
business and industry majority and ensuring representation from labor and employment and training
organizations.
The Executive Committee of the local WIOA board met January 21, 2016 and approved a recommended WIOA
Board configuration, subsequently approved by the Board of Supervisors on March 29, 2016. To meet the
categorical membership percentages, the WDB recommended a board of twenty-five (25) members. This option
represents the minimum required local board size under WIOA plus an additional six (6) optional representatives
in the following enumerated categories: 1) business; 2) workforce; 3) education and training.
Category – Representatives of Business (WIOA Section 107(b)(2)(A))
•Thirteen (13) representatives (52%)
Category – Representatives of Workforce (WIOA Section 107(b)(2)(A))
•Five (5) representatives (20%)
Category – Representatives of Education and Training (WIOA Section 107(b)(2)(C))
•One (1) Adult Education/Literacy Representative (WIOA title II)
•One (1) Higher Education Representative
•One (1) Economic and Community Development Representative
•One (1) Wagner Peyser Representative
•One (1) Vocational Rehabilitation Representative
Two (2) additional seats from the above categories, including constituencies referenced in
Attachment III of Training Employment & Guidance Letter (TEGL) 27-14.
DONNA VAN WERT
EXECUTIVE DIRECTOR
F&HS Agenda Packet Page 5
Recommendation:
a)Recommend approval of local board candidate for the vacant
Adult Education & Literacy Seat # 1 to the new WIOA-compliant board (Attached application &
board roster)
•Interview Date – June 29, 2017
•G.Vittoria Abbate - Approved on July 12,2017 at the Executive Committee Meeting
•No other candidate competed for the vacant Adult Education & Literacy Seat # 1
NEW APPOINTMENT
Seat Last Name First Name Address & District
#
Term of
Expiration
District
(Resident)
Adult Education
& Literacy Seat
#1
Abbate G.Vittoria
Concord, CA 94519
District#5
6/30/2020 District #2
Thank you
DVW/rms
attachment
F&HS Agenda Packet Page 6
ubmit Date: Jun 08, 2017
First Name Middle Initial Last Name
Email Address
Home Address Suite or Apt
City State Postal Code
Primary Phone
Employer Job Title Occupation
Contra Costa County Boards & Commissions
Application Form
Profile
This application is used for all boards and commissions
Do you, or a business in which you have a financial interest, have a contract with Contra
Costa Co.?
Yes No
Is a member of your family (or step-family) employed by Contra Costa Co.?
Yes No
Interests & Experiences
Which Boards would you like to apply for?
Workforce Development Board: Submitted
G. Vittoria Abbate
vittoriausa@yahoo.com
P. O. Box 435
Orinda CA 94563
Mobile: (415) 726-3456
Mt. Diablo Unified School District
Director, College & Career and
Adult Education Director (Administrator)
G. Vittoria Abbate Page 1 of 7
F&HS Agenda Packet Page 7
Upload a Resume
If "Other" was Selected Give Highest Grade or
Educational Level Achieved
Please describe your interest in serving as a member of the board(s) you have selected and
if applicable which seat you are applying for.
I am interested in serving as the representative of the eight (8) Adult Education programs in Contra Costa
County which include Acalanes Adult Education (Acalanes HSD), Mt. Diablo Adult Education (Mt. Diablo
USD), Martinez Adult Education (Martinez USD), Pittsburg Adult Education Center (Pittsburg USD),
Liberty Adult Education (Liberty HSD), Antioch Adult Education (Antioch USD), West Contra Costa Adult
Education (West Contra Costa USD) and the Contra Costa County Office of Education (CCCOE) Contra
Costa Adult School jail ed program in Richmond. Currently I serve as years as the Co-Chair of the state-
mandated Contra Costa County Adult Education Consortium (CCCAEC) and previously for four (4) years
as President of the Contra Costa Adult Education Network (CCAEN), which recently voted unanimously
that I represent them as the Adult Education representative on the Workforce Development Board,
replacing Kathy Farwell former DIrector of Martinez Adult Education who served as our representative
during the past two years.
Have you previously served on a government or non-profit board or committee?
Yes and as mentioned above, I am currently serving as Co-Chair of the Contra Costa County Adult
Education Consortum (CCCAEC) which is a legislatively-authorized and mandated regional Consortium
that represents the eight (8) Contra Costa County Adult Education programs, the Contra Costa
Community College District Office and its three community colleges (Diablo Valley College, Los Medanos
College and Contra Costa College.) In addition, I have served for two years and will continue for two more
years as the State Legislative Chair of the California Council for Adult Education (CCAE) which is the
primary professional association representing Adult Education in California.
Please describe how your education, work experience, or other activities have prepared you
to serve on the board or commission you have selected.
I have more than 35 years of professional training and work in educational administration serving in both
private and public education. In particular, my training, background and experience is in the area of
international education as well as educational programs serving under-served populations.
Education History
Select the highest level of education you have received:
Other
Master's of Arts
G. Vittoria Abbate Page 2 of 7
F&HS Agenda Packet Page 8
Name of College Attended
Course of Study / Major
Units Completed
Degree Type
Date Degree Awarded
Name of College Attended
Course of Study / Major
Units Completed
College/ University A
Type of Units Completed
Semester
Quarter
Degree Awarded?
Yes No
College/ University B
Type of Units Completed
Semester
Quarter
G. Vittoria Abbate
Applied Linguistics (Specialization
in Teaching English to Speakers of
Other Langauges)
Master's of Arts Degree
Linguistics (Specialization in
Teaching English to Speakers of
Other Languages)
1975
California State University (East
Bay)
Education Administrative
Credential
G. Vittoria Abbate Page 3 of 7
F&HS Agenda Packet Page 9
Degree Type
Date Degree Awarded
Name of College Attended
Course of Study / Major
Units Completed
Degree Type
Date Degree Awarded
Course Studied
Hours Completed
Degree Awarded?
Yes No
College/ University C
Type of Units Completed
Semester
Quarter
Degree Awarded?
Yes No
Other schools / training completed:
Preliminary & Clear Administrative
Services Credential
2006-2007
G. Vittoria Abbate Page 4 of 7
F&HS Agenda Packet Page 10
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Position Title
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Certificate Awarded?
Yes No
Work History
Please provide information on your last three positions, including your current one if you are
working.
1st (Most Recent)
Volunteer Work?
Yes No
Employer's Name and Address
Duties Performed
2nd
April 2003 to Present
Salaried Employee (60+)
G. Vittoria Abbate Page 5 of 7
F&HS Agenda Packet Page 11
Position Title
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Position Title
Volunteer Work?
Yes No
Employer's Name and Address
Duties Performed
3rd
Volunteer Work?
Yes No
Employer's Name and Address
Duties Performed
Final Questions
How did you learn about this vacancy?
Other
G. Vittoria Abbate Page 6 of 7
F&HS Agenda Packet Page 12
If "Other" was selected please explain
. Do you have a Familial or Financial Relationship with a member of the Board of
Supervisors?
Yes No
If Yes, please identify the nature of the relationship:
Do you have any financial relationships with the County such as grants, contracts, or other
economic relations?
Yes No
If Yes, please identify the nature of the relationship:
From current work as a
representative of Contra Costa
County Adult Education programs.
G. Vittoria Abbate Page 7 of 7
F&HS Agenda Packet Page 13
&HS Agenda Packet Page 14
FAMILY AND HUMAN SERVICES COMMITTEE 4.
Meeting Date:09/25/2017
Subject:Assisted Outpatient Treatment (Laura's Law) Annual Implementation Update
Report
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:
The Assisted Outpatient Treatment Demonstration Project Act (AB 1421), known as Laura’s
Law, was signed into California law in 2002 and is authorized until January 1, 2017. Laura’s Law
is named after a 19 year old woman working at a Nevada County mental health clinic. She was
one of three individuals who died after a shooting by a psychotic individual who had not engaged
in treatment.
AB 1421 allows court-ordered intensive outpatient treatment called Assisted Outpatient Treatment
(AOT) for a clearly defined set of individuals that must meet specific criteria. AB 1421 also
specifies which individuals may request the County Mental Health Director to file a petition with
the superior court for a hearing to determine if the person should be court ordered to receive the
services specified under the law. The County Mental Health Director or his licensed designee is
required to perform a clinical investigation, and if the request is confirmed, to file a petition to the
Court for AOT.
If the court finds that the individual meets the statutory criteria, the recipient will be provided
intensive community treatment services and supervision by a multidisciplinary team of mental
health professionals with staff-to-client rations of not more that 1 to 10. Treatment is to be
client-directed and employ psychosocial rehabilitation and recovery principles. The law specifies
various rights of the person who is subject of a Laura’s Law petition as well as due process
hearing rights.
If a person refuses treatment under AOT, treatment cannot be forced. The Court orders meeting
with the treatment team to gain cooperation and can authorize a 72 hour hospitalization to gain
cooperation. A Laura’s Law petition does not allow for involuntary medication.
F&HS Agenda Packet Page 15
AB 1421 requires that a county Board of Supervisors adopt Laura’s Law by resolution to
authorize the legislation within that county. AB 1421 also requires the Board of Supervisors to
make a finding that no voluntary mental health program serving adults or children would be
reduced as a result of implementation.
At its June 3, 2013 meeting, the Legislation Committee requested that this matter be referred to
the Family and Human Services Committee (F&HS) for 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.
On July 9, 2013, the Board of Supervisors referred the matter to F&HS for consideration. F&HS
received reports on the implementation of Laura's Law on October 16, 2013 and March 10, 2014,
and on February 3, 2015 the Board accepted the recommendations to implement Laura's Law. In
February 2016, Laura's Law was implemented and the Department provided F&HS with a
6-month implementation report on September 12, 2016 and a data report on the 6-month
implementation on December 12, 2016. Both reports were accepted by the Board on September
27, 2016 and December 20, 2016, respectively.
On May 22, 2017 the Family and Human Services Committee received and approved a report on
the AOT implementation for the period February through December 2016. The report was later
approved by the Board of Supervisors at their July 11, 2017 meeting. The department reported
that they would be prepared to provide a full fiscal year report to F&HS and the Board after the
July 1, 2016 through June 30, 2017 data was available.
Referral Update:
In partnership with Resource Development Associates (RDA), the Health Services Department
Behavioral Health Division has provided the attached reports, which include the AOT Program
Evaluation Summary, the Contra Costa County Assisted Outpatient Treatment (AOT) Evaluation
for fiscal year 2016/17, and the Contra Costa County Assisted Outpatient Treatment (AOT)
Evaluation MHS' ACTiOn Team 2017 Fidelity Assessment.
Recommendation(s)/Next Step(s):
CONSIDER accepting the Assisted Outpatient Treatment evaluation reports for fiscal year
2016-17 as provided by the Health Services Department and Resource Development Associates
and forwarding the attached reports to the Board of Supervisors for their information.
Fiscal Impact (if any):
There is no fiscal impact; the report is informational.
Attachments
AOT FY 16-17 Evaluation Summary Report
AOT FY 16-17 Evaluation Report
AOT Evaluation Fidelity Assessment Summary
AOT Evaluation Presentation Slides
F&HS Agenda Packet Page 16
Assisted Outpatient Treatment (AOT) Program Evaluation Summary
Resource Development Associates (RDA) completed a first full year evaluation (July 1, 2016 through June
30, 2017) of Contra Costa County’s Assisted Outpatient Treatment Program. This program started in
March of 2016 to serve seriously mentally ill adults who have demonstrated a resistance to mental
health treatment, their condition is substantially deteriorating, and are unlikely to survive safely in the
community without supervision. Findings should be considered preliminary due to the program being
early in its operations with a resultant small number of consumers included for data analysis.
Methodology. Data was collected from Contra Costa Behavioral Health Services (CCBHS), Mental Health
Systems (MHS), the Sheriff’s Office, and Superior Court and included 1) the number and type of persons
served, 2) frequency and intensity of services, 3) rates of hospitalization, incarceration and
homelessness, 4) clinical assessment of change in social functioning and independent living skills, and 5)
dollars spent and cost avoided.
Findings.
1) Number and Type of Persons Served. During this period:
CCBHS investigated 177 persons who were referred, and
o Determined 42 to meet AOT eligibility and referred to MHS for services;
o Connected 19 non-AOT eligible individuals with a new or current service provider;
o Have 25 cases still pending; and
o Closed 91 cases as not being AOT eligible, unable to be assessed, or the referral
requestor either withdrew the referral or could not be reached.
MHS provided outreach and engagement services in a variety of settings to 74 consumers, and
o Enrolled 34 individuals voluntarily in Assertive Community Treatment (ACT);
o Enrolled 9 individuals in ACT with court involvement;
o Connected 4 individuals with another service provider;
o Have 10 individuals still receiving outreach and engagement services; and
o Closed 17 cases with CCBHS – 4 of whom successfully completed the program.
At the time of ACT enrollment, salient features of the 43 individuals include 34 who had a co-
occurring substance use disorder, 17 who were homeless or living in a shelter, and 11 who
were under the age of 26.
2) Frequency and Intensity of Services. On average, the AOT Program took 107 days from referral
from a qualified requestor to ACT enrollment, with 17 individuals taking longer than the 120
days called for in the program design. Once enrolled, MHS averaged 6.5 contacts per week
lasting about 6 hours a week. This exceeds the expectation for ACT teams to have at least 4
face-to-face contacts for at least two hours of service per week. 93% of ACT consumers were
considered “treatment adherent” by virtue of receiving at least one hour of face-to-face
engagement with their ACT team at least two times per week.
3) Hospitalization, incarceration and homelessness rates. Of the 43 enrolled ACT consumers:
40 had an average of 4.7 crisis episodes before ACT enrollment, while 25 had an average of 3.1
crisis episodes during ACT enrollment;
F&HS Agenda Packet Page 17
29 had psychiatric hospitalizations before ACT enrollment, while 13 had hospitalizations during
ACT enrollment;
31 had bookings and incarcerations before ACT enrollment, while 14 had bookings and
incarcerations during ACT enrollment; and
6 consumers who were not housed before ACT enrollment obtained housing, while 3 lost their
housing during ACT enrollment.
4) Clinical assessment of change. MHS clinicians utilized the Self Sufficiency Matrix (SSM) to assess
consumers’ social functioning and independent living capacity both at intake and at regular
intervals of participation in ACT. Average aggregate score increased from 41.15 to 45.87 for the
15 individuals who completed six months of the program, and 41.15 to 59.75 for the 4
individuals who completed one year of the program.
5) Dollars spent and cost avoided.
For FY 2016-17, Contra Costa County spent $2,144,226 of the $2,250,000 budgeted amount.
MHS generated $271,836 in Medi-Cal reimbursement, with $206,589 as the target amount.
Of the 37 consumers with data available, a total of $2,315,254 was spent on all behavioral
health services in the 12 months before ACT, while $2,685,812 was spent during ACT, for an
increased cost of $370,558. Note that the caseload of MHS is approximately at half capacity.
Bookings costs decreased from $101,018 to $57,028, for a savings of $43,990.
Psychiatric hospitalization costs decreased from $870,157 to $478,765, for a savings of
391,392.
Discussion.
1) Both CCBHS and MHS staff work together to persistently and effectively engage and serve
consumers who by the nature of their psychiatric disability and co-occurring substance use
disorders are difficult to find and engage.
2) AOT program participants experience significant benefits from their participation in ACT.
3) Preliminary cost/savings analysis indicate that significant overall savings to the County can be
effected once MHS approximates the 75 consumers they are contracted to serve.
Recommendations.
1) A significant number of referred individuals are closed due to losing contact. It may be useful to
develop training and mechanisms to that would allow Psychiatric Emergency Services, Inpatient
Unit 4-C, jail mental health, as well as family members and other significant others to make AOT
program staff aware of an AOT-referred individual’s presence with enough time available for
AOT staff to respond.
2) A number of individuals are taking much longer than 120 days from referral to services, and
there is a group of individuals who initially agree to participate and fail to maintain sustained
engagement and/or don’t make expected gains. The program may wish to consider utilizing the
court petition sooner or differently as a means to encourage participation in mental health care.
F&HS Agenda Packet Page 18
Contra Costa County Assisted Outpatient
Treatment (AOT) Evaluation
Fiscal Year 2016/17 Evaluation Report
F&HS Agenda Packet Page 19
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 1
Table of Contents
Introduction ......................................................................................................................................5
Background Information ........................................................................................................................... 5
External Evaluation ................................................................................................................................... 5
Contra Costa County’s AOT Program Model............................................................................................. 6
AOT Process ........................................................................................................................................... 6
AOT Process Outcomes ......................................................................................................................... 7
AOT and ACT ......................................................................................................................................... 8
Methodology .....................................................................................................................................9
Data Measures and Sources ..................................................................................................................... 9
Data Analysis ........................................................................................................................................... 11
Limitations and Considerations .............................................................................................................. 11
Findings ........................................................................................................................................... 12
Pre-Enrollment ........................................................................................................................................ 12
Referral to AOT .................................................................................................................................... 13
Care Team ........................................................................................................................................... 14
AOT Enrollment ....................................................................................................................................... 19
ACT Consumer Profile .......................................................................................................................... 20
Service Participation............................................................................................................................ 23
ACT Consumer Outcomes .................................................................................................................... 25
AOT Costs and Cost Savings ................................................................................................................ 29
Discussion and Recommendations .................................................................................................... 32
Appendices ...................................................................................................................................... 35
Appendix I. AOT Eligibility Requirements ............................................................................................... 35
F&HS Agenda Packet Page 20
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 2
Appendix II. Description of Evaluation Data Sources .............................................................................. 36
Appendix III. FSP Consumer Profile ......................................................................................................... 38
F&HS Agenda Packet Page 21
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 3
Table of Figures
Figure 1. Contra Costa County AOT Program Stages .................................................................................... 6
Figure 2. Process Outcomes during AOT Process ......................................................................................... 7
Figure 3. Consumers Referred to AOT and/or Receiving MHS Services during FY16/17 ........................... 12
Figure 4. FY16/17 AOT Program.................................................................................................................. 13
Figure 5. Average Investigation Contact Attempts per Consumer (N = 177) ............................................. 15
Figure 6. Type of Outreach and Engagement Contacts (N = 652) .............................................................. 17
Figure 7. Average Length of Time from AOT Referral to ACT Enrollment .................................................. 18
Figure 8. Length of Time from AOT Referral to ACT Enrollment ................................................................ 18
Figure 9. Referred Consumers .................................................................................................................... 19
Figure 10. FY16/17 AOT Treatment Program Participants ......................................................................... 20
Figure 11. Primary Diagnosis at Referral (N = 43) ....................................................................................... 21
Figure 12. Educational Attainment ............................................................................................................. 22
Figure 13. School Attendance at Enrollment .............................................................................................. 22
Figure 14. Intensity of ACT Contacts per Week ......................................................................................... 24
Figure 15. Frequency of ACT Contacts per Week ....................................................................................... 24
Figure 16. ACT Consumers .......................................................................................................................... 25
Figure 17. Criminal Justice Involvement during ACT .................................................................................. 27
Figure 18. Type of Bookings during ACT ..................................................................................................... 27
Figure 19. Consumers’ Housing Status before and during ACT (N = 39) .................................................... 28
Figure 20. FY16/17 FSP Primary Diagnosis at Enrollment (N = 272) ........................................................... 38
F&HS Agenda Packet Page 22
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 4
Table of Tables
Table 1. AOT Outcomes and Corresponding Data Measures ....................................................................... 9
Table 2. Data Sources and Elements ........................................................................................................... 10
Table 3. Summary of Qualified Requestors ................................................................................................ 14
Table 4. Outcome of CCBHS Investigations (N = 177) ................................................................................. 15
Table 5. MHS Outreach and Engagement Outcomes (N = 74) .................................................................... 16
Table 6. ACT Consumer Demographics (N = 43) ......................................................................................... 21
Table 7. Housing Status at ACT Enrollment (N = 43) ................................................................................... 22
Table 8. Sources of Financial Support at and before ACT Enrollment (N = 43) .......................................... 22
Table 9. ACT Consumer Service Engagement (N = 43) ................................................................................ 23
Table 10. Consumers’ Crisis Episodes before and during ACT .................................................................... 26
Table 11. Consumers’ Psychiatric Hospitalizations before and during ACT ............................................... 26
Table 12. Bookings and Incarcerations before and during ACT .................................................................. 27
Table 13. Self Sufficiency Matrix Scores ..................................................................................................... 29
Table 14. Contra Costa County Department Costs ..................................................................................... 30
Table 15. Mental Health Service and Booking Costs before and during ACT (N = 37) ............................... 31
Table 16. FY16/17 FSP Consumer Demographics (N = 272) ....................................................................... 38
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Introduction
Background Information
In 2002, the California legislature passed Assembly Bill (AB) 1421 (also known as “Laura’s Law”), which
authorized the provision of Assisted Outpatient Treatment (AOT) in counties that adopt a resolution for
its implementation. 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. AOT uses an expanded referral and outreach process that may include civil court
involvement, whereby a judge may order participation in outpatient treatment. The California Welfare
and Institutions Code1 defines the target population, intended goals, and specific suite of services required
to be available for AOT consumers in California (see Appendix I).
On February 3, 2015, the Contra Costa County Board of Supervisors adopted a resolution to authorize the
implementation of AOT. Currently, Contra Costa County Behavioral Health Services (CCBHS) provides
behavioral health services to AOT consumers through an Assertive Community Treatment (ACT) team
operated by Mental Health Systems (MHS), a contracted provider organization. Contra Costa’s AOT
program represents a collaborative partnership between CCBHS, the Superior Court, County Counsel, the
Public Defender, and MHS; community mental health stakeholders and advocates have remained involved
in providing feedback and supporting the program to meet its intended objectives. The County’s AOT
program became operational on February 1, 2016 and accepted its first consumer in March 2016.
External Evaluation
Contra Costa County retained Resource Development Associates (RDA) to conduct an independent
evaluation of its AOT program implementation. The purposes of this evaluation are to: 1) satisfy California
Department of Healthcare Services (DHCS) reporting requirements; 2) provide information to the Board
of Supervisors, AOT collaborative partners, and the community; and 3) inform the continuous quality
improvement of the AOT program to support the County’s intended objectives. Since the beginning of
Contra Costa County’s AOT program, RDA has produced three distinct evaluation reports, including two
reports mandated by DHCS and another detailed report written specifically for CCBHS to better
understand the implementation of its AOT program. All three prior evaluation reports documented: 1)
program services, 2) consumers served, 3) fidelity to the ACT model, and 4) potential areas of
improvement for the County’s consideration. The reports were produced approximately six months apart,
and document the implementation and continued progression of the AOT program since it began.
This report is the fourth report produced for the AOT program evaluation. The purpose of this report is to
assist Contra Costa County with identifying the program’s accomplishments and opportunities for
1 Welfare and Institutions Code, Section 5346
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improvement. This report begins with a brief description of the AOT program’s model followed by data
analysis methodologies, evaluation findings, and discussion and recommendations.
In this report, RDA presents its evaluation findings in the same order that individuals experience the AOT
program, from referral, investigation, outreach, and engagement that occur pre-enrollment, through the
suite of services that individuals receive during AOT enrollment. One of the main purposes of AOT is to
provide a mechanism to identify, engage, and retain individuals with the most serious mental health needs
who are unable and/or unwilling to engage in services without additional supports and who may
otherwise “fall through the cracks” in medically necessary mental health services. This report provides
findings and recommendations that are intended to enable the County to: 1) build upon program
strengths and resources, 2) identify and address emerging gaps and challenges, and 3) provide evidence -
based services to consumers who require AOT to engage in medically necessary mental health services.
Contra Costa County’s AOT Program Model
Contra Costa County has designed an AOT program model that responds to the needs of its communities
and exceeds the requirements set forth in the legislation. The Contra Costa County AOT program includes
a Care Team comprised of CCBHS Forensic Mental Health (FMH) and MHS staff. Figure 1 below depicts
the Pre-Enrollment (Referral and Investigation; Outreach and Engagement) and AOT Enrollment (ACT
outpatient treatment services) components of the AOT program.
Figure 1. Contra Costa County AOT Program Stages
AOT Process
The first stage of engagement with Contra Costa County’s AOT program is through a telephone call referral
whereby any “qualified requestor”2 can make an AOT referral. Within five business days, a CCBHS mental
health clinician connects with the requestor to gather additional information on the referral, and reaches
out to the referred individual to begin determining if they meet AOT eligibility criteria (see Appendix I).
2 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.
CCBHS receives
referral and
conducts
investigation
Referral and
Investigation
MHS provides
outreach and
engagement to
AOT eligible
individuals
Outreach and
Engagement
Consumers enroll in
ACT voluntarily or
via court
agreement
ACT Team
Enrollment
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If the person initially appears to meet eligibility criteria, a CCBHS investigator from the FMH staff facilitates
a face-to-face meeting with the consumer and/or family to gather information, attempts to engage the
consumer, and develops an initial care plan. If the consumer continues to appear to meet eligibility
criteria, FMH investigators share the consumer’s information with the MHS team. MHS then conducts a
period of outreach and engagement activities with the consumer to encourage their participation in ACT.
If at any time the consumer accepts voluntary services and continues to meet eligibility criteria, they are
immediately connected to and enrolled in MHS’ ACT services.
However, if after a period of outreach and engagement, the consumer does not accept voluntary services
and continues to meet eligibility criteria, the County mental health director or designee may choose to
complete a declaration and request that County Counsel 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 one to two court hearings to determine if
criteria for AOT are met. At this time, the consumer has the option to enter into a voluntary settlement
agreement with the court to participate in AOT. If the consumer chooses not to participate in AOT
treatment services voluntarily, then he/she may be court ordered into 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 of mandated participation. At every stage of this process, CCBHS’
FMH and MHS staff continue to offer the individual opportunities to engage voluntarily in services and
may recommend a 72-hour hold if the consumer meets existing criteria.
AOT Process Outcomes
There are a variety of outcomes that may occur at each stage of the AOT process (see Figure 2). Given
that the County’s AOT program is relatively new, exploring the AOT process outcomes supports a shared
understanding of program implementation, including implementation strengths, challenges, and gaps.
Figure 2. Process Outcomes during AOT Process
Referral and
Investigation
•Ineligible
•Unavailable/ unable to
locate
•Referred to another
service provider
•Referred to MHS
Outreach and
Engagement
Outreach and
Engagement
•Unavailable/ unable to
locate
•Accepts ACT services
on a voluntary basis
•Requires additional
support to participate
ACT Team Enrollment
•Accepts services
through a voluntary
settlement agreement
•Accepts services with
an AOT court order
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AOT and ACT
It is important to note that Assertive Community Treatment (ACT) is not synonymous with Assisted
Outpatient Treatment (AOT). AOT is a mechanism by which a county can use a civil court process to
compel eligible individuals into a community mental health treatment program who are otherwise
unwilling and/or unable to accept mental health treatment. An AOT petition can be initiated at any stage
of the process, including:
During the pre-enrollment phases of referral and investigation, or outreach and engagement;
Following voluntary service acceptance, if the person fails to participate in services; and
After the person participates in treatment, if they request discharge prematurely.
In Contra Costa County, the community mental health treatment component of AOT is ACT. Mental Health
Services (MHS) is the contracted agency hired by CCBHS to implement an ACT team for County residents
referred to AOT. It is not a requirement of AOT programs to offer ACT services to their consumers.
When the County first chose to implement AOT, the County also elected to implement a new level of
outpatient mental health services by an ACT team. Additionally, it should be noted that the use of a civil
court order process is in alignment with the ACT model. Fidelity to the ACT model includes the expectation
that ACT programs apply assertive engagement mechanisms, including street outreach and available legal
mechanisms, to compel participation. Legal mechanisms typically used in ACT programs include
representative payees, terms and conditions of probation, outpatient commitment, and AOT court
agreements such as voluntary settlement agreements and court orders.
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Methodology
RDA employed a mixed-methods evaluation approach to assess implementation of the County’s AOT
program, as well as the extent to which individuals receiving AOT services during FY16/17 experienced
decreases in hospitalization, incarceration, and homelessness, and improvements in psychosocial
outcomes such as social functioning and independent living skills. This evaluation is intended to meet
regulatory DHCS requirements and support continuous quality improvement (CQI) of the County’s AOT
program. We highlight the current evaluation period and who is included in the evaluation below:
Evaluation Period: July 1, 2016 through June 30, 2017
Consumers Included: Any consumer who was referred or received Care Team and/or ACT services
during the evaluation period
Consumers Excluded: Any consumer who was referred and closed before the evaluation period
The following sections describe the data measures, sources, and analytic techniques used to develop this
report and evaluate Contra Costa County’s AOT program.
Data Measures and Sources
This report is meant to provide a thorough evaluation of Contra Costa County’s AOT program
implementation and outcomes in order to identify programmatic strengths, as well as areas for
continuous improvement. To this end, RDA assessed the outcomes and corresponding data measures
highlighted in Table 1 below.
Table 1. AOT Outcomes and Corresponding Data Measures
Outcomes Data Measures
Program Outcomes
Homelessness Housing Status
Crisis Episodes Number and length of crisis episodes
Hospitalizations Number and length of hospitalizations
Criminal Justice Involvement Number and length of bookings into county jail
Number of criminal cases for which charges were filed
Number of criminal convictions
Program Costs Costs incurred and/or saved by the County
Treatment Outcomes
Service Participation Intensity and frequency of services
Treatment Adherence and Retention
Social Functioning &
Independent Living
Self Sufficiency Matrix scores
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RDA collected data from several sources for this evaluation report. Table 2 below presents the County
departments or agencies that provided data for this evaluation, as well as the data sources and elements
captured by each data source. Appendix II provides additional information on each data source.
Table 2. Data Sources and Elements
County Department/Agency Data Source Data Element
Contra Costa County
Behavioral Health Care Services
CCBHS AOT Request Log Individuals referred
Qualified requestor
information
CCBHS AOT Investigation
Tracking Log
CCBHS investigation
attempts
Contra Costa County PSP Billing
System
Behavioral health service
episodes and encounters,
including hospitalizations
and crisis episodes
Consumer diagnoses and
demographics
CCBHS Financial Data Costs associated with
implementing the AOT
program, including ACT
Mental Health Systems MHS Outreach and Engagement
Log
Outreach and engagement
encounters
FSP Forms in Access Database Residential status, including
homelessness
Employment
Education
Financial support
MHS Outcomes Spreadsheet Social Functioning
Independent Living
Recovery
Contra Costa County Sheriff’s
Office
Sheriff’s Office Jail Management
System
Booking and release dates
Booking offense
Superior Court of California -
Contra Costa County
Contra Costa Superior Court
Case Management System
Charges
Convictions
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Data Analysis
Throughout the data analysis process, RDA collaborated with CCBHS and MHS staff to vet analytic
decisions and findings. RDA matched clients across the disparate data sources described above and used
descriptive statistics (e.g., frequencies, mean, and median) for all analyses, including pre- and post-
enrollment outcome analyses. In order to compare pre- and post-enrollment outcomes (i.e.,
hospitalizations, crisis episodes, and criminal justice involvement), RDA analyzed the rate (per 180 days)
at which consumers experienced hospitalization, crisis, arrest, and criminal justice outcomes prior to and
after enrolling in ACT. In future reports with larger sample sizes and longer consumer enrollment periods,
both descriptive and inferential statistics will be used to explore AOT implementation and consumer
outcomes.
Limitations and Considerations
As is the case with all “real-world” evaluations, there are important limitations to consider. One limitation
of this evaluation is that only 43 consumers participated in the AOT treatment program during FY16/17.
Because relatively few individuals were enrolled during this period, the proportion of individuals who
experienced crisis, hospitalization, and criminal justice involvement, as well as the average rates of
occurrence, shift somewhat drastically based on the experiences of relatively few individuals.
It is also important to note that there is more data available for the longer pre-enrollment time periods
compared to the shorter post-enrollment time periods. Therefore, AOT consumers had greater
opportunities to experience negative outcomes prior to program enrollment than after program
enrollment. To account for differences in the pre- and post-time periods, RDA standardized outcomes
measures to rates per 180 days. Nevertheless, because consumers have spent much less time in AOT than
in the pre-enrollment period, there is less opportunity for them to experience outcomes such as
hospitalization, arrest, and/or incarceration during their AOT participation period. As a result, these
outcomes may be underestimated if a large number of consumers experienced zero negative outcomes
during shorter periods while they were enrolled in AOT. On the other hand, if consumers experienced a
number of negative outcomes for lengthy periods during their AOT enrollment period, these estimations
may be overestimated.
Despite these limitations, this evaluation will help Contra Costa County to identify the successes and
challenges of its AOT implementation, as well as to highlight the outcomes of consumers who participated
in the County’s AOT treatment program in FY16/17. These findings resulted in recommendations for the
County to consider as they strive to continuously improve implementation and outcomes for all individuals
referred to the County’s AOT program.
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Findings
This evaluation includes findings for all consumers who were referred to AOT or received Care Team
and/or ACT services from July 1, 2016 through June 30, 2017 . During this time, CCBHS received 190
referrals to AOT for 177 unique individuals. Of these 177 individuals, 76% (n = 135) were not referred to
MHS for outreach and engagement. The remaining 42 consumers were referred to MHS for outreach and
engagement, and 15 enrolled in the County’s AOT treatment program. In addition, 32 consumers who
were referred to AOT in FY15/16 received MHS services during FY16/17 and are included in this report.
Figure 3. Consumers Referred to AOT and/or Receiving MHS Services during FY16/17
Findings are divided into two sections: “Pre-Enrollment” and “AOT Enrollment.” CCBHS staff and/or MHS’
ACTiOn team provide investigation, outreach, and engagement services for all individuals who are
referred to AOT in order to connect them to the AOT treatment program, if eligible, or some other mental
health treatment, if they are not. We explore the outcomes of this process in the “Pre-Enrollment”
section, and report on outcomes for all individuals who met AOT eligibility requirements and participated
in the County’s AOT treatment program during FY16/17 in the “AOT Enrollment” section.
Pre-Enrollment
Figure 4 below demonstrates that 177 individuals were referred to AOT in FY16/17. Among those
individuals, 135 were not referred to MHS for outreach and engagement. The remaining 42 consumers
were referred to MHS for outreach and engagement, and an additional 32 consumers were referred to
AOT in FY15/16 and received MHS outreach and engagement and/or ACT services during FY16/17.
CCBHS received and
investigated 177
referrals
MHS provided
outreach and
engagement to 74
individuals
43 consumers enrolled
in AOT treatment
program
*9 with court
involvement
Pre-Enrollment AOT-Enrollment
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Figure 4. FY16/17 AOT Program
First, we provide an overview of referrals made to AOT during FY16/17, including a profile of who made
these referrals, and referral dispositions. Next, we detail the investigation, outreach, and engagement
processes — led by CCBHS FMH and MHS’ ACTiOn team respectively — and assess outcomes such as
hospitalization and/or criminal justice involvement experienced by consumers prior to enrolling in the
County’s AOT treatment program.
Referral to AOT
CCBHS received 190 AOT referrals during FY16/17 for 177 unique individuals. Thirteen consumers were
referred to AOT twice during this fiscal year; these consumers 1) did not initially meet AOT eligibility
criteria, 2) were initially connected or reconnected with other services, or 3) were still under investigation
at the conclusion of the evaluation period.
The majority of AOT referrals (63%) continue to come from consumers’ family members.
Since program inception, the majority of referrals to AOT have been made by consumers’ family members.
This trend continued in FY16/17, with 63% of referrals coming from family members (see Table 3).
Referrals to AOT were also made by treating or supervising mental health providers (23%, n = 43) and
members of law enforcement agencies (11%, n = 20).
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Table 3. Summary of Qualified Requestors
Requestor % of Referrals
February – June 2016
(n = 88)
% of Referrals
July 2016 – June 2017
(n = 190)
Parent, spouse, adult sibling, or adult child 61% (n = 54) 63% (n = 120)
Treating or supervising mental health provider 11% (n = 10) 23% (n = 43)
Probation, parole, or peace officer 16% (n = 14) 11% (n = 20)
Adult who lives with individual 2% (n = 2) 1% (n = 2)
Director of hospital where individual is hospitalized 2% (n = 2) 0% (n = 0)
Director of institution where individual resides 0% (n = 0) 0% (n = 0)
Not a qualified requestor or “other” 7% (n = 6) 2% (n = 5)
It is also worth noting that only 2% of referrals were from unqualified requestors during FY16/17,
compared to 7% of referrals from unqualified requestors during the program’s first five months. It appears
that over time, Contra Costa County residents have developed a greater understanding of the AOT
treatment program, including who meets the requirements of a qualified requestor.
Care Team
Contra Costa County’s Care Team consists of CCBHS’ FMH and MHS staff. CCBHS FMH receives all AOT
referrals and conducts an investigation for each individual referred in order to determine AOT eligibility
(see Appendix I for AOT eligibility requirements). CCBHS FMH refers AOT eligible consumers to MHS staff,
who conduct outreach and engagement to enroll them in ACT services. The following section discusses
the investigations conducted by CCBHS FMH, and outreach and engagement activities conducted by MHS.
After CCBHS receives an AOT referral, the FMH team conducts an investigation to determine if the
individual meets the eligibility criteria for the AOT program. In addition to consulting prior hospitalization
and mental health treatment records for the individual, and gathering information from the qualified
requestor, the FMH investigation team also attempts to make contact with the referred individual in the
field.
Approximately one-fourth of consumers referred to CCBHS FMH (24%) were eligible for AOT and
subsequently referred to MHS; approximately half (51%) of consumers referred were ineligible
for AOT.
During FY16/17, CCBHS FMH investigated 177 unique consumers.3 Approximately one-fourth (24%, n=42)
of consumers were determined to be eligible for AOT and referred to MHS for outreach and engagement,
while 11% (n = 19) of consumers engaged or re-engaged with another provider, and 14% (n = 25) were
still being investigated by CCBHS FMH at the conclusion of FY16/17 (see Table 4 below).
3 An additional nine consumers were still under investigation from the previous fiscal year. All of these nine
consumers were ineligible.
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Table 4. Outcome of CCBHS Investigations (N = 177)
Approximately one-half (51%) of individuals referred to AOT were determined to be ineligible. Individuals
were ineligible for the following reasons:
They did not meet the AOT eligibility criteria;
They were unable to be assessed for eligibility (i.e., unable to locate, extended incarceration, or
extended hospitalization);
The qualified requestor withdrew the referral; or
The qualified requestor could not be reached.
CCBHS FMH worked to connect individuals who were ineligible for AOT to the appropriate level of mental
health treatment, and also provided resources and education for ineligible consumers’ family members.
The County’s investigation team was persistent in their efforts to locate consumers, determine
consumers’ eligibility for AOT, and connect eligible consumers to MHS.
On average, CCBHS FMH’s investigation team made four contact attempts to each individual referred to
AOT. As shown in Figure 5, the investigation team made the most contact attempts, on average, to those
consumers who were eventually referred to MHS for outreach and engagement.
Figure 5. Average Investigation Contact Attempts per Consumer (N = 177)
The investigation team worked to meet consumers “where they’re at,” as evidenced by the variety of
locations where investigation contacts occurred. While approximately one-quarter (26%, n = 199) of
investigation contact attempts occurred in a County office, another quarter (24%, n = 184) of investigation
8
3 2 3
0
1
2
3
4
5
6
7
8
9
Referred to MHS
(n = 42)
Engaged or Re-Engaged
with a Provider
(n = 19)
Investigated and
Closed
(n = 91)
Ongoing Investigation
(n = 25)Average Number of Contact AttemptsInvestigation Outcome Number of Referred
Consumers
% of Referred
Consumers
Referred to MHS 42 24%
Engaged or Re-Engaged with a Provider 19 11%
Investigated and Closed 91 51%
Ongoing Investigation 25 14%
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attempts took place in the field. Teams also met consumers at their place of residence, as well at inpatient,
healthcare, and correctional facilities.
If the CCBHS FMH team determines that a consumer is eligible for AOT, the consumer is connected with
MHS. The MHS team then conducts outreach and engagement activities with those individuals and their
family to engage the individual in AOT services. As per the County’s AOT program design, MHS is charged
with providing opportunities for the consumer to participate on a voluntary basis. If, after a period of
outreach and engagement, the person remains unable and/or unwilling to voluntary enroll in ACT and
continues to meet AOT eligibility criteria, MHS may refer the individual back to FMH to file a petition to
compel court ordered participation.
MHS conducted comprehensive outreach in order to engage consumers — and their support
networks — and enroll them in the County’s ACT program.
MHS conducted outreach and engagement with 74 consumers, 43 of whom enrolled in ACT.4 The
remaining consumers either engaged/re-engaged with another provider, were closed by CCBHS (for
reasons described above), or were still receiving outreach and engagement services as of June 30, 2017
(see Table 5).
Table 5. MHS Outreach and Engagement Outcomes (N = 74)
Outreach and Engagement Outcome Number of
Consumers
% of
Consumers
Enrolled in ACT Services in FY16/17 43 58%
Enrolled Voluntarily 34 --
Enrolled with Court Involvement 9 --
Engaged or Re-Engaged with Another Provider 4 5%
Closed by CCBHS 17 23%
Still Receiving Outreach and Engagement Services 10 14%
MHS provided outreach and engagement services to consumers as well as consumers’ support networks.
Approximately three-fourths (75%) of all outreach and engagement attempts were with consumers, while
one-fourth (24%) of outreach and engagement attempts were with consumers’ support networks. Overall,
the majority of successful contacts with consumers were in person, and approximately one in five
outreach and engagement efforts were unsuccessful.
4 17 ACT consumers who received outreach and engagement services in FY15/16 are included in this discussion in
order to capture the total efforts of outreach and engagement required to enroll all FY16/17 ACT consumers.
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Figure 6. Type of Outreach and Engagement Contacts (N = 652)
MHS relies on a diverse multidisciplinary team to conduct outreach and engagement. For consumers
receiving services in FY16/17, the majority of outreach attempts were either from a peer partner (45%)
or the clinical team leader (26%). As with the County’s investigation team, MHS was persistent in their
efforts to meet consumers “where they’re at.” Most contact attempts occurred in the community (25%),
the hospital (21%), consumers’ homes (15%), or at MHS’ office (15%).
This section explores the period from initial referral through AOT enrollment. This includes referral and
investigation efforts by CCBHS FMH as well as outreach and engagement efforts by MHS.
The average length of time from referral to enrollment is 107 days.
Contra Costa County designed an AOT program model that sought to engage and enroll consumers in ACT
within 120 days of referral. On average, it took the Care Team approximately 107 days to collectively
conduct investigation, outreach and engagement, and enrollment of consumers in AOT. Specifically, it
took an average of 52.5 days from the point of AOT referral to MHS’ first contact, and 55 days from the
point of MHS’ first contact to enrollment in ACT (Figure 7).
Collateral
24%
In-person
Unsuccessful
19%
In-person
Successful
55%
Phone/Email
2%
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Figure 7. Average Length of Time from AOT Referral to ACT Enrollment
Some individuals experienced referral to enrollment periods longer than 120 days.
Contra Costa County’s AOT program model has an expected maximum period of four months from the
point of referral to enrollment in AOT treatment services. Although the average length of time from
referral to enrollment aligned with the County’s program design, 17 consumers (40%) had investigation
and outreach periods lasting longer than 120 days (Figure 8). Data suggest that these individuals were
difficult to locate, and that the Care Team invested additional time to attempt to locate, assess, and
engage these individuals.
Figure 8. Length of Time from AOT Referral to ACT Enrollment
Among individuals whose pre-enrollment period lasted longer than 120 days, approximately 63% (n = 10)
experienced a hospitalization and/or criminal justice involvement during this referral to enrollment
period.
5
10
6
5
3
4
3 3
2
1 1
0
2
4
6
8
10
12
0-30 31-60 61-90 91-120 121-150 151-180 181-210 211-240 241-270 271-300 300+Number of ACT ConsumersDays from Referral to Enrollment
Average days
from AOT
referral to first
MHS contact
52.5
Average days
from MHS first
contact to ACT
enrollment
55
0 20 40 60 80 100 120
FY16/17
ACT Consumers
(N = 43)
Days
107 average
days from
referral to
enrollment
4 – 281 days in
range
79 median
days
Consumers enrolled in 120 days or fewer
Consumers enrolled in more than 120 days
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Summary
Figure 9 summarizes the outcomes of all referrals to AOT following the Care Team’s investigation,
outreach, and engagement efforts. At the end of FY16/17, 110 consumers were closed, while 25 were still
under investigation. Of those investigated and connected to MHS (n = 74), 43 enrolled in ACT. Among
those not enrolled, 17 were closed by the County, 4 engaged or re-engaged with another provider, and
10 were still receiving outreach and engagement services.
Figure 9. Referred Consumers
AOT Enrollment
Figure 10 below demonstrates that the MHS ACTiOn team enrolled and/or served 43 consumers in
FY16/17. Thirty-two (32) consumers were active at the conclusion of FY16/17, while 13 consumers
discharged from the AOT treatment program at some point during the fiscal year. Of the 13 who
discharged from the program, two re-enrolled in ACT during this fiscal year, four completed the program,
and seven left prematurely. This section describes outcomes for the 43 consumers who received ACT
services during FY16/17.
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Figure 10. FY16/17 AOT Treatment Program Participants
In this section, we first provide a consumer profile of AOT treatment program participants, including their
demographic characteristics and diagnoses. Then, we focus on the intensity and frequency of service
participation among consumers, followed by a discussion of consumer outcomes, including the extent to
which participants experienced crisis episodes, psychiatric hospitalizations, and criminal justice
involvement. Finally, we highlight program costs and costs savings associated with reduced numbers of
hospitalizations and criminal justice involvement, as well as revenue generated through federal
reimbursement.
ACT Consumer Profile
The following section describes consumers’ demographic characteristics, as well as their diagnoses,
employment status, educational attainment, and sources of financial support when they enrolled in ACT.
The AOT treatment program is enrolling the target population, although 25% of those enrolled
are younger than expected.
As shown in Table 6, ACT consumers were primarily male (53%, n = 23), white (56%, n = 24), and between
the ages of 26 and 59 (70%, n = 30). Approximately 25% of ACT consumers are transitional age youth (TAY)
between the ages of 18 and 25. While this is not completely unexpected given that the majority of major
mental health disorders have an onset during the TAY period, TAY may have service needs that differ from
the adult population.
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Table 6. ACT Consumer Demographics (N = 43)
Category ACT Consumers
Gender
Male 53% (n = 23)
Female 47% (n = 20)
Race and Ethnicity
Black or African American 23% (n = 10)
Hispanic 12% (n = 5)
White 56% (n = 24)
Other or Unknown 9% (n = 4)
Age at Enrollment
18 – 25 25% (n = 11)
26 – 59 70% (n = 30)
60+ 5% (n = 2)
Sixty-one percent (61%) of ACT consumers (n = 26) had a primary diagnosis of a psychotic disorder (see
Figure 11) and 79% (n = 34) had a co-occurring substance use disorder at the time of enrollment.
Figure 11. Primary Diagnosis at Referral (N = 43)
At the time of enrollment, approximately 42% (n = 18) of consumers were housed (e.g., living with family
or in a supervised placement) and 9% (n = 4) were living in a residential program. Approximately 40% (n =
17) of consumers were homeless or living in a shelter at enrollment; four consumers ’ housing status was
unknown.
Psychotic disorder,
including schizophrenia
and schizoaffective
disorders
26, 61%
Mood disorder,
including bipolar and
depressive disorders
13, 30%
Other
4, 9%
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Table 7. Housing Status at ACT Enrollment (N = 43)
Residence Living Arrangement at Enrollment
Housed 42% (n = 18)
Residential Program 9% (n = 4)
Shelter/Homeless 40% (n = 17)
Unknown or Not Reported 9% (n = 4)
ACT consumers also reported on their highest level of educational attainment, and whether they were in
school at the time of enrollment. Most consumers had some college education or technical training (35%,
n = 15) or higher levels of education (19%, n = 8), and the majority were not in school (72%, n = 31; see
Figure 12 and Figure 13). All consumers with a high school diploma/GED or less were not in school at the
time of ACT enrollment, or their school status was unknown. Just over half of consumers (53%) included
education as a recovery goal.
Figure 12. Educational Attainment
(N = 43)
Figure 13. School Attendance at Enrollment
(N = 43)
The majority of ACT consumers (81%, n = 35) were not employed when they enrolled, while 16% (n = 7)
did not report their employment status. Obtaining employment was a recovery goal for just over half
(53%) of AOT consumers, and as shown in Table 8, most consumers (54%, n = 23) received Supplemental
Security Income as their primary source of financial support. Additionally, almost all ACT consumers
received the same financial support at the time of enrollment as they had in the year leading up to
enrollment.
Table 8. Sources of Financial Support at and before ACT Enrollment (N = 43)
Financial Support Support Received in the Year
Prior to ACT Enrollment
Support Receiving at ACT
Enrollment
Family Member/Friend 9% (n = 4) 9% (n = 4)
Retirement/Social Security Income 5% (n = 2) 5% (n = 2)
Less than High
School
7, 16%
High
School/GED
8, 19%Some
College/Technical
Training
15, 35%
College/
Technical Degree
or Higher
8, 19%
Unknown/
Not Reported
5, 12%
Not in school
31, 72%
Tech/
Vocational
School
1, 2%
Unknown
/Not
Reported
11, 26%
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Financial Support Support Received in the Year
Prior to ACT Enrollment
Support Receiving at ACT
Enrollment
Supplemental Security Income 54% (n = 23) 54% (n = 23)
Social Security Disability Insurance 2% (n = 1) 0% (n = 0)
Other (including Housing Subsidy, General
Relief/Assistance, and Food Stamps)
4% (n = 2) 2% (n = 1)
No Financial Support 12% (n = 5) 14% (n = 6)
No Information Reported 14% (n = 6) 16% (n = 7)
Service Participation
The following sections describe the type, intensity, and frequency of service participation, as well as
consumers’ adherence to treatment while in the ACT program.
The ACT model is designed to provide intensive community-based treatment, measured by: 1) the
intensity of services, which is the amount of service an individual receives in a defined time period; and 2)
the frequency of services, which is how often an individual receives services. ACT teams are expected to
provide at least four face-to-face contacts per week for a total of at least two hours of service per week.
The ACT team continues to provide intensive services to consumers.
Although the length of consumers’ enrollment varies, ACT consumers were enrolled for an average of 243
days, with an average of 6.5 face-to-face contacts per week lasting a total of about six hours per week
(see Table 9), which clearly exceeds the ACT standards for intensity and frequency of services.
Table 9. ACT Consumer Service Engagement (N = 43)
Average Range
Length of ACT Enrollment 243 days 4 – 483 days
Frequency of ACT Service Encounters 6.5 face-to-face contacts
per week
<1 – 18 face-to-face
contacts per week
Intensity of ACT Services Encounters 6 hours of face-to-face
contact per week
<1 – 17 hours of face-to-
face contact per week
The majority of ACT consumers (93%) were adherent to ACT treatment during FY16/17.
Consumers were considered “treatment adherent” if they received at least one hour of face-to-face
engagement with their ACT team at least two times a week. Only three consumers (n = 7%) did not meet
this standard of adherence (see Figure 14 and Figure 15).
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Figure 14. Intensity of ACT Contacts per Week
Figure 15. Frequency of ACT Contacts per Week
A subset of consumers requested discharge from ACT during FY16/17.
As shown in Figure 16, 30% (n = 13) of consumers were discharged from ACT during FY16/17, two of whom
re-enrolled in the program at least once. According to the ACTiOn team, four discharges were the result
of successful program completion (e.g., consumers transitioned to a more appropriate level of care or
moved out of the area). However, three individuals were discharged because they were incarcerated,
while four others were discharged because they were not engaging in treatment. Among these seven
consumers, six experienced hospitalization and/or justice involvement following discharge.
7%, 3 5%, 2
30%, 13
21%, 9
37%, 16
0
4
8
12
16
20
<1 hour
per week
1 hour per
week
2-4 hours
per week
5-6 hours
per week
7 or more
hours per
week
5%, 2 5%, 2
33%, 14
21%, 9
37%, 16
0
4
8
12
16
20
<1 contact
per week
1 contact
per week
2-4
contacts
per week
5-6
contacts
per week
7 or more
contacts
per week
Non-Adherent Consumers
Adherent Consumers
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Figure 16. ACT Consumers
ACT Consumer Outcomes
The following sections provide a summary of consumers’ experiences with psychiatric hospitalizations,
crisis episodes, criminal justice involvement, and homelessness before and during ACT enrollment. As
previously discussed, these outcomes are standardized to rates per 180 days in order to account for
variance in length of enrollment and pre-enrollment data.
This section describes consumers’ crisis stabilization episodes and psychiatric hospitalizations before and
during ACT enrollment. The County’s PSP Billing System was used to identify consumers’ hospital and crisis
episodes in the 36 months prior to and during AOT enrollment.
On average, the number of consumers experiencing crisis episodes and psychiatric
hospitalization, as well as the frequency of those experiences, decreased post-AOT enrollment.
Almost all consumers (93%, n = 40) had at least one crisis episode in the three years before ACT, averaging
approximately 4.7 episodes for every six months, with episodes lasting an average of just under two days.
Fewer consumers had a crisis episode during ACT (58%, n = 25) with an average of 3.1 episodes for every
six months (see Table 10).
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Table 10. Consumers’ Crisis Episodes before and during ACT
Crisis Episodes
Before ACT enrollment During ACT enrollment
Number of Consumers (N = 43) n = 40 n = 25
Number of Crisis Episodes 4.7 episodes per 180 days 3.1 episodes per 180 days
Average Length of Stay 1.8 days 1.1 days
Similarly, the number of consumers who experienced a psychiatric hospitalization decreased during ACT.
Approximately two-thirds of consumers (67%, n = 29) had at least one hospitalization in the three years
before ACT, compared to 30% of consumers who experienced a hospitalization during ACT. Those with at
least one hospitalization before ACT averaged approximately 1.3 hospitalizations every six months, lasting
an average of just under ten days. Though consumers had fewer hospitalizations (1.1 per 180 days) while
enrolled in ACT, the average length of stay increased substantially from 9.7 to 28.6 days (see Table 11).
Table 11. Consumers’ Psychiatric Hospitalizations before and during ACT
Psychiatric Hospitalizations
Before ACT enrollment During ACT enrollment
Number of Consumers (N = 43) n = 29 n = 13
Number of Hospitalizations 1.3 hospitalizations per 180 days 1.1 hospitalizations per 180 days
Average Length of Stay 9.7 days 28.6 days
This section describes consumers’ criminal justice system involvement. Data from the Sheriff’s Office and
Courts were used to identify their justice involvement in the 36 months prior to and during AOT
enrollment.
RDA received the following criminal justice data from Contra Costa County’s Sheriff’s Office and the
Superior Court in order to assess the criminal justice involvement of ACT consumers:
Bookings: Following an arrest, individuals are typically booked into local county jail. Once booked,
individuals remain in jail until they are released through bail payment or on their own
recognizance.
Charges: The District Attorney’s Office determines whether to file charges once a criminal
complaint is sought. Charges are a formal allegation of an offense for which an individual is
arrested and booked.
Convictions: A conviction is the determination of guilt or innocence (or “no contest”) for a given
charge following a plea bargain or trial.
RDA received data from the Contra Costa County Sheriff’s Office to assess the number of bookings, and
average lengths of stay in jail, for each consumer pre- and post-AOT enrollment. In addition, RDA received
charges and conviction data from Contra Costa’s Superior Court in order to understand the outcomes of
consumers’ bookings.
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The number of consumers experiencing criminal justice involvement decreased during ACT.
The majority of ACT consumers (72%, n = 31) were arrested and
booked into county jail at least once in the three years prior to
ACT enrollment. During ACT participation, however, only
approximately 33% (n = 14) of consumers were arrested and
booked. Of those 14 consumers, seven were subsequently
charged and four were convicted of a new criminal offense (see
Figure 17). Most of the bookings were for probation violations
(30%), assault and battery (22%), or trespassing or disorderly
conduct (16%).
Figure 18. Type of Bookings during ACT
Table 12. Bookings and Incarcerations before and during ACT
Bookings and Incarcerations
Bookings before ACT enrollment Bookings during ACT enrollment
Number of Consumers n = 31 n = 14
Number of Incidents 3.4 bookings per 180 days 3.5 bookings per 180 days
In addition to improving consumers’ mental health outcomes, ACT services are also designed to support
consumers in attaining suitable housing situations that support their community mental health treatment.
Trespassing or
Disorderly Conduct
16%
Assault and
Battery
22%
Theft
16%
Drug Offense
10%
Probation
violation
30%
Other
6%
14
Arrested
and
Booked
7
Charged
4
Convicted
Figure 17. Criminal Justice
Involvement during ACT
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The majority of consumers (64%, n = 25) either obtained or maintained housing while in ACT.
Self-reported housing data from before and during ACT were available for 39 of the 43 ACT consumers.
As shown in Figure 19, the majority of consumers either obtained housing while in ACT (15%, n = 6) or
maintained their housing from before ACT (49%, n = 19). Just over one-third of consumers (36%) either
lost their housing (8%, n = 3) or continued to be homeless while in ACT (28%, n = 11).
Figure 19. Consumers’ Housing Status before and during ACT (N = 39)
A small group of consumers continues to experience difficulty.
Thirty percent (30%, n = 13) of enrolled consumers continued to struggle with psychiatric hospitalizations
and/or criminal justice involvement, and experienced an increase in the rate of these events while
enrolled in ACT. Of these 13 individuals:
Almost half (46%) are TAY,
Half (50%) are homeless and/or unstably housed,
Almost all (92%) have a psychotic or mood disorder and a co-occurring substance use disorder,
and
The majority (85%) enrolled in ACT voluntarily.
Consumers’ abilities to function independently and participate in activities that are a part of daily living
are also of key importance in ACT programs.
ACT consumers experienced slight increases in their self-sufficiency while enrolled in ACT.
Throughout consumers’ enrollment in ACT, the team administers the Self Sufficiency Matrix (SSM) to
assess consumers’ social functioning and independent living. The SSM consists of 18 domains scored on a
scale of one (“in crisis”) to five (“thriving”). Clinicians assessed consumers at intake, every 90 days, and
upon discharge. Intake data was available for 27 consumers, 21 of whom also had at least one
reassessment. Table 13 reports the average scores for consumers at intake, 90 days, 180 days, and one
year; “n/a” indicates where no scores were given for those domains.
Consumers who
obtained housing
•15% of consumers who
were not housed before
ACT obtained housing
while enrolled
Consumers who
maintained housing
•49% of consumers who
were housed before
ACT continued to
maintain housing while
enrolled
Consumers who were
not stably housed
•8% of consumers were
housed before ACT but
did not maintain
housing during ACT
•28% of consumers were
not housed before or
during ACT enrollment
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Table 13. Self Sufficiency Matrix Scores
Domain
Intake
Average
Score
90-Day
Average
Score
180-Day
Average
Score
1-Year
Average
Score
Housing 3.00 3.57 3.20 4.25
Employment 1.15 1.24 1.27 1.50
Income 1.96 2.57 2.67 3.50
Food 2.65 3.24 2.67 4.00
Child Care n/a n/a n/a n/a
Children's Education 5.00 5.00 n/a n/a
Adult Education 3.70 3.67 3.60 4.50
Health Care Coverage 4.07 4.10 3.87 4.50
Life Skills 2.89 3.38 3.53 3.75
Family/Social Relations 2.26 4.19 3.07 4.25
Mobility 2.15 2.71 2.80 4.00
Community
Involvement
2.44 3.20 3.13 4.75
Parenting Skills 4.00 2.00 4.00 n/a
Legal 3.67 3.90 3.93 4.25
Mental Health 2.07 2.29 2.73 4.00
Substance Abuse 3.19 3.48 3.20 4.00
Safety 3.70 4.00 4.21 4.50
Disabilities 2.40 2.30 2.62 4.00
Other 1.00 n/a n/a n/a
Total Score 41.15 48.14 45.87 59.75
Sample Size 27 21 15 4
Consumers’ average scores across domains at the 90-day, 180-day, and one-year SSM administrations
were higher than the average intake scores.
AOT Costs and Cost Savings
There are a number of expenses associated with Contra Costa County’s AOT program. However, there are
also cost savings likely to result from decreases in crises, hospitalization, and incarceration. Additionally,
the County generates revenue for Medi-Cal eligible mental health services. To analyze AOT-related costs
and cost savings, RDA collected cost-related information from the CCBHS Finance Department, as well as
from other County departments involved in the implementation of AOT.
The sections below provide a preliminary review of costs associated with AOT program implementation,
as well as the extent to which AOT has generated revenue through Medi-Cal billing and reduced
hospitalizations and justice involvement.
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The cost to Contra Costa County for implementing AOT in FY16/17 was $1,872,390, which
includes actual expenses and revenue projections.
During FY16/17, AOT implementation cost Contra Costa County approximately $2,144,226 (see Table 14).
CCBHS spent a total of $1,960,001, with $378,195 for Forensic Mental Health to investigate referrals, and
$1,581,806 paid to Mental Health Services as the contracted provider delivering the ACT program.
In addition to CCBHS’ costs, the County also reported AOT-related expenses incurred by the County
Counsel, the Office of the Public Defender, and the Superior Court in supporting the court proceedings
element of the AOT process. Costs to County Counsel included providing consultation services for CCBHS,
preparing and filing all petitions to the Court, and representing the County in Court hearings. The Office
of the Public Defender has one part-time employee who represents all AOT clients, and the Superior Court
is responsible for holding AOT court hearings each week.
Table 14. Contra Costa County Department Costs
County Department FY 16/17 Cost
CCBHS (including FMH and MHS) $1,960,001
County Counsel $68,347
Public Defender’s Office $112,5005
Superior Court $3,378.00
Total County Costs $2,144,226
The County estimated that they would receive 35% (accounting for a 15% disallowance rate) in revenue
from Medi-Cal billing, or $206,589. In actuality, MHS provided approximately $776,675 worth of Medi-Cal
eligible services during this time period, and the County estimates that they will receive approximately
$271,836 in revenue from Medi-Cal billing for these services. It is worth noting that the County’s AOT
program only served 43 consumers during FY16/17, and has the capacity to serve up to 75 clients as
currently configured; the amount of revenue generated through service provision should continue to grow
as the AOT treatment program enrolls more individuals.
Service costs were estimated for all ACT consumers enrolled in the program for more than 90 days (n =
37). Data sources included PSP billing data and bookings data from the Contra Costa County Sheriff’s
Office. PSP billing data included a charge for each mental health service, while booking costs were
estimated using a projected cost of $106 per consumer per day.6 As shown in Table 15, the overall costs
of mental health services increased; however, the cost of bookings and corresponding jail stays have
decreased. This confirms that the County has increased its investment in the well-being and recovery of
5 Public Defender costs include staff benefits.
6 Grattet, R. and Martin, B. (2015). Probation in California. Retrieved on August 24, 2017 from
http://www.ppic.org/publication/probation-in-california/.
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consumers, which has led to better outcomes for consumers and a reduced burden on institutions like
Inpatient Unit 4C and the County’s jails.
Table 15. Mental Health Service and Booking Costs before and during ACT (N = 37)
Actual Cost Average Annual Cost per Consumer
12 Months
before ACT
During ACT 12 Months
before ACT
During ACT
All Behavioral Health
Services
$2,315,254 $2,685,812 $82,788 $95,699
Bookings $101,018 $57,028 $7,807 $2,450
Psychiatric
Hospitalizations
$870,157 $478,765 $69,715 $56,512
It is also important to note that while there are cost savings associated with reducing incarceration and
hospitalization for the 43 AOT enrolled consumers, the County is still incurring expenses for a 75 person
AOT program. This means that funds are being expended based on an expected enrollment of 75
consumers, while only 43 consumers are receiving services that are likely to reduce incarceration and
hospitalization expenses.
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Discussion and Recommendations
This FY16/17 evaluation of Contra Costa County’s AOT program recognizes the shared efforts of CCBHS,
County Counsel, Office of the Public Defender, the Superior Court, and MHS in identifying, engaging, and
serving AOT consumers, as well as the Board of Supervisors and community of stakeholders who continue
to invest in the success of this program. The following discussion summarizes consumer accomplishments
and implementation successes since program inception, and includes recommendations for the County
to consider around engaging individuals who are difficult to locate, as well as how to more effectively use
the civil court process to compel participation.
CCBHS FMH and MHS work together to identify, outreach, and engage eligible consumers in
order to enroll them in ACT.
CCBHS FMH and MHS continue to build their collaborative processes to ensure that appropriate
consumers are identified and connected to services. Both teams are persistent in their efforts to work
with consumers who may be — by the nature of their diagnoses and co-occurring substance use disorders
— difficult to find and engage. Both investigation and outreach and engagement data indicate that the
Care Team are meeting consumers “where they’re at” and are continuously striving to find and engage
consumers and consumers’ support networks. The Care Team is consistently outreaching to consumers
and their families at a variety of locations and with diverse team members in order to both determine
consumers’ eligibility for AOT and engage consumers in AOT treatment services.
Contra Costa County’s AOT program has engaged 46% of all AOT referrals in the appropriate
level of mental health services.
Together, CCBHS FMH and MHS resolved 142 referrals in FY16/17, with 35 referred consumers either still
under investigation to determine eligibility for AOT or receiving outreach and engagement in order to
connect them to AOT treatment services. Of the 142 referrals closed during FY16/17, 43 engaged with
MHS’ team, either voluntarily or through the AOT court process. Another 23 consumers were not eligible
for AOT and were instead connected to another service provider. Thus, 46% (n = 66) of all referred
consumers were connected to the appropriate level of mental health services. The subset of 23 referred
consumers who engaged in services other than AOT treatment after referral indicates that AOT provides
an additional pathway into the mental health system that benefits more consumers than those who are
AOT-eligible.
The majority of consumers experienced benefits from participating in the AOT treatment
program.
Consumers experienced a range of benefits from their participation in ACT. Not only did fewer consumers
experience crisis episodes, hospitalizations, and justice involvement while in the AOT treatment program,
but those who experienced these outcomes both before and after ACT enrollment did so with less severity
while enrolled in the AOT treatment program. Further, consumers’ average scores on the Self-Sufficiency
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Matrix (SSM) reassessment were higher than their average scores at intake, suggesting that consumers
are improving in their social functioning and independent living skills through program participation.
A group of individuals referred to AOT were unable to be located during the investigation or
outreach and engagement processes.
CCBHS receives AOT referrals for individuals in confined settings (e.g., hospital, jail) as well as the
community. Referrals for consumers in the community present a unique challenge, because AOT
consumers are likely to be homeless, unstably housed, or otherwise difficult to locate. Other large
California counties implementing AOT, such as Orange County, also experience similar difficulty in locating
referred consumers who are homeless or unstably housed.
Eighteen (18) individuals who were unable to be located either by CCBHS FMH during the investigation
process or by MHS during the outreach and engagement phase experienced a crisis episode or
hospitalization following the referral. Of the consumers unable to be located by FMH, seven consumers
experienced a hospitalization post referral. Of the consumers unable to be located by MHS, 11 consumers
experienced a crisis and seven consumers experienced a crisis episode or hospitalization. Some of these
experiences occurred while the referral was open to FMH and/or MHS and some occurred after the
referral had been closed.
FMH attends the weekly case conference at the Contra Costa Regional Medical Center (CCRMC) Inpatient
Unit 4C to determine if there are any individuals with open investigations at the hospital so that they can
assess and engage the individual during their stay. However, FMH does not currently have a way to
determine if there are previously referred individuals now hospitalized in order to re-open the
investigation. While the FMH clinicians may remember some of the individuals referred, the volume of
individuals they investigate likely requires additional tracking mechanisms. It may be useful for CCBHS to
develop a mechanism that would allow Psychiatric Emergency Services (PES), Inpatient Unit 4C, and jail
mental health to make FMH or MHS aware of an AOT-referred individual’s presence at their unit with
enough time available for FMH or MHS to be able to conduct an assessment or outreach visit. This may
be more difficult at PES where the length of stay is much shorter, which would require that FMH or MHS
become aware of the person’s presence at PES as soon as possible following entry rather than waiting
until discharge.
As such, suggested options could include:
A tracking mechanism on the face sheet to note an open or previous AOT referral.
Training for PES, Inpatient Unit 4C, and jail mental health staff to screen for AOT with a process
to contact FMH or MHS when a potentially AOT-eligible individual shows up.
Education for qualified requestors, including family members, to call FMH or MHS to alert them
that the individual is at PES, hospital, or jail so that they can go to the facility and make contact.
It might also be useful to build an automated alert within PSP so that MHS and/or FMH receive a
notification if one of the referred individuals has an episode opening at PES, hospital, or jail mental health.
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Additional exploration of the court’s role in AOT may assist with compelling participation in
treatment.
During each stage of the AOT process, there are opportunities to assertively engage and compel
participation. It may make sense for the County to consider the role of the AOT court petition in increasing
the number of eligible individuals who enroll in ACT treatment, decreasing the length of time to
enrollment, and increasing retention in AOT treatment in the following circumstances:
While the person is hospitalized and/or incarcerated;
If the person is unlikely to engage within 120 days;
If the person voluntarily agrees to participate but fails to engage or requests discharge
prematurely; or
If the person voluntarily agrees to participate but continues to experience crisis, hospitalization,
and/or criminal justice involvement.
This set of recommendations is based on aggregate analyses presented throughout this report and is not
informed by a review of individual cases. Nothing in this discussion is intended to question the
independent, clinical judgment of the professionals working within Contra Costa County’s AOT system.
Rather, this discussion suggests that there may be additional opportunities to consider how the petition
may be useful to address some of the gaps noted in this evaluation report.
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Appendices
Appendix I. AOT Eligibility Requirements7
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.
7 Welfare and Institutions Code, Section 5346
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Appendix II. Description of Evaluation Data Sources
CCBHS AOT Request Log: This spreadsheet includes the date of each AOT referral, as well as the
demographic characteristics of each individual referred to AOT and the initial disposition of each referral
(e.g., unqualified requestor, open AOT investigation, voluntarily accept MHS services, court involved MHS
participation) and an updated disposition if the investigation outcome changed.
These data were used to identify the total number of referrals to the County’s AOT program during
FY16/17, as well as the number of individuals who received more than one AOT referral.
CCBHS Investigation Tracking Log: CCBHS staff logged investigation Blue Notes (i.e., field notes from
successful outreach events) into an Access form tracking the date, location, and length of each CCBHS
Investigation Team outreach encounter. Future reports will also include the recipient of the service (i.e.,
consumer or collateral) and outcome of the investigation (e.g., consumer no-show or non-billable service).
These data were used to assess the average number of investigation attempts 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.
Data from this source were used to calculate the average number of outreach encounters the MHS team
provided each consumer, as well as the average length of each outreach encounter, the location (e.g.,
community, secure setting, telephone) of outreach attempts, and the average number of days of outreach
provided for reach referral.
Contra Costa County PSP Billing System (PSP): These data track all behavioral health services provided to
ACT participants, as well as diagnoses at the time of each service. PSP service claims data were used to
identify the clinical diagnoses and demographics of ACT participants at enrollment, as well as the types
and costs of services consumers received pre- and during-ACT enrollment (e.g., outpatient, inpatient,
residential, and crises), the average frequency with which consumers received ACT FSP services, and the
average duration of each service encounter.
FSP Partnership Assessment Form (PAF), Key Event Tracking (KET), and Quarterly Assessment Form
(3M): Though the PAF, KET, and 3M are entered into the Data Collection and Reporting (DCR) system, data
queries were unreliable and inconsistent; therefore, MHS staff entered PAF, KET, and 3M data manually
into a Microsoft Access database. These data were used in this report to generate consumer profile
measures and self-reported changes in outcome measures such as homelessness before and during ACT.
MHS Outcomes Files: These files include assessment data for a number of clinical assessments MHS
conducts on ACT participants. For the purposes of this evaluation, the Self Sufficiency Matrix (SSM) was
used to assess consumers’ social functioning and independent living. Future reports will include findings
F&HS Agenda Packet Page 55
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 37
from the MacArthur Abbreviated Community Violence Instrument to address consumers’ experiences of
victimization and violence.
F&HS Agenda Packet Page 56
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Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 38
Appendix III. FSP Consumer Profile
The following information describes the individuals served by an FSP program in Contra Costa County
during FY16/17.
Just over half of FSP clients were male (57%, n = 156) and over half were between the ages of 26 and 59
(60%, n = 162). The majority of FSP consumers were either Black or African American (38%, n = 103) or
White (33%, n = 91; see Table 16).
Table 16. FY16/17 FSP Consumer Demographics (N = 272)
Category ACT Consumers
Gender
Male 57% (n = 156)
Female 43% (n = 116)
Race and Ethnicity
Black or African American 38% (n = 103)
Hispanic 18% (n = 48)
White 33% (n = 91)
Other or Unknown 11% (n = 30)
Age at Enrollment
18 – 25 39% (n = 106)
26 – 59 60% (n = 162)
60+ 1% (n = 4)
About half of consumers enrolled in a FSP program in FY16/17 were diagnosed with a psychotic disorder
at the time of their enrollment into the program (see Figure 20).
Figure 20. FY16/17 FSP Primary Diagnosis at Enrollment (N = 272)
51%, 139
30%, 81
11%, 31
8%, 21
Psychotic disorder, including schizophrenia and schizoaffective
disorders
Mood disorder, including bipolar and depressive disorders
Other
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Assisted Outpatient Treatment Program FY16/17 Evaluation
September 15, 2017 | 39
In the three years before FSP enrollment, just over half of FSP consumers (56%, n = 151) had at least one
crisis episode and just over one-third of FSP consumers (37%, n = 100) had at least one hospitalization.
Future reports will explore their rates of these experiences before and during FSP enrollment, and will
compare appropriately matched FSP consumers to ACT consumers on these outcomes.
F&HS Agenda Packet Page 58
Contra Costa County Assisted Outpatient
Treatment (AOT) Evaluation
MHS’ ACTiOn Team 2017 Fidelity Assessment
F&HS Agenda Packet Page 59
Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 1
Introduction
As an evidence-based psychiatric rehabilitation practice, Assertive Community Treatment (ACT) provides
a comprehensive approach to service delivery to consumers with severe mental illness (SMI). ACT uses a
multidisciplinary team, which typically includes a psychiatrist, a nurse, substance abuse and vocational
specialists, and a peer counselor. ACT is characterized by 1) low client to staff ratios; 2) providing services
in the community rather than in the office; 3) shared caseloads among team members; 4) 24-hour staff
availability, 5) direct provision of all services by the team (rather than referring consumers to other
agencies); and 6) time-unlimited services. When done to fidelity, the ACT model consistently shows
positive outcomes for individuals with psychiatric disabilities. This flexible, client-driven comprehensive
treatment has been shown to reduce risk and improve mental health outcomes.
The ACT service-delivery model relies on a multidisciplinary team of professionals who work closely
together to serve consumers with the most challenging and persistent mental health needs. The ACT team
works as a unit rather than having individual caseloads in order ensure that consumers receive the
services and support necessary to live successfully in the community. The ACT team provides direct
services to consumers in vivo, which means the ACT team must have a flexible service delivery model,
providing consumers the services they need in the places and contexts they need them, as opposed to
primarily in an office setting.
ACT is a nationally recognized evidence based practice with evidence dating back to the 1970s. According
to outcomes from 25 randomized controlled trials, compared to usual community care, ACT more
successfully engages clients into treatment, substantially reduces psychiatric hospital use, increases
housing stability, and moderately improves symptoms and subjective quality of life.1 Perhaps more
importantly, research also suggests there are no negative outcomes associated with the ACT service
delivery model. Recent research seeking to identify which client populations ACT is most effective for
demonstrates that ACT is strongly effective and cost-effective for clients with a high frequency of
psychiatric hospitalizations and less effective and not cost-effective for clients with a low frequency of
psychiatric hospitalizations.
In Contra Costa County, Mental Health Systems (MHS) administers ACT. It is funded by the Mental Health
Services Act (MHSA) Community Services and Supports as a Full Service Partnership program, and serves
as the service component of Contra Costa’s Assisted Outpatient Treatment (AOT) program. ACT offers
adults with serious mental illness a full service partnership program that addresses mental health, housing
needs, and community reintegration. Clients in the program have access to any team member, small
caseloads for more individualized attention, nursing services and psychiatry, housing supports, and 24-
hour availability.
1 Bond, G.R., Drake, R.E., Mueser, K.T., and Latimer, E. (2001). Assertive Community Treatment for people with
severe mental illness. Disease Management and Health Outcomes, 9(3), 141-159.
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MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 2
Fidelity Assessment Process
Contra Costa County, as part of a larger evaluation of the newly implemented AOT program, was
interested in learning about ACT implementation. 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 to 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.
Roberta Chambers, PsyD, and John Cervetto, MSW, conducted the ACT Fidelity Assessment. Both raters
have extensive experience in community mental health programs as well as quality improvement and
evaluation.
The fidelity assessment began with a series of project launch activities. This included:
1. 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.
2. 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 July 13, 2017.
During the site visit, the assessors engaged in the following activities:
ACT team meeting observation
Interviews with seven (7) ACT team members
Review of available documentation
Consumer focus group
Family member focus group
Debrief with the Team Leader
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 completed the fidelity rating scale
independently and then met to seek consensus on each individual rating and to 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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Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 3
Fidelity Assessment Results
The ACT program was rated on the following three domains set forth in the ACT Fidelity Scale:
Human Resources: Structure and Composition
Organizational Boundaries
Nature of Services
Each domain has specific criterion rated on a 5-point Likert scale with clearly defined descriptions for each
rating. The following chart provides an overview of the domains, criterion, and ACTiOn Team’s 2016 and
2017 program ratings. As shown in the table below, the ACTiOn Team received an overall fidelity score
of 4.42 indicating a high level of fidelity to the ACT Model. The following section provides descriptions,
justifications, and data sources for each criterion and rating.
Domain Criterion 2016 Rating 2017 Rating
Human
Resources:
Structure and
Composition
Small caseload 5 5
Team approach 5 4
Program meeting 5 5
Practicing ACT leader 4 4
Continuity of staffing 4 3
Staff capacity 5 4
Psychiatrist on team 5 5
Nurse on team 5 5
Substance abuse specialist on team 5 5
Vocational specialist on team 5 5
Program size 5 5
Organizational
Boundaries
Explicit admission criteria 3 2
Intake rate 5 5
Full responsibility for treatment services 5 5
Responsibility for crisis services 5 5
Responsibility for hospital admissions N/A 5
Responsibility for hospital discharge planning N/A 5
Time-unlimited services 5 5
Nature of
Services
In vivo services 3 3
No drop-out policy 5 3
Assertive engagement mechanisms 5 2
Intensity of services 5 5
Frequency of contact 4 4
F&HS Agenda Packet Page 62
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MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 4
Domain Criterion 2016 Rating 2017 Rating
Work with support system 5 5
Individualized substance abuse treatment 5 5
Co-occurring disorder treatment groups 5 5
Co-occurring disorders model 5 5
Role of consumers on treatment team 5 5
ACT Fidelity Score 4.73 4.42
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 12.5 FTEs who provide direct services, as well
as two administrative staff, for 32 active 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 4 for this criterion as 70% 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. This is a slight decrease from the 2016 rating of 5 when 90% of consumers had face-to-face
interactions with more than one team member in a two (2) week period.
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
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 30% of the time. These
direct services include both formal and informal interactions and may or may not include formal progress
notes.
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MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 5
Continuity of staffing measures the program’s level of staff retention. Full fidelity requires less than 20%
turnover within a two-year period. During the evaluation period, seven staff discontinued employment
with MHS’ ACTiOn Team, which is a 47% turnover rate. This results in a rating of 3 based on the scoring
rubric and was assessed through a review of personnel records and staff interviews. This is a slight
decrease from the 2016 rating of 4 where there was a 20% turnover rate.
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 94% of the time. This is a slight
reduction from the 2016 rating of 4 where they operated at 100% staffing during the evaluation period.
Fidelity to the ACT model requires 1.0 FTE psychiatrist per 100 consumers. Currently, MHS’ ACTiOn Team
provides 0.5 FTE psychiatrist for 32 active consumers, 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 two staff with at least one year of training or clinical experience in substance
abuse for 100 consumers. Currently, MHS’ ACTiOn Team employs 2.0 FTE who meet criteria for a
substance abuse specialist, as observed by personnel records and staff interviews. This exceeds the
required ratio given 32 enrolled consumers and results in a rating of 5.
The ACT model includes two staff with at least one year of training or experience in vocational
rehabilitation and support for 100 consumers. 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 for 32 enrolled consumers and results in a rating of 5. When at full capacity of 75 consumers, 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.
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Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 6
Organizational Boundaries
Explicit admission criteria refers 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, and MHS takes all consumers
referred, regardless of independent review. For this reason, MHS’ ACTiOn Team received a score of 2. This
represents a slight decrease from the 2016 rating of 3 because the MHS’ ACTiOn Team has accepted
consumers that they do not believe meet ACT criteria, including consumers who they believe have a
primary substance use diagnosis as well as individuals with developmental disabilities. It is important to
note that this does not suggest that MHS and CCBHS should change the process for ACT admission, but
that there may be to strengthen collaboration between the two agencies during the admission process.
Intake rate refers to the rate at which consumers are accepted into the program to maintain a stable
service environment. In order to implement ACT with fidelity, a provider should have a monthly intake
rate of six or lower. In the past six months, there have been no more than six consumers admitted in any
given month resulting in a rating of 5.
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 shared by all program staff, with the
exception of administrative staff. The Team Leader provides back-up coverage and support. This was
observed through program meeting observation and staff interviews 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 collaborated with Psychiatric Emergency Services and Unit 4C on all
decisions to hospitalize ACT consumers, resulting in a rating of 5.
F&HS Agenda Packet Page 65
Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 7
The ACT model includes the ACT program participating in hospital discharge planning. Currently, MHS’
ACTiOn Team collaborated with Unit 4C and other inpatient units on all hospital discharge plans, resulting
in a rating of 5.
The ACT model is designed to be time-unlimited with the expectation that less than 5% of consumers
graduate annually. MHS’ ACTiOn Team graduated one consumer during the evaluation period, resulting
in a rating of 5. This was determined through consumer records and staff interview. There were two
consumers who moved out of the area during the evaluation period who were removed from this scoring
criteria.
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. For the period
of evaluation, 59% of all encounters between the Action Team and Clients occurred in the community-
based settings, which is a slight increase from last year’s result of 53%. 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, nine consumers dropped out of the program, resulting in a 22% drop out rate
and a rating of 3. Any consumer who moved out of the area was removed from the analysis for this
criterion. This represents a decrease from last year’s rating of 5.
As part of ensuring engagement, the ACT model includes using street outreach and legal mechanisms as
indicated and available to the ACT team. While MHS’ ACTiOn Team applies street outreach and other
assertive engagement mechanisms, they do not appear to be using legal mechanisms specifically available
to them, including the civil court petition for AOT, and instead appear to focus on building motivation for
consumers to accept treatment voluntarily. This rating is informed by a small subset of consumers who
initially accepted services on a voluntary basis but either 1) refused to participate once enrolled or 2)
requested discharge despite continuing to meet criteria for ACT services. It is important to note that the
decision to use legal mechanisms is a collaborative effort between CCBHS and MHS, and the actual
implementation of a legal mechanism, (i.e. AOT voluntary settlement agreement or court order) is shared
between all AOT partners.
F&HS Agenda Packet Page 66
Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 8
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. During the evaluation period, ACT consumers received an average of 2.67 hours per
week, resulting in a score of 5.
Fidelity to the ACT model requires that ACT consumers have an average of at least four face-to-face
contacts per week. During the evaluation period, ACT consumers received an average of 3.15 contacts per
week, resulting in a score of 4.
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. According to staff, consumer, and family member discussions, MHS’ ACTiOn
Team is exceeding the expectation of 4 contacts per month with informal support systems, resulting 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 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.
F&HS Agenda Packet Page 67
Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 9
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. In addition to the strengths noted last year of professional staff,
partnership and responsivity, and an inclusive approach to services, program strengths noted are:
Caring Staff: Consumers and family members discussed feeling like MHS’ ACTiOn Team staff are
truly invested in consumers’ lives and recovery processes. This was a clear differentiating factor
for consumers and family when discussing if this program was different from other treatment
experiences and how.
Outreach: Both family members and consumers discussed how helpful the outreach process is
with MHS’ ACTiOn Team. Specifically, consumers and family discussed that staff come out to their
homes or wherever they are and listen to their experiences and needs. Consumers described
feeling cared about during the process and family discussed the relief they felt in knowing that
someone was committed to help and willing to take the time to work with them and explain the
process.
Consumer Outcomes: It is notable that many consumers have made significant progress while in
the program. Every consumer and family member interviewed was easily able to acknowledge an
accomplishment as a result of participating. The assessors were also impressed with the
consumers who have obtained and maintained housing, reduced crisis and hospitalization, and
are either working or volunteering.
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. This was a
recommendation from last year, and appears to still be an area for continued growth.
Enrollment Process and Use of Petition: Family members expressed concern at how long the
enrollment process took to get their loved one through the process. Some family members
discussed being denied services initially and then re-referring their family member after an
additional crisis or jail experience in order to get them approved for the program. Additionally,
family members expressed concern at the limited use of the petition and the length of time to
decide to use a petition, if at all.
F&HS Agenda Packet Page 68
Contra Costa County Behavioral Health Services
MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 10
Discussion
Strengths
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 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
Opportunities
While the fidelity assessment revealed a high degree of alignment with the ACT model, there appear to
be opportunities for improvement.
Staffing: While MHS’ ACTiOn Team is robustly staffed for the current caseload of 32, there would
be gaps in some of the positions if the team were to grow to the contracted number of 75
consumers. Specifically, there would be a need to increase vocational rehabilitation and
psychiatry time to ensure alignment with the model. Additionally, there has been a higher rate of
turnover than expected. ACT being a new program in the County may influence this, and MHS may
wish to explore how to increase staff retention for this program.
Civil Court Involvement: The lowest scores from this assessment include the drop-out rate and
use of legal mechanisms to compel participation. It may be useful for MHS and CCBHS to explore
if there are ways for the program to maximize the use of the petition, specifically for 1) those who
are determined by CCBHS to be eligible but are not willing to accept services after a period of
outreach and engagement from MHS, and 2) those individuals who initially agree to ACT services
on a voluntary basis and then fail to engage or request to be discharged despite continuing to
meet eligibility criteria for AOT.
Capacity: MHS’ ACTiOn Team is contracted for up to 75 consumers and has served 43 consumers,
of whom 32 are currently enrolled. MHS and CCBHS may wish to explore the barriers to
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MHS’ ACTiOn Team 2017 Fidelity Assessment
August 21, 2017 | 11
enrollment for consumers, including the use of the civil court petition and the length of time to
become enrolled, as discussed previously, as well as consider how to best scale the program to
ensure continued fidelity to the ACT model.
Conclusion
MHS’ ACTiOn Team received an average fidelity rating of 4.42 and scored in the “high fidelity” range. The
assessors were impressed with the staff, program implementation, and the success stories shared by staff,
consumers, and their families. The assessors also recognized the opportunity to continue to improve the
program, specifically around issues related to timely admission, the use of legal mechanisms to compel
participation, and staff turnover. Additionally, the assessors recommend that CCBHS and MHS’ ACTiOn
Team explore what steps would be needed to enroll and serve 75 consumers while continuing the high
degree of fidelity to the ACT model.
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9/15/2017
1
CONTRA COSTA COUNTY
ASSISTED OUTPATIENT
TREATMENT INTERIM
EVALUATION
September 25, 2017
Resource Development Associates
Agenda
2
Introduction
AOT Program Overview
Pre-Enrollment
AOT Enrollment
Discussion
F&HS Agenda Packet Page 71
9/15/2017
2
Introduction3
AOT Timeline
4
February
5, 2015
• Contra
Costa
Board of
Supervisors
authorized
Assisted
Outpatient
Treatment.
February
1, 2016
• CCBHS
began
accepting
AOT
referrals.
February
1, 2016
• CCBHS
received its
first referral
and
conducted
its first
investigatio
n.
February
5, 2016
• MHS
outreaches
to the first
eligible
individual.
March 4,
2016
• MHS enrolls
the first
ACT
consumer.
June 30,
2017
• In FY16/17,
CCBHS
received
177
referrals
and MHS
enrolled 43
ACT
consumers
F&HS Agenda Packet Page 72
9/15/2017
3
FY16/17 Interim Evaluation
◻Interim Evaluation
Activities ⬜Secondary data
analyses on AOT
program services⬜Measure MHS’ ACT
fidelity
◻Interim Evaluation
Period ⬜July 1, 2016 – June 30,
2017
5
Purpose of FY16/17 Interim
Evaluation:➢Provide information about AOT
program implementation, ACT
service provision, and preliminary
findings.➢Support continuous quality
improvement process to ensure
the AOT program is meeting its
intended goals.
Data and Limitations
Data Provided
◻CCBHS⬜Referral and investigation
information⬜Service utilization data for all
specialty mental health services
provided or paid for by CCBHS⬜MHS contract payments⬜Estimated expenditures from
CCBHS and justice partners
◻MHS⬜Outreach and engagement
contacts⬜Clinical assessments/outcomes⬜FSP assessments (PAF, KET, 3M)⬜ACT consumer and family focus
groups (from ACT fidelity
assessment)
◻Sherriff’s Office and Superior Court⬜Bookings, charges, and convictions
Limitations
◻In 17 months, the program is still
developing and modifying, which
impacts data accessibility and
quality.
◻There are still relatively few
consumers in ACT (43 who have
spent an average of 243 days in
ACT).⬜RDA standardized outcomes
measures to rates per 180 days
to account for variability in
enrollment lengths and the vastly
longer pre-enrollment data
periods.
6
F&HS Agenda Packet Page 73
9/15/2017
4
AOT Program Overview7
Pre- and AOT-Enrollment
8
Referral and InvestigationCCBHS received and investigated 177 referrals
Outreach and EngagementMHS provided outreach and engagement to 74 individuals
ACT Team Enrollment43 consumers enrolled in AOT treatment program*9 with court involvement
Pre-Enrollment AOT-Enrollment
F&HS Agenda Packet Page 74
9/15/2017
5
Pre-Enrollment 9
Referrals and Investigations
10
Requestor % of ReferralsFebruary – June 2016(n = 88)
% of ReferralsJuly 2016 – June 2017(n = 190)Parent, spouse, adult sibling, or adult child 61% (n = 54) 63% (n = 120)Treating or supervising mental health provider 11% (n = 10)23% (n = 43)Probation, parole, or peace officer 16% (n = 14)11% (n = 20)Adult who lives with individual 2% (n = 2)1% (n = 2)Director of hospital where individual is hospitalized 2% (n = 2)0% (n = 0)Director of institution where individual resides 0% (n = 0)0% (n = 0)Not a qualified requestor or “other”7% (n = 6)2% (n = 5)
Referrals from
mental health
providers increased,
while referrals from
unqualified
requestors
decreased.
Investigation Outcome Number of Referred Consumers
% of Referred ConsumersReferred to MHS 42 24%Engaged or Re-Engaged with a Provider 19 11%
Investigated and Closed 91 51%Ongoing Investigation 25 14%
8
3 2 3
0246810
Referred toMHS(n = 42)
Engaged orRe-Engagedwith aProvider(n = 19)
Investigatedand Closed(n = 91)
OngoingInvestigation(n = 25)Average Number of Contact AttemptsInvestigations resulting in referrals to MHS had many more contacts than other
investigation outcomes.
F&HS Agenda Packet Page 75
9/15/2017
6
Outreach & Engagement
11
Over 80% of MHS’ contacts were
successful in reaching the
consumer or collateral.
Outreach and Engagement Outcome
Number of Consumers % of Consumers
Enrolled in ACT Services in FY16/17 43 58%
Enrolled Voluntarily 34 --
Enrolled with Court Involvement 9 --
Engaged or Re-Engaged with Another Provider 4 5%
Closed by CCBHS 17 23%
Still Receiving Outreach and Engagement Services 10 14%
Collateral24%
In-personUnsuccessful19%
In-personSuccessful55%
Phone/Email2%
Nearly two-thirds (63%) of
consumers that MHS conducted
outreach and engagement with
resulted in enrollment in ACT or
another program.
Referral to Enrollment
Outcomes
12
Average Length of Time from
AOT Referral to ACT Enrollment
Length of Time from AOT
Referral to ACT Enrollment
Average days from AOT referral to first MHS contact52.5
Average days from MHS first contact to ACT enrollment55
0 20 40 60 80 100 120
FY16/17ACT Consumers(N = 43)
Days
107 average days from referral to enrollment4 – 281 days in range79 median days
5
10
6 5
3 4 3 3 2 1 1
0
2
4
6
8
10
12
Number of ACT ConsumersDays from Referral to Enrollment
On average, for AOT treatment program consumers, it takes 107 days from
the point of AOT referral to ACT enrollment.
F&HS Agenda Packet Page 76
9/15/2017
7
AOT Enrollment13
AOT Treatment Program
F&HS Agenda Packet Page 77
9/15/2017
8
Consumer Profile (N = 43)
◻Diagnosis⬜61% of consumers had primary
diagnosis of psychotic disorder,
including schizophrenia and
schizoaffective disorders
◻Housing⬜40% of consumers were
homeless at ACT enrollment
◻Employment⬜54% of consumers have
supplemental security income⬜9% of consumers rely on family
members or friends for financial
support
15
Category ACT ConsumersGenderMale53% (n = 23)Female 47% (n = 20)Race and EthnicityBlack or African American 23% (n =10)
Hispanic 12% (n =5)White 56% (n =24)Other or Unknown 9% (n =4)Age at Enrollment18 – 25 25% (n =11)26 – 59 70% (n =30)60+5% (n =2)
ACT Service Participation (N =
43)
◻Avg. length of
enrollment: 243 days
◻Avg. number of service
encounters: 6.5 face-to-
face contacts per week
◻Avg. intensity of services:
6 hours of face-to-face
contact per week
◻The majority of
consumers were
adherent to ACT
treatment (93%)
◻13 consumers were
discharged from ACT
during FY16/17⬜2 re-enrolled at least
once
16
ACT Services ACT Treatment Adherence &
Discharges
F&HS Agenda Packet Page 78
9/15/2017
9
ACT Fidelity Assessment
◻Site visit on 7/13/17 that
included:
⬜Team meeting observation
⬜Data and documentation
review⬜Interviews with ACT team
members (7)⬜Consumer Focus Group⬜Family Focus Group
◻ACT Fidelity Score:4.42
⬜High fidelity
◻Other Feedback
⬜MHS staff are caring and
truly invested in
consumers’ lives and
recovery processes⬜MHS conducts helpful
outreach activities⬜Many consumers have
made significant progress
◻Participant Suggestions
⬜Activity-based groups may
be helpful⬜Consider using the AOT
petition sooner
17
ACT Fidelity Assessment
◻Robust staffing who are
committed to consumers
◻Familiarity with motivational
interviewing and the recovery
model
◻Team members work
together throughout the day
to provide individualized
support
◻With MHS’ current staffing,
there would be gaps in some
positions if the program had
75 consumers
◻Explore if there are ways to
maximize use of the petition
◻Explore ways to scale the
program to ensure continued
fidelity to the ACT model
18
Strengths Opportunities
F&HS Agenda Packet Page 79
9/15/2017
10
Psychiatric Hospitalizations and Crisis
Episodes
19
On average, the number of consumers experiencing crisis episodes
and psychiatric hospitalization, as well as the frequency of crisis,
decreased post-AOT enrollment.
Crisis EpisodesBefore ACT enrollment During ACT enrollmentNumber of Consumers (N = 43)n = 40 n = 25Number of Crisis Episodes 4.7 episodes per 180 days 3.1 episodes per 180 daysAverageLength of Stay 1.8 days 1.1 days
Psychiatric Hospitalizations Before ACT enrollment During ACT enrollmentNumber of Consumers (N = 43)n = 29 n = 13Number of Hospitalizations 1.3 hospitalizations per 180 days 1.1 hospitalizations per 180 daysAverageLength of Stay 9.7 days 28.6 days
Criminal Justice Involvement
20
The number of consumers experiencing criminal justice involvement
decreased during ACT, from 31 consumers pre-enrollment to 14
consumers during ACT enrollment.
14 Arrested and Booked
7Charged 4Convicted
Criminal Justice Involvement during ACT Trespassing or Disorderly Conduct16%
Assault and Battery22%
Theft16%Drug Offense10%
Probation violation30%
Other 6%
Types of Bookings during ACT
F&HS Agenda Packet Page 80
9/15/2017
11
Housing Status
21
The majority of ACT consumers (64%, n = 25) either obtained or
maintained housing while in ACT.
Consumers who obtained housing•15% of consumers who were not housed before ACT obtained housing while enrolled
Consumers who maintained housing•49% of consumers who were housed before ACT continued to maintain housing while enrolled
Consumers who were not stably housed•8% of consumers were housed before ACT but did not maintain housing during ACT•28% of consumers were not housed before or during ACT enrollment
Consumers’ Housing Status before and during ACT (N = 39)
Social Functioning and
Independent Living
22
ACT consumers experienced slight increases in their self-sufficiency
while enrolled in ACT.
◻Self-Sufficiency Matrix (18 domains, score out of 90 pts)⬜Intake average score: 41.15 pts (n = 27)⬜90-day reassessment average score: 48.14 pts (n = 21)⬜180-day reassessment average score: 45.87 pts (n = 15)
F&HS Agenda Packet Page 81
9/15/2017
12
Preliminary AOT Investments
and Costs
◻Expenses
◻The cost of implementing
AOT is $1,872,390, which
includes actual expenses and
revenue projections.
◻3.5% savings in average
annual cost per consumer⬜Reductions in costs incurred
from criminal justice
involvement and psychiatric
hospitalizations
23
AOT Investments Cost Savings to Contra Costa
County
CountyDepartment FY 16/17 CostCCBHS (including FMH and MHS)$1,960,001CountyCounsel$68,347Public Defender’sOffice $112,500SuperiorCourt$3,378.00 Total CountyCosts $2,144,226
Average Annual Cost per Consumer12 Months before ACT During ACT
All Behavioral Health Services $82,788 $95,699
Bookings $7,807 $2,450
Psychiatric Hospitalizations $69,715 $56,512
Discussion24
F&HS Agenda Packet Page 82
9/15/2017
13
AOT Care Team
◻FMH and MHS work
together to identify,
outreach, and engage
eligible consumers in
order to enroll them in
ACT.⬜The Care Team meets
consumers “where
they’re at” and strive to
find and engage
consumers and their
support networks.
◻AOT program has
engaged 46% of all AOT
referrals in the
appropriate level of
mental health services.⬜Care Team resolved
142 referrals in
FY16/17⬜66 referred consumers
were connected to
ACT or another service
provider
25
Consumer Outcomes
26 ◻The majority of consumers experienced benefits from
participating in the AOT treatment program.⬜Fewer consumers experience mental health crisis
episodes, hospitalizations, and criminal justice
involvement while in the AOT treatment program.⬜Increased social functioning and independent living skills
after 6 months in the AOT treatment program
F&HS Agenda Packet Page 83
9/15/2017
14
Consumers that are
Challenging to Locate
27 ◻Some referred individuals were
unable to locate.⬜Referrals from confined
settings (hospitals & jails) can
be challenging to coordinate.⬜Referrals from the community
present unique challenges
because they may be
homeless, unstably housed, or
otherwise difficult to locate.
Considerations for AOT Team:➢Tracking mechanism on
consumer face sheet to note an
open or previous AOT referral.➢Training for PES, Inpatient Unit
4C, and jail mental health to
screen for AOT and contact
FMH/MHS when someone is
ready for discharge.➢Education for qualified
requestors to call FMH/MHS
when individuals are at PES,
hospital, or jail so they can go to
the facility and make contact.
Using the Court Petition
28 ◻Some individuals are very
difficult to engage in treatment.⬜18 non-AOT individuals continued
to experience crisis, jail, and/or
hospitalization post-referral.⬜40% of ACT consumers enrolled
more than 120 days post-referral.⬜14% of ACT consumers requested
and were discharged before
completing ACT.⬜30% of ACT consumers
experienced increases in crisis,
hospitalization, and criminal
justice involvement.
Considerations for AOT Team:➢Using the AOT court petition in
the following circumstances:•While the person is
hospitalized/incarcerated;•If the person is unlikely to
engage within 120 days;•If the person agrees to
voluntarily participate but
fails to engage or requests
discharge prematurely; or•If the person agrees to
participate but continues to
experience crisis,
hospitalization, and/or
criminal justice involvement.
F&HS Agenda Packet Page 84
9/15/2017
15
Next Steps
29
◻2018 DHCS Report⬜Data collection and analysis: December 2017 – February 2018⬜DHCS Report (January 1, 2017 – December 31, 2017): March 2018⬜Presentation of DHCS report findings: April – May 2018
◻ACT Fidelity Assessment⬜ACT Fidelity Assessment Activities: July 2018⬜ACT Fidelity Assessment Report: August 2018
◻2017-2018 Evaluation Report⬜Data collection and analysis: June – September 2018⬜AOT Evaluation Report (July 1, 2017 – June 30, 2018): October 2018⬜Presentations of Evaluation Report findings: November 2018
Roberta Chambers, PsyD
rchambers@resourcedevelopment.net
510.984.1478
Questions and Answers30
F&HS Agenda Packet Page 85
FAMILY AND HUMAN SERVICES COMMITTEE 5.
Meeting Date:09/25/2017
Subject:Annual Report on Challenges for EHSD - Continuum of Care Reform
Submitted For: FAMILY & HUMAN SERVICES COMMITTEE,
Department:County Administrator
Referral No.: 44
Referral Name: Challenges for EHSD - Continuum of Care Reform
Presenter: Kathy Gallagher, Employment and Human
Services Director
Contact: Enid Mendoza, (925)
335-1039
Referral History:
This referral to the Family and Human Services Committee (F&HS) was originally made by the
Board of Supervisors on April 25, 2000. Another referral to F&HS, number 19, on Welfare
Reform was referred on January 21, 1997. On January 1, 2005, the Board of Supervisors
combined these two referrals so that the Department could provide updates on various aspects of
their programs as the need arose. Since that time, the Family and Human Services Committee has
received annual updates from the Employment and Human Services Department on a variety of
issues impacting the Department.
On January 5, 2016, the Board approved the staff recommendation to carry forward this referral to
the 2016 F&HS. On June 7, 2016, the Board approved the recommendation of the Employment
and Human Services Director to eliminate the "Office of the Future" component of the referral
and expand the referral to include a report on the Continuum of Care (Foster Care) topic.
Referral Update:
The last report on this referral came to F&HS on September 12, 2016 and was later approved by
the Board of Supervisors at their November 8, 2016 meeting.
Please see the attached report from the Employment and Human Services Department, which
provides an update on the Department's implementation of the Continuum of Care Reform (AB
403) and their efforts to improve services to dependent children and youth.
Recommendation(s)/Next Step(s):
CONSIDER accepting the report from the Employment and Human Services Department on the
foster care Continuum of Care Reform implementation efforts and forwarding it to the Board of
Supervisors for their information.
Fiscal Impact (if any):
F&HS Agenda Packet Page 86
There is no fiscal impact, the report is informational.
Attachments
Report on Continuum of Care Reform Implementation
Continuum of Care Reform Implementation Presentation Slides
F&HS Agenda Packet Page 87
EMPLOYMENT AND HUMAN SERVICES
CONTRA COSTA COUNTY
TO: Family Human Services Committee DATE: September 25, 2017
David Twa
FROM: Kathy Gallagher, Director, Employment and Human Services Department
Kathy Marsh, Director, Children and Family Services Bureau
SUBJECT: Continuum of Care Reform (CCR)
RECOMMENDATION
Accept this report from the Employment and Human Services Department; and continue
to support the Children and Family Services (CFS) Bureau and its efforts to improve
services to dependent children and youth.
BACKGROUND
The Continuum of Care Reform, AB 403, is a comprehensive reform effort built on many
years of policy changes designed to improve outcomes for youth in foster care. The goal
is to ensure that youth in foster care have their day-to-day physical, mental, and
emotional needs met; that they have the greatest chance to grow up in permanent and
supportive homes; and that they have the opportunity to grow into self-sufficient,
successful adults.
FUNDAMENTAL PRINCIPLES OF CCR:
All children deserve to live with a committed, nurturing, and permanent family that
prepares the youth for a successful transition into adulthood.
The goal for all children in foster care is safety, permanency and well being while
establishing permanent life-long relationships. CCR guides the transition away from the
traditional use of long-term group home care by transforming existing group home care
into short term, residential treatment programs for youth who are not ready to live with
families in home-based care.
All placement types should be able to provide access to the services and supports,
including behavioral and mental health services that the child in placement needs.
Agencies serving children and youth including; child welfare, probation, mental health,
education, and other community service providers, need to collaborate effectively to
F&HS Agenda Packet Page 88
surround the child and family with needed services, resources and supports rather than
requiring the child and caregivers to navigate multiple service providers.
Both the child and family's experience and voice are important in assessment,
placement and service planning. Child and Family Team meetings, which include the
child, family, and members of their formal and informal support network, will meet as a
foundation for ensuring all perspectives are considered throughout the life of the case.
PROGRESS TO DATE:
Contra Costa County implemented Resource Family Approval (RFA) January 1, 2017.
RFA is an important shift in the way that Children and Family Services approves
caregivers as it supports placement with families that can provide a lifelong connection
by determining permanency approval upfront.
EHSD has a collaborative CCR Executive Team and a Steering Committee with
management representatives from Children and Family Services, the CAO’s office,
Behavioral Health Department, and Probation Department to guide workgroups tasked
with different components of CCR, such as Child and Family Team Meetings, Group
Homes and Foster Family Agencies, Training, and Data.
Children and Family Services is regularly collecting data on the (approximately) one
hundred dependent children who are currently in group home placements to assess
their potential for stepping down to home-based care and to determine their specific
services and treatment needs.
Children and Family Services has also been meeting with providers, including Group
Homes and Foster Family Agencies (FFAs) in order to communicate the needs of Contra
Costa County dependents and assist them with their transition to CCR.
Over the past year and a half, Children and Family Services has also developed new
strategies and a renewed focus on recruiting and retaining quality non-relative and
relative resource families.
SUMMARY/CONCLUSION
The Continuum of Care Reform draws together a series of existing and new reforms to
our child welfare services program designed out of an understanding that children who
must live apart from their biological parents do best when they are cared for in
committed, nurturing family homes. AB 403 provides the statutory and policy
framework to ensure services and supports provided to the child and his or her family
are tailored toward the ultimate goal of maintaining a stable, permanent family.
F&HS Agenda Packet Page 89
With the Board’s support and commitment to the Continuum of Care Reform, EHSD will
utilize CCR to better meet the needs of our dependent children and to promote positive
outcomes for youth as they transition out of foster care.
F&HS Agenda Packet Page 90
CALIFORNIA’S CHILD WELFARE
CONTINUUM OF CARE REFORM (CCR)
OVERVIEW FOR CONTRA COSTA COUNTY
F&HS Agenda Packet Page 91
CCR is mandated by AB 403 and is a comprehensive
framework that supports children, youth and families across
placement settings in achieving permanency.
CCR includes:
THE CONTINUUM OF CARE REFORM
•Increased engagement with children, youth and families
•Increased capacity for home-based family care
•Limited use of group home care
•Changes in rates, training, accreditation, mental health
services and accountability & performance
F&HS Agenda Packet Page 92
VISION OF CCR
Group Home care, when needed, is a short-term, high quality, intensive intervention
that is just one part of a continuum of care available for children, youth and young
adults
Focus on permanent family and preparation for successful
adulthood
Individualized and coordinated services and supports
All children live with a committed, permanent and nurturing family
F&HS Agenda Packet Page 93
CCR IMPLEMENTATION STRUCTURE
Communication
Staff Development
Data
CCR Executive Team
CCR Steering Committee
Group
Home/Behavioral
Health Workgroup
Resource Family
Approval Workgroup
Child and Family
Team Workgroup
F&HS Agenda Packet Page 94
Group Home Short Term Residential
Treatment Program
(STRTP)
Children who cannot be safely placed in a family
setting, and who meet the specific criteria can
receive short-term, residential care with intensive
therapeutic interventions and services to support
their transition to home based family care.
THE PARADIGM SHIFT
F&HS Agenda Packet Page 95
GROUP HOME/BEHAVIORAL HEALTH WORKGROUP
Meeting regularly since early 2016 to plan for transition of
youth from congregate care to Home Based Family Care
Workgroup Highlights:
Support Group Homes in their transition to STRTPs
Identify youth who will require STRTP level placement
Support Foster Family Agencies (FFAs) in expanding their
capacity to accommodate High Needs Youth
Work with Mental Health to identify and arrange
necessary supports in place for those placements
accepting High Needs Youth
Preparation for Step Downs…
F&HS Agenda Packet Page 96
STEPPING DOWN TO HOME BASED CARE
Group
Home/
STRTP
FFA / ITFC/TFC
home
Resource Family
Home
Children requiring highly
intensive 24-hour supervision
and treatment. STRTPs will be
designed to quickly transition
children back to their own or
another permanent family
Provide various
levels of care to
meet a broader
range of individual
child needs
F&HS Agenda Packet Page 97
CORE SERVICES:All placement types will be held to higher
standards and be accountable to coordinated
care among all service providers.
Child
Behavioral
and mental
health
support Transitional
support
services
Educational
support
Physical
Health
supportIndian
Child
services
Activities to
support a
successful
adulthood
Achieve
permanency
Maintain/
establish
family
connections
F&HS Agenda Packet Page 98
INCREASED BEHAVIORAL HEALTH SERVICES
Intensive Care Coordinators (ICC): assigned to
children who meet medical neccesity criteria to
facilitate teaming and coordinate mental health care
216 ICC eligibility
screenings
complete
71 were eligible and
referred to ICC services
62 clients closed
out of ICC services
Based on meeting goals
and no longer needing
additional services
389 referrals
made to Care Managed
Unit for outpatient
therapy referrals for
children with mild to
moderate symptoms
Total open ICC cases as of 07/2017: 326
From 01/2017 – 07/2017
F&HS Agenda Packet Page 99
CCR CORE ELEMENT:
INCREASED ENGAGEMENT
Child & Family Team(CFT)
Up-front and continuing assessment that includes
youth, family members, and their formal and informal
support network collaborating in regards to support,
services, and placement needs of the youth and family
F&HS Agenda Packet Page 100
CFT WORKGROUP
A Child and Family Team workgroup meets regularly to
work towards:
Holding CFT meetings for all open cases within 60
days
Holding a CFT meeting not less than once every 6
months for all open cases
Holding a CFT meeting once every 90 days for youth
who are placed in an STRTP (and/or meet special
mental health criteria)
Inviting appropriate resources, i.e., Domestic Violence
Liaisons, Public Health Nurses, etc.
Ensuring a voice for families and the child
F&HS Agenda Packet Page 101
CHILD AND FAMILY TEAM (CFT)
CCC has hired 4 Full Time CFT Facilitators and contracted
out assistance from another agency for the 6 month
review CFTs and Youth Transition Meetings (YTM).
F&HS Agenda Packet Page 102
SINCE JANUARY 1…
CCC CFS has completed 302 CFT meetings between 01/2017 and 07/2017
164 Team Decision Making/CFT meetings
(referral)
21 Court CFTs
35 Continuing/Intensive Family Services
meetings
20 placement disruption
62 Youth Transition Meetings
F&HS Agenda Packet Page 103
Resource Family
Relative
Caregiver
Foster
Family
Adoptive
Family
Resource Family Approval:
•A new single, unified process
for approving all caregivers,
including: Kin, Non Related
Extended Family Members
(NREFM), licensed foster
families, and FFA foster
families
Foster Families/Relatives Resource Families
CCR also includes another big shift from:
F&HS Agenda Packet Page 104
RESOURCE FAMILY APPROVAL WORKGROUP
Meeting monthly since late 2015 to:
Plan and implement Resource Family Approval
effective 01/01/2017
Train staff and caregivers to meet new RFA standards
Improve emergency relative placement and overall
relative placements
Plan for conversion of existing licensed foster homes
and approved relative homes
Develop recruitment, training and support of current
and prospective caregivers
F&HS Agenda Packet Page 105
RFA APPLICATION DATA
Consistently 40-45
Resource Family
applications per
month since
04/2017
On average, from
4/2017 – 06/2017,
2/3 of the
applications are
relatives/NREFMs
F&HS Agenda Packet Page 106
RESOURCE FAMILY APPROVAL
Challenges
• Length of
application/approval
process
• Pre-Approval training
requirement for all
potential caregivers
• Short timelines
• Staffing
• Conversion of existing
Approved Relative
/Licensed Fother Homes
Successes
• Increased Emergency
Placements
• New Resource Family
Approval database
• Reorganization and
restructuring of existing
staff
• Increased applications
• Regional collaboration
F&HS Agenda Packet Page 107
CONTRA COSTA COUNTY PLACEMENT RESOURCE DATA
80% of dependent children’s placements
will be affected by CCR
328 total approved relative homes and
Licensed Foster Homes will need to be
converted to RFA homes
F&HS Agenda Packet Page 108
CHILDREN & FAMILY SERVICES PLACEMENTS
SILP
6%
Guardian Home
(Dependent)
1%
Foster Family
Home
16%
Relative/
NREFM
25%
Foster Family
Agency
27%
Group Home
9%
Guardian
Home
(Voluntary)
12%
Resource Family
4%
F&HS Agenda Packet Page 109
CONTRA COSTA PROBATION PLACEMENTS
Group
Home; 26;
51%
SILP/THPP;
25; 49%
Resource
Family; 0;
0%
SILP:Supervised Independent Living Placement
THPP:Transitional Housing Placement Program
F&HS Agenda Packet Page 110
PLACEMENT IMPACT – CFS CHILDREN
42 children will need to transition from Group Home
placements to STRTPs
Very few group homes have successfully made this
transition successfully yet
55 children will need to transition from a Group
Home placement to a lower level of Home Based Care
CCC will need home based caregivers that are willing to take
dependents with higher needs levels
The most difficult 1% of dependent youth will still need
specialized placement and their needs still may not be
met by STRTPs. Counties are presenting these cases
to the state for review.
F&HS Agenda Packet Page 111
• Increased recruitment: buses, movie
theater ads
• Targeted recruitment for older youth and
high needs youth
CCC needs to actively
recruit and approve
more Resource
Family Homes
• CFS has entered into a Mental Health
interagency agreement to provide
additional mental mealth services to
support youth in home based family care
• Mental Health has begun expansion of
specialty services such as Parent Partners,
Emergency Foster Care Unit, ICCs
CCC needs to
develop additional
services to support
youth formerly in
Group Homes now in
home based settings
IMPLICATIONS FOR CONTRA COSTA COUNTY
Response:
Response:
F&HS Agenda Packet Page 112
ADDITIONAL IMPLICATION:
UPDATED PROVIDER RATE STRUCTURE
Phase 1 implemented 01/01/2017 and established one rate for
Resource Family Homes, Licensed Foster Homes, Relatives,
NREFMs, and NMDs in Supervised Independent Living
Placements
Rate structure for FFAs includes a detailed breakdown of rate for
Admin, Social Worker, the Certified Family, etc.
One STRTP rate for all STRTP facilities
Phase 2 goes into effect 12/01/2017 and includes a new Home
Based Foster Care LOC Protocol and Intensive Services Foster
Care rates to support children in placement with more specific
and/or specialized needs
F&HS Agenda Packet Page 113
CHALLENGES AHEAD
Some Group Homes will not be able to make the
conversion to STRTP resulting in few placement
options for high needs youth
Recruiting Foster Families
Increase Family Finding
Increase community awareness of need for caregivers and
the specific needs of our youth
In Home supports needed for caregivers and for
children entering home based family care
In order for step downs to be successful, appropriate
supportive services will need to be in place
Lack of interest in becoming TFC
F&HS Agenda Packet Page 114
MENTAL HEALTH SERVICES CHALLENGES
Increased need of Outpatient and Crisis services that will
require greater resources and Staffing
Increased need for Utilization Review, authorization, and
monitoring of Service delivery and documentation
Additional resources needed to monitor and facilitate the
implementation of EPSDT Specialty Mental Health Services
by FFA’s and Foster homes, as well as provide Mental
Health Consultation and Training.
F&HS Agenda Packet Page 115
LOOKING AHEAD
“All children deserve to live with a committed, nurturing,
and permanent family that prepares youth for a successful
transition into adulthood.”
Children and Family Services, Behavioral Health
and Probation will continue to collaborate as
we address the challenges and implications of
CCR to effectively meet the needs of the
children and families we serve.
F&HS Agenda Packet Page 116