HomeMy WebLinkAboutBOARD STANDING COMMITTEES - 12032018 - FHS Cte Agenda PktFAMILY & HUMAN SERVICES
COMMITTEE
SPECIAL MEETING
Note the change in date, time and location for this meeting!
December 3, 2018
12:00 P.M.
Redwood Room, 651 Pine Street, 3rd Floor, Martinez
Supervisor Candace Andersen, Chair
Supervisor John Gioia, 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.RECEIVE and APPROVE the draft Record of Action for the October 22, 2018 Family
& Human Services Committee meeting. (Julie DiMaggio Enea, County Administrator's
Office)
4.CONSIDER accepting follow-up report from the Employment and Human Services
Director in response to the CalFresh Partnership's recommendations pertaining to wait
times experienced by CalFresh clients. (Kathy Gallagher, EHS Director; Wendy
Therrian, EHS Workforce Services Bureau Director)
5.CONSIDER recommending to the Board of Supervisors the appointment of Jill Kleiner
to At Large #19 seat with a term expiring September 30, 2019, and Steve Lipson to At
Large #6 seat, and Jatin Mehta to At Large #8 seat with terms expiring September 30,
2020, on the Advisory Council on Aging, as recommended by the Council. (Anthony
Macias, Employment and Human Services Department)
6.CONSIDER accepting the annual report from the Public Health Division of the Health
Services Department on the implementation of the Secondhand Smoke Protections
Ordinance and directing staff to report back to the Family and Human Services
Committee meeting in 2019. (Daniel Peddycord, Public Health Director)
7.CONSIDER accepting the annual report from the Public Health Department on the
implementation of the Tobacco Retailer Licensing and Businesses Ordinances and
DIRECT staff to forward the report to the Board of Supervisors for their information.
(Daniel Peddycord, Public Health Director)
8.CONSIDER accepting report from the Health Services Department on the County's
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8. CONSIDER accepting report from the Health Services Department on the County's
Assisted Outpatient Treatment Program, as authorized by the Board of Supervisors and
AB 1421 (Laura's Law), and forward the report to the Board of Supervisor for approval.
(Matthew White, M.D., Acting Behavioral Health Services Director; Roberta
Chambers, Ph.D., Resource Development Associates)
9.This is the final meeting of the 2018 Committee. No further meetings are scheduled.
10.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.
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:
Julie DiMaggio Enea, Interim Committee Staff
Phone (925) 335-1077, Fax (925) 646-1353
julie.enea@cao.cccounty.us
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FAMILY AND HUMAN SERVICES
COMMITTEE 3.
Meeting Date:12/03/2018
Subject:RECORD OF ACTION FOR THE OCTOBER 22, 2018 F&HS
MEETING
Submitted For: David Twa, County Administrator
Department:County Administrator
Referral No.: N/A
Referral Name: N/A
Presenter: Julie DiMaggio Enea Contact: Julie DiMaggio Enea (925)
335-1077
Referral History:
County Ordinance requires that each County body keep a record of its meetings. Though the
record need not be verbatim, it must accurately reflect the agenda and the decisions made in the
meeting.
Referral Update:
Attached is the draft Record of Action for the October 22, 2018 Family & Human Services
Committee meeting.
Recommendation(s)/Next Step(s):
RECEIVE and APPROVE the draft Record of Action for the October 22, 2018 Family & Human
Services Committee meeting.
Fiscal Impact (if any):
None.
Attachments
DRAFT FHS Committee Record of Action for October 22, 2018
3
FAMILY AND HUMAN SERVICES
COMMITTEE
RECORD OF ACTION FOR
OCTOBER 22, 2018
Supervisor Candace Andersen, Chair
Supervisor John Gioia, Vice Chair
Present: Candace Andersen, Chair
John Gioia, Vice Chair
Staff Present:Timothy Ewell, Chief Asst. County Administrator
Attendees: Julia Taylor, County Admin Office
Kathy Gallagher, EHS Director
Victoria Tolbert, EHSD
Camilla Rand, EHSD
Juliana Mondragon, EHSD
Members, SEIU, Local 1021
Members, Local 21
1.Introductions
Chair Andersen convened the meeting at 10:35 a.m. and self-introductions were
made around the room.
2.Public comment on any item under the jurisdiction of the Committee and not on this
agenda (speakers may be limited to three minutes).
The Committee accepted public comment. Four Speakers: One regarding Local 21,
and three regarding SEIU 1021, all addressed the issues of high health insurance
costs for Contra Costa County employees and high caseloads.
3.RECEIVE and APPROVE the draft Record of Action for the September 24, 2018
Family & Human Services Committee meeting.
The Committee approved the Record of Action for the September 24, 2018 meeting
as presented.
AYE: Chair Candace Andersen, Vice Chair John Gioia
Passed
4.RECOMMEND to the Board of Supervisors the appointment of Olga Jones to the At
DRAFT
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4.RECOMMEND to the Board of Supervisors the appointment of Olga Jones to the At
Large 5 seat on the Family and Children's Trust Committee to a new term that will
expire on September 30, 2020.
The Committee approved the appointment of Olga Jones to the At Large 5 seat on
the Family and Children’s Trust Committee to a term that will expire on September
30, 2020, and directed staff to forward the recommendation to the Board of
Supervisors.
AYE: Chair Candace Andersen, Vice Chair John Gioia
Passed
5.RECOMMEND to the Board of Supervisors the appointment of Joan M. D'Onofrio to
the At Large 3 seat and Lanita L. Mims to the At Large 4 seat on the Arts and Culture
Commission of Contra Costa County (AC5), as recommended by AC5.
The Committee approved the appointment of Joan M. D’Onofrio to the At Large 3
seat and Lanita L. Mims to the At Large 4 seat on the Arts and Culture
Commission (AC5) to terms that will expire on June 30, 2021, and directed staff to
forward the recommendation to the Board of Supervisors.
AYE: Chair Candace Andersen, Vice Chair John Gioia
Passed
6.ACCEPT the report from the Employment and Human Services Department on aging
and adult services, including the progress made to address the issue of elder abuse in
Contra Costa County.
Employment and Human Services Department, Aging and Adult Services Director,
Victoria Tolbert, presented the report. Ms. Tolbert reported that the two major
challenges facing the aging population are housing insecurity and poverty. Ms.
Tolbert explained that Aging and Adult Services offers a continuum of services that
address a range of needs. Examples of services include putting safety features in
the home, a Whole Person Care program for individuals with significant medical
issues, adult protective services, and “no wrong door”.
Supervisor Andersen asked what number people should call for support: It is
1-800-510-2020. Ms. Tolbert reported that awareness of this number has increased.
Supervisor Andersen supported increasing awareness of this number.
An internal challenge to the Department that Ms. Tolbert reported on was the
shortage of direct services staff, particularly social workers and in-home support
services staff. She indicated that it is a priority with Kathy Gallagher, David Twa
and Human Resources. Also, the Department is working on placing more energy
into staff development to internally build the needed knowledge and skill sets.
Aging and Adult Services is working to identify non-licensed facilities and help
them achieve licensing to increase supply. An option discussed was creating a
County certification, so if they cannot obtain a state license, they come out of the
DRAFT
5
shadows and have some oversight.
Another issue discussed was hospital discharges lacking safe locations to which to
discharge. Aging and Adult Services coordinates with discharge planners and
hospitals to coordinate safe discharges. Possible legislation would ban hospital
discharges to shelters without an available bed. Senior specific shelters would help
to close the capacity gap.
The department made a final request for the Board of Supervisors to engage in
supporting and spreading awareness about these services.
AYE: Chair Candace Andersen, Vice Chair John Gioia
Passed
7.ACCEPT the report from the Employment and Human Services Department on the
oversight and activities of the Community Services Bureau.
Employment and Human Services Department, Community Services Bureau
Director Camilla Rand presented the report. One item reported on was the closing
of one Richmond child service facility and seeking relocation for the Central
Kitchen. The Kitchen currently produces about 40,000 meals each month.
A positive legislative change discussed was the consolidation of childcare license to
requiring one for ages 0 to 5.
An internal challenge to the Department that Victoria Tolbert reported on was the
shortage of staff. One tactic for addressing the staff shortage is additional staff
development through a Teacher Apprenticeship program.
Ms. Rand notified Supervisor Andersen that three reviews are expected this year,
and they will want to interview the Board of Supervisors. The Board will need to be
versed in programmatic details.
AYE: Chair Candace Andersen, Vice Chair John Gioia
Passed
8.ACCEPT report from the Employment and Human Services Director on the
Department's use of technology to support client services and staff efficiencies.
Employment and Human Services Department, Administrative Services Director
Michael Roetzer presented the report. Mr. Roetzer reported on some of the
technological advancements EHSD has made, including: video conferencing for
American Sign Language customers, redesigning the website, expanding video
conferencing in lieu of in-person or over the phone for increased efficiency and
effectiveness, using electronic signatures on certain forms, getting mobile devices
to more in-home supportive services staff, and encouraging clients to use My
Benefits in CalWIN for case updates.
AYE: Chair Candace Andersen, Vice Chair John Gioia
DRAFT
6
Passed
9.The November 26, 2018 FHS Committee meeting is canceled due to schedule
conflicts. The date for the final 2018 meeting is yet to be determined.
The final FHS Committee meeting has been scheduled for Monday, December 3,
2018 at 9:00 a.m. in Room 101.
10.Adjourn
DRAFT
7
FAMILY AND HUMAN SERVICES
COMMITTEE 4.
Meeting Date:12/03/2018
Subject:SNAP/CalFresh (Food Stamp) Program Follow-up Report
Submitted For: Kathy Gallagher, Employment & Human Services Director
Department:Employment & Human Services
Referral No.: FHS #103
Referral Name: SNAP/CalFresh (Food Stamp) Program
Presenter: Kathy Gallagher Contact: Wendy Therrian, Workforce Svcs
Director
Referral History:
The SNAP Program was originally referred to the Family and Human Services Committee by the
Board or Supervisors on February 15, 2011. This program was formerly known as Food Stamps
and is currently known as the Federal Supplemental Nutrition Assistance Program (SNAP). In
California, the name of the program is CalFresh.
On September 24, 2018, Workforce Services Director Wendy Therrian presented the annual
status report to the FHS Committee. Wendy reported that applications increased by 121% over a
ten year period but that that CalFresh applications and disbursements decreased this year from
last year likely due to higher employment. She highlighted her concern about the Federal
Administration's forthcoming guidelines that will restrict eligibility for cash aid and permanent
housing to permanent residents.
Supervisor Gioia observed that we are at nearly a 20% poverty level and that Devorah Levine has
done work to apply what the definition of poverty level is for Contra Costa County. The
Committee requested information on how this is affecting Contra Costa County specifically.
Supervisor Gioia asked why usage has decreased and what staff are doing to address the different
reasons (other than unemployment decreasing) for the decrease. He suggested greater outreach.
Staff advised that they conduct cross-sector outreach through Meals on Wheels packets, for
example, but are always battling stigma.
Lisa Arnold spoke during the public comment period about the need to close the gap between jail
release and cash aid receipt, saying it can take as long as two weeks. She suggested that the
Medi-Cal application be initiated while a person is still incarcerated so he/she does not come out
desperate and the re-offend. Staff verified that they work with parolee entities and Rubicon center
on this.. Supervisor Andersen suggested that staff network with the Office of Re-entry and Justice
to obtain information about jail inmates who are preparing to emancipate.
8
Mariana Moore offered three recommendations from the CalFresh Partnership in pertinence to the
long wait times experienced by clients in County offices and call centers, which she attributed to a
lack of frontline staff in County offices:
Lift the hiring freeze on the Workforce Services Bureau so they can hire more frontline CalFresh staff.1.
Commit any augmented allocation this year to fund additional front line staff so that people can receive the
customer service they need to navigate the benefits process.
2.
In reference to customer service, access to benefits, and fighting hunger, create transparency about where the
resources for the CalFresh allocation are being used within the County to ensure that the best use of taxpayer
dollars. To do so, engage an independent contractor to conduct an impartial analysis of how CalFresh and
other public benefits administrative dollars are allocated, and share the results with the public.
3.
The Committee requested that these recommendations be forwarded to Kathy Gallagher for
response and scheduled as the first item of discussion at a future FHS Committee meeting.
Referral Update:
Please see attached report from EHS Director Kathy Gallagher that discusses the CalFresh
Partnership recommendations.
Recommendation(s)/Next Step(s):
ACCEPT follow-up report from the Employment and Human Services Director in response to
CalFresh Partnership recommendations pertaining to wait times experienced by CalFresh clients.
Attachments
Follow-up EHSD Report on Sept 24 CalFresh Partnership Recommendations
9
CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 1
40 Douglas Drive, Martinez, CA 94553 • (925) 608 5000 • Fax (925) 313-9748 • www.ehsd.org
To: Family and Human Services Committee
Contra Costa County Board of Supervisors
Date: December 3, 2018
From: • Kathy Gallagher, Department Director
• Wendy Therrian, Workforce Services Director
• Rebecca Darnell, Workforce Services Deputy Director
• Kathi Kelly, CalFresh Policy Manager
Subject: FOLLOW-UP: CALFRESH PROGRAM UPDATE
I. Overview – Inquiries/Requests and Responses
For your Committee meeting on September 24, 2018, a comprehensive report on our
CalFresh program had been submitted for review and discussion. During the September
24th discussion your Committee and Community Partners raised the following primary
issues, concerns, and questions on which to report back.
A. Committee Members
1. Community Outreach especially with the Re-entry population
Response:
We continually endeavor to expand and strengthen outreach to potential CalFresh
recipients especially to more disenfranchised groups such as the re-entry population. Our
community partners regularly conduct outreach at County Parolee Education meetings as
well as partner with several “No Wrong Door” reentry services. Conversations are
planned to be held with the West County Reentry Services Center through the Food Bank of
Contra Costa and Solano to provide for this coordination.
In addition, we are hopeful to have funded through AB 109 a Re-Entry Coordinator position
which will increase access and services coordination for all EHSD programs targeting the
County’s reentry population.
The WFS Bureau is also currently planning to have an Eligibility Worker assigned on a
rotational, part-time basis to the West County Reentry Services Center. This is planned
similarly to the assignment and connection planned with Lovonya Dejean Middle School.
M E M O R A N D U M
Kathy Gallagher, Director
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 2
2. The denial rate and reasons for denials of CalFresh applications
Response:
Our current denial rate is 45% (from January 1 through June 2018). The chart below
compares our denial rates with those of other counties in the Bay Area.
The top two reasons for denials are participants not keeping scheduled interview
appointments, and failure to provide verifications. These are the same primary two reasons
the Food Bank of Contra Costa and Solano experiences.
Additionally, applicants (particularly those making on-line applications) have reported not
being aware interviews are required and then do not follow through with the entire
application process. Other applicants generally feel we are “too much in their business”
and decide not to continue with the eligibility process.
Currently the Department is exploring ways to better ensure CalFresh recipients are aware
of interview requirements. We are also planning for new and continuous CalFresh
verification training to ensure our workers understand necessary verifications to grant
32%
45%
33%
44%
38%
44%
30%
33%34%
62%
33%
0%
10%
20%
30%
40%
50%
60%
70%
Alameda Contra
Costa
Marin Napa San
Francisco
San Mateo Santa
Clara
Santa Cruz Solano Sonoma Statewide
CalFresh Denials Average Percentages, January 2018 thru June 2018
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 3
eligibility. Additionally, and in conjunction with other counties, we are exploring other best
practices to minimize denials. For example, we know of one county who has a dedicated
clerical pool which continually reaches out to applicants to explain what is needed to
determinate eligibility and then provides for direct, “warm hand-offs” to Eligibility
Workers.
3. The number of those eligible, but not participating in the CalFresh program
Response:
According to the California Department of Social Services website and using their most
current information for 2016 under the Program Reach Index (PRI) (which estimates the
CalFresh utilization among those individuals estimated to meet CalFresh eligibility
requirements based on the U.S. Census), there are an estimated 40,000 persons who are not
being served in the County.
However, these estimates are frequently questioned given the population counted in the
Census who are not necessarily eligible, or who are known to be reluctant to apply even if
they are under the income threshold (130% FPL). The reasons for this are listed below.
Ineligible:
a. Undocumented immigrants
b. Residents receiving federal Supplement Security Income (SSI) benefits
(approximately 26,000 in Contra Costa County) are ineligible for CalFresh
benefits and are typically under the income threshold. These individuals will
become CalFresh eligible on June 1, 2019 with the implementation of the new
SSI Cash-Out policy change.
Eligible, but report the following reasons for not applying:
a. Seniors who feel they are taking the benefit away from others who may need it
more
b. Perceived stigma of being a Food Stamp (CalFresh) recipient
c. Students and Seniors report the benefit amount is so small ($10.00 to $25.00)
that it is not worth their time to apply
d. Students report the process of maintaining their benefits is confusing and
cumbersome.
However, with the implementation of the new SSI Cash-Out program we expect additional
County residents to be reached. And, under the new Able-Bodied Adults without
Dependents (ABAWD) program, our objective and that of our CalFresh community partners
is to preserve the eligibility of those existing CalFresh households through the use of
exemption criteria as well as assistance with meeting the work requirements.
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 4
4. A copy of the Department’s Public Charge announcement
Response:
A link to the text of the proposed Public Charge rules and the accompanying press release
was sent to the FHS Committee on September 24, 2018. The Department’s Public Briefing
document on Public Charge can be found at https://ehsd.org/2018/10/09/proposed-public-
charge-rule-changes-signal-chilling-effect-on-benefit-programs/.
And, as your Committee is aware, your Board took action on October 23, 2018 to amend
the County’s 2018 Federal Legislative Platform to include your opposition to proposed
regulatory changes on public charge.
At the September 24, 2018 FHS meeting the following three recommendations were offered
by the CalFresh Partnership Group to be brought back at a later FHS meeting.
B. Community Partners
1. “Lift the hiring freeze on the Workforce Services Bureau so they can hire more
frontline CalFresh staff.”
Response:
Given our existing budget constraints, the Department is unable to lift the existing two (2)
year hiring freeze for the WFS Bureau particularly given new employee costs which will be
required to be incorporated and paid from existing and future allocations including
CalFresh. However, in order to align our individual allocations for Medi-Cal, CalFresh,
and CalWORKs in the current program year, we are planning to move fifteen (15) Eligibility
Workers (EWs) from CalWORKs to our Medi-Cal CalFresh Service Center (MCSC). This
staff movement will contribute to decreasing the wait times at the MCSC thereby improving
our services to the public in both CalFresh and Medi-Cal.
Additionally, we are expecting to receive an augmented CalFresh allocation by the end of
the calendar year which is provided for the expected influx of SSI recipients who will
become eligible to CalFresh under the new SSI Cash-Out rule. We are planning to
operationalize this new requirement effective June 1, 2019.
Once we know the amount of the augmented CalFresh allocation, we will more specifically
determine the number of additional eligibility staff needed to process and carry these special
cases.
In the meantime, we are estimating the number of SSI recipients who are likely to apply for
CalFresh to make the initial determination of how many additional CalFresh workers we
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 5
will need come June 1, 2019. This number will then be concretized at the time our
augmented CalFresh allocation is known.
2. “Commit any augmented allocation this year to fund additional front-line staff so
that people can receive the customer service they need to navigate the benefits
process. This request especially related to the newly eligible Supplemental Security
Income (SSI) population as well as the Able Bodied Adults Without Dependents
(ABAWD) waiver roll out effective September 1, 2019”.
Response:
Because of the new SSI Cash-Out rule to be implemented June 1, 2019 and the new ABAWD
program to be implemented September 1, 2019, it is the Department’s goal to commit as
many front-line and support staff as may be necessary to provide efficient and timely
services to these new applicants and clients many of which are expected to be elderly and/or
disabled. The staffing level will be based on both the existing and augmented CalFresh
allocations the latter of which is not yet known (as of the writing of this report).
We are currently planning to provide easy access and coordination amongst our two
primary Bureaus – Workforce Services, and Adult and Aging Services to serve the existing
and new CalFresh population.
3. “In reference to customer service, access to benefits, and fighting hunger; create
transparency about where the resources for the CalFresh allocation are being used
within the County to ensure the best use of taxpayer dollars. To do so, engage an
independent contractor to conduct an impartial analysis of how CalFresh and other
public benefits administrative dollars are allocated, and share CalFresh and other
public benefits administrative dollars are allocated, and share the results with the
public.”
Response:
The CalFresh program locally administered by the County Employment and Human
Services Department (EHSD) is subject to and included under the County’s Single Audit
financial reviews. The outcome of these reviews are included in the Comprehensive Annual
Financial Reports (CAFRs) and are available on-line via the County Auditor’s website.
The responsibility for these financial reviews fall under the auspices of the Office of the
County Auditor-Controller and are conducted by independent CPA firms.
The manner in which these financial reviews are conducted and published allow for
maximum transparency into the Department’s operation and use of all allocations and
funding sources.
Typically, twelve (12) to fifteen (15) percent of all primary EHSD funding allocations
(including CalFresh) are earmarked for both administrative and operational support with
the remainder supporting direct operations and services.
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 6
For the above reasons, we believe an additional and outside audit expenditure related to
this suggestion is unnecessary with the financial review being duplicative.
II. Updated Review of Major Upcoming Legislation affecting CalFresh
A. Able Bodied without Dependents (ABAWD) Program
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA)
limits the receipt of CalFresh benefits to three months in a 36-month period for the Able
Bodied without Dependents (ABAWD) CalFresh population if they are not working:
participating at least 80 hours per month in a qualifying education or training activity;
participating in a workfare program or exempt due to age; caring for a child or incapacitated
household member; or certified as medically unfit for employment.
Previously, there was a waiver to this requirement which was expected to end August 31,
2018, and with the exception of three (3) counties (San Francisco, San Mateo, and Santa
Clara) was extended to August 31, 2019 for the remainder of California counties including
Contra Costa. However, we recently were notified by the California Department of Social
Services (CDSS) that we are now one of three additional counties who will be subject to this
requirement with the end of the waiver for us on August 31, 2019. Consequently, we will be
required to implement effective September 1, 2019. When this occurs, ABAWDs who do not
meet exemption criteria will be required to participate in work activities in order to continue
to receive benefits.
The implementation of ABAWD exemptions and work requirements is a major emphasis
of the Bureau and Community Partners at this time.
In partnership with EHSD, the Food Bank of Contra Costa and Solano has secured
significant private funding from four local foundations to tackle this issue. EHSD has
engaged in this new partnership, specifically focused on mitigating the negative effects of
the ABAWD roll-out and ensuring adequate supports for work in the community. This
project has involved contracting with the Glen Price Group consulting firm to convene
necessary stakeholders and to leverage partnerships to create a community-wide response
to this impending challenge.
B. Supplemental Security Income and/or California State Supplementary Payment
(SSI/SSP) Cash-Out Policy
Effective June 1, 2019 individuals receiving or authorized to receive SSI/SSP are now
eligible for CalFresh, providing all other eligibility criteria are met.
This policy changes California’s “Cash-Out” policy that began in 1974 when it opted to
increase the monthly SSP allotment by $10 instead of administering food benefits to
SSI/SSP recipients. Two state funded programs will also be created to provide benefits to
continuing households that will have their monthly benefits reduced or discontinued due to
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CalFresh 12-3-18 Follow-up Report to FHS Meeting of 09.24.18 - Page 7
adding a previously excluded SSI/SSP individual.
This is another primary planning and implementation project for the Department and our
Community Partners.
III. Important Next Steps
The Department remains committed to providing timely and ready access to CalFresh
benefits for those with unmet food needs, and in continuing to serve our CalFresh customers
in a timely and accurate manner. We have a continual improvement objective in the areas
of outreach, access, enrollment, and services delivery.
Part of this objective is to continue our community outreach efforts and to work even more
closely with our community partners to expand access to CalFresh benefits. Expanding
access includes our continued rollout of electronic and other alternative means for applying
for benefits despite our staffing reductions. We will also continue our efforts to further
streamline our CalFresh application and benefits renewal process, and will continue to work
on increasing knowledge and awareness of the CalFresh program and the application
process throughout and to targeted areas within the County.
In coordination with our CalFresh Partners, this awareness campaign will include the
impacts and implementation of the new SSI Cash-Out and ABAWD programs which will
be closely monitored to ensure ready access, efficient services, and continued eligibility.
16
FAMILY AND HUMAN SERVICES
COMMITTEE 5.
Meeting Date:12/03/2018
Subject:Appointments to the Advisory Council on Aging
Submitted For: Kathy Gallagher, Employment & Human Services Director
Department:Employment & Human Services
Referral No.: N/A
Referral Name: Appointments to Advisory Bodies
Presenter: Anthony Macias Contact: Anthony Macias (925)
602-4175
Referral History:
On December 6, 2011 the Board of Supervisors adopted Resolution No. 2011/497 adopting policy
governing appointments to boards, committees, and commissions that are advisory to the Board of
Supervisors. Included in this resolution was a requirement that applications for at
large/countywide seats be reviewed by a Board of Supervisors sub-committee.
The Advisory Council on Aging provides a means for county-wide planning, cooperation and
coordination for individuals and groups interested in improving and developing services and
opportunities for the older residents of this County. The Council provides leadership and
advocacy on behalf of older persons and serves as a channel of communication and information
on aging.
The Advisory Council on Aging consists of 40 members serving 2 year staggered terms each
ending on September 30. The Council consists of representatives of the target population and the
general public, including older low-income and military persons; at least one-half of the
membership must be made up of actual consumers of services under the Area Plan.
The Council includes: 19 representatives recommended from each Local Committee on Aging, 1
representative from the Nutrition Project Council, 1 Retired Senior Volunteer Program, and 19
Members at-Large.
Referral Update:
There are currently 29 seats filled on the Advisory Council on Aging and 11 vacancies. These
vacant seats include: Local Committee Pinole, Local Committee Richmond, Local Committee
Pittsburg, Local Committee San Ramon, Local Committee San Pablo, Local Committee Martinez,
Local Committee Oakley, and Member-At-Large seats 6, 8, 10 and 19.
Approving the three appointments in this Board Order, will bring the vacancy level down to 8,
17
with 32 filled seats. With these new seats filled, the Membership would be as follows:
Seat title Current Incumbent Incumbent
Supervisor District
Nutrition Project Council Garrett Gail I
At-Large 1 Adams Fred II
At-Large 2 Krohn Shirley IV
At-Large 3 Ed Benson
At-Large 4 Welty Patricia V
At-Large 5 Card Deborah V
At-Large 6 Steve Lipson I
At-Large 7 Selleck Summer V
At-Large 8 Jatin Mehta III
At-Large 9 Xavier Rita I
At-Large 10
At-Large 11 Jagjit Bhambra V
At-Large 12 Neemuchwalla Nuru IV
At-Large 13 Dunne-Rose Mary D II
At-Large 14 Dennis Yee IV
At-Large 15 Bruns Mary IV
At-Large 16 O'Toole Brian IV
At-Large 17 Donovan Kevin D.II
At-Large 18 Nahm Richard III
At-Large 19 Jill Kleiner II
At-Large 20 Frederick Susan I
Local Committee Lafayette McCahan Ruth II
Local Committee Orinda Clark Nina II
Local Committee Antioch Fernandez Rudy III
Local Committee Pleasant Hill Van Ackern Lorna IV
Local Committee Pinole
Local Committee Concord Fuad Omran IV
Local Committee Richmond
Local Committee El Cerrito Kim-Selby Joanna I
Local Committee Hercules Doran Jennifer V
Local Committee Pittsburg
Local Committee San Ramon
Local Committee Clayton Tervelt Ron IV
Local Committee Alamo-Danville Janes Donnelly II
Local Committee Walnut Creek Jessica Thomas IV
Local Committee Moraga Katzman Keith II
Local Committee San Pablo
Local Committee Martinez
Local Committee Brentwood Kee Arthur III
Local Committee Oakley
Recommendation(s)/Next Step(s):
RECOMMEND to the Board of Supervisors the appointment of Jill Kleiner to At Large #19 seat
18
RECOMMEND to the Board of Supervisors the appointment of Jill Kleiner to At Large #19 seat
with a term expiring September 30, 2019, and Steve Lipson to At Large #6 seat, and Jatin Mehta
to At Large #8 seat with terms expiring September 30, 2020, on the Advisory Council on Aging,
as recommended by the Council.
Fiscal Impact (if any):
There is no fiscal impact.
Attachments
J. Kleiner Recommendation Memo
J. Kleiner Application
J. Mehta Recommendation Memo
J. Mehta Application
S. Lipson Recommendation Memo
S. Lipson Application
19
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Kathy Gallagher, Director
40 Douglas Dr., Martinez, CA 94553 Phone: (925) 313-1579 Fax: (925) 313-1575 www.cccounty.us/ehsd .
MEMORANDUM
DATE: 11/2 1/2018
T O: Family and Human Services Committee
CC: Victoria Tolbert, Director Aging and Adult Services
FROM : Anthony Macias, Staff Representative for the Advisory Council on Aging
SUBJECT: Advisory Council on Aging – Appointment Requested
The Contra Costa Area Agency on Aging (AAA) recommends for immediate appointment to the
Contra Costa Advisory Council on Aging (ACOA) the following applicant: Ms. Jill Kleiner for
Member at Large Seat # 19. The MAL #19 seat is undesignated and has remained vacant since
March 20, 2018.
Recruitment has been handled by both the Area Agency on Aging, the ACOA and the Clerk of the
Board using CCTV. AAA staff has encouraged interested individuals including minorities to apply
through announcements provided at the Senior Coalition meetings and at the regular monthly
meetings of the ACOA. The Contra Costa County EHSD website contains dedicated web content
where interested members of the public are encouraged to apply and are provided an application with
instructions on whom to contact for ACOA related inquiries, including application procedure.
Ms. Kleiner was interviewed by the ACOA Membership Committee on 8/15/18 to fill MAL #19 on
the ACOA with term ending 9/30/2019. Ms. Kleiner submitted an application for ACOA membership
dated 6/23/2018 that is provided as a separate attachment. The ACOA voted to approve Ms.
Kleiner’s appointment recommendation at their 9/19/18 meeting.
Thank You
20
Submit Date: Jun 23, 2018
Seat Name (if applicable)
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
Which Boards would you like to apply for?
Advisory Council on Aging: Submitted
Describe why you are interested in serving on this advisory board/commission (please limit
your response to one paragraph).
Having recently retired from a 30+ year career as a Retirement Plan consultant to Fortune 500 companies
as well as volunteering 20+ years for the Western Pension and Benefits Council, including being
president of their governing board of 11 chapters, I'm thrilled to have time to become more involved in my
community.
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
Jill M Kleiner
Moraga CA
N/A - Retired 1/2/18
Jill M Kleiner Page 1 of 7
21
If "Other" was Selected Give Highest Grade or
Educational Level Achieved
Name of College Attended
Course of Study / Major
Units Completed
Degree Type
Date Degree Awarded
Is a member of your family (or step-family) employed by Contra Costa Co.?
Yes No
Education History
Select the highest level of education you have received:
Other
College/ University A
Type of Units Completed
Quarter
Degree Awarded?
Yes No
College/ University B
College undergrad degree
UC Berkeley
Statistics
enough for degree
BA
1985
Jill M Kleiner Page 2 of 7
22
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
Degree Type
Type of Units Completed
None Selected
Degree Awarded?
Yes No
College/ University C
Type of Units Completed
None Selected
Degree Awarded?
Yes No
Jill M Kleiner Page 3 of 7
23
Date Degree Awarded
Course Studied
Hours Completed
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Position Title
Other schools / training completed:
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
Willis Towers Watson 345 California Street San Francisco, CA 94104
3/5/2001-1/2/18
40
Senior Retirement Consultant
Jill M Kleiner Page 4 of 7
24
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Position Title
Dates (Month, Day, Year) From - To
Hours per Week Worked?
Duties Performed
Recently retired after a 30+ career in the retirement field. Consulted with fortune 500 and larger employers
on their Defined Contribution Plans (401(k), 403(b), nonqualified plans, etc), including plan design, vendor
selection, governance, compliance, and regulatory/legislative updates and trends.
2nd
Volunteer Work?
Yes No
Employer's Name and Address
Western Pension and Benefits Council - Governing Board of 11 chapters across the west
Duties Performed
Member of the Western Pension and Benefits Council over 20+ years performing various duties from
being on committees to chairing San Francisco Chapter Program Committee and Spring Conference to
Board Member at Large to Board Treasurer to VP and then President of SF chapter. Once SF VP level
also joined Governing board of 11 chapters, with roles of secretary, VP marketing, & finally President of
Gov Board.
3rd
7/1/14-7/1/15
varies
President of Governing Board
1996-2001
40
Jill M Kleiner Page 5 of 7
25
Position Title
Upload a Resume
If "Other" was selected please explain
Volunteer Work?
Yes No
Employer's Name and Address
PriceWaterhouseCoopers 333 Market Street San Francisco, CA
Duties Performed
Defined contribution retirement plan relationship manager for clients and managed outsourcing teams.
Responsible for selling and retaining clients as well as developing colleagues.
Final Questions
How did you learn about this vacancy?
Newspaper Advertisement
. 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
Director
Jill M Kleiner Page 6 of 7
26
If Yes, please identify the nature of the relationship:
Jill M Kleiner Page 7 of 7
27
1 of 1
Kathy Gallagher, Director
40 Douglas Dr., Martinez, CA 94553 Phone: (925) 313-1579 Fax: (925) 313-1575 www.cccounty.us/ehsd .
MEMORANDUM
DATE: 11/20/2018
T O: Family and Human Services Committee
CC: Victoria Tolbert, Director Aging and Adult Services
FROM : Anthony Macias, Staff Representative for the Advisory Council on Aging
SUBJECT: Advisory Council on Aging – Appointment Requested
The Contra Costa Area Agency on Aging (AAA) recommends for immediate appointment to the
Contra Costa Advisory Council on Aging (ACOA) the following applicant: Mr. Jatin Mehta for
Member at Large Seat # 8. The MAL #8 seat is undesignated and has remained vacant since July 10,
2018.
Recruitment has been handled by both the Area Agency on Aging, the ACOA and the Clerk of the
Board using CCTV. AAA staff has encouraged interested individuals including minorities to apply
through announcements provided at the Senior Coalition meetings and at the regular monthly
meetings of the ACOA. The Contra Costa County EHSD website contains dedicated web content
where interested members of the public are encouraged to apply and are provided an application with
instructions on whom to contact for ACOA related inquiries, including application procedure.
Mr. Mehta was interviewed by the ACOA Membership Committee on 8/15/18 to fill MAL #8 on the
ACOA with term ending 9/30/2020. Mr. Mehta submitted an application for ACOA membership
dated 6/10/2018 that is provided as a separate attachment. The ACOA voted to approve Mr. Mehta’s
appointment recommendation at their 9/19/18 meeting.
Thank You
28
29
30
31
1 of 1
Kathy Gallagher, Director
40 Douglas Dr., Martinez, CA 94553 Phone: (925) 313-1579 Fax: (925) 313-1575 www.cccounty.us/ehsd .
MEMORANDUM
DATE: 11/20/2018
T O: Family and Human Services Committee
CC: Victoria Tolbert, Director Aging and Adult Services
FROM : Anthony Macias, Staff Representative for the Advisory Council on Aging
SUBJECT: Advisory Council on Aging – Appointment Requested
The Contra Costa Area Agency on Aging (AAA) recommends for immediate appointment to the
Contra Costa Advisory Council on Aging (ACOA) the following applicant: Mr. Steve Lipson for
Member at Large Seat # 6. The MAL #6 seat is undesignated and has remained vacant since July 24,
2018.
Recruitment has been handled by both the Area Agency on Aging, the ACOA and the Clerk of the
Board using CCTV. AAA staff has encouraged interested individuals including minorities to apply
through announcements provided at the Senior Coalition meetings and at the regular monthly
meetings of the ACOA. The Contra Costa County EHSD website contains dedicated web content
where interested members of the public are encouraged to apply and are provided an application with
instructions on whom to contact for ACOA related inquiries, including application procedure.
Mr. Lipson was interviewed by the ACOA Membership Committee on 8/15/2018 to fill MAL #6 on
the ACOA with term ending 9/30/2020. Mr. Lispson submitted an application for ACOA
membership dated 8/13/2018 that is provided as a separate attachment. The ACOA voted to approve
Mr. Lipson’s appointment recommendation at their 9/19/2018 meeting.
Thank You
32
33
34
35
FAMILY AND HUMAN SERVICES
COMMITTEE 6.
Meeting Date:12/03/2018
Subject:Secondhand Smoke Ordinance
Submitted For: Anna Roth, Health Services Director
Department:Health Services
Referral No.: FHS #82
Referral Name: Secondhand Smoke Ordinance
Presenter: Daniel Peddycord, Public Health
Director
Contact: Jen Grand-Lejano (925)
313-6216
Referral History:
At the November 13, 2017 Family and Human Services Committee meeting, Public Health
presented its annual report on the implementation of the County’s Secondhand Smoke ordinance
with a recommendation that the Committee consider a proposed ordinance to strengthen the
current smoking protections to prohibit smoking inside dwelling units of multi-unit housing,
including condos and townhomes. The Committee accepted the report and recommendations,
requested that language be added to extend smoking restrictions to guest rooms of hotels and
motels, and directed staff to forward those recommendations to the Board of Supervisors for
discussion and approval.
The ordinance, titled Smoke-free Multi Unit Residences, was adopted by the Board of Supervisors
on March 13, 2018 with implementation to begin for new and renewing leases on July 1, 2018,
and for continuing leases and owner-occupied units on July 1, 2019. The following report is
specific to implementation of the new Smoke-free Multi-Unit Residences ordinance, including
information on the continued implementation of the broader Smoke-free Secondhand Protections
Ordinance.
Referral Update:
Please see the attached report from the Public Health Division of the Health Services Department
with an update on the implementation of the Secondhand Smoke Protections Ordinance.
Recommendation(s)/Next Step(s):
36
Recommendation(s)/Next Step(s):
ACCEPT the annual report from the Public Health Division of the Health Services Department on
the implementation of the Secondhand Smoke Protections Ordinance and DIRECT staff to
forward the report to the Board of Supervisors for their information.
DIRECT staff to provide another update on the Secondhand Smoke Protections Ordinance to the
Family and Human Services Committee in 2019.
Fiscal Impact (if any):
There is no fiscal impact, the recommended ordinance provisions would be implemented by the
Public Health Division's Tobacco Prevention Program and would be funded through the
program's current funding sources.
Attachments
2018 Second Hand Smoke Report
37
38
39
40
FAMILY AND HUMAN SERVICES
COMMITTEE 7.
Meeting Date:12/03/2018
Subject:Policy Options to Protect Youth from Tobacco Influences in the Retail
Environment
Submitted For: Anna Roth, Health Services Director
Department:Health Services
Referral No.: FHS #112
Referral Name: Policy Options to Protect Youth from Tobacco Influences in the Retail
Environment
Presenter: Dan Peddycord Contact: Jen Grand-Lejano (925)
313-6216
Referral History:
The Board of Supervisors approved two tobacco control ordinances in July 2017 to protect youth
from tobacco influences in the retail environment: a zoning ordinance and a tobacco retailer
licensing ordinance. Of particular concern were the marketing and availability of youth-friendly
flavored tobacco products, small pack sizes of cigars and cigarillos, and density and location of
tobacco retailers, since these contribute largely to youth exposure to tobacco influences and
tobacco use. The tobacco retailer licensing ordinance required extensive preparation for
implementation, and tobacco retailers were required to be compliant with the new provisions by
January 1, 2018. As requested, Contra Costa Public Health staff provided a report to the Board of
Supervisors in March 2018 on preliminary implementation efforts. This report provides a brief
recap of those implementation efforts up to March 2018, with information on continued
implementation since March as well as next steps.
Referral Update:
Please see the attached report from the Public Health Department with an update on the
implementation of the Tobacco Retailer Licensing and Businesses Ordinances.
Recommendation(s)/Next Step(s):
ACCEPT the annual report from the Public Health Department on the implementation of the
Tobacco Retailer Licensing and Businesses Ordinances and DIRECT staff to forward the report to
the Board of Supervisors for their information.
DIRECT staff to report back to the Family and Human Services Committee in 2019.
41
Fiscal Impact (if any):
There is no fiscal impact, the recommended ordinance provisions would be implemented by the
Public Health Division's Tobacco Prevention Program and would be funded through the
program's current funding sources.
Attachments
2-18 Tobacco Retail Environment Report
42
43
44
45
46
FAMILY AND HUMAN SERVICES COMMITTEE 8.
Meeting Date:12/03/2018
Subject:Behavioral Health Services Cumulative Evaluation Report on Contra Costa’s
Assisted Outpatient Treatment Program
Submitted For: Anna Roth, Health Services Director
Department:Health Services
Referral No.: FHS #107
Referral Name: Laura's Law
Presenter: Matthew P. White, M.D.; Roberta
Chambers, Ph.D.
Contact: Warren Hayes (925)
957-2616
Referral History:
The Assisted Outpatient Treatment Demonstration Project Act (AB 1421), known as Laura’s
Law, was signed into California law in 2002 and was authorized until January 1, 2017. Laura’s
Law is named after a 19 year-old woman who worked 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 a 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, 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 recipient as well as due process hearing rights.
If a person refuses treatment under AOT, treatment cannot be forced. The court orders a 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.
AB 1421 requires that a county Board of Supervisors adopt Laura’s Law by resolution to
47
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 (FHS) 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 FHS for consideration. FHS received reports on
the implementation of Laura's Law on October 16, 2013 and March 10, 2014, and on February 3,
2015, the Board of Supervisors adopted Resolution No. 2015/9 to direct the implementation of
Assisted Outpatient Treatment (Laura’s Law) for a three-year period and directed the Health
Services Department (HSD) to develop a program design with stakeholder participation. The
Board further authorized the Health Services Director to execute a contract with Resource
Development Associates, Inc. to provide consultation and technical assistance with regard to the
evaluation of the County’s Assisted Outpatient Treatment (AOT) Program for persons with
serious mental illness who demonstrate resistance to voluntarily participating in behavioral health
treatment.
In February 2016, Laura's Law was implemented and the Department provided FHS with status
reports on September 12 and December 12, 2016, and May 22 and September 25, 2017, at which
FHS received and discussed the AOT Program reports for fiscal year 2016-17 as provided by the
Health Service Department and Resource Development Associates. Contra Costa Behavioral
Health Services was directed to coordinate with the Health, Housing and Homeless Services
Division and develop a plan to maximize enrollment in Assertive Community Treatment (ACT)
of persons who are eligible for the AOT Program and are homeless or at risk of homelessness.
Mental Health Systems is the contract agency providing Assertive Community Treatment to
fidelity.
On October 17, 2017 the Board of Supervisors accepted the Plan for Maximum Enrollment of
Persons Eligible for the AOT Program, as well as the July, 2016 through June 30, 2017 evaluation
report from Resource Development Associates.
Referral Update:
Behavioral Health Services has implemented the aforementioned plan, and the program currently
reports 70 individuals enrolled in Assertive Community Treatment (ACT) (target maximum
enrollment = 75), with an additional 16 persons deemed eligible and receiving outreach and
engagement services prior to enrollment for treatment. AOT Program staff now meet regularly
with Health, Housing and Homeless Services Division staff to maximize coordination and
enrollment for persons who meet AOT eligibility and are homeless. Mental Health Systems, the
ACT provider, now has 20 housing units via master leasing arrangements in order to house
enrollees in shared and scattered site housing units.
On November 2, 2018 Resource Development Associates presented their Cumulative Evaluation
Report to the Assisted Outpatient Treatment Workgroup and interested stakeholders for
discussion and input regarding recommendations and next steps. (attached) Program
improvements enacted to date were identified, as well as areas for consideration in the coming
48
months.
Recommendation(s)/Next Step(s):
CONSIDER accepting the cumulative evaluation report from the Health Services Department on
the implementation of Laura’s Law – Assisted Outpatient Treatment (AOT) program during the
period February 2016 through June 2018, and
CONSIDER recommending to the Board of Supervisors that the AOT Program be extended
beyond the previously authorized three-year pilot period as part of Contra Costa Behavioral
Health Services’ ongoing service delivery for persons experiencing serious mental illness.
Fiscal Impact (if any):
Actual expenditures for FY 17/18: Funding Source:
CCBHS - $1,812,919 Mental Health Services Act
County Counsel - 32,379 County General Fund
Public Defender - 56,250 County General Fund
Superior Court - 2,585 County General Fund
$1,904,133
Funds are budgeted for the CCBHS portion of the AOT Program for the balance of FY 2018/19,
and MHSA revenue is expected to sustain the CCBHS portion of the program costs for the fiscal
years 2020-23.
Fiscal Impact (if any):
Actual expenditures for FY 17/18: Funding Source:
CCBHS - $1,812,919 Mental Health Services Act
County Counsel - 32,379 County General Fund
Public Defender - 56,250 County General Fund
Superior Court - 2,585 County General Fund
$1,904,133
Funds are budgeted for the CCBHS portion of the AOT Program for the balance of FY 2018/19,
and MHSA revenue is expected to sustain the CCBHS portion of the program costs for the fiscal
years 2020-23.
Attachments
Contra Costa County Assisted Outpatient Treatment (AOT) Cumulative Evaluation Report 2016-2018
Contra Costa County Assisted Outpatient Treatment (AOT) Cumulative Evaluation Report Presentation
49
Contra Costa County Assisted Outpatient
Treatment (AOT) Evaluation
Cumulative Evaluation Report
50
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program – Cumulative Evaluation Report
October 26, 2018 | 1
Table of Contents
Executive Summary ............................................................................................................................3
Introduction ......................................................................................................................................6
Background Information ........................................................................................................................... 6
Contra Costa County’s AOT Program Model............................................................................................. 6
External Evaluation ................................................................................................................................... 8
Report Overview ....................................................................................................................................... 9
Methodology ................................................................................................................................... 11
Evaluation Approach and Overview ........................................................................................................ 11
Target Populations for Evaluation .......................................................................................................... 12
Data Sources ........................................................................................................................................... 12
Limitations and Considerations .............................................................................................................. 16
Question 1 | ACT Consumer Findings ................................................................................................ 18
Pre-Enrollment ........................................................................................................................................ 19
AOT Enrollment ....................................................................................................................................... 26
Discussion................................................................................................................................................ 43
Question 2 | ACT and AOT Comparison Findings ............................................................................... 45
Consumer Profile .................................................................................................................................... 45
Service Participation ............................................................................................................................... 46
Consumer Outcomes .............................................................................................................................. 47
Discussion................................................................................................................................................ 49
Question 3 | ACT and FSP Comparison Findings ................................................................................ 51
Consumer Profile .................................................................................................................................... 52
Service Participation ............................................................................................................................... 53
Consumer Outcomes .............................................................................................................................. 55
Discussion................................................................................................................................................ 59
Summary of Findings ........................................................................................................................ 61
Program Development and Continuous Quality Improvement .............................................................. 61
Service Delivery ....................................................................................................................................... 62
Level of Care Impressions ....................................................................................................................... 63
Conclusion ............................................................................................................................................... 65
51
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program – Cumulative Evaluation Report
October 26, 2018 | 2
Appendices ...................................................................................................................................... 66
Appendix I. AOT Eligibility Requirements ............................................................................................... 66
Appendix II. MHS’ ACTiOn Team 2018 Fidelity Assessment Report ....................................................... 67
52
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program – Cumulative Evaluation Report
October 26, 2018 | 3
Executive Summary
In California, Assembly Bill (AB) 1421 (also known as “Laura’s Law”) authorizes 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/or 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. In February 2015, Contra Costa County began a 36-month
AOT pilot project, including civil court intervention, to determine if it would effectively identify, engage,
and treat individuals who were unable to engage in existing adult mental health services and interrupt
the cycle of crisis and hospitalization, incarceration, and/or homelessness. The County also elected to
implement Assertive Community Treatment (ACT), which is an evidence-based approach that provides
the highest level of outpatient services available in the community for those who need it most. Contra
Costa’s AOT program represents a collaborative partnership between Contra Costa Behavioral Health
Services (CCBHS), the Superior Court, County Counsel, the Public Defender, and Mental Health Systems
(MHS).
The Contra Costa County AOT program includes a Care Team comprised of CCBHS Forensic Mental Health
(FMH) and the MHS ACTiOn team (ACT providers). The two main components of the AOT program are
Pre-Enrollment (Referral and Investigation; Outreach and Engagement) and AOT Enrollment (ACT
outpatient treatment services).
Contra Costa County contracted with Resource Development Associates (RDA) to conduct an evaluation
of its AOT pilot program. This report presents findings about the AOT program spanning the period of
February 2016 through June 2018. Three key questions guided RDA’s evaluation:
1. What are the outcomes for people who participate in ACT and AOT, including the DHCS required
outcomes? How faithful are ACT services to the ACT model?
2. What are the differences in demographics, service patterns, and outcomes between those who
agree to participate in ACT services voluntarily and those who participate with an AOT court order
or voluntary settlement agreement?
3. What are the differences in demographics, service utilization, and outcomes between those who
engage in existing Full Service Partnership (FSP) services and those who receive ACT services?
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
53
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program – Cumulative Evaluation Report
October 26, 2018 | 4
Implementation Challenges and Improvements: In the initial stages of AOT implementation, County
agencies collaborated on the new processes and procedures required to support the referral and
investigation process as well as the court component. As with any new program in its formative stages,
there were unanticipated challenges along the way that the County and stakeholders worked together to
address, including how to:
❖ Ensure that qualified requestors had the knowledge and resources to make appropriate referrals
to the program for individuals most in need;
❖ Reduce the length of time from referral to enrollment, particularly for those individuals who were
continuing to experience crisis, hospitalization, incarceration and/or homelessness during the
investigation and outreach process;
❖ Determine the most efficient and effective ways for FMH and MHS to work together with referred
individuals, engage them in care, and identify the need for a civil court petition where indicated;
and
❖ Discern the appropriate use of the petition and benefit of the civil court component to encourage
participation in ACT services.
While the County and partners worked diligently to identify and resolve these issues as they arose, the
net impact early on in the process was that not all qualified requestors were equipped to do so, enrollment
in the program took longer than expected for eligible individuals, and there was hesitation to implement
the court component. This resulted in a lower census than originally estimated despite a continued
perception of need for these high-end services. Along the way, the County and its partners sought to
proactively identify and address issues as well as seek input from stakeholders, elected officials, and the
evaluation team as to how they might continuously improve the program. Their investments in ongoing
continuous quality improvement ultimately increased the diversity of qualified requestors, shortened the
length of time from referral to enrollment, more swiftly implemented the court component for those who
require that level of support, and increased the number of consumers who are enrolled in and benefitting
from the program.
ACT Fidelity: ACT has one of the strongest evidence-bases of any mental health intervention for reducing
crisis and hospitalization, incarceration, and homelessness for those with the most serious mental illness
when performed to fidelity. While the ACT team did experience some challenges early on with recruitment
and hiring and understanding that the use of AOT and the civil court component was in alignment with
the ACT model, as well as the staff turnover experienced in early-2018, they continue to score in the high-
fidelity range across all three annual fidelity assessments.
Over the course of the nearly 2.5 years of implementation, the AOT program received 475 duplicated
referrals, of which about one-third resulted in a subsequent referral to MHS for outreach and engagement
into the AOT program. Seventy consumers enrolled in AOT during this evaluation period. These AOT
consumers were primarily male in gender, White in race/ethnicity, and over age 26. MHS’ ACT team
provided a high amount of services (average of four hours of face-to-face contacts a week) on a very
frequent basis (average of four contacts per week) to its consumers. Moreover, two-thirds of consumers
54
Contra Costa County Behavioral Health Services
Assisted Outpatient Treatment Program – Cumulative Evaluation Report
October 26, 2018 | 5
were adherent to their ACT treatment services, demonstrating the AOT population was really engaged in
their treatment.
In order to assess how this AOT program impacted its consumers, RDA’s evaluation examined how key
outcomes of interest changed for the AOT population from prior to their AOT participation to during/after
program enrollment. Key outcomes findings include:
❖ Consumers experienced significant decreases in both the amount and frequencies of crisis
episodes and psychiatric hospitalizations during ACT enrollment.
❖ Significantly fewer consumers were arrested and booked in jail during ACT enrollment.
❖ The majority of consumers either obtained or maintained housing during while enrolled in ACT.
❖ Over one-third of consumers continued to experience crisis episodes and/or psychiatric
hospitalizations after being discharged from ACT, signaling these consumers may have been
prematurely discharged.
❖ The AOT program produces an estimated $371,069 of hard cost savings per year, including cost
avoidance from reduced outpatient and residential mental health service as well as jail costs.
Given that AOT consumers join the program in one of two ways (voluntarily agreeing to services or being
given a court order to participate), this evaluation examined potential differences in outcomes between
these two types of AOT consumers and discovered the following:
❖ A larger proportion of court-involved consumers had lower service participation compared to
voluntarily enrolled consumers.
❖ Consumers who enrolled voluntarily saw a substantial decrease in crisis episodes, inpatient
hospitalizations, and justice involvement during ACT.
❖ A larger proportion of voluntarily enrolled consumers were stably housed compared to court-
ordered consumers.
In Contra Costa County, there was an existing network of FSPs providing outpatient mental health services
to the seriously mentally ill. RDA’s evaluation discovered the following key findings comparing the
outcomes of FSP versus ACT consumers in the County:
❖ The FSP and ACT populations were similar across age and gender, but differed in that the ACT
population had a greater proportion of White and smaller proportion of Black and Latino
consumers. ACT consumers were also more likely to be diagnosed with a disorder that included
psychosis.
❖ Compared to FSP consumers, ACT consumers engaged in services more often and for longer
durations, as well as received more direct services.
❖ Both the ACT and FSP consumer populations experienced decreases in numbers and frequencies
of crisis episodes and psychiatric hospitalizations.
It is clear that individuals with serious mental illness who participate in AOT and ACT experience notable
benefits, specifically in reducing experiences of crisis and hospitalization, incarceration, and
homelessness. While this program took longer than originally anticipated to get started and there were
challenges to address along the way, the County and its partners worked diligently over the pilot period
to strengthen the program and ensure that those individuals most in need had access to services that
were likely to help them.
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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/or 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).
Contra Costa recognized that while they had Full Service Partnership (FSP) programs funded by the Mental
Health Services Act (MHSA), there remained a group of individuals who were cycling in and out of crisis
and hospitals, jails, and homelessness. In order to address this issue, the Contra Costa County Board of
Supervisors adopted a resolution to authorize the implementation of AOT for a 36-month pilot project on
February 3, 2015 and pilot AOT, including civil court intervention, to determine if it would effectively
identify, engage, and treat individuals who were unable and/or unwilling to engage in existing adult
mental health services and interrupt the cycle of crisis and hospitalization, incarceration, and/or
homelessness. The County also elected to implement Assertive Community Treatment (ACT), which is an
evidence-based approach that provides the highest level of outpatient services available in the community
for those who need it most. Contra Costa’s AOT program represents a collaborative partnership between
Contra Costa Behavioral Health Services (CCBHS), the Superior Court, County Counsel, the Public
Defender, and Mental Health Systems (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.
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 the MHS ACTiOn team (ACT
providers). 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.
1 Welfare and Institutions Code, Section 5346
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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 from FMH 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).
If the individual initially appears to meet eligibility criteria, a CCBHS investigator from the FMH staff
facilitates a face-to-face meeting with the individual and/or family to gather information, attempts to
engage the individual, and develops an initial care plan. If the referred individual does not meet AOT
eligibility criteria, FMH staff attempts to connect them to other mental health services to meet their needs
or reconnect them to services that had previously been effective. If the individual continues to appear to
meet AOT eligibility criteria, FMH investigators share their information with the MHS team. MHS then
conducts a period of outreach and engagement activities with the individual to encourage their
participation in ACT. If at any time the individual 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 individual does not accept voluntary services
and continues to meet AOT 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 individual has the option to enter into a voluntary settlement
agreement with the court to participate in AOT. If the individual still 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 individual continues to meet AOT criteria, they
may authorize an additional six-month period of mandated participation. At every stage of this process,
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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CCBHS’ FMH and MHS staff continue to offer the individual opportunities to engage voluntarily in services
and may recommend a 72-hour hold if they meet the existing criteria. It is important to note that both
the voluntary settlement agreement and AOT court order are both agreements between the individual
and the court and involve judicial supervision. It is also important to acknowledge that those individuals
who agree to participate in ACT on a voluntary basis and without a petition filing or agreement with the
court are not formally supervised by the court.
AOT and ACT in Contra Costa County
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 consumer fails to participate in services; and
❖ After the consumer participates in treatment, if they request discharge prematurely.
When the County first chose to implement AOT, it also elected to implement a new level of outpatient
mental health services through an ACT team, complementing the County’s established FSP programs that
were already serving individuals with serious mental illness. It is not a requirement of AOT programs to
offer ACT services to their consumers. Mental Health Services (MHS) is the contracted agency hired by
CCBHS to implement the ACT team for County residents referred to AOT.
It is also important to note that the use of a civil court order process is in alignment with the ACT model
when the individual requires that level of support to participate. Fidelity to the ACT model includes the
expectation that ACT programs apply assertive engagement mechanisms, including all available 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.
External Evaluation
Contra Costa County retained Resource Development Associates (RDA) to conduct an independent
evaluation of its AOT program implementation and outcomes. The purposes of this evaluation are to: 1)
satisfy California Department of Healthcare Services (DHCS) reporting requirements; 2) provide
information to the Contra Costa County 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 four distinct evaluation reports, including two reports mandated by DHCS, and two additional
reports written specifically for CCBHS to better understand the implementation of its AOT program. These
reports have 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 each produced
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approximately six months apart and document the implementation and continued progression of the AOT
program since it began.
The purpose of this evaluation report is to assist Contra Costa County with identifying the program’s
accomplishments and opportunities for improvement. To accomplish this, RDA provides a comprehensive
evaluation that assesses:
❖ AOT program outcomes, including the extent to which MHS is implementing ACT to fidelity, and
DHCS required outcomes for people who participate in the County’s AOT program;
❖ Differences in demographics, service patterns, and outcomes between those who agree to
participate in ACT services without court involvement and those who participate with an AOT
court order or voluntary settlement agreement; and,
❖ Differences in demographics, service utilization, and outcomes between those who engage in
existing FSP services and those who receive ACT services.
Report Overview
This report is intended to address three key evaluation questions that will enable CCBHS to understand
the outcomes of ACT programming, differences between the court-involved and voluntarily enrolled ACT
consumers, and differences between ACT and FSP consumers. To address these questions, this report is
organized in the following format:
❖ Introduction: This section summarizes the background of AOT legislation and provides a
description of Contra Costa County’s AOT program model and the overarching evaluation
questions.
❖ Methodology: This section describes the data sources used to address the evaluation questions,
the analytic steps taken to answer each question, and the limitations of the analyses.
❖ Question 1 | ACT Consumer Findings: This section provides a detailed discussion of ACT
consumers’ experiences from referral through enrollment and, when appropriate, discharge.
Findings include pre-enrollment investigation and outreach and engagement; consumer profile;
service participation; outcomes including crisis episodes, inpatient hospitalizations, housing,
social functioning and independent living; and costs and cost savings.
❖ Question 2 | ACT and AOT Comparison Findings: This section looks at the same components as
Question 1, but with a comparison of findings based on those ACT consumers who enrolled
voluntarily and those AOT consumers who required civil court involvement to participate. Findings
for individuals who enrolled in ACT voluntarily are compared to findings for those who enrolled
with court involvement; both voluntary settlement agreement and AOT court order are included
in the AOT consumer population.
❖ Question 3 | ACT and FSP Comparison Findings: This section also looks at the same components
as Question 1, but with a comparison of findings for all ACT consumers and for consumers who
enrolled in an FSP during the same time that ACT was implemented in the County.
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❖ Summary of Findings: This final section summarizes and integrates findings from each research
question to highlight key overarching findings that may be used to inform decision-making and
next steps for AOT program implementation in Contra Costa County.
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Methodology
Evaluation Approach and Overview
The following evaluation report was guided by a rigorous methodological approach that addresses real
world constraints and documents the actions and outcomes resulting from the County’s investments in
ACT and AOT, with an emphasis on continuous quality improvement throughout implementation. The
evaluation will also likely inform decision-making at the end of the 36-month pilot project. This report is
a cumulative evaluation of CCBHS’s AOT program since its implementation began in February 2016. As
such, it reflects on recommendations made in previous reports and discusses findings in light of those
recommendations with a recognition for the natural growth and change that occurs in the delivery of a
new program within the behavioral health system.
This evaluation report spans from the AOT program start date, February 1, 2016 through June 30, 2018.
Figure 2 presents the overarching research questions that guide this report.
Figure 2. Evaluation Research Questions
In order to answer these questions, RDA employed a mixed-methods evaluation approach to assess: 1)
the implementation of the County’s AOT program, 2) the extent to which individuals receiving AOT
services have experienced decreases in homelessness, crisis, hospitalization, and incarceration, and 3)
improvements in AOT consumers’ psychosocial outcomes, such as social functioning and independent
living skills.
The following sections describe the data measures, sources, and analytic techniques used to develop this
report and evaluate Contra Costa County’s AOT program.
Question 1
•What are the
outcomes for people
who participate in ACT
and AOT, including the
DHCS required
outcomes? How
faithful are ACT
services to the ACT
model?
Question 2
•What are the
differences in
demographics, service
patterns, and
outcomes between
those who agree to
participate in ACT
services voluntarily
and those who
participate with an
AOT court order or
voluntary settlement
agreement?
Question 3
•What are the
differences in
demographics, service
utilization, and
outcomes between
those who engage in
existing FSP services
and those who receive
ACT services?
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Target Populations for Evaluation
This report examines three distinct consumer populations, all of whom have a serious mental illness and
a history of crisis and hospitalization, incarceration, and/or homelessness.
1. FSP consumers are individuals who enrolled in and received services from an FSP program. FSP
consumers are generally those who are experiencing crisis and hospitalization, incarceration,
and/or homelessness and are willing and able to engage in voluntary services without additional
support. Generally, these individuals are able to follow through with services enough so as not to
require a separate referral or outreach and engagement from a third party or civil court
involvement.
2. ACT consumers are individuals who enrolled in and received services from the MHS ACTiOn team
voluntarily (i.e., they did not require civil court involvement to compel participation). ACT
consumers are generally those experiencing crisis and hospitalization, incarceration, and/or
homelessness and are willing and able to engage in voluntary services with strong encouragement
from a third party. With this population, a qualified requestor has referred them to the program
and FMH and/or MHS has proactively provided outreach and engagement to encourage
participation. Unlike FSP, these consumers require additional support to connect to mental health
services and have not been successful in accomplishing this independently. However, with this
assertive outreach and engagement, they are able to participate in mental health services without
court involvement.
3. AOT consumers are individuals who required civil court involvement to compel their participation
in mental health services. This group of consumers has been referred by a third party, and despite
FMH and/or MHS’ proactive outreach and engagement, have been unable to consent to needed
mental health services voluntarily. Unlike the FSP and ACT consumer populations, these
consumers require civil court compulsion to participate in outpatient mental health services.
Data Sources
The evaluation includes data from CCBHS, MHS, and the Contra Costa County Sheriff’s Office. Throughout
the data collection and analysis process, RDA collaborated with CCBHS and MHS staff to vet analytic
decisions and findings. Table 1 below outlines the data sources and elements used for this report.
Table 1. 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
• Investigation attempts
Contra Costa County PSP Billing
System
• Behavioral health service
episodes and encounters,
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County Department/Agency Data Source Data Element
including hospitalizations
and crisis episodes
• Consumer diagnoses and
demographics
CCBHS Financial Data • Costs associated with
implementing the AOT
program, including ACT
Point-in-Time KET Forms (Key
Event Tracking) collected from
all ACT and FSP clients during
July 1 - August 15, 2018
• Homelessness and
employment measures
Mental Health Systems MHS Outreach and Engagement
Log
• Outreach and engagement
encounters
FSP Forms (Partner Assessment
Form and KET)
• Residential status, including
homelessness
• Employment
• Education
• Financial support
MHS Outcomes Spreadsheet
(Self-Sufficiency Matrix, Brief
Psychiatric Rating Scale –
Expanded, MacArthur Tool)
• Social functioning
• Independent living
• Recovery
• Violence and victimization
ACT Fidelity Assessment
(conducted by RDA in July 2018)
• Key informant interviews
with ACT managers and
providers
• Focus groups with ACT
consumers and family
members
Contra Costa County Sheriff’s
Office
Sheriff’s Office Jail Management
System
• Booking and release dates
• Booking offense
RDA matched consumers across the disparate data sources described above and used descriptive statistics
(e.g., frequencies, mean, and median) for all analyses, as well as inferential analyses to evaluate the extent
to which changes in consumer outcomes were likely a result of program participation versus chance, when
appropriate.
The following section provides detail regarding the analytic approach for each evaluation question.
Analytic Approach
Pre-Enrollment: To understand how referral, investigation, and outreach and engagement processes are
going, RDA employed descriptive statistics to highlight: the number of referrals to AOT; types of referral
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sources; types, frequencies, and location of outreach and engagement activities; time period between
referral and enrollment; and dispositions of each referral. RDA also examined the extent to which
individuals who were referred to ACT services but did not enroll were connected to appropriate mental
health services, and/or experienced crisis and hospitalization.
Consumer Profile and Service Outcomes: In order to describe Contra Costa County’s ACT population, RDA
calculated basic frequencies and percentages to examine the demographic attributes (e.g., age, race, and
gender); clinical profiles (e.g., primary diagnosis, presence of co-occurring substance abuse disorder); and
education, employment, and sources of financial support of all individuals enrolled in ACT since AOT was
implemented in Contra Costa County. In addition, RDA examined the types, lengths, frequencies, and
durations of services and programs that ACT program participants utilized, ultimately assessing the extent
to which they maintained adherence to their treatment plans once enrolled in ACT (treatment adherence
is defined as receiving at least one hour of face-to-face engagement with the ACT team at least two times
a week).
ACT Consumer Outcomes: In order to assess changes in consumer outcomes such as homelessness, crisis,
and hospitalization, RDA employed a pre/post-test design to measure consumer experiences prior to and
during ACT enrollment. To measure changes in housing status, RDA assessed the proportion of ACT
consumers who self-reported experiencing homelessness in the year prior to and during ACT enrollment.
RDA also analyzed the proportion of ACT consumers who experienced crisis episodes, psychiatric
hospitalizations, and criminal justice system involvement in the three years prior to and during ACT
enrollment, as well as the rate (per 180 days) at which consumers experienced these outcomes, and the
average length of each episode. RDA conducted statistical hypothesis tests to assess whether reductions
in the proportion of ACT consumers who experienced crisis and hospitalization prior to and during ACT
were likely the result of ACT participation, rather than chance.
Clinicians administer the Self-sufficiency Matrix, Brief Psychiatric Rating Scale-Expanded (BPRS-E), and the
MacArthur Tool to assess outcomes such as social functioning and independent living; symptomology;
and violence and victimization respectively. RDA measured changes in these assessment scores among all
ACT consumers who received an assessment at intake (or as close to intake as possible), and at least one
follow-up assessment six months after their initial assessment. In addition, the County required MHS (and
all FSPs) to administer summary Key Event Tracking (KET) forms in July and August of 2018 to assess the
extent to which consumers participated in significant meaningful activities, measured as changes in self-
reported employment-related activities including job training, volunteering, part-time, and full-time work.
ACT Fidelity: To determine whether MHS’ ACT services were provided to fidelity, RDA conducted a
separate ACT fidelity analysis. The fidelity assessment process measures the extent to which MHS’ ACT
treatment services align with the ACT model and to identify opportunities to strengthen ACT services. For
the assessment, RDA applied the ACT Fidelity Scale developed at Dartmouth University3 and incorporated
3 ACT Fidelity Scale retrieved on December 6, 2017 from: https://www.centerforebp.case.edu/resources/tools/act-dacts
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it into a SAMHSA toolkit.4 This established assessment includes a set of data collection activities and a
scoring process in order to determine a fidelity rating as well as qualifications of assessors. MHS’ ACT
program was rated across 28 items within the 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 five-point Likert scale with clearly defined descriptions for
each rating. In this report, RDA presents MHS’ ACT fidelity scores for the assessments conducted annually
in both 2017 and 2018.
Cost: To determine the financial impacts of implementing the ACT program, RDA analyzed data from three
sources: 1) AOT operation costs; 2) billing data for treatment services provided by MHS, County mental
health crisis units, and County inpatient psychiatric hospitalizations; and 3) Sheriff’s Office data on jail bed
days spent by ACT consumers. The treatment services billing data includes the specific dollar amounts
that were billed for each service; the expected Medi-Cal reimbursement was then subtracted from the
total charges to determine the total cost to the County. The Sheriff’s Office data, when paired with the
estimated cost for an average jail bed day in Contra Costa County, represents the costs incurred by the
criminal justice system for incarceration.
RDA replicated the analyses described above for all individuals who enrolled in ACT services voluntarily
versus those who enrolled in ACT with court involvement in order to assess differences in consumer
profiles, service utilization, and outcomes associated with each population. Because only 16 individuals
enrolled in ACT with court involvement, RDA aggregated the data to maintain confidentiality when
appropriate.
In order to evaluate differences in demographics, service utilization, and outcomes between the County’s
FSP and ACT populations, RDA identified all individuals with beginning FSP services on or after February
1, 2016 (the AOT program start date) and replicated the analyses described in the analytic approach for
Evaluation Question 1.
4 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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RDA conducted statistical hypothesis tests (e.g., chi-squared tests, etc.) to measure the likelihood that
observed differences in consumer demographics and diagnoses were a result of chance, or systematic
differences between ACT and FSP consumer characteristics. RDA also conducted chi-squared tests to
assess the likelihood that differences in the proportion of FSP and ACT consumers who experienced
negative outcomes (e.g. crisis and hospitalization) in the three years prior to and during program
enrollment were a result of chance versus real differences between the two groups’ experiences. This
allowed RDA to evaluate whether these populations had systematically different experiences with these
outcomes prior to enrolling in FSP or ACT, and whether these differences remained for consumers during
enrollment. RDA also conducted statistical hypothesis tests (i.e., McNemar’s test) to assess the likelihood
that reductions in the proportion of FSP and ACT consumers who experienced crisis and hospitalization
prior to and during program enrollment were likely the result of program participation versus chance.
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 16 consumers participated in the AOT treatment with a court order or
voluntary settlement agreement. Because relatively few individuals have enrolled in ACT with court
involvement, the proportion of individuals who experienced crisis, hospitalization, and criminal justice
involvement, as well as the average rates of occurrence, shift dramatically based on their experiences. As
a result, RDA aggregated some consumer characteristics and outcomes to maintain consumer
confidentiality.
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 and FSP consumers had greater
opportunities to experience negative outcomes prior to program enrollment. To account for these
differences in the pre- and post-time periods, RDA standardized outcome measures to rates per 180 days.
Nevertheless, because consumers have spent much less time enrolled than in the pre-enrollment period,
there was less opportunity for them to experience outcomes such as crisis or hospitalization during the
enrollment 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 outcomes may be overestimated.
Lastly, this evaluation only has access to the services paid for by Contra Costa County, which includes the
MHS ACTiOn program, CCBHS, the AOT Court, County Counsel, and the Public Defender. The consumers
served by this AOT program also receive services from entities not directly paid for by the County. In order
to understand the totality of all costs incurred and saved by the consumers participating in AOT, it would
be necessary to analyze data from the myriad of entities interfacing with this population. It is a limitation
of this evaluation in that it is not possible to obtain this breadth of data.
Despite these limitations, this evaluation will help Contra Costa County identify the successes and
challenges of its AOT implementation, as well as highlight the outcomes of consumers who participated
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in the County’s AOT treatment program throughout its implementation. The evaluation findings provide
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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Question 1 | ACT Consumer Findings
This evaluation section reports findings for all individuals who were referred to AOT since the program
began in February 2016. During this time, CCBHS received 475 total referrals for 405 unique individuals.
Of the 405 individuals referred throughout implementation, 34% (n = 138) were referred to MHS for
outreach and engagement, and 70 eventually enrolled in ACT.
Figure 3. Consumers Referred to AOT since February 2016
As previously documented, CCBHS’s AOT program implementation evolved over time as processes were
streamlined and partnerships were built. Specifically, the AOT program model changed within the first
few months of implementation. As originally designed, the agencies who comprise the Care Team would
work concurrently; however, the program model was adjusted so that CCBHS forensic mental health
(FMH) clinicians conduct the referral investigation to determine eligibility first, and then they refer eligible
individuals to MHS for outreach and engagement. Because the AOT program required multiple new
elements to come together at once, it was natural for such programmatic modifications to occur in
response to unexpected challenges. The model was also refined throughout implementation in order to
1) ensure that all qualified requestors have the knowledge and ability to refer eligible individuals, 2)
decrease the length of time from referral to enrollment, and 3) strengthen the identification of those
eligible individuals who may require a court petition to participate in services.
The following discussion of findings for all ACT consumers is divided into two sections: “Pre-Enrollment”
and “ACT Enrollment.” Throughout each section, findings are reported for three different types of groups:
• Referrals: These findings include information reported on (duplicated) individuals who were
referred to either the AOT program, or from FMH clinicians to the MSH ACTiOn team more than
once. Findings are reported at this level to illustrate the scope of the AOT program and how many
total referrals the county received and connected to appropriate behavioral health services. In
several instances, an individual was referred to the overall AOT program or to the MHS ACT
program more than once.
• Enrollments: These findings include information reported on (duplicated) individuals who were
enrolled in ACT services more than once. Findings are reported at this level to illustrate both the
total number of individuals served by MHS, as well as how many were enrolled more than once.
CCBHS received and
investigated 475 total
referrals, for 405 unique
individuals
MHS provided outreach
and engagement to 138
individuals
70 individuals enrolled in
ACT
*16 with court
involvement
Pre-Enrollment ACT Enrollment
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• Consumers: These findings report only on the unique individuals enrolled in ACT. Findings are
reported at this level to illustrate the specific outcomes of each consumer enrolled in ACT.
The Care Team provides investigation, outreach, and engagement services for all AOT referrals in order to
connect eligible individuals to the ACT program. The Care Team also works to connect those who are not
eligible for ACT to other appropriate behavioral health treatment services. The following section explores
the outcomes of this process in the “Pre-Enrollment” section, including a discussion of the experiences of
individuals who were referred to MHS ACTiOn team but not enrolled. The “AOT Enrollment” section
reports on outcomes for individuals who met AOT eligibility requirements and enrolled in ACT.
Pre-Enrollment
CCBHS received referrals from a diversity of qualified requestors, including family members,
mental health providers, and law enforcement officials.
Table 2 demonstrates that a qualified requestor made almost all AOT referrals. Family members made
over half of referrals, while the individual’s mental health provider made 20% of referrals. Law
enforcement officials made 13% of referrals. It is important to acknowledge that CCBHS made concerted
efforts throughout the program to ensure that qualified requestors were aware of the program and had
the knowledge and resources to make appropriate referrals. These efforts included: 1) ongoing training
and educational presentations to family members, law enforcement, and mental health provider groups;
and 2) specific actions, such as linking law enforcement officers coming into contact with potentially
eligible individuals with the CORE team (a County-provided homeless outreach team) so that they could
work together to successfully refer those eligible individuals to the program.
Table 2. Summary of Qualified Requestors
Requestor Percent of Total Referrals (N = 475)
Parent, spouse, adult sibling, or adult child 60% (n = 286)
Treating or supervising mental health provider 20% (n = 95)
Probation, parole, or peace officer 13% (n = 63)
Not a qualified requestor or “other” 4% (n = 20)
Director of hospital where individual is hospitalized <3%
Adult who lives with individual <3%
Care Team
Contra Costa County’s Care Team consists of CCBHS’ FMH and MHS ACTiOn 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. Figure 4 summarizes
the outcome of each referral CCBHS received since February 2016. The summary includes duplicated
counts to capture the volume of referrals. The following sections discuss the CCBHS FMH investigations
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and MHS outreach and engagement activities. Where appropriate, unique counts of individuals are
reported as well.
Figure 4. Outcomes for Every Referral to AOT Referred Consumers
After CCBHS receives an AOT referral, the FMH team conducts an investigation to determine if the referred
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.
Nearly every referred individual who was eligible for AOT and/or was able to be located was
connected to mental health services.
Since February 2016, FMH received and investigated a total of 475 referrals. Four hundred and five of
those referrals were unique individuals (70 individuals had been referred more than once). As Table 3
illustrates, approximately one-third of all referrals (32%, n = 154) resulted in a subsequent referral to MHS
for outreach and engagement, while just over another third (37%, n = 174) were investigated and closed.
The FMH team connected 14% (n = 66) of referred individuals with another behavioral health service
provider, such as an FSP, and another 17% were still under investigation to determine their AOT eligibility
as of June 30, 2018.
Duplicated individuals
referred to AOT
N = 475
FMH intervention, not
referred to MHS
n = 320
Investigation ongoing
n = 81
Engaged or re-engaged
with provider
n = 66
Investigated and closed
n = 174
Referred to MHS
n = 154
Did not enroll in ACT
n = 72
Enrolled in ACT
voluntarily
n = 66
Enrolled in ACT through
court
n = 17
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Table 3. Outcome of CCBHS Investigations
Investigation Outcome Percent of Referrals (N = 475)
Referred to MHS 32% (n = 154)
Engaged or Re-Engaged with a Provider 14% (n = 66)
Ongoing Investigation 17% (n = 81)
Investigated and Closed 37% (n = 174)
CCBHS FMH attempted to connect the 174 referred individuals who were ineligible for AOT to an
appropriate level of mental health treatment, as well as provided resources and education for their family
members. Importantly, program implementation modifications (including increased outreach by FMH
clinicians to Unit 4C and law enforcement) alongside improved data collection allows for a more specific
understanding of what happened to the referred individuals who were considered ineligible for AOT.
These individuals were investigated and closed for a number of reasons:
❖ 56% (n = 98) were closed because the referred individuals did not meet AOT eligibility criteria.
❖ 16% (n = 27) were closed because the person making the referral was unqualified, could not be
reached after the initial request, or rescinded the initial request.
❖ 12% (n = 21) were closed because the referred individual was unavailable, which includes
individuals who were conserved, determined to be incompetent to stand trial, incarcerated, or
placed in an Institute for Mental Disease (IMD).
❖ 9% (n = 16) were closed because the referred individual could not be located after a persistent
search.
❖ 7% (n = 12) were closed because the referred individual either lived or moved out of the county
during the investigation.
Contra County’s CCBHS FMH investigation team made significant and persistent efforts to locate
referred individuals to determine their AOT eligibility and connect them to MHS.
On average, CCBHS FMH’s investigation team made five investigation contact attempts for each referral
received. The investigation team worked to meet individuals “where they’re at,” as evidenced by the
variety of locations where investigation contacts occurred. Figure 5 shows that 43% of investigation
contacts occurred in person at a location other than a county office.
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Figure 5. Location of FMH Investigation Contacts
MHS relies on a diverse multidisciplinary team to conduct outreach and engagement, the MHS ACTiOn
team. If the CCBHS FMH team determines that a referred individual is eligible for AOT during the
investigation period, the individual is connected with MHS. The MHS ACTiOn team then conducts outreach
and engagement activities with those individuals and their families to engage them in ACT services. As per
the County’s program design, MHS is charged with providing opportunities for the individual to participate
on a voluntary basis. If the individual remains unable and/or unwilling to voluntary enroll in ACT after a
period of outreach and engagement, 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 has enrolled half of all AOT referred individuals to ACT through their ongoing outreach and
engagement efforts.
Since the program began in February 2016, MHS provided outreach and engagement services for 138
consumers and their support networks. Fifty-one percent (n = 70) eventually enrolled in ACT at least once
as of June 30, 2018. Notably, eight of those consumers enrolled more than once. Another 12% of referred
individuals (n = 17) were still receiving outreach and engagement services as of June 30, 2018 (see Table
4). This trend of approximately half of the individuals whom MHS outreached to ultimately enrolling in
ACT stayed about the same during the entire pilot implementation period.
Table 4. MHS Outreach and Engagement Outcomes (N = 138)
Outreach and Engagement
Outcome Percent of Consumers Number of Consumers
Enrolled in ACT services 51%
70 total
54 voluntarily
16 with court involvement
Still receiving outreach and
engagement services 12% 17
Not enrolled in ACT 37% 51
15
17
35
41
126
173
251
458
624
842
Licensed Care Facilities
Healthcare facility
Shelter
Other
Correctional facility
Consumer or Requestor’s Home
Inpatient facility
Field
Office
Phone
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The MHS ACTiOn team provided intensive
and persistent outreach and engagement
to individuals referred to AOT in a variety
of settings.
MHS provided outreach and engagement
services to individuals as well as their support
networks. Approximately 57% of outreach and
engagement attempts were successful contacts
with individuals, while approximately one in
five contact attempts were with the individuals’
support networks (collateral), including family
members and other providers (see Figure 6).
The majority of the MHS ACTiOn team’s outreach attempts were either by a peer partner (47%) or the
clinical team leader (21%). As with the County’s investigation team, MHS was persistent in their efforts to
meet consumers “where they’re at.” As shown in Figure 7, most contacts occurred in the community or
the consumer/family home.
Figure 7. Location of MHS Outreach and Engagement Attempts
Many of the individuals who received outreach and engagement services but did not enroll in
ACT continued to cycle through crisis, hospital, and jail.
Among the 51 individuals who were referred to MHS and received outreach and engagement but did not
enroll in ACT, 73% (n = 37) experienced at least one crisis episode after referral and 13 also had an
inpatient hospitalization. Additionally, 41% (n = 21) of those who were referred to MHS but not enrolled
in ACT had at least one mental health service while in jail. Approximately 25% (n = 13) engaged in some
form of outpatient treatment; however, almost half of those who engaged in outpatient treatment also
had an inpatient hospitalization. These findings suggest that a subset of individuals was difficult to engage
and may have benefitted from an AOT petition.
16
23
59
76
83
112
146
159
197
Pyschiatric Emergency Services
Homeless Shelter
Phone/ Email
Criminal Justice Locations
Residential Treatment Facility
MHS Office
Hospital
Consumer or Family's Home
Community
Collateral
19%
Unsuccessful
14%
In-person
57%
Phone/Email
10%
Figure 6. Type of Outreach and Engagement Contacts
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Referral to Enrollment Outcomes
This section explores the time period between consumers’ initial AOT referral and their ACT 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 ACT enrollment is 108 days.
Contra Costa County designed an AOT program model that sought to engage and enroll referred
individuals in ACT within 120 days of referral. On average, it took the Care Team approximately 108 days
to collectively conduct investigation, outreach and engagement, and enroll the referred individuals in ACT.
Specifically, it took an average of 49 days from the point of AOT referral to MHS’ first contact, and then
66 days from the date of MHS’ first contact to enrollment in ACT (see Figure 8). This trend of the average
length of time between referral and enrollment for ACT consumers being right under 16 weeks remained
consistent during the entire pilot implementation period.
Figure 8. Average Length of Time from AOT Referral to ACT Enrollment5
Approximately one out of every three ACT consumers experienced referral to enrollment periods
longer than 120 days.
Contra Costa County’s AOT program model has an expected maximum period of 120 days 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, 26 consumers (33%) experienced investigation and
outreach periods lasting longer than 120 days (see Figure 9). Data suggests that these individuals were
difficult to locate, and that the Care Team invested additional time to attempt to locate them.
5 For consumers with multiple ACT enrollments, each period from referral to enrollment is counted separately.
Average days from
AOT referral to first
MHS contact
49
Average days from
MHS first contact to
ACT enrollment
66
ACT Consumers
(N = 70)
• 108 average days from referral to enrollment
o Range = 4 to 367 days
o Median = 73 median
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Figure 9. Length of Time from AOT Referral to ACT Enrollment
The ACT program has seen a steady increase in the number of consumers enrolled during its
pilot period.
As shown in Figure 10, with few exceptions, the number of consumers enrolled in ACT during any given
month has increased since the program began in February 2016. At the conclusion of this evaluation
period, MHS was serving 51 enrolled consumers, with 18 individuals either still receiving outreach and
engagement services or pending ACT enrollment.
Figure 10. Number of Individuals Enrolled in ACT by Month
As of October 23, 2018, there were 64 consumers enrolled in treatment services with the MHS ACTiOn
team.
9
18 17
9
15
11
0-30 31-60 61-90 91-120 121-210 211+Number of ACT ConsumersDays from Referral to Enrollment
4
7
10
13
17 19
22
26 28
31 31
35 35 36 36 35 33 34 36 35 35
38 40
44 46 48
52 51
Mar-16Apr-16May-16Jun-16Jul-16Aug-16Sep-16Oct-16Nov-16Dec-16Jan-17Feb-17Mar-17Apr-17May-17Jun-17Jul-17Aug-17Sep-17Oct-17Nov-17Dec-17Jan-18Feb-18Mar-18Apr-18May-18Jun-18Consumers enrolled in 120 days or fewer Consumers enrolled in more than 120 days
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AOT Enrollment
As shown in Figure 11 below, MHS had a total of 79 enrollments for 70 individuals since February 2016.
Seven individuals were enrolled in ACT more than once, and two of those seven re-enrolled twice. The
majority of enrollments (78%, n = 62) were voluntary.
Figure 11. AOT Treatment Program Participants
This section includes the following components:
• A review of the ACT consumer profile, including demographic characteristics, diagnoses and
baseline employment, education, and financial status;
• A discussion of consumer outcomes, including the change in their experiences of crisis episodes,
inpatient hospitalizations, and homelessness; and
• A discussion of program costs and cost savings associated with reduced numbers of
hospitalizations, 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 majority of ACT consumers are male and White and have both primary psychotic disorders
and co-occurring substance use issues.
80 ACT enrollments
Enrolled in ACT voluntarily
n = 63
Currently enrolled
n = 44
Discharged from ACT
n = 19
Enrolled in ACT through court
n = 17
Currently enrolled
n = 6
Discharged from ACT
n = 11
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As shown in Table 5, ACT consumers were primarily male (56%, n = 39) and White (56%, n = 39). A subset
of 21% (n = 15) were transitional age youth (TAY) between the ages of 18 and 25.
Table 5. ACT Consumer Demographics (N = 70)
Category ACT Consumers
Gender
Male 56% (n = 39)
Female 44% (n = 31)
Race and Ethnicity
Black or African American 19% (n = 13)
Hispanic 16% (n = 11)
White 56% (n = 39)
Other or Unknown 9% (n = 7)
Age at Enrollment
18 – 25 21% (n = 15)
26+ 79% (n = 55)
The majority of ACT consumers (64%, n = 45) have a primary diagnosis of a psychotic disorder (see Figure
12), and 71% (n = 50) had a co-occurring substance use disorder at the time of enrollment.
Figure 12. Primary Diagnosis at Referral (N = 70)
Most ACT consumers are unemployed, have minimal post-high school education, and receive
financial support from supplemental security income.
At the time of enrollment, no ACT consumers were enrolled in school. Over half of ACT consumers had a
GED or higher education level at the time of enrollment (see Figure 13). Slightly more than one-third (38%,
n = 24) of consumers specified continuing education as a recovery goal for their time in ACT.
6 Baseline housing, education, employment, and financial support data were available for 63 of the 70 consumers.
10%, 7
26%, 18
64%, 45
Other (including mood disorders)
or Unknown
Bipolar disorders
Psychotic disorder, including
schizophrenia and schizoaffective
disorders
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Figure 13. Educational Attainment at Enrollment (N = 63)
Over half of ACT consumers were unemployed during the 12 months prior to their enrollment in ACT
(59%, n = 37). Prior employment status was not provided by 33% of consumers (n = 21) (see Figure 14).
Obtaining employment was a recovery goal for almost half (46%) of ACT consumers.
Figure 14. Employment 12 months before ACT
(N = 63)
Table 6 illustrates the sources of financial support and income for ACT consumers in the 12 months prior
to enrollment, as well as at the time of enrollment. The “Other” category includes a variety of financial
support sources: support from family or friends, retirement/Social Security, tribal benefits, wages or
savings, food stamps and housing subsidies. The majority of consumers both prior to and at enrollment
received financial support from supplemental security income.
11%, 7
17%, 11
19%, 12
25%, 16
27%, 17
Unknown/ Not Reported
Less than High School
College/Technical Degree or Higher
High School/GED
Some College/
Technical Training
Unknown
employment
status
21, 33%
Unemployed
before ACT
37, 59%
Some
employment
before ACT
5, 8%
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Table 6. Sources of Financial Support at and before ACT Enrollment (N = 43)
Financial Support Support Received in the Year
Prior to ACT Enrollment
Support Being Received
at ACT Enrollment
Supplemental Security Income 49% (n = 31) 45% (n =29)
Other 36% (n = 23) 30% (n = 19)
No Financial Support or Unknown/Not
Reported 14% (n = 9) 24% (n = 15)
Service Participation
The following sections describe the type, intensity, and frequency of ACT service participation, as well as
adherence to treatment.
To determine whether MHS’ ACT services were provided to fidelity, RDA conducted a separate ACT fidelity
analysis (see Appendix II). The fidelity assessment process measures the extent to which MHS’ ACT
treatment services align with the ACT model and to identify opportunities to strengthen ACT services. For
the assessment, RDA applied the ACT Fidelity Scale developed at Dartmouth University7 and incorporated
it into a SAMHSA toolkit.8 This established assessment includes a set of data collection activities and a
scoring process in order to determine a fidelity rating as well as qualifications of assessors. MHS’ ACT
program was rated across 28 items within the 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 five-point Likert scale with clearly defined descriptions for
each rating. The following chart provides an overview of the domains, criterion, and the MHS ACTiOn
team’s 2017 and 2018 program ratings. As shown in Table 7 below, the MHS ACTiOn team received an
overall fidelity score of 4.50 indicating a high level of fidelity to the ACT model.
Table 7. MHS ACTiOn Team’s ACT Fidelity Assessment Scores (2017 & 2018)
Domain Criterion 2017 Rating 2018 Rating
Human
Resources:
Structure and
Composition
Small caseload 5 5
Team approach 4 5
Program meeting 5 5
Practicing ACT leader 4 5
Continuity of staffing 3 4
7 ACT Fidelity Scale retrieved on December 6, 2017 from: https://www.centerforebp.case.edu/resources/tools/act-dacts
8 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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Domain Criterion 2017 Rating 2018 Rating
Staff capacity 4 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 2 5
Intake rate 5 5
Full responsibility for treatment services 5 5
Responsibility for crisis services 5 5
Responsibility for hospital admissions 5 1
Responsibility for hospital discharge planning 5 5
Time-unlimited services 5 5
Nature of
Services
In vivo services 3 4
No drop-out policy 3 5
Assertive engagement mechanisms 2 5
Intensity of services 5 4
Frequency of contact 4 3
Work with support system 5 5
Individualized substance abuse treatment 5 3
Co-occurring disorder treatment groups 5 3
Co-occurring disorders model 5 5
Role of consumers on treatment team 5 5
ACT Fidelity Score 4.42 4.50
There were notable changes in scores for three domains between the 2017 and 2018 ACT fidelity
assessment processes conducted with MHS. There was a large decline in the domain regarding the MHS
ACTiOn team having some involvement in the decision-making around their consumers’ hospital
admissions. And, there were large increases in two domains: 1) the MHS ACTiOn team having explicit
criteria for whom it admits into ACT services, and 2) the MHS ACTiOn team having and utilizing assertive
engagement mechanisms with its consumers.
As discussed in the methodology section, the following discussion of ACT service participation treats each
enrollment individually for intensity and frequency analysis, even if an individual was enrolled more than
once, in order to avoid misrepresenting service engagement. Since the program began in February 2016,
eight individuals had more than one discrete enrollment. Additionally, any enrollments that were less
than one month in duration were removed from the following analysis. Finally, five individuals enrolled in
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ACT did not have any available service data and were not included in the analysis. As a result, the following
analysis includes 71 total enrollments for 62 unique individuals.
The ACT team is providing a high amount of services on a very frequent basis to its consumers.
Among the 71 total enrollments included in this analysis, consumers were enrolled and receiving ACT
services for an average of 354 days. On average, they received four face-to-face service encounters per
week for a total average of four hours of face-to-face services per week (see Table 8).
Table 8. ACT Service Engagement (N = 71)
ACT Consumers
Average Range
Length of Enrollment 354 days 33-830 days
Frequency of Service
Encounters
4 face-to-face contacts per week <1 – 13 face-to-face contacts per
week
Intensity of Services 4 hours of face-to-face contact per
week
<1 – 12 hours of face-to-face contact
per week
The ACT team is actively providing direct services to its consumers.
The majority of services provided by the
ACT team are direct services to consumers.
On average, 92% of service hours logged by
ACT providers were direct services to ACT
consumers, such as assessment or crisis
intervention. A smaller proportion of
services were with consumers’ support
networks or other administrative duties
(see Figure 15).
Two-thirds of ACT consumers (66%)
were adherent to ACT treatment during program implementation.
Treatment adherence is defined as consumers agreeing to meet with the treatment team and
operationalized as receiving at least one hour of face-to-face engagement with the ACT team a minimum
of two times per week. According to this definition, 33% (n = 24) of consumers did not meet this standard
of adherence. This may be related to their unwillingness to engage, as well as service unavailability, which
may have been impacted by staffing changes in FY 17-18 (see Figure 16 and Figure 17).
14.4 hours
0.7 hours0.5 hours
ACT Consumers
Other Services
Collateral Services
Direct Services
Figure 15. ACT Service Hours per Month
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Figure 16. Intensity of ACT Contacts per Week
Figure 17. Frequency of ACT Contacts per Week
In order to account for early implementation challenges, which are common when a new program goes
through its start-up phase, this treatment adherence definition was also applied only to consumers who
enrolled after the first six months of implementation. With individuals from the first six months of
implementation removed, the proportion of individuals who were not adherent increased from 33% to
45%. Further, when consumers who enrolled in FY 17-18 were removed from the analysis, the proportion
of individuals who were not adherent decreased from 33% to 20%. These differences suggest that the
staffing changes that occurred in FY 17-18 may have influenced consumers’ ability to meaningfully engage
in treatment, resulting in lower adherence rates as specified by this definition.
During this evaluation period, 30 individuals were discharged from the MHS ACTiOn program. Of these 30
individuals, 10 subsequently re-enrolled in the program. Moreover, during this evaluation period, seven
consumers (23%) either successfully completed the program or were discharged into a more appropriate
level of care, such as conservatorship or a residential treatment program.
ACT Consumer Outcomes
The following sections provide a summary of consumers’ experiences with psychiatric hospitalizations,
crisis episodes, and homelessness before and during ACT enrollment.
This section describes consumers’ crisis stabilization episodes and psychiatric hospitalizations before,
during, and after 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.
ACT consumers experienced a significant decrease in both the amount and frequency of crisis
episodes and psychiatric hospitalizations during ACT enrollment.
Almost all consumers (91%, n = 61) had at least one crisis episode in the three years before ACT, averaging
approximately 3.1 episodes for every six months, with episodes lasting an average of 1.4 days. Fewer
14%, 10 15%, 11
21%, 15
14%, 10
10%, 7
25%, 18
0
4
8
12
16
20
<1 hour
per week
1-1.9
hours
per week
2-2.9
hours
per week
3-3.9
hours
per week
4-4.9
hours
per week
5 or
more
hours
per week
15%, 11 17%, 12
13%, 9
18%, 13
13%, 9
24%, 17
0
4
8
12
16
20
<1
contact
per week
1-1.9
contacts
per week
2-2.9
contacts
per week
3-3.9
contacts
per week
4-4.9
contacts
per week
5 or
more
contacts
per week
Non-Adherent Consumers
Adherent Consumers
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consumers had a crisis episode during their ACT enrollment (52%, n = 35) with an average of 2.2 episodes
each six months (see Table 9). Reductions in the proportion of consumers who experienced at least one
crisis episode in the three years prior to ACT enrollment and during ACT enrollment are significant9,
suggesting that ACT participants were less likely to experience crisis episodes during AOT enrollment as a
result of program participation.
Table 9. Consumers’ Crisis Episodes Before and During ACT (N = 67)10
Before ACT Enrollment During ACT Enrollment
Number of Consumers 91%, n = 61 52%, n = 35
Average Number of Crisis Episodes 3.1 episodes per 180 days 2.2 episodes per 180 days
Average Length of Stay 1.4 days 1.2 days
Similarly, the number of consumers who experienced a psychiatric hospitalization decreased during ACT.
Over half of ACT consumers (55%, n = 37) had at least one hospitalization in the three years before ACT,
compared to 31% of consumers who experienced a hospitalization during ACT. Those with at least one
hospitalization before ACT averaged approximately one hospitalization every six months, lasting
approximately seven days each. Although consumers had fewer hospitalizations (0.7 per 180 days) while
enrolled in ACT, the average length of stay increased slightly from 7.3 to 10.0 days (see Table 10).
Reductions in the proportion of consumers who experienced a psychiatric hospitalization in the three
years prior to ACT enrollment and during ACT enrollment are also significant11, suggesting that ACT
participants were also less likely to experience psychiatric hospitalizations during AOT enrollment than
prior.
Table 10. Consumers’ Inpatient Hospitalizations Before and During ACT (N = 67)
Before ACT Enrollment During ACT Enrollment
Number of Consumers 55%, n = 37 31%, n = 21
Average Number of Hospitalizations 1.0 episodes per 180 days 0.7 episodes per 180 days
Average Length of Stay 7.3 days* 10.0 days**
*Average is 12 days if two long-term hospitalizations of over 100 days are retained;
** Average is 24 days if two long-term hospitalizations of over 100 days are retained
Over one-third of consumers (n = 13) continued to experience crisis episodes and/or psychiatric
hospitalizations after being discharged from ACT.
Among the 30 individuals discharged from ACT, 10 subsequently re-enrolled in the program. Seven
consumers (23%) either successfully completed the program or were discharged into a more appropriate
level of care, such as conservatorship or a residential treatment program. Findings suggest that the
remaining consumers, who often returned to jail, PES, and inpatient hospitalization, may have been
9 A p-value is used to determine the probability of observed findings being the result of chance. The above finding
was statistically significant at a p-value threshold of .01. This indicates that there is less than a 1% likelihood that the
observed outcomes are a result of chance.
10 Three consumers were removed from the analysis because they were enrolled for less than one month.
11 A p-value is used to determine the probability of observed findings being the result of chance. The above finding
was statistically significant at a p-value threshold of .01. This indicates that there is less than a 1% likelihood that the
observed outcomes are a result of chance.
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discharged prematurely from ACT. In some instances, these individuals completely disengaged from
treatment and could not be located. In other instances, the consumers had originally voluntarily enrolled
in ACT, and there may have been opportunities to utilize the AOT petition to further compel their
participation in the program.
This section describes consumers’ criminal justice system involvement by exploring Sheriff’s Office
bookings, charges, and jail stay data, which were available for the 36 months prior to ACT implementation
through June 30, 2018. Following an arrest, individuals are typically booked into local county jail and
remain in jail until released through bail payment or on their own recognizance. 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. Conviction data were not available
for this report.
Significantly fewer ACT consumers were arrested and booked during ACT enrollment.
The proportion of ACT consumers who were arrested and booked decreased during ACT from 67% (n =
45) before enrollment to 31% (n = 21) during ACT (see Table 11).12 While the average number of bookings
stayed consistent for ACT consumers, their average length of jail stays decreased from 29 days to
approximately 18.5 days.
Table 11. Consumers’ Bookings and Incarcerations before and during ACT (N = 67)
Before ACT enrollment During ACT enrollment
Number of Consumers 67%, n = 45 31%, n = 21
Average Number of Bookings 2.3 bookings per 180 days 2.4 bookings per 180 days
Average Length of Incarceration 29.0 days 18.5 days
Consumers were often charged with multiple offenses during one booking. Figure 18 categorizes these
charges into the following groups:
• Justice System Compliance Violations: Charges involving violating probation or other court
orders, or obstruction.
• Crimes against People: Charges involving assault, battery, robbery, weapons possession, driving
under the influence, false imprisonment, or violation of protective orders.
• Nuisance: Charges involving trespassing or disorderly conduct.
• Crimes against Property: Charges involving arson, theft, burglary, shoplifting, and vandalism.
• Drug or Sex-Related Crimes: Charges involving possession of controlled substances, indecent
exposure, sexual battery, or soliciting a lewd act.
• Other or Unknown: Charges involving driving without a license or a suspended license, fraud, or
unknown charge.
12 A p-value is used to determine the probability of observed findings being the result of chance. The above finding
was statistically significant at a p-value threshold of .01. This indicates that there is less than a 1% likelihood that the
observed outcomes are a result of chance.
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The majority of charges against ACT consumers were for system compliance violations, which were
primarily probation violations. The majority of ACT consumers’ crimes against people were either assault
or battery.
Figure 18. Types of Charges During ACT Enrollment
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.
The majority of consumers either obtained or maintained housing while in ACT.
Self-reported housing data were available for 75% (n = 53) of all ACT consumers. Among th3 53 ACT
consumers with available housing data, 62% (n = 33) were in stable housing at the conclusion of the
evaluation period.13 RDA compared consumers’ baseline housing status to their last known residence as
of June 30, 2018 to explore changes in consumers’ housing status during ACT enrollment. As shown in
Figure 19, 13% (n = 7) of consumers obtained housing while enrolled in ACT, while approximately half
(49%, n = 26) maintained the stable housing they had before ACT enrollment. The remaining 37% of
consumers either lost their housing while in ACT, or never had nor gained stable housing.
13 RDA used the Department of Housing and Urban Development (HUD) definition of stable housing to determine
which categories from the FSP PAF and KET forms should be considered “housed.”
9
16
31
44
58
92
Other or unknown
Drug- or sex-related
Crimes against property
Nuisance charges
Crimes against people
Justice system compliance violations
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Figure 19. Consumers’ Housing Status before and during ACT14
Consumers’ abilities to function independently and participate in meaningful activities that are a part of
daily living are also of key importance in ACT programs. In order to understand how ACT participation may
influence these abilities, this section examines changes in consumers’ severity of mental illness (assessed
with the BPRS-E instrument), as well as changes in their self-sufficiency across a number of domains
(assessed with the Self-Sufficiency Matrix).
ACT consumers experience a significant variety of severe psychiatric symptoms.
To assess the severity of consumers’ symptoms, the MHS ACTiOn team administered the BPRS-E
instrument with each consumer at the point of intake. The BPRS-E is a rating scale for clinicians to measure
psychiatric symptoms and assess treatment changes across a comprehensive set of common symptom
characteristics; it rates the severity of consumers’ experience of symptoms from one (“not present”) to
seven (“extremely severe”). Overall, MHS assessed 47 of its 70 consumers at intake with the BPRS-E
instrument. The average scores for ACT consumers ranged between 2.9 (“very mild” to “mild”) for
Activation-related symptoms to 3.6 (“mild”) for Positive Symptoms (see Table 12). Some individual
consumers scored up to 7 (“extremely severe”) on certain domains. On average, ACT consumers
demonstrated mild to moderate scores in their psychiatric symptomology at the point of AOT enrollment;
but there was a high degree of variation between the minimum and maximum scores for each domain.
The domain which the highest proportion of ACT consumers (23%) scoring worse than Moderately Severe
was having Positive Symptoms (hallucinations, unusual thought content, suspiciousness, grandiosity).
14 Due to rounding, percentages do not add up to 100.
Consumers who obtained
housing
•13% of consumers were
not housed before ACT
but obtained housing
while enrolled
Consumers who
maintained housing
•49% of consumers were
housed before ACT and
continued to maintain
housing while enrolled
Consumers who were not
stably housed
•9% 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 12. Baseline BPRS-E Scores (N=47)15
Symptom
Domains
Subscale Items
Average
Score
Minimum
Score
Maximum
Score
% of
Consumers
Scoring
above
Moderately
Severe
Affect Anxiety, guilt, depression,
suicidality
3.2 0.5 5.8 9%
Positive
Symptoms
Hallucinations, unusual thought
content, suspiciousness, grandiosity
3.5 0.3 7.0 23%
Disorganizations Conceptual disorganization,
disorientation, self-neglect,
mannerisms-posturing
3.0 0.5 6.0 6%
Negative
Symptoms
Blunted affect, emotional
withdrawal, motor retardation
3.3 1.0 7.0 13%
Activation Excitement, motor hyperactivity,
elevated mood, distractibility
2.9 0.3 7.0 11%
Legend: 1 = Not
Present 2 = Very Mild 3 = Mild 4 = Moderate 5 = Moderately
Severe 6 = Severe 7 = Extremely
Severe
Overall, the severity of psychiatric symptoms for ACT consumers decreased across most
symptom domains during ACT program enrollment.
MHS staff conducted the BPRS-E assessment with 26 ACT consumers at both their AOT intake and six
months later (interim). The average scores for all ACT consumers ranged between 2.7 (“very mild”) for
Activation-related symptoms up to 3.6 for Positive Symptoms (see Table 13). The overall average severity
score decreased for all psychiatric symptom domains during ACT program participation. Moreover, the
Positive Symptoms domain saw the greatest decrease between intake and six months later in the
proportion of ACT consumers who scored worse than moderately severe (decrease from 31% to 15% of
ACT consumers).
15 Data Source: Brief Psychiatric Rating Scale Expanded (BPRS-E)
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Table 13. Comparing Changes in BPRS-E Average Scores (N=26)16
Symptom
Domains
Subscale Items
Intake
Interim
% of
Consumers
Scoring
above
Moderately
Severe @
Intake
% of
Consumers
Scoring
above
Moderately
Severe @
Interim
Affect Anxiety, guilt, depression,
suicidality
3.0 2.8 8% 4%
Positive
Symptoms
Hallucinations, unusual thought
content, suspiciousness,
grandiosity
3.6
3.3
31% 15%
Disorganizations Conceptual disorganization,
disorientation, self-neglect,
mannerisms-posturing
3.1
3.0
12% 23%
Negative
Symptoms
Blunted affect, emotional
withdrawal, motor retardation
3.1
2.9
8% 8%
Activation Excitement, motor hyperactivity,
elevated mood, distractibility
2.7
2.4
8% 8%
Legend: 1 = Not
Present 2 = Very Mild 3 = Mild 4 = Moderate 5 = Moderately
Severe 6 = Severe 7 = Extremely
Severe
Across most domains, ACT clients are vulnerable in their abilities to be self-sufficient.
Consumers’ ability to be self-sufficient in their daily lives is also of key importance in AOT programs. The
Self-Sufficiency Matrix, administered to the ACT clients by MHS, provides information about consumers’
social functioning and independent living at intake on a scale from 1 (“in crisis”) to 5
(“empowered/thriving”). Intake data was collected for 57 consumers; Table 14 reports the average scores
for consumers at their first assessment. On average, consumers scored higher than 3 (“stable”) in domains
related to health care coverage, life skills, adult education, legal, and safety. The higher scores for these
domains may be attributed to consumers achieving sufficient stability and accessing supportive services
when discharged from psychiatric hospitals or other mental health facilities prior to enrolling in AOT.
Consumers scored lower than 3 (“stable”) in domains related to housing, employment, income, food and
nutrition, relationships, transportation, community involvement, mental health, substance abuse, and
disabilities. The lower scores for these domains indicate the domains in which ACT consumers may need
additional support – from the ACT program or elsewhere – in order to increase their own abilities to be
more sufficient in those domains.
Table 14. Baseline Self-Sufficiency Matrix Scores (N=57)17
Domain Average
Score
Score Description
Housing 2.6 • 2= In transitional, temporary or substandard housing; and/or current rent/mortgage
payment is unaffordable (over 30% of income)
16 Data Source: Brief Psychiatric Rating Scale Expanded (BPRS-E)
17 Data Source: Self-Sufficiency Matrix (SSM)
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Domain Average
Score
Score Description
• 3= In stable housing that is safe but only marginally adequate
Employment 1.1 • 1= No job
Income 2.0 • 2= Inadequate income and/or spontaneous or inappropriate spending
Food and Nutrition 2.6 • 2= Household is on food stamps
• 3= Can meet basic food needs but requires occasional assistance
Adult Education 3.5 • 3= Has high school diploma/GED
• 4= Needs additional education/training to improve employment situation and/or to resolve
literacy problems to where they are able to function effectively in society
Health Care
Coverage
3.9 • 3= Some members (e.g. children) have medical coverage
• 4= All members can get medical care when needed but may strain budget
Life Skills 3.0 • 3= Can meet most but not all daily living needs without assistance
Family/Social
Relations
2.5 • 2= Family/friends may be supportive but lack ability or resources to help; family members
do not relate well with one another; potential for abuse or neglect
• 3= Some support from family/friends; family members acknowledge and seek to change
negative behaviors; are learning to communicate and support
Mobility/
Transportation
2.5 • 2= Transportation is available, but unreliable, unpredictable, unaffordable; may have vehicle
but no insurance, license, etc.
• 3= Transportation is available and reliable but limited and/or inconvenient; drivers are
licensed and minimally insured
Community
Involvement
2.4 • 2= Socially isolated and/or no social skills and/or lacks motivation to become involved
Legal 3.5 • 3= Fully compliant with probation/parole terms
• 4= Has successfully completed probation/parole within past 12 months; no new charges filed
Mental Health 2.2 • 2= Recurrent mental health symptoms that may affect behavior but not a danger to
self/others; persistent problems with functioning due to mental health symptoms
Substance Abuse 2.9 • 2= Meets criteria for dependence; preoccupation with use and/or obtaining drugs/alcohol;
withdrawal or withdrawal avoidance behaviors evident; use results in avoidance or neglect
of essential life activities.
• 3= Use within last 6 months; evidence of persistent or recurrent social, occupational,
emotional or physical problems related to use (such as disruptive behavior or housing
problems); problems have persisted for at least one month
Safety 3.4 • 3= Current level of safety is minimally adequate; ongoing safety planning is essential
Disabilities 2.3 • 2= Vulnerable - sometimes or periodically has acute or chronic symptoms affecting housing,
employment, social interactions, etc.
Legend: 1 = In Crisis 2 = Vulnerable 3 = Safe 4 = Building Capacity 5 = Empowered
ACT consumers experienced very little change in their self-sufficiency scores during program
enrollment.
MHS staff conducted the Self-Sufficiency Matrix (SSM) assessment at AOT enrollment and then six months
later with 35 ACT consumers. Table 15 reports the average scores for those consumers at their first
assessment and again six months later. On average, consumers’ scores improved to higher (higher than
3 “stable”) in domains related to housing and food and nutrition. All the other scores remained relatively
the same between these two assessment timepoints.
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Table 15. Comparing Changes in Self-Sufficiency Matrix Average Scores (N=35)18
Domain
Intake
Average
Score
Interim
Average
Score
Score Description
Housing
2.9
3.2
• 2= In transitional, temporary or substandard housing; and/or current rent/mortgage
payment is unaffordable (over 30% of income)
• 3= In stable housing that is safe but only marginally adequate
Employment 1.2 1.3 • 1= No job
Income 2.3 2.4 • 2= Inadequate income and/or spontaneous or inappropriate spending
Food and
Nutrition 2.9 3.2 • 2= Household is on food stamps
• 3= Can meet basic food needs but requires occasional assistance
Adult Education
3.6 3.5
• 3= Has high school diploma/GED 4= Needs additional education/training to improve
employment situation and/or to resolve literacy problems to where they are able to
function effectively in society
Health Care
Coverage 4.2 4.3 • 4= All members can get medical care when needed but may strain budget
Life Skills 3.2 3.5 • 3= Can meet most but not all daily living needs without assistance
Family/Social
Relations 2.6 2.8
• 2= Family/friends may be supportive but lack ability or resources to help; family members
do not relate well with one another; potential for abuse or neglect
• 3= Some support from family/friends; family members acknowledge and seek to change
negative behaviors; are learning to communicate and support
Mobility/
Transportation 2.5 2.8
• 2= Transportation is available, but unreliable, unpredictable, unaffordable; may have
vehicle but no insurance, license, etc.
3= Transportation is available and reliable but limited and/or inconvenient; drivers are
licensed and minimally insured
Community
Involvement 2.6 2.8 • 2= Socially isolated and/or no social skills and/or lacks motivation to become involved
• 3= Lacks knowledge of ways to become involved
Legal
3.5 3.6
• 3= Fully compliant with probation/parole terms
• 4= Has successfully completed probation/parole within past 12 months; no new charges
filed
Mental Health 2.4 2.4 • 2= Recurrent mental health symptoms that may affect behavior but not a danger to
self/others; persistent problems with functioning due to mental health symptoms
Substance Abuse
3.1 3.3
• 3= Use within last 6 months; evidence of persistent or recurrent social, occupational,
emotional or physical problems related to use (such as disruptive behavior or housing
problems); problems have persisted for at least one month
Safety 3.6 3.9 • 3= Current level of safety is minimally adequate; ongoing safety planning is essential
• 4= Environment is safe, yet future of such is uncertain; safety planning is important
Disabilities 2.5 2.4 • 2= Vulnerable - sometimes or periodically has acute or chronic symptoms affecting
housing, employment, social interactions, etc.
Legend: 1 = In Crisis 2 =
Vulnerable 3 = Safe 4 = Building Capacity 5 = Empowered
Few ACT consumers perpetuate violence towards others and/or experience victimization.
MHS implemented the Abbreviated MacArthur Community Violence Tool (MacArthur Tool) to assess
changes in violence and victimization of consumers during ACT program enrollment. The MacArthur tool
18 Data Source: Self-Sufficiency Matrix (SSM)
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includes 17 questions that assess the frequency of violence, victimization or perpetration of assaultive
behavior by consumers during the last month. Victimization and violent behaviors include behaviors that
causes physical or emotional harm to themselves or others. It can range from verbal abuse to physical
harm to self, others, or property.
MHS administered the MacArthur Tool with 33 ACT clients. The majority of ACT clients at baseline
reported that they had not been victimized nor perpetrated violence towards someone in the month prior
to enrollment. However, given the sensitive nature of these questions and that very few individuals
reporting experiencing either activity during both timepoints, these results are likely an
underrepresentation of these outcomes and should be interpreted with caution.
AOT Costs and Cost Savings
The County’s AOT program is funded through a variety of sources. Mental health services provided by
CCBHS and MHS are funded by MHSA Community Services and Supports (CSS) and Medi-Cal Federal
Financial Participation. Legal costs associated with the program from County Counsel, the Public
Defender, and the Superior Court19 are funded through the County general fund. In FY 17-18, the entirety
of the AOT program was budgeted at $2,782,500. However, the actual cost for FY 17-18 was
$1,904,132.83. All partners’ actual expenses were less than budgeted in FY 17-18, as demonstrated in
Table 16. Of the actual expenses, $1,812,919 was funded by MHSA CSS and Medi-Cal FFP funds, and
$91,214 came from the County general fund.
Table 16. FY 17-18 AOT Budget and Actual Expenses
Partner FY 17-18 Budget FY 17-18 Actual Costs
MHS $2,014,000 $1,560,080
CCBHS $350,000 $252,839
County Counsel $157,000 $32,379
Public Defender $133,500 $56,250
Superior Court $128,000 $2,585
Total $2,782,500 $1,904,133
For services associated with ACT, it was anticipated that 70% of all services provided would be billable and
35% of the revenue would therefore come from Medi-Cal FFP. According to CCBHS Medi-Cal billing
reports, the total billing for FY 17-18 was $383,163 (25% of actual expenses), which is below what was
anticipated. There are a number of factors that influence Med-Cal billing and all of the sources of funds
19 Actual court costs for FY 17-18 were 2% of the budgeted amount, and the court agreed to participate in the
program with no funds from the county beginning in FY 18-19.
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for the MHS contract are MHSA and FFP, so this difference changes the amount of funding being drawn
from the County’s MHSA CSS allocation but does not impact the actual cost to the County.
Mental health and jail costs were calculated for all ACT consumers enrolled in the program (n = 70) to
determine the actual cost savings and cost avoidance produced by the AOT program. Pre-enrollment costs
were calculated using actual charges from PSP and jail booking data using a projected cost of $106 per
consumer per day20 for the 36 months preceding each individual’s enrollment. Post-enrollment data
included all PSP and jail data for the entirety of the project period following each individual’s enrollm ent
in the AOT program. Given the differences in pre- and post-enrollment timeframes, pre-enrollment costs
were standardized to 29 months to allow for direct comparison. Table 17 compares the pre- and post-
AOT enrollment cost differences by type of charge.
Table 17. Pre- and Post-Enrollment Cost Comparison
Pre-
Enrollment
Post-
Enrollment
Total
Difference
Annual
Estimate
Outpatient and Residential
Mental Health Services
$5,280,971 $3,868,976 $1,411,995 $584,274
Psychiatric Hospitalization $2,167,051 $1,049,866 $1,117,185 $462,283
Jail Bed Days $507,722 $194,192 $313,530 $129,737
Total Mental Health Services $7,448,022 $4,918,842 $2,529,180 $1,046,557
Total Mental Health and Jail $7,955,744 $5,113,034 $2,842,710 $1,176,294
Overall, the program reduced the total cost of care for the 70 enrolled consumers by $2,842,710 from
February 2016 through June 2018 (approximately $1,176,294 per year). However, not all cost reductions
resulted in actual cost savings to the County. Of this amount, the AOT program produced a hard cost
savings of $1,117,185 over the first 29 months of implementation, which is approximately $462,283 per
year. Given that the actual County expenditures for the program in FY 17-18 were $91,214, the program
produces an estimated $371,069 of hard cost savings per year. Additionally, the program resulted in cost
avoidance from reduced outpatient and residential mental health service costs as well as from a reduction
in jail bed days. While these do not reflect actual cost savings to the County, they are representative of an
overall reduction in the cost of services for the 70 enrolled consumers.
20 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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Discussion
In February 2015, the Contra Costa County Board of Supervisors adopted a resolution to authorize the
implementation of AOT for a 36-month pilot project to determine if it would effectively identify, engage,
and treat a group of individuals who were previously unable to engage in mental health services and
cycling in and out of crisis, hospitals, jails, and homelessness. The County also elected to implement
Assertive Community Treatment (ACT), an evidence-based outpatient treatment approach that provides
the highest level of outpatient services available in the community for those who need it most. This
required contracting with a new service provider, MHS, to deliver ACT services in Contra Cost County. The
County’s AOT program became operational on February 1, 2016 and accepted its first consumer in March
2016.
One of the important components of the County’s AOT program is the investigation, outreach, and
engagement process used to connect individuals referred to AOT to the appropriate level of care. At the
start of program implementation, fewer individuals than anticipated were enrolled in ACT, and the
investigation, outreach, and engagement process was taking longer than expected (on average over three
months). While this is a long period of time for individuals suffering from serious mental illness not to be
connected to services, it is not too surprising that the process was taking that long given that AOT
implementation required not only the development of new cross-system partnerships, but also
integration of a new contracted service provider in Contra Costa County. Additionally, at program onset,
both CCBHS FMH and MHS staff sought to enroll individuals in ACT on a voluntary basis if possible, and
staff were very diligent in their implementation of the court process. However, after acknowledging that
individuals referred to AOT continued to suffer during the investigation, outreach and engagement
process, the County put steps in place to speed up the pre-enrollment process (for example, CCBHS FMH
staff institutionalized processes to review whether individuals referred to AOT should receive an AOT
petition on a weekly basis). While the County has implemented many changes to support the
investigation, outreach and engagement process, the time from referral to ACT enrollment for all
individuals referred to AOT in FY 17-18 remained on average longer than three months.
Although it has taken longer than anticipated to enroll AOT-eligible consumers into ACT, the program is
reaching its target population and achieving positive outcomes. Since implementing ACT as the service
component of the AOT program, MHS has scored high fidelity to the ACT model each year. MHS has
maintained a commitment to supporting ACT consumers despite experiencing staffing issues that resulted
in sudden turnover. As a result, fewer ACT consumers have experienced crisis episodes and psychiatric
inpatient hospitalizations while enrolled in ACT because of their support commitment.
While ACT participants as a whole are experiencing positive outcomes, some continue to have trouble
while enrolled in the program, with a subset of consumers continuing to experience inpatient
hospitalizations and justice involvement. In addition, it appears that a number of consumers are
discharged from ACT prematurely. Over one-third of consumers that have been discharged from ACT
continued to experience crisis episodes and/or psychiatric inpatient hospitalizations, and many were
never connected to other services upon discharge. The County should consider what the appropriate
criteria for discharge is. The County can then ensure that all consumers who are discharged meet this
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criterion, and that concrete steps are in place to connect discharged consumers to an appropriate level of
care. This criterion should include determining for which consumers it is appropriate to file a petition
through the court to compel a longer tenure of AOT participation.
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Question 2 | ACT and AOT Comparison
Findings
In 2015, the County elected to implement two complementary but discrete programs, ACT and AOT. ACT
is an evidence-based behavioral health program for people with serious mental illness who are at-risk of
or would otherwise be served in institutional settings (e.g. hospitals, jails/prisons) or experience
homelessness. ACT has the strongest evidence base of any mental health practice for people with serious
mental illness, which dates back to the 1970s. When done to fidelity, ACT produces reliable results that
decrease consumers’ negative outcomes such as hospitalization, incarceration, and homelessness and
improve psychosocial outcomes, described above. AOT has a more limited evidence base; while it has
been available in some states for longer than in California, its implementation is relatively new (although
becoming much more widespread). AOT refers specifically to the legal mechanism by which a judge may
mandate or compel a person with serious mental illness to comply with a treatment plan on an outpatient
basis. In Contra Costa County, the majority of ACT consumers (77%, n = 54) enrolled voluntarily, without
the use of the AOT legal mechanism. A smaller subset of consumers (23%, n = 16) required court
involvement, either through an AOT settlement agreement or a court petition, to compel participation in
ACT services.
The following section explores what differences may exist between individuals who participate voluntarily
and those who participate through AOT court involvement. Specifically, it examines the potential
differences in the consumer profile, service patterns, and psychosocial outcomes of these individuals.21
Consumer Profile
There are few differences in the demographics and diagnoses between consumers enrolled in
ACT voluntarily and those enrolled through the court.
Overall, the voluntary and court-ordered ACT consumer populations are similar. Both groups are mostly
male and mostly White. Non-White consumers make up a slightly higher proportion of voluntary
consumers (43%) compared to court-involved consumers (38%). Additionally, there is a larger proportion
of transition age youth (TAY) in the court-involved population (25%) than the voluntary population (17%).
In both groups, the largest proportion of consumers were diagnosed with a psychotic disorder, including
schizophrenia and schizoaffective disorders.
While consumers in both groups received comparable amounts of outreach and engagement
from MHS, it took more time for the Care Team to enroll court-involved individuals.
21 Given that the court-involved population is less than 20, this section reports descriptive statistic findings and does
not include any inference analysis.
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Overall, court-involved and voluntarily enrolled consumers received similar amounts of outreach and
engagement services for both themselves and their support networks. As shown in Table 18 below, court-
involved consumers received slightly more contact attempts for themselves, while voluntarily enrolled
consumers received slightly more collateral contact attempts (i.e., outreach attempts with their families
and other providers).
Table 18. Outreach and Engagement Attempts by Consumer Enrollment Type
All ACT
Consumers
Voluntarily Enrolled
ACT Consumers
Court-Involved
ACT Consumers
Number of Consumers who Received
Outreach and Engagement 67 53 15
Average Contact Attempts per
Consumer 8.7 8.4 9.3
Average Collateral Contact Attempts
per Consumer 2.3 2.5 1.6
Notably, though consumers in both groups received comparable amounts of outreach to get enrolled in
ACT services, it took on average almost two more months for court-involved consumers to enroll. From
referral to AOT enrollment, voluntary consumers took an average of 96 days to enroll, while court-
involved consumers took approximately 151 days.
Service Participation
A larger proportion of court-involved consumers have lower service participation compared to
voluntarily enrolled consumers.
As discussed earlier, this evaluation operationalizes treatment adherence as at least one hour of face-to-
face engagement with the ACT team at least two times a week. Using this definition, over half (53%) of
court-involved consumers included in the analysis were not adherent, while just over a quarter (28%) of
those who enrolled voluntarily were not adherent. Figure 20 and Figure 21 below illustrate this difference.
Figure 20. Intensity of ACT Contacts per Week
Figure 21. Frequency of ACT Contacts per Week
7%
13%
26%
17%
13%
24%
35%
24%
6%6%
29%
<1 1-1.9 2-2.9 3-3.9 4-4.9 5+
7%
19%
15%
20%
13%
26%
41%
12%
6%
12%12%
18%
<1 1-1.9 2-2.9 3-3.9 4-4.9 5+
Hours per week Contacts per week
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Consumer Outcomes
The following sections provide a summary of voluntarily enrolled and court-involved consumers’
experiences with psychiatric hospitalizations, crisis episodes, and housing instability before and during
ACT enrollment. It also provides a high-level description of outcomes for a subset of consumers each
group who were discharged from ACT.
Consumers who enrolled voluntarily saw a substantial decrease in crisis episodes, inpatient
hospitalizations, and criminal justice involvement during ACT.
Among the ACT consumers who enrolled voluntarily, nearly half of the consumers who had at least one
crisis experience before enrollment had another crisis experience during enrollment. On average, they
experienced one less episode per 180 days during ACT compared to before, and their average length of
stay in a crisis facility remained about the same (see Table 19).
A similar trend exists in consumers’ inpatient hospitalization experiences. First, the proportion of
individuals with a hospitalization before ACT enrollment is similar between the court-involved and
voluntarily enrolled consumers. However, a significantly larger proportion of court-involved consumers
had a hospitalization during ACT enrollment. As with crisis episodes, the proportion of voluntarily enrolled
consumers with at least one hospitalization prior to ACT decreased during their ACT enrollment, from 53%
to 24%.
Table 19. Crisis Episodes and Inpatient Hospitalizations Before and During ACT by Enrollment Type
Before ACT Enrollment During ACT Enrollment
Voluntarily
Enrolled ACT
Consumers
(n = 51)
Crisis Hospitalization Crisis Hospitalization
Number of
Consumers 90%, n = 46 53%, n = 27 47%, n = 24 24%, n = 12
Average Number
of Episodes
3.2 episodes
per 180 days
1.1 episodes
per 180 days
2.1 episodes
per 180 days
0.8 episodes
per 180 days
Average Length
of Stay 1.5 days 13.3 days 1.2 days 25.8 days
Court-
Involved ACT
Consumers
(n = 16)
Number of
Consumers 94%, n = 15 63%, n = 10 69%, n = 11 56%, n = 9
Average Number
of Episodes
2.9 episodes
per 180 days
0.9 episodes
per 180 days
2.7 episodes
per 180 days
0.8 episodes
per 180 days
Average Length
of Stay 1.3 days 8.1 days 1.2 days 21.3 days
As shown in Table 20, a larger proportion of court-involved consumers were arrested and booked both
prior to and during ACT enrollment, compared to voluntarily enrolled consumers.
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Table 20. Consumers’ Bookings and Incarcerations Before and During ACT by Enrollment Type
Before ACT Enrollment During ACT Enrollment
Voluntarily
Enrolled ACT
Consumers (n =
51)
Number of Consumers 61%, n = 31 20%, n = 10
Average Number of
Bookings
1.7 bookings per 180 days 0.7 bookings per 180 days
Average Length of
Incarceration
33.7 days 14.4 days
Court-
InvolvedACT
Consumers (n =
16)
Number of Consumers 88%, n = 14 69%, n = 11
Average Number of
Bookings
3.6 bookings per 180 days 3.9 bookings per 180 days
Average Length of
Incarceration
18.5 days 22.3 days
The disparity in criminal justice outcomes between court-involved and voluntarily enrolled consumers is
also apparent in the number and type of charges they received for each booking. Charges were
categorized in the following way:
• Justice System Compliance Violations: Charges involving violating probation or other court
orders, or obstruction.
• Crimes against People: Charges involving assault, battery, robbery, weapons possession, driving
under the influence, false imprisonment, or violation of protective orders.
• Nuisance: Charges involving trespassing or disorderly conduct.
• Crimes against Property: Charges involving arson, theft, burglary, shoplifting, and vandalism.
• Drug or Sex-Related Crimes: Charges involving possession of controlled substances, indecent
exposure, sexual battery, or soliciting a lewd act.
• Other or Unknown: Charges involving driving without a license or a suspended license, fraud, or
unknown charge.
As shown in Figure 22, while the number of people who were booked and charged during ACT was similar
(10 voluntary consumers and 11 court-involved consumers), court-involved consumers were booked more
and charged with more offenses.
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Figure 22. Types of Charges During ACT by Enrollment Type
A subset of discharged consumers in both consumer groups were likely discharged prematurely.
As of June 30, 2018, eight of the voluntarily enrolled ACT consumers were discharged without re-enrolling
in the program. About half of these individuals were likely discharged prematurely, as they could not be
found and/or experienced additional inpatient, crisis, and justice episodes following discharge. Among
court-involved consumers, a similar trend was observed. Moreover, in both groups, an even smaller
portion of discharged consumers either successfully graduated from AOT or were discharged to a more
appropriate level of care, such as conservatorship or residential treatment.
A larger proportion of voluntarily enrolled consumers were stably housed compared to court-
involved consumers.
The majority of voluntarily enrolled ACT consumers either maintained or obtained stable housing from
the time of enrollment to their most recent KET before June 30, 2018. Approximately half of court-
involved consumers were able to maintain or obtain stable housing during this period.
Discussion
In 2016, Contra Costa County implemented two complementary but discrete programs, ACT and AOT.
ACT has a robust evidence base dating back to the 1970s, and is a service model widely implemented
across the nation and internationally. AOT has a more limited evidence base and provides a mechanism
to compel treatment for individuals who are unable to engage in mental health services and who are a
danger to themselves or others.
20
23
40
63
5
7
8
18
29
Other (including drug or sex-related) or
unknown
Nuisance charges
Crimes against property
Crimes against people
Justice system compliance violations
Voluntarily Enrolled (n = 51)Court-Involved (n = 16)
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All individuals enrolled in Contra Costa County’s ACT program were referred to AOT through the County’s
AOT referral line, however only one-quarter of ACT consumers (23%, n=16) were compelled to treatment
through court involvement. There were negligible differences in the demographic characteristics of
consumers who enrolled in ACT voluntarily versus those who enrolled with court involvement: both
groups were mostly male and mostly White, and the largest proportion of consumers in both groups were
diagnosed with a psychotic disorder, including schizophrenia and schizoaffective disorders. The average
age of consumers was also similar; however, there is a larger proportion of transition age youth (TAY) in
the court-involved population (25%) than the voluntary-enrolled population (17%).
While ACT consumers are mostly similar across demographic characteristics, a greater proportion of
court-involved consumers participated in services fewer than two times per week (53%) for less than two
hours per week (59%) compared to voluntarily enrolled consumers (26% and 20% respectively).
Additionally, the proportion of court-involved AOT consumers who experienced crisis episodes or
psychiatric inpatient hospitalizations while enrolled in ACT compared to prior did not significantly
decrease, while among consumers who enrolled in ACT voluntarily, the proportion who experienced crisis
episodes and psychiatric inpatient hospitalizations significantly decreased while enrolled in ACT because
of program participation.
When taken together, these findings indicate that people who enroll in ACT with court involvement have
lower levels of participation in the program than those who enroll on a voluntary basis and subsequently
experience smaller decreases in crisis and hospitalization than their voluntary counterparts. However,
they are more likely to be TAY and have shorter tenures in the program. Given that the County made
substantive changes to increase the use of the petition and civil court component of this program in its
final year, these analyses should be interpreted cautiously as the lower age of the court-involved group
and their shorter tenure in the program may be influencing these results. Regardless, Contra Costa County
and MHS should continue to work together to develop strategies to support court-involved ACT
consumers so that they are more likely to become adherent to their treatment plans and experience
positive outcomes while enrolled in AOT. The County may also wish to consider what role AOT plays in
the TAY system of care and how to best leverage this resource to intervene as early on as is possible in
the development of serious mental illness.
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Question 3 | ACT and FSP Comparison
Findings
In this section of the report, RDA compares ACT and AOT consumers with Full Service Partnership
consumers (i.e., individuals participating in FSP services) in order to examine the addition of AOT and ACT
to the existing system of mental health services, and better understand differences in consumer profiles,
service utilization, and outcomes between the County’s FSP and ACT/AOT populations. Descriptions of
these populations are provided below:
❖ FSP consumers are those individuals who enrolled in and received services from an FSP program.
FSP consumers are generally those who are experiencing crisis and hospitalization, incarceration,
and/or homelessness and are willing and able to engage in voluntary services without additional
support. Generally, these individuals are able to follow through with services enough so as not to
require a separate referral or outreach and engagement from a third party or civil court
involvement.
❖ ACT and AOT consumers are those individuals who enrolled in and received services from MHS’
ACTiOn team voluntarily and those who required civil court involvement to compel participation
in MHS’ services. For these consumers, a qualified requestor has referred them to the program
and FMH and/or MHS has proactively provided outreach and engagement to encourage
participation. Unlike FSP, these individuals required additional support to connect to mental
health services and had not been successful in accomplishing this independently. However, with
assertive outreach and engagement, ACT consumers were able to participate in mental health
services voluntarily. Only after civil court compulsion were AOT consumers able to participate in
mental health services. Throughout this section of the report, RDA refers to all individuals
receiving ACT services through MHS’ ACTiOn team (including AOT consumers who only agreed to
participate after being compelled through the AOT court mechanism) as ACT consumers, or the
ACT population, in order to compare these individuals with the County’s FSP population.
The research questions answered in this section include the following:
❖ What, if any differences exist between those who are able to participate in FSP services versus
those who are unable to participate without the additional supports and provisions included
within AOT? In other words, are there characteristics that can be identified which explain who
may be able more likely to engage in FSP services versus those who are unlikely to engage without
AOT?
❖ What are the differences in services provided by FSP versus ACT? Given that both models are
intended to serve similar populations with a flexible, interdisciplinary team, this question will
explore the differences in service frequency and intensity of FSP services as compared to ACT.
❖ What are the differences in outcomes for those who are able to participate in FSP services versus
those who are unable to participate without the additional supports and provisions included
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within AOT? Given the potential differences in persons served and actual services provided, there
may also be differences in outcomes between the two groups that may inform future service
designs and/or modifications as well as treatment assignments.
Unless otherwise specified, all ACT consumers (including those enrolled after court involvement) were
included in the following analysis. FSP consumers were included if they enrolled in an FSP program on or
after the AOT program start date (February 1, 2016).
Consumer Profile
This section provides a summary of the demographic characteristics and diagnoses among the ACT and
FSP populations, highlighting key differences across each group.
The FSP and ACT populations are similar across age and gender; however, compared to the FSP
population, there is a greater proportion of White consumers and a smaller proportion of Black
and Latino consumers enrolled in ACT.
As shown in Table 21, the gender breakdown of ACT and FSP consumers is similar, as is the age breakdown.
There are significant differences in the racial and ethnic make-up of each consumer group. Specifically,
Black or African American consumers made up a greater proportion of FSP programs (35%, n = 57) than
in the ACT program (19%, n = 13).22 Additionally, White consumers made up a greater proportion of ACT
(56%, n = 39) than in the FSP programs (31%, n = 51).
Table 21. Demographic Characteristics of ACT and FSP Consumers
ACT Consumers
(N =70)
FSP Consumers
(N = 163)
Gender
Male 56% (n = 39) 57% (n = 93)
Female 44% (n = 31) 43% (n = 70)
Race and Ethnicity
Black or African American 19% (n = 13) 35% (n = 57)
Hispanic 16% (n = 11) 19% (n = 31)
White 56% (n = 39) 31% (n = 51)
Other or Unknown 9% (n = 7) 15% (n = 24)
Age at Enrollment
18 – 25 21% (n = 15) 31% (n = 51)
26 + 79% (n = 55) 69% (n = 112)
ACT consumers were more likely to be diagnosed with a disorder that included psychosis (i.e.
psychotic and bipolar disorders) and less likely to be diagnosed with unipolar depression.
22 This finding was statistically significant at a p-value threshold of .05. This indicates that there is a less than 5%
likelihood that the observed outcomes are a result of chance.
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Consumers in the FSP programs and ACT program differed in their behavioral health diagnoses. As shown
in Figure 23, a significantly larger proportion of ACT consumers were diagnosed with bipolar disorders
(25%, n = 18) compared to FSP consumers (9%, n = 14).23 Additionally, a significantly larger proportion of
FSP consumers were diagnosed with depressive disorders (25%, n = 41) than ACT consumers (n < 10).24
Figure 23. Mental Health Diagnoses of ACT and FSP Consumers
Overall, almost all ACT (92%) consumers were diagnosed with psychotic or bipolar disorders, compared
to 62% of FSP consumers who were diagnosed with psychotic or bipolar disorders at the time of
enrollment. These findings suggest that ACT consumers may have had more acute or severe symptoms
than FSP consumers at the time of enrollment.
Service Participation
The following section provides a summary of service utilization experiences across the ACT and FSP
populations, highlighting key differences in service dosage between each group.
ACT consumers engaged in services more often and for longer durations than FSP consumers.
ACT and FSP consumers were enrolled for similar lengths of time over the course of the evaluation period.
As would be expected based on the different service delivery models, consumers enrolled in ACT received,
on average, a greater service dosage than consumers enrolled in FSP programs. Over half of all ACT
consumers (68%, n = 48) engaged in treatment at least two times per week, for one hour per week,
compared to only 38% of FSP consumers (n = 63).25 On average, ACT consumers received significantly
23 This finding was statistically significant at a p-value threshold of .05. This indicates that there is a less than 5%
likelihood that the observed outcomes are a result of chance.
24 This finding was statistically significant at a p-value threshold of .001. This indicates that there is a less than 1%
likelihood that the observed outcomes are a result of chance.
25 This finding was statistically significant at a p-value threshold of .001. This indicates that there is a less than 1%
likelihood that the observed outcomes are a result of chance.
26%, 18
10%, 7
<10
64%, 45
9%, 14
13%, 21
25%, 41
53%, 87
Bipolar disorders
Other or Unknown
Depressive disorders
Psychotic disorder, including
schizophrenia and schizoaffective
disorders
FSP
ACT
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more face-to-face service contacts (3.8 versus 1.8) for greater durations (3.6 hours versus 2.8 hours) each
week.26 Table 22 provides a summary of these differences.
Table 22. ACT and FSP Consumer Service Engagement
ACT Consumers (N = 7127) FSP Consumers (N = 16728)
Average Range Average Range
Length of Enrollment 354 days 33-830 days 400 days 38 – 880 days
Frequency of Service
Encounters
3.8 face to face
contacts per week
<1 – 13 face-to-face
contacts per week
1.8 face-to-face
contacts per week
<1 – 8 face-to-face
contacts per week
Intensity of Services
3.6 hours of face-to-
face contact per
week
<1 – 12 hours of
face-to-face contact
per week
2.8 hours of face-to-
face contact per
week
<1 – 13 hours of
face-to-face contact
per week
ACT consumers also received more direct services than FSP consumers.
On average, ACT consumers received significantly more hours of direct service contact per month than
FSP consumers. However, FSP consumers received significantly more hours of other types of services,
including linkage and advocacy, plan development, or placement services.29 Figure 24 shows the
distribution of the types of services received by ACT and FSP consumers.
Figure 24. Service Hours per Month for ACT and FSP Consumers
26 This finding was statistically significant at a p-value threshold of .001 for service frequency and .05 for intensity.
This indicates that there are a less than 1% and 5% likelihood that the observed outcomes are a result of chance,
respectively.
27 Eight individuals were enrolled in ACT at least once. Their enrollments are counted separately in this analysis. One
individual enrolled for less than 30 days was dropped from the analysis. Five individuals enrolled in ACT did not have
data available and were not included in the analysis.
28 Four individuals were enrolled in an FSP twice. Their enrollments are counted separately in this analysis.
29 These findings were statistically significant at a p-value threshold of .05 and .001. This indicates that there are a
less than 5% and 1% likelihood that the observed outcomes are a result of chance, respectively.
14.4
10.9
0.7 0.50.5 1.3
ACT Consumers FSP ConsumersAverage Hours per MonthDirect Services Collateral Services Other Services
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Both FSP and ACT providers also deliver services in a variety of settings. ACT and FSP consumers received
services in many settings at similar rates, including in-home-based settings (family homes or the unlocked
facilities), the field, and clinics. However, ACT consumers received a greater proportion of their services
(about 3%) in an institutional setting (i.e., jail or inpatient) than FSP consumers (less than 1%). Additionally,
FSP consumers received, on average, a greater proportion of services over the phone (about 22%)
compared to ACT consumers (about 17%).
Consumer Outcomes
The following sections provide a summary of ACT and FSP consumers’ experiences with psychiatric
inpatient hospitalizations, crisis episodes, housing instability, and employment before and during
enrollment.30 These sections also explore the crisis and hospitalization outcomes for ACT and FSP
consumers who were discharged from their respective program at least 30 days prior to the end of the
evaluation period (June 30, 2018).
Crisis Episodes and Psychiatric Inpatient Hospitalizations
This section describes ACT and FSP consumers’ crisis stabilization episodes and psychiatric hospitalizations
before, during, and after enrollment. The County’s PSP Billing System was used to identify consumers’
hospitalizations and crisis episodes in their 36 months prior to enrollment, as well as during and after
enrollment.
A greater proportion of ACT consumers experienced adverse outcomes prior to program
enrollment compared to FSP consumers.
Almost all ACT consumers (91%, n = 61) experienced at least one crisis episode in the three years before
ACT, compared to 75% of FSP consumers (n = 122) who experienced a crisis episode prior to their most
recent FSP enrollment. Additionally, over half of ACT consumers (55%, n = 37) experienced a psychiatric
hospitalization, compared to 42% (n = 68) of FSP consumers who did in the three years prior to program
enrollment (see Table 23). These differences are significant and demonstrate that, compared to FSP
consumers, a greater proportion of ACT consumers experienced these outcomes prior to enrollment.31
Furthermore, ACT consumers who had a crisis episode and/or hospitalization experienced them more
often than FSP consumers.
30 Housing stability and employment were key measures that CCBHS wanted to explore with this AOT evaluation.
31 This finding was statistically significant at a p-value threshold of .05. This indicates that there is a less than 5%
likelihood that the observed outcomes are a result of chance.
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Table 23. ACT and FSP Consumers’ Crisis Episodes and Psychiatric Hospitalizations Before and During
Program Enrollment32
ACT Consumers (N = 67)
Before ACT Enrollment During ACT Enrollment
Crisis Hospitalization Crisis Hospitalization
Number of
Consumers 91%, n = 61 55%, n = 37 52%, n = 35 31%, n = 21
Average Number
of Episodes
3.1 episodes
per 180 days
1.0 episodes
per 180 days
2.2 episodes
per 180 days
0.7 episodes
per 180 days
Average Length of
Stay 1.4 days 7.6 days 1.2 days 10.0 days**
FSP Consumers (N = 163)
Before FSP Enrollment During FSP Enrollment
Crisis Hospitalization Crisis Hospitalization
Number of
Consumers 75%, n = 122 42%, n = 68 43%, n = 70 19%, n = 31
Average Number
of Episodes
1.5 episodes
per 180 days
0.6 episodes
per 180 days
2.3 episodes
per 180 days
0.9 episodes
per 180 days
Average Length of
Stay 1.2 days 8.5 days* 1.2 days 8.1 days**
*Average is 12 days if two long-term hospitalizations of over 100 days are retained;
** Average is 24 days if two long-term hospitalizations of over 100 days are retained
The proportion of both ACT and FSP consumers experiencing crisis episodes and psychiatric
hospitalization, as well as the frequency of those experiences, decreased during enrollment.
As noted previously, a smaller proportion of ACT consumers experienced a crisis episode (52%) or
psychiatric hospitalization (31%) while enrolled in ACT compared to their three years prior to ACT
enrollment. The same is true for FSP programs, which also saw reductions in the proportion of consumers
experiencing crisis episodes (43%) and psychiatric hospitalizations (19%) while enrolled in FSP compared
to prior. These reductions in the proportions of consumers who experienced at least one crisis episode or
hospitalizations are significant, suggesting that ACT and FSP participants were less likely to experience
these outcomes while enrolled because of program participation and not by chance.
During enrollment, ACT consumers had comparable crisis experiences to FSP consumers ,
suggesting that the intensive services ACT consumers receive are effective and have the
potential to support ACT consumers in reaching a level of stability similar to FSP consumers.
While a slightly higher percentage of ACT consumers (52%) than FSP consumers (43%) experienced crisis
episodes while enrolled in ACT or FSP, these differences were not statistically significant. This indicates
that the differences may be a result of chance. Thus, we cannot conclude that ACT consumers are more
likely than FSP consumers to experience crisis while enrolled in outpatient mental health services. This
could suggest that ACT participation is supporting consumers to reach a level of stability similar to FSP
32 Three consumers were removed from the analysis because they were enrolled for less than one month.
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consumers during program enrollment. However, it is worth noting that a significantly greater proportion
of ACT consumers continued to experience psychiatric hospitalizations during enrollment in comparison
to FSP consumers.
A group of ACT and FSP consumers appear to have been discharged prematurely without being
connected to an appropriate level of care.
As of June 30, 2018, among the 30 ACT consumers and 43 FSP consumers who were discharged prior to
the end of the evaluation period, only 10 ACT consumers and 11 FSP consumers had new episode
openings. This is of concern because anyone discharged from ACT or FSP programs may continue to need
professional support and should be connected to an appropriate level of care within 30 days. Among the
10 ACT consumers with at least one episode opening after discharge, seven (70%) continued to experience
crises and/or psychiatric hospitalizations after discharge before getting connected with other services.
Discharged FSP consumers experienced better outcomes, as only three (27%) cycled in and out of crisis
episodes without being connected to services.
Housing Status
In order to reliably compare housing outcomes for individuals enrolled in ACT and an FSP program, all
providers submitted a point-in-time Key Event Tracking (KET) form that documented consumers’ housing
status at the time of enrollment and again during the period of July 1 – August 15, 2018.
For the AOT population, at the point of AOT enrollment, 35% (n=19 of 55)33 of consumers reported
experiencing homelessness in the prior 12 months. These AOT consumers reported being homeless for an
average of 8.0 months out of the prior 12 months. Between consumers’ AOT enrollment and July 1 –
August 15, 2018, there was an 18% reduction in AOT consumers experiencing homelessness.
For the FSP population, at the point of FSP enrollment, 45% (n=115 of 257) of consumers reported
experiencing homelessness in the prior 12 months. These FSP consumers reported being homeless for an
average of 7.5 months out of the prior 12 months. Between consumers’ FSP enrollment and July 1 – August
15, 2018, there was a 23% reduction in FSP consumers experiencing homelessness.
Compared to the AOT consumers served by the MHS ACT program, FSP consumers appear to exhibit the
following homelessness patterns (see Table 24):
• Similar homelessness patterns (35% of AOT consumers, 45% of FSP consumers); and
• Similar lengths of homelessness in the year prior to program enrollment (8.0 months for AOT
clients, 7.5 months for FSP clients).
33 The point-in-time KET forms were completed between July 1 – August 15, 2018, which is after this report’s
evaluation period (February 1, 2016 – June 30, 2018). Because of this discrepancy, data was received and included
for two additional AOT clients for whom data were not available during the evaluation window.
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Table 24. Homelessness Measures for AOT and FSP Clients
Homelessness Measures AOT Consumers FSP Consumers
Homeless at some point in 12 months prior to program
enrollment (% Y/N)
35% 45%
Length of homelessness in 12 months prior to program
enrollment (# of months)
8.0 months 7.5 months
Homeless at some point in 30 days prior to program
enrollment (% Y/N)
41% 45%
Homeless at some point during July 1 – August 15, 2018 (%
Y/N)
23% 22%
Employment
For the AOT population, at the point of enrollment, less than 10% of AOT consumers reported having
employment at some point in the prior 12 months. These AOT consumers reported being employed for
an average of 26.0 weeks out of the prior 12 months, for an average of 24.3 hours per week. Between
consumers’ AOT enrollment and July 1 – August 15, 2018, there is a 16% increase in consumers having
employment, with a corresponding average increase of 8.5 hours per week of employment.
For the FSP population, at the point of enrollment, 18% (n=46 of 258) of FSP consumers reported having
employment at some point in the prior 12 months. These FSP consumers reported being employed for an
average of 18.7 weeks out of the prior 12 months, for an average of 22.4 hours per week. Between
consumers’ FSP enrollment and July 1 – August 15, 2018, there is a 14% decrease in consumers having
employment, with a corresponding average decrease of 2.8 hours per week of employment.
Compared to the AOT consumers served by the MHS ACT program, FSP consumers appear to exhibit the
following employment patterns (see Table 25):
• Increased employment prior to program enrollment (<10% of AOT clients, 18% of FSP clients);
• Shorter lengths of employment prior to program enrollment (26.0 weeks for AOT clients, 18.7
weeks for FSP clients); and
• Decreases in employment during program enrollment (16% increase for AOT clients, 11%
decrease for FSP clients).
Table 25. Employment Measures for AOT and FSP Consumers
Employment Measures AOT Consumers FSP Consumers
Employed at some point in 12 months prior to program
enrollment (% Y/N)
<10% 18%
Length of employment in 12 months prior to program
enrollment (# of weeks)
26.0 weeks 18.7 weeks
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Employment Measures AOT Consumers FSP Consumers
Average amount of employment in 12 months prior to
program enrollment (hours/week)
24.3 hours/week 22.4 hours/week
Employed at some point in 30 days prior to program
enrollment (% Y/N)
<10% 18%
Employed at some point during July 1 – August 15, 2018 (%
Y/N)
21% 7%
Average amount of employment in 30 days prior to program
enrollment (hours/week)
16.5 hours/week 20.0 hours/week
Average amount of employment in July 1 – August 15, 2018
(hours/week)
25.0 hours/week 17.2 hours/week
Discussion
RDA sought to better understand Contra Costa County’s ACT implementation as related to the
effectiveness of the County’s FSP programs by comparing outcomes of ACT and FSP consumers,
respectively. First, RDA assessed whether there were significant differences between each population at
the time of enrollment. Next, they assessed whether there were differences in patterns of service receipt.
Lastly, differences in consumer outcomes were assessed.
As expected, findings demonstrated that at the time of program enrollment, ACT consumers exhibited
more severe psychiatric symptoms than FSP consumers. A significantly greater percentage of ACT
consumers (92%) than FSP consumers (62%) were diagnosed with psychotic or bipolar disorders at
enrollment, and significantly greater proportions of ACT consumers experienced crisis episodes (91%) and
psychiatric inpatient hospitalizations (55%) than FSP consumers (75% and 42%, respectively) in the three
years prior to program enrollment.
As would be expected based on the two different service delivery models, individuals enrolled in ACT
received more intense services than individuals enrolled in an FSP program. On average, ACT consumers
received significantly more service contacts for greater durations than FSP consumers each week, of which
a greater proportion were also for direct services (as opposed to collateral or some other type of services).
For both populations, services had the intended effects, as ACT and FSP consumers both experienced
significant reductions in crisis and hospitalization episodes during program enrollment. The intensive
services that ACT consumers received appear to be more effective than FSP services, since ACT consumers
generally experienced greater improvements in their psychiatric symptoms. This was evidenced by ACT
consumers achieving a level of stability similar to FSP consumers, despite starting out significantly less
stable prior to enrollment.
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As is the case with ACT consumers, there appears to be a group of FSP consumers who are discharged
prematurely, and not immediately connected with appropriate services. As a result, some of these
consumers continue to experience crisis and hospitalization without receiving regular outpatient
treatment for their mental health condition. The County should consider what potentially more
appropriate discharge criteria would be for both FSP and ACT consumers. The County could then explore
ways to ensure that all consumers who are discharged from either program type meet these criteria, and
that concrete steps are in place to connect discharged consumers to an appropriate level of care. This
criterion should include determining for which consumers it is appropriate to file an AOT petition through
the court to compel participation in outpatient mental health services.
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Summary of Findings
Program Development and Continuous Quality Improvement
Prior to the decision to implement AOT, the County and stakeholders worked together to consider and
design a program that would meet the needs of people with the most serious mental illness who were
“falling through the cracks.” As a result of these efforts, the Board of Supervisors directed County
departments to implement ACT and AOT, which combined a new service model and a civil court process.
In the initial stages of implementation, County agencies collaborated on the new processes and
procedures required to support the referral and investigation process as well as the court component. As
with any new program in its formative stages, there were unanticipated challenges along the way that the
County and stakeholders worked together to address, including how to:
❖ Ensure that qualified requestors had the knowledge and resources to make appropriate referrals
to the program for individuals most in need;
❖ Reduce the length of time from referral to enrollment, particularly for those individuals who
were continuing to experience crisis, hospitalization, and incarceration and/or homelessness
during the investigation and outreach process;
❖ Determine the most efficient and effective ways for FMH and MHS to work together on referred
individuals, engage them in care, and identify the need for a petition, where indicated; and
❖ Discern the appropriate use of the petition and benefit of the civil court component to encourage
participation in ACT services.
While the County and partners worked diligently to identify and resolve these issues as they arose, the
net impact early on in the process was that not all qualified requestors were equipped to do so, enrollment
in the program took longer than expected for eligible individuals, and there was hesitation to implement
the court component. This resulted in a lower census than originally estimated despite a continued
perception of need for these high-end services. Along the way, the County and partners sought to
proactively identify and address issues as well as seek input from stakeholders, elected officials, and the
evaluation team as to how they might continuously improve the program. Their efforts included:
❖ A renewed effort to provide educational presentations and training to the entirety of qualified
requestors, with a particular focus on law enforcement, linking police with the CORE teams to
ensure that any beat police officer could connect with a provider from CORE to refer eligible
individuals;
❖ Attendance at weekly case rounds at Contra Costa Regional Medical Center for PES and Unit 4C
to identify potential AOT candidates, as well as partner on discharge planning for referred and
enrolled consumers;
❖ A change from a concurrent to a consecutive pre-enrollment phase whereby FMH conducted the
referral and investigation process to determine eligibility prior to engaging MHS; and
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❖ A new set of monitoring and communication practices for FMH to continuously review referred
and enrolled individuals throughout the referral and investigation, outreach and engagement, and
voluntary ACT service enrollment phases and ensure that those individuals who require or would
benefit from the civil court component have a petition filed.
These investments in ongoing continuous quality improvement have increased the diversity of qualified
requestors, shortened the length of time from referral to enrollment, more swiftly implemented the court
component for those who require that level of support, and ultimately increased the number of
consumers who are enrolled in and benefitting from the program. While each of these issues has been
cause for concern at different times, the commitment of the County, partners, and stakeholders to openly
and honestly raise these issues and implement process improvements is what has supported this program
to grow to its present capacity. As has been seen across California, AOT programs take time to launch and
mature despite the high level of need for these services. In almost every County across California who
implemented AOT, the time to launch the program took longer than expected and initial enrollment
numbers were lower than expected. Contra Costa County’s commitment to this program and the
investment in continuous quality improvement is something that should be recognized, appreciated, and
preserved.
Service Delivery
ACT Fidelity
ACT has one of the strongest evidence-bases of any mental health intervention for reducing crisis and
hospitalization, incarceration, and homelessness for those with the most serious mental illness when
performed to fidelity. One component of this program evaluation was to engage in ACT fidelity monitoring
in order to support ACT implementation in the County as well as ensure that outcomes observed in the
program were not influenced by fidelity issues. In other words, regular fidelity monitoring ensured that
evaluation findings could be attributed to AOT and AOT implementation rather than ACT fidelity issues.
While the ACT team did experience some challenges early on with recruitment and hiring and
understanding that the use of AOT and the civil court component was in alignment with the ACT model,
as well as the staff turnover in early-2018, they continued to score in the high-fidelity range across all
three annual fidelity assessments. Additionally, they implemented all recommended programmatic
improvements suggested in the fidelity assessments to further align the program with the evidence-based
model. In comparison to other counties, not all counties are implementing ACT as the service component
of AOT, and many counties who have ACT programs do not engage in fidelity monitoring to ensure that
their ACT programs are delivered in alignment with the model and producing the expected outcomes.
Contra Costa County’s commitment to implementing this level of service to fidelity ensures that
consumers with the highest level of need who enroll in the program, either voluntarily or through civil
court involvement, have access to evidence-based interventions with the highest likelihood of being
effective. As seen through the outcomes in preceding sections, this investment has clearly made a
difference for the consumers who had access to these services, their families, and their communities.
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Length of Tenure
The ACT model is designed to be time-unlimited and allows for consumers to participate in the program
for as long as is needed, and the California Welfare and Institutions Code allows for a judge to enter into
a settlement agreement or issue a court order for AOT in six-month increments. Research suggests people
participating in AOT generally experience reductions in crisis and hospitalization, incarceration, and
homelessness during the program and that these benefits are more likely to continue after discharge from
AOT if the consumer participates in AOT for at least 12 months, regardless of whether or not they continue
to participate in mental health services on an outpatient basis. In Contra Costa County, the average length
of enrollment in ACT and AOT is approximately one year, although there is a proportion of consumers who
participated for less than 12 months. If the County continues to provide ACT and AOT, it may be useful to
consider how to best keep individuals engaged and enrolled for at least 12 months, if not longer, in order
to preserve the benefits arising from service participation. To this end, the County may need to determine
if there are any barriers to service authorization or court processes that would preclude consumers from
receiving the maximum benefit from their time in the program.
Symptoms versus Negative Outcomes
One of the primary reasons that the County implemented AOT was to address the needs of those with the
most serious mental illness who were unable and/or unwilling to participate in mental health services and
were continuing to experience crisis and hospitalization, incarceration, and/or homelessness. This
included a desire to reduce symptoms, improve quality of life, and address issues related to public safety.
It is interesting to note that while the program did succeed in reducing crisis and hospitalization,
incarceration, and homelessness, the level of symptoms experienced by individuals remained relatively
static as did measures of self-sufficiency and violence and victimization. This means that the combination
of ACT and AOT was able to successfully support individuals with the most serious mental illness in the
community and reduce experiences of crisis and hospitalization, incarceration, and homelessness without
reducing symptoms or other mental health indicators. To this end, the County has demonstrated that it
has the capacity to successfully support the target population within the community using ACT and AOT
and reduce experiences of confinement.
Level of Care Impressions
Full Service Partnership and Assertive Community Treatment
When the County elected to implement ACT, in addition to AOT, a new level of service became available
that was more intensive than FSP programs and could be easily combined with the AOT civil court
component. Early on, there were questions about how FSP differed from ACT and if both types of
programs could be expected to serve the same types of consumers with similar rates of success. Based on
the County’s experience over the past three years, it has become clear that:
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1. FSP and the ACT programs are serving different consumer groups. While both FSP and ACT
consumers have a serious mental illness, ACT consumers are more likely to have a psychotic
disorder. Additionally, while FSP and ACT consumers have experiences of crisis and
hospitalization, ACT consumers experience higher rates of crisis and hospitalization prior to
enrollment.
2. FSP and ACT provide different levels of service. The amount of service provided is higher for the
ACT team than FSP programs. The ACT team also receives a higher level of funding to provide this
additional service.
3. FSP and ACT teams produce similar outcomes when consumers are in the correct level of care.
FSP and ACT consumers alike experience reductions in crisis and hospitalization, incarceration,
and homelessness as a result of participating in the programs. However, there are a number of
ACT consumers who were originally enrolled in FSP and were referred to the ACT team as a result
of needing a more intensive program and/or the civil court component.
Given the data resulting from this evaluation and the entirety of the County’s experience over the past
three years of implementation, it may be useful for the County to develop data-informed benchmarks to
support level of care decisions regarding FSP and ACT. While the consequences are minimal for referring
someone to ACT who could otherwise improve or maintain with FSP, the consequences of referring
someone to FSP who really actually requires ACT to remain in the community are impactful. Specifically,
the County may wish to consider developing guidance based on individuals’ level of crisis and
hospitalization to better inform whether they should be referred to FSP or ACT services.
AOT and the Use of Petition
Across the state and nation, there has been a renewed discussion about how to best: 1) support
individuals with the most serious mental illnesses; 2) interrupt the repetitive cycle of crisis and
hospitalization, incarceration, and/or homelessness; and 3) compel participation in outpatient mental
health services for those who are unable and/or unwilling to participate on a voluntary basis but do not
meet criteria for involuntary services. In order to address this issue, the County elected to implement both
ACT and AOT.
At the beginning of program implementation, there appeared to be agreement that voluntary service
participation was preferred when possible, and that the use of the court petition should be reserved for
those who would not consent to services on a voluntary basis despite the program’s best efforts to do so.
This led to an investment of time and resources with referred individuals to obtain their voluntary
participation in ACT services and prolonged the amount of time from referral to enrollment. Specifically,
the data showed that:
❖ Referred individuals were continuing to experience crisis and hospitalization, incarceration,
and/or homelessness post-referral and that it may be useful to file a petition sooner in order to
interrupt these experiences; and
❖ Some portion of consumers who enrolled on a voluntary basis were not benefiting from the
program as expected, and a petition may be useful to compel more consistent participation,
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prevent premature discharge, and reduce the experiences of crisis and hospitalization,
incarceration, and/or homelessness.
As a result of these learnings, the County and partners worked together to establish mechanisms to review
whether or not a petition would be useful on a monthly basis during the investigation and outreach
periods as well as implementing a review of consumers who enrolled on a voluntary basis and continued
to struggle with crisis and hospitalization, incarceration, and/or homelessness. Across the state, some
counties have also struggled with the tension between voluntary service participation for those who were
able to do accept and participate in outpatient mental health services and those who require a petition
and civil court involvement to do so. Contra Costa County’s ability to swiftly engage in process
improvements based on evaluation findings and stakeholder feedback has resulted in an increased use of
the petition for those who require that level of support and has ultimately helped more individuals engage
in medically necessary mental health services more quickly.
Conclusion
Overall, this evaluation documents Contra Costa County’s efforts to serve individuals with the most
serious mental illnesses in the community using evidence-based practices and interventions. Across all of
the interim evaluation reports and continuing through this evaluation period, it is clear that people who
participate in ACT and AOT experience benefits, specifically in reducing experiences of crisis and
hospitalization, incarceration, and homelessness. While the program took longer than originally
anticipated to get started and there were challenges to address along the way, the County and its partners
worked diligently over the pilot period to strengthen the program and ensure that those individuals most
in need had access to services that were likely to help them. If the County extends the approval of these
investments in ACT and AOT, it will be important to continue to monitor the program and make
adjustments informed by the data gathered and lessons learned to ensure that the program and
investments continue to produce the expected results for consumers, their families, and the community.
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Appendices
Appendix I. AOT Eligibility Requirements34
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.
34 Welfare and Institutions Code, Section 5346
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Appendix II. MHS’ ACTiOn Team 2018 Fidelity Assessment Report
Introduction
As an evidence-based psychiatric rehabilitation practice, Assertive Community Treatment (ACT) provides
a comprehensive approach to service delivery to consumers with serious 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 to 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.35 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.
35 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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Fidelity Assessment Process
Contra Costa County, as part of a larger evaluation of the 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 University36 and codified in a SAMHSA toolkit.37 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 the
requisite qualifications for assessors.
Roberta Chambers, PsyD, and Jamie Dorsey, MSPH, 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 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 June 20, 2018.
During the site visit, the assessors engaged in the following activities:
❖ ACT team meeting observation
❖ Interviews with eight (8) ACT team members
❖ Review of available documentation
❖ Consumer focus group
❖ Family member focus group
❖ Debrief with the ACT team
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 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.
36 http://www.dartmouth.edu/~implementation/page15/page4/files/dacts_protocol_1-16-03.pdf
37 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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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 the MHS ACTiOn team’s
2017 and 2018 program ratings. As shown in the table below, the MHS ACTiOn team received an overall
fidelity score of 4.50 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 2017 Rating 2018 Rating
Human
Resources:
Structure and
Composition
Small caseload 5 5
Team approach 4 5
Program meeting 5 5
Practicing ACT leader 4 5
Continuity of staffing 3 4
Staff capacity 4 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 2 5
Intake rate 5 5
Full responsibility for treatment services 5 5
Responsibility for crisis services 5 5
Responsibility for hospital admissions 5 1
Responsibility for hospital discharge planning 5 5
Time-unlimited services 5 5
Nature of
Services
In vivo services 3 4
No drop-out policy 3 5
Assertive engagement mechanisms 2 5
Intensity of services 5 4
Frequency of contact 4 3
Work with support system 5 5
Individualized substance abuse treatment 5 3
Co-occurring disorder treatment groups 5 3
Co-occurring disorders model 5 5
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Domain Criterion 2017 Rating 2018 Rating
Role of consumers on treatment team 5 5
ACT Fidelity Score 4.42 4.50
Small caseload: 5
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 at they have 9.5 FTEs who provide direct services, as well
as two administrative staff, for 49 active consumers, which exceeds the 10:1 consumer-to-provider ratio.
This was assessed through personnel records and staff interviews.
Team Approach: 5
Team approach refers to the provider group functioning as a team rather than as individual team members
with all ACT team members knowing and working with all consumers. MHS’ ACTiOn team received a rating
of 5 for this criterion as more than 90% of consumers had face-to-face interactions with more than one
team member in a two-week period. This was assessed through consumer records and further supported
through the team meeting observation, staff interviews, and consumer and family focus groups. This is an
increase from the 2017 rating of 4 when 70% of consumers had face-to-face interactions with more than
one team member in a two-week period.
Program Meeting: 5
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 the 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 the program meeting through available documentation and staff interviews.
Practicing ACT Leader: 5
Practicing ACT leader refers to the supervisor of frontline staff providing direct service to consumers. MHS’
ACTiOn team received a rating of 5 as the Team Leader spends at least 50% of their time providing direct
services to consumers. The rating was assessed through staff interviews and was supported through the
team meeting observation, review of consumer records, and consumer and family focus groups. This
rating is an increase from the 2017 rating of 4 when the Team Leader spent approximately 30% of their
time providing direct services. It is important to note that the MHS ACTiOn team had significant changes
in leadership during the past year, including a new Team Leader.
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Continuity of Staffing: 4
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, 10 staff discontinued employment with
MHS’ ACTiOn team, resulting in a 36% turnover rate. As the turnover rate falls within the range of 20-
39%, the rating for this measure is 4. The turnover rate was assessed through a review of personnel
records and staff interviews. This rating is an increase from the 2017 rating of 3, when there was a 47%
turnover rate.
Staff Capacity: 4
Staff capacity refers to the ACT program operating at full staff capacity. Full fidelity requires the program
to operate at 95% or more of full staff capacity over the last 12 months. According to personnel records,
MHS’ ACTiOn team operated at 82% of full staff capacity over the previous year, resulting in a rating of 4
as it falls within the range of 80-90%. Although the ACTiOn team also received a rating of 4 in 2017,
there was a slight decrease in staff capacity from 2017 where the team operated at 94% staff capacity
during the evaluation period. The reduced staff capacity reflects staff transitions and turnover in the
past year due to changes in MHS ACTiOn team leadership.
Psychiatrist on Team: 5
Fidelity to the ACT model requires 1.0 FTE psychiatrist per 100 consumers. Currently, MHS’ ACTiOn team
provides 0.5 FTE psychiatrist for 49 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 0.75 FTE psychiatrist to meet full fidelity to the ACT model.
Nurse on Team: 5
The ACT model requires a 1.0 FTE nurse per 100 consumers. Currently, MHS’ ACTiOn team employs one
full-time licensed vocational nurse (LVN) for the 49 active consumers, as observed by personnel records
and staff interviews. This exceeds the required ratio and results in a rating of 5. The ACT model does not
specify the level of nursing required in terms of Registered Nurse (RN) versus LVN or Licensed Psychiatric
Technician (LPT); however, there are differences in scope of practice between an RN and LVN or LPT in
California. In previous years, the ACTiOn team has included an RN as a part of the team, although the
position is currently vacant. While additional nursing is not required for up to 50 consumers, the ACTiOn
team may wish to consider hiring an RN as the second nursing position as the program increases
enrollment.
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Substance Abuse Specialist on Team: 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 1.0 FTE substance abuse specialist for
the 49 active consumers, as observed by personnel records and staff interviews. This meets the required
ratio, given there are 49 active consumers and results in a rating of 5. Once the program is at full capacity
of 75 enrolled consumers, the team will require at least 1.5 FTE with the requisite experience in substance
abuse to meet full fidelity to the ACT model.
Vocational Specialist on Team: 5
The ACT model includes two staff with at least one year of training or experience in vocational
rehabilitation and support for 100 consumers. MHS’ ACTiOn team includes 1.0 FTE who meet criteria for
a vocational rehabilitation specialist, as observed by personnel records and staff interviews. This meets
the required ratio for 49 enrolled consumers and results in a rating of 5. Once the program is at full
capacity of 75 enrolled consumers, the team will require at least 1.5 FTE with the requisite experience in
training or experience in vocational rehabilitation and support to meet full fidelity to the ACT model.
Program Size: 5
Program size refers to the size of the staffing to provide necessary staffing diversity and coverage. MHS’
ACTiOn team meets the staffing ratio, as observed by personnel records and staff interview. This results
in a rating of 5.
Explicit Admission Criteria: 5
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.
Although the responsibility for identifying and engaging potential ACT consumers lies primarily with
CCBHS as part of the larger AOT program, MHS also independently outreaches to and assesses referred
individuals for ACT criteria and works closely with CCBHS to reach consensus around who should be
enrolled in the program. This results in a rating of 5, which was assessed through staff interviews and
program documentation. The rating demonstrates significantly improved collaboration between CCBHS
and the MHS ACTiOn Team during the admission process, represented by a substantial increase from the
2017 rating of 2, when MHS accepted referred consumers they did not believe met criteria.
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Intake Rate: 5
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. This was assessed through consumer records and staff interviews.
Full Responsibility for Treatment Services: 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, resulting in a rating of 5. This was observed through team
meeting observation, staff interviews, a review of consumer records, and input from consumer and family
focus groups.
Responsibility for Crisis Services: 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 results
in a rating of 5, which was assessed through staff interviews, team meeting observation, and input from
the consumer focus group.
Responsibility for Hospital Admissions: 1
The ACT model includes the ACT team participating in decision-making for psychiatric hospitalization. The
MHS ACTiOn team is willing and available to participate in all decisions to hospitalize consumers. However,
this requires that hospitals and emergency departments are 1) aware that a consumer is enrolled in ACT,
and 2) willing to involve the ACT team in the decision-making process. ACTiOn team members shared that
when possible, they share their opinion of whether a consumer should be hospitalized when arriving with
a consumer at PES. However, the ACTiOn team noted that PES does not meaningfully involve the MHS
ACTiOn team in the decision-making process and typically only notifies the ACTiOn team when the
consumer has already been hospitalized or is being discharged from PES. This removes a key function of
the ACT program to intervene with consumers and reduce associated hospitalizations and results in a
rating of 1. This rating represents a marked decrease from the 2017 rating of 5. As noted previously, the
MHS ACTiOn team experienced significant staff turnover and changes in leadership during the past year,
and it is unclear if the lower rating reflects changes in hospital admission processes or differences in how
ACTiOn team leadership describes the hospital admission process. Nevertheless, MHS shared that they are
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currently working with CCBHS to strengthen collaboration with PES to improve communication and shared
decision-making for PES discharge and hospital admission planning for enrolled consumers.
Responsibility for Hospital Discharge Planning: 5
The ACT model includes the ACT team participating in hospital discharge planning. Although MHS’ ACTiOn
team is infrequently involved in the decision to hospitalize consumers, the ACTiOn team works closely
with Unit 4C and other inpatient units once a consumer is hospitalized and collaborates with inpatient
units on all hospital discharge plans. This results in a rating of 5 and was assessed through staff interviews
and consumer records.
Time-unlimited Services: 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 two consumers during the evaluation period, resulting
in a rating of 5. This was determined through consumer records and staff interview.
In Vivo Services: 4
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 (i.e., in vivo), which refers to location where clients live, work, and interact with other people.
According to ACT service records, 66% of MHS ACTiOn team encounters with consumers during the
evaluation period occurred in community-based settings. As this percentage falls within the range of 60-
79%, the rating for this measure is 4. This represents an increase from 2017’s rating of 3, when 59% of
MHS ACTiOn team encounters with consumers occurred in the community.
No Drop Out Policy: 5
This criterion refers to the retention rate of consumers in the ACT program over a 12-month period.
According to consumer records and staff report, three consumers dropped out of the program during the
evaluation period, resulting in a 6% drop out rate and a rating of 5. Any consumers who moved out of the
area or required and enrolled in a higher level of care (e.g., conserved) were removed from analysis for
this criterion. This represents an increase from the 2017 rating of 3, when there was a 22% dropout rate.
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Assertive Engagement Mechanisms: 5
As part of ensuring engagement, the ACT model includes using street outreach and legal mechanisms as
indicated and available to the ACT team. During the evaluation period, MHS’ ACTiOn team demonstrated
well thought-out and consistent use of street outreach and legal mechanisms to engage consumers,
including working closely with CCBHS to implement the AOT civil court process for consumers who meet
AOT criteria and refuse to accept or participate in ACT voluntarily. It is important to note that the decision
to use or commence a civil court process is a collaborative effort between MHS and CCHBS, and the actual
implementation of a legal mechanism, (i.e. AOT voluntary settlement agreement or court order) is shared
between all AOT partners. The assertive engagement mechanism rating was based upon staff interviews,
team meeting observation, and consumer records. The increased use of the civil court petition for AOT,
when appropriate, demonstrates significant improvement in the use of all available legal mechanisms to
engage consumers in treatment and is reflected in an increased rating from 2 in 2017 to 5.
Intensity of Services: 4
Intensity of services is defined by the face-to-face service time MHS’ ACTiOn team staff spend with clients.
Full fidelity to the ACT model requires that consumers receive an average of two hours per week of face-
to-face contact. According to ACT service records, ACT consumers received an average of 1.91 hours of
ACT services per week, resulting in a rating of 4. This represents a decrease from the 2017 rating of 5,
when consumers received 2.67 hours of ACT services per week. The decrease in service intensity may reflect
reduced staff capacity due to the increased number of active consumers and/or the staff turnover
experienced during the last year.
Frequency of Contact: 3
Fidelity to the ACT model requires that ACT consumers have an average of at least four face-to-face
contacts per week. According to ACT service records, ACT consumers received an average of 2.65 face-to-
face contacts per week during the evaluation period, resulting in a rating of 3 as it falls within the range
of 2-3 face-to-face contacts per week. This represents a decrease from the 2017 rating of 4, when
consumers received an average 3.15 face-to-face contacts per week. The decrease in service frequency
may reflect reduced staff capacity due to the increased number of active consumers and/or the staff
turnover experienced during the last year.
Work with Informal Support Systems: 5
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
community integration and functioning. According to staff, consumer, and family member discussions as
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well as ACT service records, MHS’ ACTiOn team exceeds the expectation of four contacts per month with
informal support systems, resulting in a rating of 5.
Individualized Substance Abuse Services: 3
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. Full fidelity to the ACT model requires that consumers with substance use disorders receive an
average of at least 24 minutes of formal, individualized substance abuse services per week. MHS’ ACTiOn
team incorporates principles of dual disorder recovery into treatment and provides informal substance
use services through their encounters with ACT consumers. However, based upon interviews with staff, it
does not appear that the ACTiOn team is currently providing formal, individualized substance use services,
resulting in a rating of 3. The rating represents a decrease from the 2017 rating of 5. The difference in the
level of substance use treatment from may reflect staff changes in the previous year—including the
departure of a full-time staff member who provided substance use services—as well the increased number
of ACT consumers, approximately two-thirds of whom have co-occurring disorders. Moving forward, the
ACTiOn team should explore ways to expand formal, individualized substance use treatment to meet the
treatment needs of a growing number of ACT consumers with co-occurring disorders.
Co-Occurring Treatment Groups: 3
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. Full fidelity to the ACT model requires that 50% or more of consumers with substance use
disorders attend at least one substance abuse treatment group per month. The MHS’ ACTiOn team
provides a weekly co-occurring disorder group led by the dual recovery specialist, family partner, and
other clinical staff. Of the 49 active ACT consumers, 34 had documented co-occurring substance use
disorders. However, according to ACTiOn team staff, typically only 20% of these consumers participate in
the co-occurring disorder group each month, resulting in a rating of 3. This rating represents a decrease
from the 2017 rating of 5. As described previously, the lower rating may reflect the increased number of
consumers with co-occurring disorders and/or reduced staff capacity associated with staff turnover.
Moving forward, the ACTiOn team should explore ways to engage more consumers in co-occurring
treatment groups.
Dual Disorders Model: 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
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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.
Role of Consumers on Team: 5
The ACT model includes the integration of consumers as full-fledged ACT team members, usually in the
provision of peer support and/or peer counseling. MHS’ ACTiOn team does include consumer membership
as a part of the ACT team staffing, resulting in a rating of 5. This was observed through a review of
personnel records, team meeting observation, and staff interviews.
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 in previous years of
professional and caring staff, partnership and responsiveness of the staff to consumer and family needs,
the outreach process, and an inclusive approach to services, program strengths noted are:
❖ Trust: Consumers and family members discussed their trust in the ACTiOn Team, noting that they
can talk to staff about anything without judgement. Some consumers shared that although they
were initially distrustful of the ACTiOn team and the program, the staff developed consumers’
trust by always meeting consumers where they are in their recovery and consistently
demonstrating their interest and investment in consumers’ lives and recovery.
❖ Meaningful Activities: In response to consumer and family feedback during previous years, the
ACTiOn team began implementing a recreation group, which includes weekly bowling trips, hiking,
swimming, and other outings. Consumers highlighted these activities as one of their favorite
aspects of the program and mentioned that it gives them something to look forward to. Some
consumers also shared that the activities and groups help them in their recovery by filling their
free time and maintaining a routine schedule, particularly after returning from the hospital or jail.
❖ Consumer Outcomes: As with last year, it is notable that many consumers 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 impressed by
consumers who obtained and maintained housing, reduced crisis and hospitalization, decreased
or stopped substance use, improved and repaired family relationships, are either working or
volunteering, and enrolled in or graduated school since enrolling in the program.
The following areas for program improvement also emerged through discussions with consumers and
family members:
❖ Family Groups: Through the assessor’s observation of participant focus groups, it became
apparent that consumers are all in different stages of recovery and that families need meaningful
opportunities to interact with other families and/or their loved ones to share their experiences,
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share knowledge and resources, and provide support to maintain hope in their loved ones
recovery. MHS’ ACTiOn team should consider re-introducing family support and psychoeducation
groups as well as multi-family groups with loved ones to provide these opportunities.
❖ Reliability: Although consumers and family members generally shared a high level of satisfaction
with MHS’ ACTiOn team and services, focus group participants noted some changes in the
frequency and/or reliability of scheduled encounters associated with staff changes and turnover.
Specifically, focus group participants mentioned a few instances when staff missed or re-
scheduled appointments or when their medications were late or running low before being refilled.
While no consumer went without medications, they did discuss the anxiety they experienced
when their medication supply ran low and they were unsure when the refill would be delivered.
Consumers also discussed the departure of the dedicated vocational specialist and missed having
more formal vocational support. It is important to note that at the time of the fidelity assessment,
MHS had recently hired a staff member with vocational rehabilitation training and has also since
filled a number of vacant positions to stabilize staffing.
Discussion
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
adequately staffed with team members with diverse skill sets and who are 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 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, consumers and family members
shared accounts of increasing stability, as well as a number of tangible successes and accomplishments.
The program also substantially improved fidelity to the ACT model on a number of measures, including
explicit admission criteria, use of assertive engagement mechanisms, and a no drop out policy. Over the
course of the last year, it appears that MHS’ ACTiOn team considerably strengthened communication and
collaboration with CCBHS contributing to 1) improved shared decision-making about consumers accepted
into the ACT program, and 2) consistent and appropriate use of the civil court petition for AOT to compel
service engagement among consumers who meet AOT criteria and refuse to accept or engage in
treatment voluntarily. The program enrolled and retained a higher number of consumers than in previous
years. At the time of the 2018 assessment, the program had 49 active consumers, compared to 32 in 2017.
Moreover, only two consumers were discharged from the program in the 12 months prior to the 2018
fidelity assessment, compared to nine consumers in year prior to the 2017 assessment.
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While the fidelity assessment revealed a high degree of alignment with the ACT model, there are
opportunities for improvement. During the year prior to the assessment, MHS’ ACTiOn team experienced
significant staff turnover and transitions, particularly among program leadership. The staff changes along
with the increased number of active consumers likely contributed to reduced staff capacity and decreases
in the intensity and frequency of services during the evaluation period. While MHS is taking steps to
stabilize staffing and has already filled several vacant positions, MHS may wish to explore the following
areas to identify how to best scale the program to continue and strengthen fidelity to the ACT model:
❖ Staffing and Program Capacity: MHS’ ACTiOn Team is adequately staffed for the current caseload
of 49. However, at the time of the fidelity assessment, there were a number of consumers who
were active in the outreach and engagement phase or the AOT petition process. As the program
approaches the contracted number of 75 consumers, there would be gaps in a number of ACT
team positions with the current staffing. Specifically, there would be a need to increase psychiatry,
nursing, substance use treatment, and vocational rehabilitation to ensure alignment with the ACT
model. Additionally, as mentioned, there was a higher rate of turnover than expected. MHS may
wish to explore how to increase staff retention and ensure staff capacity meets growing needs.
❖ Substance Abuse Services. Some of the lowest scores from this assessment include individualized
substance use services and co-occurring treatment groups. Although the ratings may be
attributable in part to staff changes and the increased numbers of consumers with co-occurring
disorders, MHS should explore ways to formalize and expand substance use treatment. One
approach may be to implement a weekly co-occurring treatment group in each of the three
regions in Contra Costa County, rather than just one group at the ACTiOn team’s main office. This
will allow more opportunities for a greater number consumers to participate in treatment.
Additionally, MHS may wish to consider re-introducing structured opportunities for family participation,
as discussed above, such as a family support or psychoeducation group as well as a multi-family group.
Conclusion
MHS’ ACTiOn Team received an average fidelity rating of 4.50 and scored in the “high fidelity” range. The
assessors were impressed with the staff; program implementation improvements over the past year; 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 staff turnover and
capacity, expanded substance use treatment, and family support. 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.
129
CONTRA COSTA COUNTY
ASSISTED OUTPATIENT TREATMENT
CUMULATIVE EVALUATION REPORT
FINDINGS
October 2018
Resource Development Associates
130
Introduction2
131
AOT Timeline
3
February 5,
2015
•Contra Costa
Board of
Supervisors
authorized
Assisted
Outpatient
Treatment.
February 1,
2016
•CCBHS began
accepting AOT
referrals.
•CCBHS
received its first
referral and
conducted its
first
investigation.
February 5,
2016
•MHS outreaches
to the first
eligible
individual.
March 4,
2016
•MHS enrolls the
first ACT
consumer.
June 30,
2018
•Since AOT
implementation,
CCBHS has
received 475
referrals and
MHS has
enrolled 70
consumers
132
Research Questions & Evaluation Period
4
Question 1
•What are the
outcomes for people
who participate in
ACT and AOT,
including the DHCS
required outcomes?
How faithful are ACT
services to the ACT
model?
Question 2
•What are the
differences in
demographics,
service patterns, and
outcomes between
those who agree to
participate in ACT
services voluntarily
and those who
participate with an
AOT court order or
voluntary settlement
agreement?
Question 3
•What are the
differences in
demographics,
service utilization,
and outcomes
between those who
engage in existing FSP
services and those
who receive ACT
services?
Evaluation Period: February 2016 –June 2018
133
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
Outreach and engagement contacts
Clinical assessments/outcomes
FSP assessments (PAF and KET)
ACT consumer and family focus groups
(from previous ACT fidelity assessment)
Sheriff’s Office
Bookings and booking reasons
Cost Data from CCBHS, County
Counsel, MHS, Public Defender’s Office,
and Superior Court
Limitations
Only 16 consumers have
participated in AOT Treatment with
court involvement
RDA aggregated some outcomes to
maintain confidentiality
Proportions, averages, and rates shift
dramatically based on experiences
of relatively few individuals
Time period prior to enrollment
longer than during/after enrollment
RDA standardized outcome measures
to rates per 180 days to account for
variability in enrollment lengths and
available pre-and post-data
5
134
•What are the outcomes for people who
participate in ACT and AOT, including the
DHCS required outcomes?
•How faithful are ACT services to the ACT
model?
Findings: Research Question 1 6
135
Pre-and AOT-Enrollment
7
Referral and
Investigation
CCBHS received and
investigated 475
referrals
Outreach and
Engagement
MHS provided
outreach and
engagement to 138
individuals
ACT Team
Enrollment
70 consumers enrolled
in AOT treatment
program
16 with court
involvement
Pre-Enrollment AOT-Enrollment
136
Referrals and Investigations
8
CCBHS received
referrals from a diversity
of qualified requestors,
including family
members, mental health
providers, and law
enforcement officials.
Nearly every referred individual who was eligible for AOT and/or was able to be
located was connected to mental health services.
Requestor Percent of Total Referrals (N = 475)
Parent,Spouse,Adult Sibling,or Adult Child 60% (n = 286)
Treating or supervising mental health provider 20% (n = 95)
Probation,parole,or peace officer 13% (n = 63)
Not a qualified requestor or “other”4% (n = 20)
Director of Hospital where individual is hospitalized <3%
Adult who lives with individual <3%
Investigation Outcome
Percent of Referrals
(N = 475)
Referred to MHS 32% (n = 154)
Engaged or Re-Engaged with a
Provider
14% (n = 66)
Ongoing Investigation 17% (n = 81)
Investigated and Closed 37% (n = 174)15
17
35
41
126
173
251
458
624
842
Licensed Care Facilities
Healthcare facility
Shelter
Other
Correctional facility
Consumer or Requestor’s Home
Inpatient facility
Field
Office
Phone
137
Outreach & Engagement
9
Over 80% of MHS’ contacts were
successful in reaching the consumer
or collateral.
MHS has enrolled half of all AOT
referred individuals to ACT through
their ongoing outreach and
engagement efforts.
Outreach and
Engagement Outcome
Percent of
Consumers
Number of
Consumers
Enrolled in ACT Services 51%
70 total
54 voluntarily
16 with court
involvement
Still Receiving Outreach
and Engagement Services 12%17
Not enrolled in ACT 37%51
Collateral
19%
Unsuccessful
14%
In-person
57%
Phone/Email
10%
138
Consumer Profile
The majority of ACT consumers
(64%, n = 45) have a primary
diagnosis of a psychotic disorder,
and 71% (n = 50) had a co-
occurring substance use disorder
at the time of enrollment.
Of the ACT consumers for whom
there was data (n = 63):
71% had a GED or higher
education level at the time of
enrollment
59% were unemployed in the12
months prior to enrolling in ACT.
49% received supplemental
security income in the 12 months
prior to enrolling in ACT.
10
Category ACT Consumers
(n=70)
Gender
Male 56%(n =39)
Female 44%(n =31)
Race and Ethnicity
Black or African American 19%(n =13)
Hispanic 16%(n =11)
White 56%(n =39)
Other or Unknown 9%(n =7)
Age at Enrollment
18 –25 21%(n =15)
26+79%(n =55)
139
ACT Fidelity
Domain Criterion 2017
Rating
2018
Rating
Human Resources:
Structure and
Composition
Small caseload 5 5
Team approach 4 5
Program meeting 5 5
Practicing ACT leader 4 5
Continuity of staffing 3 4
Staff capacity 4 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 2 5
Intake rate 5 5
Full responsibility for treatment
services
5 5
Responsibility for crisis services 5 5
Responsibility for hospital
admissions
5 1
Responsibility for hospital
discharge planning
5 5
Time-unlimited services 5 5
11
Nature of
Services
In vivo services 3 4
No drop-out policy 3 5
Assertive engagement
mechanisms
2 5
Intensity of services 5 4
Frequency of contact 4 3
Work with support system 5 5
Individualized substance
abuse treatment
5 3
Co-occurring disorder
treatment groups
5 3
Co-occurring disorders
model
5 5
Role of consumers on
treatment team
5 5
Domain Criterion 2017
Rating
2018
Rating
ACT Fidelity Score 4.42 4.50
Overall 2017 2018
140
ACT Service Participation (N = 62)*
Avg. length of
enrollment: 354 days
Avg. number of face-
to-face encounters: 4
per week
Avg. hours of face to
face encounters: 4 per
week
Overall, 66% of ACT consumers
were adherent to treatment. In
FY 16/17, 93% of consumers
were adherent.
12
ACT Services ACT Treatment Adherence
15%, 11 17%, 12
13%, 9
18%, 13
13%, 9
24%, 17
0
4
8
12
16
20
<1
contact
per week
1-1.9
contacts
per week
2-2.9
contacts
per week
3-3.9
contacts
per week
4-4.9
contacts
per week
5 or more
contacts
per week141
Crisis Episodes and Psychiatric
Hospitalizations
13
Crisis Episodes
Before ACT Enrollment
Crisis Episodes
During ACT Enrollment
Number of Consumers 91%, n = 61 52%, n = 35
Average Number of Crisis
Episodes 3.1 episodes per 180 days 2.2 episodes per 180 days
Average Length of Stay 1.4 days 1.2 days
Psychiatric Hospitalizations
Before ACT Enrollment
Psychiatric Hospitalizations
During ACT Enrollment
Number of Consumers 55%, n = 37 31%, n = 21
Average Number of
Hospitalizations
1.0 episodes per 180 days 0.7 episodes per 180 days
Average Length of Stay 7.3 days*10.0 days**
The majority of consumers experienced fewer psychiatric
hospitalizations and crisis episodes during ACT.
142
Criminal Justice Outcomes
14
Jail Bookings
Before ACT Enrollment
Jail Bookings
During ACT Enrollment
Number of Consumers 67%, n = 45 31%, n = 21
Average Number of Crisis
Episodes 2.3 episodes per 180 days 2.4 episodes per 180 days
Average Length of Stay 29 days 18.5 days
Significantly fewer ACT consumers were arrested and
booked during ACT enrollment
9
16
31
44
58
92
Other or unknown
Drug- or sex-related
Crimes against property
Nuisance charges
Crimes against people
Justice system compliance violations
Types of Charges during ACT Enrollment
143
Housing Status
15
The majority of consumers (62%, n = 33) either
obtained or maintained housing while in ACT.
Consumers who
obtained housing
•13% of consumers
were not housed
before ACT but
obtained housing
while enrolled
Consumers who
maintained housing
•49% of consumers
were housed before
ACT and continued
to maintain housing
while enrolled
Consumers who were
not stably housed
•9% of consumers
were housed before
ACT but did not
maintain housing
during ACT
•28% of consumers
were not housed
before or during
ACT enrollment
144
AOT Costs
16
Partner FY 17/18 Budget FY 17/18 Actual Costs
MHS $2,014,000 $1,560,080
CCBHS $350,000 $252,839
County Counsel $157,000 $32,379
Public Defender $133,500 $56,250
Superior Court $128,000 $2,585
Total $2,782,500 $1,904,133
County anticipated 70% of all services provided would be billable and 35% of the
revenue would therefore come from Medi-Cal FFP. Total billing for FY17/18 was
$383,163 (25% of actual expenses), which is below what was anticipated.
FY 17/18 AOT Budget and Actual Expenses
145
AOT Cost Savings
17
Pre-
Enrollment
Post-
Enrollment
Total
Difference
Annual
Estimate
Outpatient and Residential
Mental Health Services
$5,280,971 $3,868,976 $1,411,995 $584,274
Psychiatric Hospitalization $2,167,051 $1,049,866 $1,117,185 $462,283
Jail Bed Days $507,722 $194,192 $313,530 $129,737
Total Mental Health Services $7,448,022 $4,918,842 $2,529,180 $1,046,557
Total Mental Health and Jail $7,955,744 $5,113,034 $2,842,710 $1,176,294
Pre-and Post-Enrollment Cost Comparison
AOT reduced the overall cost of care for the 70 enrolled individuals by $2,842,710.
Of this amount, AOT produced a hard cost savings of $1,117,185 over the first 29
months of implementation. Accounting for FY 17/18 operations costs, AOT produced
$371,069 in hard costs savings.
146
•What are the differences in demographics,
service patterns, and outcomes between those
who agree to participate in ACT services
voluntarily and those who participate with an
AOT court order or voluntary settlement
agreement?
Findings: Research Question 218
147
Consumer Profile and Pre-Enrollment
Outcomes
19
Among the 70 consumers who enrolled in AOT
since program implementation, 16 enrolled with
court involvement.
There are few differences in the
demographics or diagnoses between
individuals enrolled in ACT voluntarily
and through the court.
While consumers in both groups
received comparable amounts of
outreach and engagement from MHS,
it took more time for the Care Team
to enroll court-involved individuals.
148
Service Utilization
20
A larger proportion of court-involved consumers have lower service participation
compared to voluntarily enrolled consumers.
149
Crisis Episodes and Psychiatric
Hospitalizations
21
Individuals who enrolled voluntarily saw a substantial decrease in crisis episodes
and inpatient hospitalizations during ACT.
Before ACT Enrollment During ACT Enrollment
Voluntarily
Enrolled ACT
Consumers (n =
51)
Crisis Hospitalization Crisis Hospitalization
Number of
Consumers 90%, n = 46 53%, n = 27 47%, n = 24 24%, n = 12
Average Number
of Episodes
3.2 episodes
per 180 days
1.1 episodes per
180 days
2.1 episodes
per 180 days
0.8 episodes
per 180 days
Average Length
of Stay 1.5 days 13.3 days 1.2 days 25.8 days
Court-Involved
ACT Consumers
(n = 16)
Number of
Consumers 94%, n = 15 63%, n = 10 69%, n = 11 56%, n = 9
Average Number
of Episodes
2.9 episodes
per 180 days
0.9 episodes per
180 days
2.7 episodes
per 180 days
0.8 episodes
per 180 days
Average Length
of Stay 1.3 days 8.1 days 1.2 days 21.3 days150
Criminal Justice Outcomes
22
Individuals who enrolled voluntarily saw a substantial
decrease in jail bookings during ACT.
Before ACT
enrollment
During ACT
enrollment
Voluntarily Enrolled
(n = 51)
Number and %of
Consumers w/ Jail Bookings
61%, n = 31
(1.7 bookings per
180 days)
20%, n = 10
(.7 bookings per
180 days)
Court Enrolled
(n = 16)
Number of % Consumers
w/ Jail Bookings
88%, n = 14
(3.6 bookings per
180 days)
69%, n = 11
(3.9 bookings per
180 days)
20
23
40
63
5
7
8
18
29
Other (including drug or
sex-related) or unknown
Nuisance charges
Crimes against property
Crimes against people
Justice system compliance
violations
Voluntarily Enrolled (n = 51)Court-Involved (n = 16)
A greater proportion of court -
involved consumers were
booked into county jail before
and after AOT enrollment, and
charged with more criminal
offense and justice system
compliance violations.151
Housing Outcomes
23
A larger proportion of
voluntarily enrolled
consumers were stably
housed compared to court-
involved consumers.
152
•What are the differences in demographics,
service utilization, and outcomes between
those who engage in existing FSP services
and those who receive ACT services?
Findings: Research Question 324
153
ACT and FSP Consumer Profiles
There are greater proportion of
White consumers and smaller
proportion of Black and Latino
consumers enrolled in ACT
compared to FSP.
ACT consumers were more
likely to be diagnosed with a
disorder that included psychosis
(92% of ACT consumers vs.
62% of FSP consumers) and
less likely to be diagnosed with
unipolar depression.
25
ACT
Consumers
(N =70)
FSP
Consumers
(N = 163)
Gender
Male 56%(n =39)57% (n = 93)
Female 44%(n =31)43% (n = 70)
Race and Ethnicity
Black or African
American 19%(n =13)35% (n = 57)
Hispanic 16%(n =11)19% (n = 31)
White 56%(n =39)31% (n = 51)
Other or Unknown 9%(n =7)15% (n = 24)
Age at Enrollment
18 –25 21%(n =15)31% (n = 51)
26 +79%(n =55)69% (n =
112)154
ACT and FSP Service Utilization
26
ACT Consumers (N = 71)FSP Consumers (N = 167)
Average Range Average Range
Length of Enrollment 354 days 33-830 days 400 days 38 –880 days
Frequency of Service
Encounters
3.8 face to face
contacts per week
<1 –13 face-to-face
contacts per week
1.8 face-to-face
contacts per week
<1 –8 face-to-face
contacts per week
Intensity of Services
3.6 hours of face-to-
face contact per
week
<1 –12 hours of
face-to-face contact
per week
2.8 hours of face-to-
face contact per
week
<1 –13 hours of
face-to-face contact
per week
ACT consumers engaged in services more often, for longer durations, than FSP
consumers.
14.4
10.9
0.7
0.5
0.5
1.3
ACT Consumers
FSP Consumers
Other Services Collateral Services Direct Services
Service
Hours per
Month for
ACT and
FSP
Consumers
155
ACT and FSP Consumer Crisis Episodes
and Psychiatric Hospitalizations
27
ACT Consumers (N = 67)
Before ACT Enrollment During ACT Enrollment
Crisis Hospitalization Crisis Hospitalization
Number of Consumers 91%, n = 61 55%, n = 37 52%, n = 35 31%, n = 21
Average Number of
Episodes
3.1 episodes per
180 days
1.0 episodes per
180 days
2.2 episodes per
180 days
0.7 episodes per
180 days
Average Length of Stay 1.4 days 7.6 days 1.2 days 10.0 days**
FSP Consumers (N = 163)
Before FSP Enrollment During FSP Enrollment
Crisis Hospitalization Crisis Hospitalization
Number of Consumers 75%, n = 122 42%, n = 68 43%, n = 70 19%, n = 31
Average Number of
Episodes
1.5 episodes per
180 days
0.6 episodes per
180 days
2.3 episodes per
180 days
0.9 episodes per
180 days
Average Length of Stay 1.2 days 8.5 days*1.2 days 8.1 days**
*Average is 12 days if 2 long term hospitalizations of over 100 days are retained;
** Average is 24 days if 2 long term hospitalizations of over 100 days are retained
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Employment Outcomes
28
Employment Measures AOT Clients (MHS’
ACT program)
FSP Clients
Employed at some point in 12 months prior to program
enrollment (%Y/N)
<10%18%
Length of employment in 12 months prior to program
enrollment (#of weeks)
26.0 weeks 18.7 weeks
Average amount of employment in 12 months prior to
program enrollment (hours/week)
24.3 hours/week 22.4 hours/week
Employed at some point in 30 days prior to program
enrollment (%Y/N)
<10%18%
Employed at some point during July/August 2018 (%Y/N)21%7%
Average amount of employment in 30 days prior to
program enrollment (hours/week)
16.5 hours/week 20.0 hours/week
Average amount of employment in July/August 2018
(hours/week)
25.0 hours/week 17.2 hours/week
Between enrollment and July/August 2018 there is a 16% increase in ACT consumers with
employment and 14% decrease in FSP consumers with employment.
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Roberta Chambers, PsyD
rchambers@resourcedevelopment.net
510.984.1478
Questions and Answers29
158