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Report of the Independent Reviewer
In the Matter of
Disability Rights California, the United States Department of Justice
and
The County of Alameda and Alameda County Behavioral Health
Department
Case: 3:20-cv-05256-CRB
Covering the Period of January 31, 2024, through July 31, 2024
Submitted By: Karen Baylor, Ph.D., LMFT
August 2024
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INTRODUCTION
Alameda County entered into a Settlement Agreement with Disability Rights California
(DRC), and the United States Department of Justice (DOJ) which became effective on
January 31, 2024. The Settlement Agreement is focused on Alameda County and the Alameda
County Behavioral Health Department (ACBHD) to provide community mental health services
for individuals with serious mental illness to reduce institutionalization and/or criminal
justice involvement and to improve the individuals ability to secure and maintain stable
permanent housing in the most integrated and appropriate settings.
The Settlement Agreement requires an Independent Reviewer to review relevant facts
and assess the County’s progress in implementing the Settlement Agreement. The
Independent Reviewer is to write a report on the County’s progress after six, fourteen,
twenty, twenty-five, and thirty-one months after the effective date of the Settlement
Agreement.
This is the first initial report and was submitted to the parties only five months after the
effective date of the Settlement Agreement. The Settlement Agreement’s definition of
Substantial Compliance refers to substantial compliance for a period of no less than six
(6) months and the on-site review occurred after four months of the Effective Date and
the initial report was produced after five months of the Effective Date. There are no
substantial compliance ratings for this initial report. which reflects the time period and
not an indication of ACBHD’s implementation of the Settlement Agreement.
As this is the initial report, time was spent on understanding the service delivery system
for ACBHD. The report reflects as assessment of the County’s progress for the previous
five months but identifies any areas where work is in progress or still needs to be
completed. This report also includes recommendations to facilitate or sustain substantial
compliance.
A draft of this report was submitted to the parties on July 1, 2024. Per the Settlement
Agreement, the Independent Reviewer is to provide a draft of the report at least thirty
(30) days prior to the finalization of the report. The parties have fifteen (15) days to
provide comments and responses to the Independent Reviewer for consideration. The
finalized report is submitted to the parties and made public, with any redactions
necessary under California or Federal Law. The Independent Reviewer and the parties
agreed to extend the review period by an additional seven days. The Independent
Reviewer was also granted an extension by an additional seven days with the final
report being due on August 7, 2024.
The Settlement Agreement identified the following five service commitments:
1. Crisis Services
2. Full Service Partnerships
3. Service Teams (Intensive Case Management)
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4. Outreach, Engagement, Linkages, and Discharge Planning
5. Culturally Responsive Services
This report will outline the requirements in each of the service commitments along with
a discussion of the County’s progress and implementation of these five areas.
METHODOLOGY
The process began with a Zoom meeting on February 14, 2024, with the Independent
Reviewer and DRC and the DOJ. It was decided at that meeting to meet every other
week in order to keep the parties apprised of the activities of the Independent Reviewer,
County progress, and to identify any challenges or barriers.
Next, the County invited the Independent Reviewer to have an on-site meeting with the
Alameda County Behavioral Health Department (ACBHD) management team. That
meeting occurred on February 21, 2024, in Oakland, California. The Independent
Reviewer was given an overview of the service delivery system, met the management
team, and discussed the role of the Independent Reviewer. It was also decided that the
Independent Reviewer would meet monthly with the two Deputy Directors of ACBHD in
order to discuss progress and any barriers or challenges. A secure ShareFile was also
established by ACHBD in order for the County to upload documents, data and other
requested documents, that could be reviewed by the Independent Reviewer.
A list of policies and procedures was requested from ACBHD on February 29, 2024, and
a list of data was requested on March 21, 2024. A list of additional documents was
requested on March 21, 2024, and a request for follow-up documents was sent on May
21, 2024. During the months of February through May, the County has uploaded
policies and procedures, protocols, data, contracts, portions of 16 individual client
records (clinical assessment and progress notes), and other related information to the
ACBHD ShareFile. All these documents were reviewed and helped form the interview
questions for the on-site review.
The Independent Reviewer developed a protocol for every service commitment in the
Settlement Agreement. A chart was developed that included all of the service
commitments in the Settlement Agreement and a list of possible sources of evidence
such as policy and procedures, operations manuals, sample of client records, data and
data analysis, and interviews of both ACBHD staff and community-based provider staff.
This protocol is an organized tool and was utilized as the foundation for the
determination of proof of practice for the ratings of compliance for every service
commitment. The protocol was shared with both the DOJ/DRC and ACBHD. Feedback
from both parties was incorporated into the final protocol and both parties agreed with
the use of the protocol.
The Independent Reviewer conducted an on-site review in Alameda County from May 7,
2024, through May 10, 2024. During that on-site review the Independent Reviewer
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interviewed County staff, toured five contract providers and interviewed their staff, and
met with ACBHD’s Senior Executive Team. The Independent Reviewer did speak to
some clients when on a tour of a facility, but no formal interviews were conducted with
clients.
There are a few limitations to this report that need to be noted. Only two client records
for each of the following service areas were reviewed: ACCESS, crisis residential
treatment, full-service partnerships, service teams, and psychiatric inpatient. It is difficult
to draw any conclusions or recommendations based on the low number of client records
reviewed. There were no formal client interviews conducted for this initial report. This
was due to the time frame and conducting interviews with clients will be a priority for the
next review. The on-site review occurred only four months after the effective date of the
Settlement Agreement. That timeframe did not give the County much time to implement
changes. This initial period was also used to understand ACBHD’s service delivery
system and all the programs and providers utilized to provide specialty mental health
services. Additional information will be gathered for future reports which is noted
throughout this report. Therefore, this report is a baseline of where the County currently
is with implementation of the Settlement Agreement based on the information available
to the Independent Reviewer, and information in this report will be compared with the
information gathered for future reports.
Throughout the five months of this process, the Independent Reviewer has had the
cooperation of the staff from the Alameda County Behavioral Health Department. They
have been collaborative and very responsive to requests for information that has been
needed to perform the review functions. The Independent Reviewer would especially
like to acknowledge the assistance provided by James Wagner, LMFT, LPC, Deputy
Director, Clinical Operations and Vanessa Baker, LMFT, Deputy Director, Plan
Administration.
OVERVIEW OF THE SERVICE DELIVERY SYSTEM
ACBHD is considered a Mental Health Plan and contracts with the State Department of
Health Care Services (DHCS) to provide services to Medi-Cal beneficiaries. ACBHD is
under the Alameda County Health (ACH) within the County structure. ACBHD contracts
79 percent of the specialty mental health services through contracts with community
based organizations. ACBHD contracts for inpatient and psychiatric emergency services
which are provided by John George Psychiatric Hospital which is under Alameda Health
Systems. ACBHD is responsible for administration of the Mental Health Services Act
which includes the provision of Full Service Partnership (FSP) services.
The ACBHD has a Behavioral Health Director, a Deputy Director of Clinical Operations,
a Deputy Director of Plan Administration, and a Chief Medical Officer which comprises
the Senior Executive Team. ACBHD has three main divisions which are as follows:
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1. Clinical Operations which include Adults and Older Adults Systems of Care, Child
and Young Adult Systems of Care, Substance Use Continuum of Care, and
Forensic, Diversion, and Re-entry Services
2. Office of the Medical Director which includes Chief Nursing Officer and Crisis
System of Care
3. Plan Administration which includes Quality Management, Finance, MHSA
management and data analytics.
The Director/Office of Health Equity also reports to the ACBHD Director and has a
smaller division than the three mentioned above. Workforce, education and training is
also a unit that reports directly to the ACBHD Director.
SUMMARY OF RATINGS
The five service commitment areas are from the finalized Settlement Agreement. As
discussed in the Methodology section above, the ratings in this first-round report are
based on an initial set of evidence. This evidence is comprised of documentation,
protocols, contracts, data, client records and other related documents, received from
ACBHD and from initial interviews with staff, and community-based provider staff.
These interviews occurred during a one-week on-site visit in May 2024. As mentioned in
the Methodology section above, there were limitations to the initial review and more
documentation and evidence of compliance will be requested in future reports, which is
noted throughout the report.
Determination of compliance with the Settlement Agreement results in a rating as
follows: Substantial Compliance (SC), Partial Compliance (PC), Non-Compliance (NC),
and Not Applicable (NA). This rating was added to the protocol and a full list of the
ratings is in Attachment 1.
The Settlement Agreement states:
“For the purposes of this Agreement, substantial compliance will mean something
less than strict or literal compliance. Substantial compliance is achieved if (1) any
violations of the Agreement are minor or occasional and are not systemic, and (2)
substantial compliance is sustained or otherwise demonstrated to be durable.
Substantial compliance refers to substantial compliance for a period of no less
than six (6) months. Non-compliance with or due to mere technicalities, or
isolated or temporary failure to comply during a period of otherwise sustained
substantial compliance, will not constitute failure to sustain substantial
compliance.”
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The Partial Compliance and Not Applicable ratings are not defined by the Settlement
Agreement. For purposes of rating the County’s compliance with the Settlement
Agreement, the Independent Reviewer adopts the following definitions:
Partial Compliance: a provision was rated Partial Compliance when there was
any evidence that steps had been taken toward implementation or that
implementation had begun. Partial Compliance includes a range of potential
progress toward Substantial Compliance, from taking preliminary steps to near-
completion of implementation. Partial Compliance was also given when a part of
the service commitment was met but not all of the requirements were met.
Non-Compliance: a provision was rated Non-Compliance when there was no
evidence that steps had been taken toward implementation.
Not Applicable: a provision was rated Not Applicable when it was not yet required
to be implemented by the Settlement Agreement, where the Independent
Reviewer has not yet begun to review or has not yet gathered sufficient evidence
to determine the rating.
The ratings were determined by a review of the documents provided from ACBHD,
public documents, and interviews with both ACBHD staff and community-based provider
staff. It was important to see a requirement in a document such as the policy and
procedure but also to see the requirement in practice. It is also important that the
requirement is occurring in practice but also that it is sustained and in a durable manner.
A rating was provided when there were several sources of evidence to the requirement.
The following is a summary table of the overall ratings regarding compliance to the
Settlement Agreement. Since the Settlement Agreement’s definition of Substantial
compliance refers to substantial compliance for a period of no less than six (6) months
and the on-site review occurred after four months of the Effective Date and the initial
report was produced after five months of the Effective Date, there are no substantial
compliance ratings for this initial report. It is a reflection of the time period and not an
indication of ACBHD’s implementation of the Settlement Agreement.
Summary of Rating Per Service Commitment
SERVICE COMMITMENT SC* PC NC NA TOTAL
1. Crisis Services - 13 0 7 20
2. Full Service Partnership - 10 0 6 16
3. Service Teams (Intensive Case Management) - 3 0 1 4
4. Outreach, Engagement, Linkages, and
Discharge Planning
- 16 0 10 26
5. Culturally Responsive Services - 3 0 3 6
Totals 0 45 0 27 72
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*Due to the temporal limitations of this report, a rating of substantial compliance was not
possible.
Percentage of Each Rating at the First Six Months
Ratings Percent
Substantial Compliance 0*
Partial Compliance 62.5%
Non-Compliance 0
Not Applicable 37.5%
Total 100%
* Due to the temporal limitations of this report, a rating of substantial compliance was
not possible.
CRISIS SERVICES
The Settlement Agreement outlines the service components under crisis services which
include the County providing a county wide crisis system and expanding crisis
intervention services. In Alameda County, crises services are organized under the Chief
Medical Officer. There is an Interim Crisis Services System of Care Director who reports
directly to the Chief Medical Officer. The Independent Reviewer was able to interview
this Acting Director, the Chief Medical Officer, the Crisis Services Division Director,
ACCESS staff and Mobile Crisis staff.
Requirement: The County will continue to offer a countywide crisis system and expand
crisis intervention services.
The County contracts with providers for crisis intervention services and crisis support
services, Crisis Residential Treatment (CRT), and Psychiatric Emergency Services
(PES). The crisis services system of care includes the following:
• Prevention and early intervention which includes outreach and engagement
teams, and referral, education and training
• Crisis intervention services which include crisis support services and mobile
crisis teams
• Crisis stabilization which includes services at either a crisis stabilization unit
(CSU) or at a crisis residential treatment facility
• Post crisis follow-up which include Crisis Connect/Post Crisis Follow-up Team.
Crisis services are provided by County staff and through contracts with community-
based providers. Specifically, the County provides or contracts with the following for
services:
• ACBHD Crisis System of Care works closely with the ACCESS staff and provides
mobile crisis services
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• Crisis Stabilization Units which are provided through a contract with Amber
House (Bay Area Community Services/BACS) and John George Psychiatric
Emergency Services (PES) with plans to open another CSU in Hayward
• Crisis Residential Treatment which includes contracts with Amber House (BACS),
Woodroe Place (BACS), and Jay Mahler (Telecare)
• Acute services through John George Psychiatric Hospital and Herrick Hospital
• Sub-acute services which include contracts with Villa Fairmont, Gladman, and
Morton Bakar.
The chart below indicates the number of crises calls and the location of the call for
Fiscal Year 2022-23.
Region Crisis City Number of Calls
1. North Alameda 129
1. North Albany 24
1. North Berkeley 286
1. North Emeryville 54
1. North Oakland 3511
1. North Piedmont 17
2. Central Castro Valley 104
2. Central Hayward 1083
2. Central San Leandro 726
2. Central San Lorenzo 56
3. South Fremont 334
3. South Newark 84
3. South Union City 153
4. East Dublin 75
4. East Livermore 130
4. East Pleasanton 77
5. Out of County Out of County 807
6. Unknown Unknown 25
ACBHD provided this data, and the chart indicates that the calls are received from all
over the county but most of the crisis calls are from Oakland and Hayward. This data
point should be combined with the mobile crisis assessment to determine the need for
expanded services.
Requirement: Maintain a 24/7 crisis hotline. The crisis hotline will provide screening
and de-escalation services on a 24/7 basis.
No later than 18 months after the Effective Date, the County will expand the 24/7 crisis
hotline to provide triage and the identification of full service partnership clients on a 24/7
basis.
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The ACCESS line is operated 24/7 as is required by the State Department of Health
Care Services (DHCS). The County staff answer the ACCESS line from 8:30am to 5pm,
Monday through Friday. ACBHD contracts Crisis Support Services for coverage of the
telephone line after hours, weekends and holidays. Crisis Support Services will write up
a referral for treatment services and then the County ACCESS team will follow up on the
referral the next morning but does not provide any crisis services. ACBHD staff reported
that if a crisis occurs after business hours, Crisis Support Services will call 911 or the
Community Assessment and Transport Team (CATT).
The ACCESS staff reported that they utilize their clinical judgement regarding where to
refer clients for services. There is a decision tree that crisis services use when out in the
field to determine the appropriate level of care.
The MHSA Three Year Program and Expenditure Plan Fiscal Year 2023 through 2026,
states that one of the reoccurring themes in the community listening session was
“Address the response time in systems such as ACCESS” (Page 66).
Requirement: The County will coordinate with entities responsible for managing urgent
and emergency care response lines, including but not limited to the crisis hotline, 911,
FSP warmlines, and 988 (when and if such coordination is available), to ensure there is
“no wrong door” for accessing appropriate crisis services. The County will have and will
implement protocols for when to conduct warm handoffs from its crisis hotline to FSP
warmline teams to provide appropriate services. The County will respond to 911-
dispatch inquiries in order to facilitate an appropriate behavioral health response to
crises.
The Interim Director of Crisis Services System of Care reported that the process has
started with communication with 988 but that has not been implemented. Although the
level of coordination will continue to deepen as plans are implemented, coordination has
already begun. ACBHD and Crisis Support Services of Alameda/988 regularly host the
quarterly 988 collaborative meetings with 911, law enforcement, fire department, all
mobile crisis teams, Emergency Medical Services (EMS), and other community-based
providers. In addition, ACBHD hosts a 988 conference annually each September.
ACBHD also meets monthly with EMS to discuss high utilizers of the services and
develop plans to provide the appropriate level of care. ACBHD receives a monthly
report of 988 calls along with documentation of planned and provided interventions.
ACBHD provided 988 data which included date and time of the call, call duration, any
safety risks, reason for the call, and the intervention.
The Interim Director also stated that 911 continues to be an entry point into the system
and that 911 Dispatchers can directly request that a mobile crisis team respond to an
emergency. Additional entry points include 911, 988, or the crisis main telephone
number (510-891-5600).
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ACBHD did report the demographics on the calls they received which are as follows:
age, sex, ethnicity, preferred language, and location of the caller. ACBHD also collects
the following data: average wait time for the call to be answered, number of abandoned
calls, and average time spent on the call. In addition, the Crisis System of Care
implemented the cloud-based telephone system, Fire 9, which will allow ACBHD to
track the number of calls, hold times, and the time of the call. A report will be developed
and generated to track the crisis contacts and the assignment to an FSP, Service Team
of to a community-based provider. The Independent Reviewer will monitor this system
and the report for subsequent reports.
ACBHD provided a copy of the warm hand-off procedure from a contracted community-
based provider. The procedure requires the community-based provider staff contact the
client within 24 hours of receiving the referral and offer an intake/assessment
appointment within one week of receiving the referral.
Requirement: The County will implement protocols and education efforts to ensure
appropriate deployment of County mobile crisis teams in response to calls received
through emergency response lines.
ACBHD has a contract with the Indigo Project to develop and conduct a Mobile Crisis
Assessment of the needs and gaps in mobile crisis coverage. It is not clear how ACBHD
deploys their mobile crisis teams and which team should respond to a particular crisis. It
seems to be based on availability and location of the crisis in the county. ACBHD
currently does not collect MCT response times. However, it is important for the Indigo
Project to complete their work and more on this requirement will be discussed in future
reports.
Requirement: Provide mobile crisis response services on a county-wide basis. Mobile
crisis teams will provide a timely in-person response to resolve crises as appropriate.
When clinically appropriate, mobile crisis services may be provided through the use of
telehealth.
ACBHD reported that it operates a total of 14 mobile crisis teams1 with the following
three different models for mobile crisis services:
• Mobile Crisis Teams (MCT) that includes two clinicians and law enforcement, if
needed. This team is available Monday through Friday, from 8am to 6pm. This
team can respond to requests from the general public, 988, and 911. ACBHD
has three of these teams.
1 There are a number of cities in Alameda County that also operate their own mobile Crisis Assessment Teams. An
example of this is the MACRO program that operates in Oakland and is housed in the fire department. The ACBHD
reported that peers and EMT’s are a part of the County’s crisis services.
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• Mobile Engagement Teams (MET) that pairs a clinician with a police officer in
Oakland and operates from Monday to Thursday, from 8am to 3pm. The
Hayward MET operates from Monday to Thursday, from 8am to 4pm. These
teams respond to 911/988 generated and Crisis System of Care mental health
calls. ACBHD has two of these teams
• Community Assessment and Transport Team (CATT) that pairs a clinician with
an Emergency Medical Technician. This team focuses on crisis intervention and
medical clearance. This service operates 7 days a week, from 7am to 11pm.
ACBHD has nine of these teams.
Per the Settlement Agreement, mobile crisis is to provide timely response. While data
collection and analysis are not required by the Settlement Agreement, it may be helpful
for the ACBHD to monitor the timeliness of the response from a quality assurance
perspective. Monitoring data on response time is also well-established in the field as an
important performance metric for mobile crisis services.2 A number of mobile crisis staff
reported that when the mobile crisis team is already responding to a crisis, there is no
other option than to contact 911 who can then contact one of the city’s mobile crisis
teams. Mobile Crisis staff also reported that the team in Oakland can be very busy with
multiple requests for mobile crisis services, and they only have one team to respond to
the crisis calls. This staff also reported that they know not to contact MCT on
Wednesday afternoon because that is when MCT has their staff meetings which occur
twice a month, but other city mobile crisis teams or CATT may be contacted during this
time. ACBHD staff stated in interviews that the purpose of MCT is to reduce interaction
with law enforcement and to reduce inpatient admissions. ACBHD also provided their
telehealth policy and procedure.
The MHSA Three Year Program and Expenditure Plan Fiscal Year 2023 through 2026,
states that one of the reoccurring themes in the community listening session was
“Expand mobile crisis teams” (Page 66).
Data collected by ACBHD on mobile crisis services include the following: number of
clients, response and outcome of the call. Response time and other outcome data for
mobile crisis services is currently not collected. While the Settlement Agreement does
not describe specific data points for which data collection is required, this data would be
useful to the ACBHD management team from a quality assurance perspective. It is
necessary data for the County to assess its mobile crisis services effectiveness and
important for the Independent Reviewer to reach a rating conclusion.
2 National Guidelines for Behavioral Health Crisis Care (samhsa.gov) at page 50-51.
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The number of clients served during the Fiscal Year (FY) 2022 -23 was 2074. The chart
below shows the number of involuntary holds (5150) during the same time period and
some clients may have had more than one episode:
Service Clients Episodes
5150 by clinician 13 13
5150 by Police 3 3
5150 Danger to Others 238 271
5150 Danger to Self 255 267
Gravely Disabled 241 271
This chart indicates that the highest number of 5150’s during the fiscal year was danger
to others and gravely disabled closely followed by danger to self. A client may have one
or more episodes during the fiscal year which is why the number of clients does not
exactly match the number of episodes. This data will be used as the baseline for
comparison in future reports.
It is noteworthy that ACBHD received a grant from DHCS from the Behavioral Health
Continuum Infrastructure Program (BHCIP) to upgrade communication devices for
existing mobile crisis teams, fund marketing materials, and increase capacity for
outreach and engagement teams who provide post crisis follow up services. This grant
was awarded in May 2024.
Requirement: Mobile crisis services shall be provided with the purposes of reducing, to
the greatest extent possible, interactions with law enforcement during a mental health
crisis, reducing 5150 and John George psychiatric emergency services (“PES”)
placement rates, and increasing use of voluntary community-based services (including
diversion, care coordination, transportation, and post-crisis linkage to services).
Evidence was found regarding the purpose of mobile crisis services. The Independent
Reviewer interviewed mobile crisis staff and the crisis system of care management staff
and reviewed mobile crisis program information. The Independent Reviewer has
requested a ride-along with the mobile crisis staff at the next on-site review. Results of
the ride-along will be discussed in the next report.
Requirement: The County has recently expanded its mobile crisis capacity to nine (9)
mobile crisis teams, and agrees to maintain this as a minimum capacity.
As described above, the County now has 14 mobile crisis teams. Future reports will
continue to monitor the number of mobile crisis teams to ensure that ACBHD retains
minimum capacity. The results of the mobile crisis assessment may influence this and
will be included in the next report.
Requirement: The County shall complete an assessment of needs and gaps in mobile
crisis coverage, no later than one year after the execution of this Agreement, that is
designed to determine the amount and number of mobile crisis teams needed to provide
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mobile crisis services consistent with this Agreement (the “Mobile Crisis Assessment”).
The Mobile Crisis Assessment will be informed by and will appropriately take into
account (i) community and stakeholder input; and (ii) all necessary data and information
sufficient to assess the need for crisis services in the County, which the County will
collect and analyze as part of the Mobile Crisis Assessment process.
The County will provide a draft of the design of the Mobile Crisis Assessment to the
Independent Reviewer (see section III.1.a of this Agreement) for review, feedback, and
comment, and will appropriately take into account such feedback and comment before
proceeding with the Mobile Crisis Assessment. As part of this review, the Independent
Reviewer will provide the draft to, and consider input from, DRC and the United States.
The assessment and conclusions in the final Mobile Crisis Assessment will promptly be
made available to the public.
Based on the County’s Mobile Crisis Assessment, the County will reasonably expand its
mobile crisis services as needed in order to operate a sufficient number of mobile crisis
teams to provide timely and effective mobile crisis response.
The Settlement also requires the County to conduct an assessment of the needs and
gaps in mobile crisis coverage. This requirement is not yet due to be completed.
ACBHD has a contract with the Indigo Project to develop and conduct a Mobile Crisis
Assessment of the needs and gaps in mobile crisis coverage. The Indigo Project
submitted a draft of the methodology for this assessment in May 2024. This draft was
submitted to DOJ and DRC for their feedback on May 14, 2024. Feedback from the
Independent Reviewer and DOJ and DRC was submitted to ACBHD on May 28, 2024. A
more in-depth analysis of this assessment will be included in the next report from the
Independent Reviewer. But the Independent Reviewer wishes to acknowledge ACBHD
for starting this assessment process early in order to meet the established deadline in
the Settlement Agreement.
Requirement: FSPs will provide crisis intervention as set forth in section II2.m in this
Agreement.
During this review period, the Independent Reviewer undertook the following activities
to determine compliance with FSPs providing crisis intervention services:
• Review of ACBHD’s FSP policy and procedures,
• Review of community-based provider contracts scope of work, and
• Interviews with community-based provider staff and supervisors.
All of the above indicated that FSP provides crisis intervention services. The
Independent Reviewer will continue to assess to ensure the requirement is occurring in
practice and sustained in a durable manner.
Requirement: Each mobile crisis team shall include at least one mental health clinician.
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As described above, the Mobile Crisis Teams includes two clinicians, Mobile
Engagement Teams pairs a clinician with a police officer, and Community Assessment
and Transport Team (CATT) pairs a clinician with an Emergency Medical Technician.
Requirement: Trained peer support specialists shall be part of the County’s crisis
services team and shall be included in outreach and engagement functions.
ACBH reported that peers and EMT’s are a part of the County’s crisis services.
Specifically, ACBH reported that peers and people with lived experience are part of their
Outreach and Engagement Teams (O&E). The Independent Reviewer will explore this
more fully in future reports to ensure the requirement is occurring in practice and is
sustained in a durable manner.
Requirement: The County will provide crisis residential services. Maintain 45 crisis
residential treatment (CRT) beds.
The current number of CRT beds is outlined in the chart below.
CRT Facility Community-Based Provider Number of Beds
Amber House BACS 16
Woodroe House BACS 16
Jay Mahler Telecare 16
TOTAL 48
While ACBHD has met this requirement, it has to be sustained for six months per the
Settlement Agreement. The Independent Reviewer will verify the sustainability and
durability of this requirement in the next report.
Requirement: Within two years of the Effective Date of the Agreement, the County will
make all reasonable efforts to contract with one or more community-based provider(s)
to add a mixture of 25 additional CRT and/or peer-respite beds.
ACBHD reported that two additional CRTs will be opened in the future. ACBHD plans to
contract for an additional 32 beds with Telecare and La Familia, which will bring the total
number of CRT beds to 80 beds.
Requirement: A purpose of CRT facilities and peer-respite homes is to promptly
deescalate or avoid a crisis and reduce unnecessary hospitalization. They are intended
to be used by people experiencing or recovering from a crisis due to their mental health
disability for short-term stays and provide support to avoid escalation of a crisis. CRT
facilities and peer-respite homes are unlocked.
During the on-site review, the Independent Reviewer was able to tour Amber House
which has the CRT on the bottom floor and crisis residential on the top floor. The
Independent Reviewer was able to review client records who had received CRT
services, community-based contracts scope of work and the community-based
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providers Operation Manual. There was evidence found that the goal of CRT facilities is
to de-escalate or avoid a crisis and reduce unnecessary hospitalization. The
Independent Reviewer was not able to tour the one peer-respite facility but will for
subsequent reports.
Requirement: Peer staff will be on-site 24-7 at peer-respite homes. Peer-respite
homes shall serve no more than 6 individuals at a time.
ACBHD reported that the County only has one peer respite home that opened in 2020
named Sally’s Place. ACBHD reported that the facility is unlocked and has peers on
site. ACBHD staff did report that the telephones at Sally’s Place are often not answered,
and that the facility usually is full. MHSA Three Year Program and Expenditure Plan
Fiscal Year 2023 through 2026 included in the program description that it is staffed by
peers and that it operates 24 hours a day in a homelike environment. The report also
included one of the challenges is that Sally’s Place has continuously received referrals
that exceed the established bed capacity (Page 334).
The Independent Reviewer was not able to tour the one peer-respite facility but will for
subsequent reports.
Requirement: Individuals shall not be required to have identified housing as a condition
of admission to a CRT facility.
The Independent Reviewer was able to review client records of clients who had
received CRT services, community-based contracts scope of work and the community-
based providers Operation Manual. Both ACBHD staff and community-based provider
staff confirmed that housing is not a condition for admission to a CRT. The Independent
Reviewer will verify the sustainability and durability of this requirement in the next
report.
Requirement: CRT facilities and peer-respite homes shall be able to accept admissions
directly from mobile crisis teams.
Admissions to a CRT may be made directly by MCT. The Independent Reviewer did
receive a tour of Amber House and interviewed the staff to confirm this. Evidence was
also found in the Operating Manual of the community-based providers. The
Independent Reviewer was also provided with client records of clients who had received
CRT services. There was evidence to support admissions directly from mobile crisis
teams. However, the Independent Reviewer was not able to tour the one peer-respite
facility but will for subsequent reports.
Data collected in FY 2022-23 by ACBHD includes total number of clients (663) who
received CRT services, length of stay and the following outcomes listed in chart below.
First Six Months Report August 7, 2024
16
Outcome Number of Clients Percentage
Admitted to hospital 48 7%
Connected to CBS 140 21%
Discharged to other facilities 130 20%
Detention to Santa Rita Jail 20 3%
This data will be used as the baseline for comparison in future reports. It is important to
note that the chart indicated outcomes for about half of the clients served. More
information regarding outcomes will be provided in subsequent reports.
Requirement: The County’s crisis system will be designed to prevent unnecessary
hospitalizations, IMD admissions, law enforcement interactions, and incarceration.
The Independent Reviewer interviewed ACBHD staff, community-based provider staff,
reviewed policy and procedures and community-based Operations Manual, indicating
that the crisis services are designed in the manner stated. However, it seems that the
services are not provided in a coordinated fashion. Crisis intervention services are
offered during business hours and a contract provider provides coverage overnight,
weekends and holidays but they contact 911 or CATT for any crisis intervention
services. It is also not clear which model of mobile crisis teams should respond to a
particular crisis. It seems to be based on availability and location of the crisis in the
county. There are outcome data that the county currently does not collect such as
mobile crisis teams response times, except for the CATT team. ACBHD also identified
the need to expand CSU, CRT, peer respite, and mobile crisis teams and that ACBHD is
waiting for completion of the mobile crisis assessment before being able to expand
services. In future reports, the Independent Reviewer will assess additional evidence to
ensure services are designed to achieve the outcomes described in the above
requirement.
Summary of Crisis Services Findings
As stated previously, no substantial compliance was given for this initial report since the
Settlement Agreement requires substantial compliance for six months and this report
was produced only five months after the Effective Date of the Settlement Agreements.
Overall, there are twenty service commitments in the Crisis Services component of the
Settlement Agreement. ACBHD received partial compliance for thirteen service
commitments and a not applicable rating for seven service commitments. There were no
non-compliant ratings given in this section.
ACBHD achieved Partial Compliance for the following requirements:
1. The County does offer county wide crisis system. Partial compliance was given so
that the Independent Reviewer can assess whether the County’s compliance is
sustained in subsequent reviews.
2. The County will coordinate with entities responsible for managing urgent and
emergency care response lines, including but not limited to the crisis hotline, 911,
First Six Months Report August 7, 2024
17
FSP warmlines, and 988 (when and if such coordination is available) to ensure
there is “no wrong door” for accessing appropriate crisis services. There is
evidence that steps have been taken and there is progress towards substantial
compliance.
3. Provide mobile crisis response services on a county-wide basis. There are several
requirements included and there is evidence that steps have been taken and
there is progress towards substantial compliance.
4. Mobile crisis services shall be provided with the purposes of reducing, to the
greatest extent possible, interactions with law enforcement during a mental health
crisis, reducing 5150 and John George psychiatric emergency services (“PES”)
placement rates, and increasing use of voluntary community-based services
(including diversion, care coordination, transportation, and post-crisis linkage to
services). There is evidence that steps have been taken and there is progress
towards substantial compliance. The Independent Reviewer requested a ride-
along with mobile crisis during the next on-site review.
5. The County has recently expanded its mobile crisis capacity to nine (9) mobile
crisis teams and agrees to maintain this as a minimum capacity. While ACBHD
currently has 14 mobile crisis teams, it is important for the Independent Review to
see that this is maintained. In addition, the results of the mobile crisis assessment
may influence this and will be included in the next report.
6. FSPs will provide crisis intervention as set forth in section II2.m in this Agreement.
There is evidence to support this but in order to obtain substantial compliance, it
has to be in practice for six months and the on-site review occurred only after four
months.
7. Each mobile crisis team shall include at least one mental health clinician. There is
evidence to support this but in order to obtain substantial compliance, it has to be
in practice for six months and the on-site review occurred only after four months.
8. Trained peer support specialists shall be part of the County’s crisis services team
and shall be included in outreach and engagement functions. This rating was
given because the Independent Reviewer needs to explore this more fully in
future reports.
9. The County will provide crisis residential services. Maintain 45 crisis residential
treatment (CRT) beds. While ACBHD currently contracts for 48 CRT beds, it has
to be maintained and the on-site review occurred only after four months. The
Independent Reviewer will verify this requirement again in subsequent reports.
10. A purpose of CRT facilities and peer-respite homes is to promptly deescalate or
avoid a crisis and reduce unnecessary hospitalization. There was evidence of the
purpose of the CRT facilities and peer-respite homes. The Independent Reviewer
was not able to tour the peer-respite home during the first on-site review but plans
to do so in a subsequent review.
11. Individuals shall not be required to have identified housing as a condition of
admission to a CRT facility. While there is evidence to support this requirement, it
has to be in practice for six months and the on-site review occurred only after four
months. The Independent Reviewer will verify this requirement again in
subsequent reports
First Six Months Report August 7, 2024
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12. CRT facilities and peer-respite homes shall be able to accept admissions directly
from mobile crisis teams. There was evidence to support admissions directly from
mobile crisis teams. However, the Independent Reviewer was not able to tour the
one peer-respite facility but will for subsequent reports.
ACBHD achieved Not Applicable for the following:
1. With the Maintain a 24/7 crisis hotline is the following requirement: No later than
18 months after the Effective Date, the County will expand the 24/7 crisis hotline
to provide triage and the identification of full service partnership clients on a 24/7
basis.
2. The County will implement protocols and education efforts to ensure appropriate
deployment of County mobile crisis teams in response to calls received through
emergency response lines. The rating was given due to ACBHD waiting for the
completion and implementation of the Mobile Crisis Assessment which is due in
the future.
3. The County shall complete an assessment of needs and gaps in mobile crisis
coverage, no later than one year after the execution of this Agreement, that is
designed to determine the amount and number of mobile crisis teams needed to
provide mobile crisis services consistent with this Agreement (the “Mobile Crisis
Assessment”).
4. The County will provide a draft of the design of the Mobile Crisis Assessment to
the Independent Reviewer.
5. Based on the County’s Mobile Crisis Assessment, the County will reasonably
expand its mobile crisis services as needed in order to operate a sufficient
number of mobile crisis teams to provide timely and effective mobile crisis
response.
6. Within two years of the effective date of the Agreement, the County will make all
reasonable efforts to contract with one or more community-based provider(s) to
add a mixture of 25 additional CRT and/or peer-respite beds.
7. Peer staff will be on-site 24-7 at peer-respite homes. Peer-respite homes shall
serve no more than 6 individuals at a time. The Independent Reviewer was not
able to tour the peer-respite home during the first on-site review.
FULL SERVICE PARTNERSHIPS
Full Service Partnerships (FSP) services are defined in California Code of Regulations,
Title 9, Section 3620 which defines the Full Spectrum of Community Services necessary
to attain the clients treatment goals. FSP services are intended to be flexible and
provided at a level of intensity and location that meets the client’s needs. FSP services
are intended to reduce hospitalization, utilization of emergency health care, and criminal
justice involvement. FSP services in Alameda County are provided through contracts
with community-based providers.
First Six Months Report August 7, 2024
19
FSP services were assessed for this initial report through interviews with ACBHD staff,
community-based provider staff and the supervisor of FSP programs, reviewing the
contracts between ACBHD and the community-based providers and reviewing two client
records of clients receiving FSP service. These client records were selected randomly
by ACBHD and provided to the Independent Reviewer. During this first review period,
the Independent Reviewer was not able to review additional records or to conduct a
broad sampling across the various ACBHD client populations to identify systemic
patterns. In addition, the Independent Reviewer was not able to interview clients
receiving FSP services to confirm that they receive services consistent with the
requirements but plans to do so in subsequent on-site reviews.
Requirement: The County offers FSPs through community-based providers that
provide services under the Community Services and Supports (“CSS”) service category,
in accordance with 9 C.C.R. §§ 3620, 3620.05, and 3620.10.
Within two years from the effective date, the County will add 100 FSP slots for adults
and transition aged youth for a total of 1,105 FSP slots for that population. The County
will utilize the FSP slots that are added under this Agreement to serve individuals 16
and older who meet FSP eligibility criteria under 9 C.C.R. § 3620.05.
ACBHD contracts with community-based providers for the provision of FSP services.
ACBHD provided the contract’s scope of work and through interviews with ACBHD staff
and community-based provider staff, this part of the requirement was confirmed.
Requirement: Within one year from the Effective Date, the County will complete an
assessment of needs and gaps in FSP services for individuals ages 16 years and older
that is designed to determine the number of additional FSP slots needed to
appropriately serve individuals ages 16 and older who meet FSP eligibility criteria under
9 C.C.R. § 3620.05 (the “FSP Assessment”).
Requirement: The FSP Assessment will be informed by and will appropriately take into
account all necessary and appropriate data and information, which the County will
collect and analyze as part of the FSP Assessment process, including but not limited to:
i. Community and stakeholder input, including from FSP and other contracted providers,
from organizations who make referrals for FSP services or regularly come into contact
with individuals who are likely eligible for FSP services, and from individuals who
receive or may benefit from FSP services; ii. Data regarding utilization of crisis services,
psychiatric inpatient services, and FSP and other CSS services; indicators of eligibility
for FSP; and numbers of individuals who have completed FSP eligibility assessments,
outcomes following assessment, and length of time from identification to enrollment; iii.
Analysis of numbers and demographics of sub-populations who (a) were not connected
to FSP services despite multiple visits/admissions to PES, John George inpatient,
and/or IMDs, (b) declined to consent to FSP services, or (c) stopped engaging with FSP
services, and analysis of relevant barriers or challenges with respect to these groups;
First Six Months Report August 7, 2024
20
and iv. Research, literature, and evidence-based practices in the field that may inform
the need for FSP services in Alameda County.
Requirement: The County will provide a draft of the design and methodology of the
FSP Assessment to the Independent Reviewer for review, feedback, and comment, and
will appropriately take into account such feedback and comment before proceeding with
the FSP Assessment. As part of this review, the Independent Reviewer will provide the
draft to, and consider input from, DRC and the United States. Following the FSP
Assessment process, the County will provide a draft of the FSP Assessment report to
the Independent Reviewer for review, feedback, and comment, and will appropriately
take into account such feedback and comment before finalizing the County’s FSP
Assessment report. As part of this review, the Independent Reviewer will provide the
draft to, and consider input from, DRC and the United States. The assessment and
conclusions in the final FSP Assessment will promptly be made available to the public.
Requirement: Based on the County’s FSP Assessment, the County will further
reasonably expand its FSP program as necessary in order to appropriately serve
individual ages 16 and older who meet eligibility criteria under 9 C.C.R. § 3620.05
consistent with their preferences.
ACBHD has contracted with the Indigo Project to conduct an FSP assessment to
identify needs and gaps for individuals ages 16 and older. Indigo Project submitted a
draft of the design and methodology of the assessment to the Independent Reviewer on
March 29, 2024. The Independent Reviewer sent the draft to DOJ and DRC on April 1,
2024, and they returned the draft with their comments and edits on May 2, 2024. A
meeting was held on June 14, 2024, with Indigo, ACBHD, and the Independent
Reviewer to discuss the edits and to finalize the design and methodology. The
implementation and results of this assessment will be discussed in subsequent reports.
Requirement: As used in this Agreement, one “slot” (such as an FSP slot or a Service
Team slot) means the ongoing capacity to serve one individual at a given time. FSP will
provide services necessary to attain the goals identified in each FSP recipients’
Individual Services and Supports Plan (ISSP) which may include the Full Spectrum of
Community Services, as defined in 9 C.C.R. § 3620(a)(1).
While evidence was found regarding the definition of one slot, the Independent
Reviewer needs to review more client records and other information regarding the ISSP
to determine if FSPs are in fact providing the services necessary.
Requirement: Consistent with 9 C.C.R. § 3620(a), (g), and (h), each FSP recipient will
have an ISSP that is developed with the person and includes the person’s individualized
goals and the Full Spectrum of Community Services necessary to attain those goals.
Each FSP recipient will receive the services identified in their ISSP, when appropriate
for the individual.
First Six Months Report August 7, 2024
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The Independent Reviewer reviewed ACBHD’s policies and procedures for FSP and
reviewed two client records. FSP client records listed the issues that the client identified,
individualized goals, and the client’s treatment plan or problem list were consistent with
the assessment. The client records indicated that the issues identified were being
addressed. But the Independent Reviewer was not able to fully review the ISSP
requirements, given the small number of client records, and plans to review additional
client records. In addition, the Independent Reviewer was not able to interview clients
receiving FSP services to confirm that they receive services consistent with the
requirements but plans to do so in subsequent on-site reviews to ensure the
requirement is occurring in practice and is sustained in a durable manner.
Requirement: Services provided through FSPs will be flexible and the level of intensity
will be based on the needs of the individual at any given time, including the frequency of
service contacts and duration of each service contact. To promote service engagement,
services will be provided in locations appropriate to individuals’ needs, including in the
field where clients are located, in office locations, or through the use of telephonic or
other electronic communication when clinically appropriate.
The Independent Reviewer reviewed ACBHD’s policies and procedures for FSP and
reviewed two client records. Client records indicated that the services were being
provided in multiple ways. However, the client records indicated that the services were
not as frequently provided as indicated in the client’s treatment plan. For example, in
one client’s record, the treatment intervention was to occur weekly, but the progress
notes indicated that the intervention was being conducted every other week. The client
record indicated that the client was only working on their activities of daily living with no
immediate plans for discharge. This was a very small sample of client charts for review,
so it is difficult to draw conclusions about the overall service delivery system. An
additional sampling of client records will be completed in subsequent reviews to ensure
the requirement is occurring in practice and is being sustained in a durable manner.
The chart below indicates the top six locations where FSP services were provided for
the Fiscal Year 2022-23.
Treatment Location # Clients % of Visits
Field 1,072 41.2%
Home 815 23.8%
Phone 1,073 20.9%
Office 1,128 14.3%
Telehealth 549 3.6%
Inpatient 286 2.4%
This chart indicates that the majority of services are being provided in the field and at
home as is appropriate for FSP services. This data will be compared to data collected in
the future.
First Six Months Report August 7, 2024
22
Requirement: FSPs serve the individuals described in 9 C.C.R. § 3620.05. FSPs will
provide their clients services designed to reduce hospitalization and utilization of
emergency health care services, reduce criminal justice involvement, and improve
individuals’ ability to secure and maintain stable permanent housing in the most
integrated setting appropriate to meet their needs and preferences.
The Independent Reviewer reviewed ACBHD’s policies and procedures for FSP,
reviewed two client records, and interviewed community-based provider staff. All
indicated that services are designed to reduce hospitalization, utilization of emergency
health care services, reduce criminal justice involvement, and improve individuals’ ability
to secure and maintain stable permanent housing.
The chart below is ACBHD outcomes for FSP clients related to housing for discharges
during Fiscal Year 2022 to 2023.
Housing
Status
At
Admission
Percent
Admission
At
Discharge
Percent
Discharge
Independent 73 31% 72 30%
Unknown or
other 45 19% 54 23%
Homeless 56 24% 48 20%
Group
Housing 45 19% 32 14%
Medical
Facility 8 3% 13 5%
Justice
Related 4 2% 12 5%
Rehabilitation 6 3% 6 3%
This chart indicates that the largest percentage of clients who received FSP services
were discharged to independent living. Over forty percent were discharged to an
unknown place or were homeless. While this seems to be a high percentage, it also
speaks to the housing issues in Alameda County. There also seems to be a slight
increase in the number of justice related clients from admission to discharge. The
Independent Reviewer will examine this more fully in subsequent reports to ensure the
requirement is occurring in practice and is being sustained in a durable manner. This
data will be used as the baseline for comparison in future reports.
Requirement: FSP programs will be implemented using high fidelity to the Assertive
Community Treatment (“ACT”) evidence-based practice, including that: (i) FSP
programs are provided by a team of multidisciplinary mental health staff who, together,
provide the majority of treatment, rehabilitation, and support services that clients need
to achieve their goals; (ii) FSP teams operate at a 1:10 mental health staff to client ratio.
During this review period, the Independent Reviewer undertook the following activities
to determine compliance with the above FSP-related services:
First Six Months Report August 7, 2024
23
• Toured two community-based providers of FSP services, one for adults and one
for Transitional Aged Youth (TAY),
• Interviewed 15 community-based provider staff and supervisors from two FSP
community-based providers visited,
• Reviewed ACBHD’s FSP policy and procedures,
• Reviewed ACBHD community-based provider contracts scope of work for the
provision of FSP services,
• Reviewed ACBHD’s ACT training materials.
The MHSA Annual Plan Update (Draft) for FY24/25 describes the difference between
FSP and the ACT model as follows:
“In California, Full Service Partnership (FSP) programs are intended to be the
most intensive level of publicly-funded outpatient treatment programs (in addition
to Laura’s Law, or Assisted Outpatient Treatment/AOT programs). Some
counties, like Alameda, base their FSP service models on the ACT evidence-
based model that operates nationally; this model is the highest intensity service
level for outpatient services. FSP ACT model programs are team structured with
a staff to partner ratio of 10:1 and provide coordinated comprehensive services
that support and promote recovery” (Page 80).
Community based providers staff reported that ACBHD conducts a fidelity assessment
to the ACT model annually. ACBHD staff and community-based provider staff reported
that the FSP program design in Alameda County is based on the ACT model. For the
next report, the Independent Reviewer will include documentation of ACBHD’s fidelity
review results.
The ACBHD Deputy Director of Clinical Operations reported that the staff to client ratio
for FSP is 1 to 10. This was also confirmed by the provider’s contract’s scope of work
and by interviews with community-based provider staff.
However, the Independent Reviewer was unable to confirm through records sampling,
data analysis, and individual client interviews that FSP programs are being implemented
using high fidelity to the ACT evidence-based practice. Review of the initial client
records discussed above indicated that services are not being provided with the
frequency required under ACT high fidelity standards, or that multidisciplinary teams are
providing the treatment, rehabilitation, and support services that clients need to achieve
their goals. In future reports, the Independent Reviewer will assess additional evidence,
including data, individual client interviews, and client records sampling, to ensure the
requirement is occurring in practice and is being sustained in a durable manner.
Requirement: FSPs will promptly provide crisis intervention 24/7, including, as
appropriate, crisis intervention at the location of the crisis as needed to avoid
unnecessary institutionalization, hospitalization, or interactions with law enforcement.
Beginning no later than eighteen (18) months after the Effective Date, the County will
ensure the prompt notification of the applicable FSP provider when an individual served
First Six Months Report August 7, 2024
24
by an FSP receives crisis intervention from another ACBHD contracted provider, such
as mobile crisis teams, or other crisis programs, so that the FSP can respond to the
crisis.
FSP services are intended to provide crisis intervention services. During this review
period, the Independent Reviewer undertook the following activities to determine
compliance with the above FSP-related requirements:
• Review of ACBHD’s FSP policy and procedures,
• Review of community-based provider contracts scope of work, and
• Interviews with community-based provider staff and supervisors.
e from the Discharge FY 2022-23 data for FSP clients.
In future reports, the Independent Reviewer will assess additional evidence, including
data, individual client interviews, and client records sampling, to ensure the requirement
is occurring in practice and is being sustained in a durable manner. Reviewer has not
Requirement: FSPs will provide or arrange for appropriate Individual Placement and
Support (IPS) supported employment services for FSP clients based on their choice.
IPS supported employment focuses on engaging a person in competitive employment
based on their individualized interests, skills, and needs.
FSP services are to include the provision of or the arrangement for Individual Placement
and Support (IPS) services. The interviews with community-based provider staff and
supervisor indicated that this was being conducted, ACBHD provided two client records
where IPS services were provided, and it was evident from the client records that
employment services were being provided. Community-based provider staff reported
that ACBHD conducts a fidelity assessment to the IPS annually. The Independent
Reviewer has not yet reviewed the fidelity assessment or results but will do so in
subsequent reports.
Requirement: Housing: The Parties recognize that permanent, integrated, stable
housing with Housing First principles is critical to improving treatment engagement and
supporting recovery. (i) FSP clients will receive a housing needs assessment, and will
receive support and assistance to secure and maintain, as needed, affordable, (1)
temporary housing, and (2) permanent housing, either directly from the FSP or by
referral by the FSP to the County Health Care Services Agency’s Coordinated Entry
System (“CES”), or through other County and community resources.
FSP participants are to receive a housing assessment and be referred to the Health
Agency Services Coordinated Entry System (CES). No evidence was found in the client
record of a formal housing assessment or of a referral to CES. However, evidence of
housing needs and wishes of the client was found in the client record. In future reports,
the Independent Reviewer will assess additional evidence, including data, policy and
procedures, individual client interviews, and client records sampling, to ensure the
requirement which includes temporary and permanent housing, is occurring in practice
and is being sustained in a durable manner.
First Six Months Report August 7, 2024
25
Requirement: As individuals with serious mental illness, FSP clients who are referred
to the CES will receive priority, with the goal of securing and maintaining permanent
housing.
The MHSA Annual Plan Update (Draft) for FY24/25 states that CES began in 2017,
underwent significant changes that started in FY 2022 and was fully implemented in FY
2023. The Housing Solution for Health Program (Alameda County Health Care Services
Agency Office of Homeless Care and Coordination (OHCC)) Housing Services Office
(HSO) and multiple subcontractors) stated in the report:
“Ongoing collaboration and coordination will be needed to ensure the maximum
effectiveness of CES. Much larger investments in affordable and supportive
housing are needed by multiple levels of government to ensure individuals with
serious mental illness have a place to call home” (Page 106).
ACBHD Senior Executive Team stated that FSP clients are to receive priority from CES.
The Independent Reviewer was not able to interview the housing staff during this initial
review period but will consider doing so in subsequent on-site reviews. At this initial
review, it is difficult to determine if this is the practice by CES.
Requirement: If an FSP client is waiting for permanent housing, the FSP will, as
needed, promptly provide or secure temporary housing for the FSP client until
permanent housing is secured. Temporary housing provided under this agreement shall
be stable and shall not be at a congregate shelter, except on an emergency basis.
Requirement: Permanent housing provided under this section II.2.o will be provided in
the least restrictive and most integrated setting that is appropriate to meet individuals’
needs and preferences. (v). Nothing in this section II.2.o is intended to override an FSP
client’s preferences.
The Independent Reviewer heard in numerous interviews with ACBHD staff and
community-based provider staff that housing is a challenging issue in Alameda County.
In addition, the MHSA Three Year Program and Expenditure Plan Fiscal Year 2023
through 2026, states a reoccurring theme in the community listening session was
“address basic needs such as insecure housing” (Page 65). The report also states that
housing and homelessness ranks as the number one concern for adults and older
adults (Page 87).
During the community input period for this MHSA report, community members were
asked to complete a 21-question survey. The following barriers to accessing mental
health services from the survey were identified:
1. Resources, ranging from basic needs such as food and housing to behavioral
and mental healthcare treatment, are in short supply.
2. If these resources are somehow available, then accessing them can be an
arduous and difficult process.
First Six Months Report August 7, 2024
26
3. Their responses speak to an overloaded, unfriendly system that does not
currently meet their needs;
4. They also speak to a desire for a more friendly, efficient, and transparent method
to access care.
The ACBHD Senior Executive Team reported that the County Housing Department used
to be under ACBHD, but it was moved to the Office of the Health Agency Director. The
Senior Executive Team reported that this change has been a challenge in serving their
clients. The County does have a number of coordinated housing resource centers
located throughout the county. ACBHD provided documentation of housing training from
the Alameda County Office of Homeless Care and Coordination. In addition, the loss of
Board and Care homes in the County and the subsequent loss of those beds, has also
had an impact the housing situation. Community-based providers also reported on the
difficulty in finding housing for their clients. One example provided was there is an
affordable housing list but it has a minimum salary requirements which their clients
cannot meet and thus do not have access to that housing.
Great Hope FSP (Adobe Services) reported the following in the MHSA Three Year
Program and Expenditure Plan Fiscal Year 2023 through 2026 regarding barriers to
services:
“Difficulty in securing units under the changing Fair Market Rates (FMR). There
was a decline in available and viable units within Alameda County. Landlords
unwillingness to work with subsidized housing was also a challenge,
discriminatory language or behaviors with landlords towards subsidized housing
recipients was a contributing factor” (Page 132).
Strides Program (Telecare) reported the following challenges in the MHSA Annual Plan
Update (Draft) for FY 24/25:
“FY22/23 was a time of great uncertainty due to the stressors of the global
pandemic (increasing COVID outbreaks again), housing insecurity, increased risk
of substance use, increase of hate crimes directed at vulnerable populations,
increased cost of living, especially for housing and food. While all these factors
impact our partners, the most challenging in the past year include the dangerous
risk of overdose and death due to fentanyl and other street drugs, as well as
increasingly complex psychiatric / medical presentations with our clients and the
shortage of appropriate, supportive housing resources available.” (Page 137).
The MHSA Annual Plan Update (Draft) for FY24/25, identifies several recurring themes
in numerous listening sessions. One theme identified was “housing continuum”. The
plan lists the following strategies and solutions:
• “Increase prevention and early intervention programs to avoid homelessness.
• Provide safe/welcoming places with direct services and housing for those with
mental health challenges, aiming to prevent additional trauma.
First Six Months Report August 7, 2024
27
• Provide emergency housing lasting a minimum of 6 months, followed by long-
term supportive housing.
• Support housing interventions with additional funding for operational support to
meet the needs of the community that include comprehensive and wraparound
services.
• Establish accountability and check-and-balance mechanisms in housing pro-
grams and services.
• Ensure transparency in decision-making processes related to housing” (Page
54).
Given the challenges in providing housing, both temporary and permanent, the
Independent Reviewer expects the implementation of housing-related settlement
provisions to require continued effort, including coordination across all relevant County
entities including those that fund and support the development of affordable housing
and/or have the authority to prioritize the delivery of existing housing to the population
covered by the settlement. The Independent Reviewer notes that the County’s activities
with respect to housing are confined to obligations with respect to FSP clients. It is
noteworthy that ACBHD was just awarded $14,040,909 from DHCS for Round 3 of the
Behavioral Health Bridge Housing Program. The Independent Reviewer will examine
the issue of both temporary housing and permanent housing in subsequent reports.
Summary of Full Service Partnership Findings
As stated previously, no substantial compliance was given for this initial report since the
Settlement Agreement requires substantial compliance for six months and this report
was produced only five months after the Effective Date of the Settlement Agreements.
There were no non-compliant ratings given in this section.
Overall, there are sixteen service commitments in the Full Service Partnership section.
There were ten service commitments that received a rating of partial compliance and six
service commitments that were not applicable. There were no non-compliant ratings
given in this section.
ACBHD achieved Partial Compliance for the following requirements:
1. As used in this Agreement, one “slot” (such as an FSP slot or a Service Team
slot) means the ongoing capacity to serve one individual at a given time. FSP will
provide services necessary to attain the goals identified in each FSP recipients’
Individual Services and Supports Plan (ISSP) which may include the Full
Spectrum of Community Services, as defined in 9 C.C.R. § 3620(a)(1). The
Independent Reviewer needs to review more client records and other information
regarding the ISSP.
2. Consistent with 9 C.C.R. § 3620(a), (g), and (h), each FSP recipient will have an
ISSP that is developed with the person and includes the person’s individualized
goals and the Full Spectrum of Community Services necessary to attain those
First Six Months Report August 7, 2024
28
goals. Each FSP recipient will receive the services identified in their ISSP, when
appropriate for the individual. The Independent Reviewer needs to review more
client records and interview clients regarding the ISSP.
3. Services provided through FSPs will be flexible and the level of intensity will be
based on the needs of the individual at any given time, including the frequency of
service contacts and duration of each service contact. To promote service
engagement, services will be provided in locations appropriate to individuals’
needs, including in the field where clients are located, in office locations, or
through the use of telephonic or other electronic communication when clinically
appropriate. While there was evidence regarding the flexibility of services, the
Independent Reviewer needs to review more client records and interview clients.
4. FSPs serve the individuals described in 9 C.C.R. § 3620.05. FSPs will provide
their clients services designed to reduce hospitalization and utilization of
emergency health care services, reduce criminal justice involvement, and
improve individuals’ ability to secure and maintain stable permanent housing in
the most integrated setting appropriate to meet their needs and preferences.
While there was evidence regarding the design of services, the Independent
Reviewer needs to review more client records and interview clients.
5. FSP programs will be implemented using high fidelity to the Assertive Community
Treatment (“ACT”) evidence-based practice, including that: (i) FSP programs are
provided by a team of multidisciplinary mental health staff who, together, provide
the majority of treatment, rehabilitation, and support services that clients need to
achieve their goals; (ii) FSP teams operate at a 1:10 mental health staff to client
ratio. While there was evidence regarding the use of the ACT model, the
Independent Reviewer needs to review more client records and interview clients.
6. FSPs will provide or arrange for appropriate Individual Placement and Support
(IPS) supported employment services for FSP clients based on their choice. IPS
supported employment focuses on engaging a person in competitive employment
based on their individualized interests, skills, and needs. While there was
evidence of employment service being provided, the Independent Reviewer has
not yet reviewed the fidelity assessment or results but will do so in subsequent
reports.
7. Housing: FSP clients will receive a housing need assessment and will receive
support and assistance to secure and maintain, as needed, affordable, (1)
temporary housing, and (2) permanent housing, either directly from the FSP or by
referral by the FSP to the County Health Care Services Agency’s Coordinated
Entry System (“CES”), or through other County and community resources. The
Independent Reviewer may need to interview CES staff, interview FSP clients,
and review a random sample of client records, for subsequent reports.
8. As individuals with serious mental illness, FSP clients who are referred to the
CES will receive priority, with the goal of securing and maintaining permanent
housing. The Independent Reviewer was not able to interview the housing staff
First Six Months Report August 7, 2024
29
during this initial review period but plans to do so in subsequent on-site reviews.
At this initial review, it is difficult to determine if this is the practice by CES.
9. If an FSP client is waiting for permanent housing, the FSP will, as needed,
promptly provide or secure temporary housing for the FSP client until permanent
housing is secured. Temporary housing provided under this agreement shall be
stable and shall not be at a congregate shelter, except on an emergency basis.
Given the challenges in providing housing, both temporary and permanent, the
Independent Reviewer may need to continue to examine the issue of both
temporary housing and permanent housing in subsequent reports.
10. Permanent housing provided under this section II.2.o will be provided in the least
restrictive and most integrated setting that is appropriate to meet individuals’
needs and preferences. (v). Nothing in this section II.2.o is intended to override
an FSP client’s preferences. Given the challenges in providing housing, both
temporary and permanent, the Independent Reviewer may need to continue to
examine the issue of both temporary housing and permanent housing in
subsequent reports.
ACBHD achieved Not Applicable for the following:
1. The County offers FSPs through community-based providers that provide
services under the Community Services and Supports (“CSS”) service category,
in accordance with 9 C.C.R. §§ 3620, 3620.05, and 3620.10. Within two years
from the effective date, the County will add 100 FSP slots for adults and
transition aged youth for a total of 1,105 FSP slots for that population.
2. Within one year from the Effective Date, the County will complete an
assessment of needs and gaps in FSP services for individuals ages 16 years and
older that is designed to determine the number of additional FSP slots needed to
appropriately serve individuals ages 16 and older who meet FSP eligibility criteria
under 9 C.C.R. § 3620.05 (the “FSP Assessment”).
3. The FSP Assessment will be informed by and will appropriately take into account
all necessary and appropriate data and information, which the County will collect
and analyze as part of the FSP Assessment process.
4. The County will provide a draft of the design and methodology of the FSP
Assessment to the Independent Reviewer for review, feedback, and comment,
and will appropriately take into account such feedback and comment before
proceeding with the FSP Assessment.
5. Based on the County’s FSP Assessment, the County will further reasonably
expand its FSP program as necessary in order to appropriately serve individual
ages 16 and older who meet eligibility criteria under 9 C.C.R. § 3620.05
consistent with their preferences.
6. FSPs will promptly provide crisis intervention 24/7, including, as appropriate,
crisis intervention at the location of the crisis as needed to avoid unnecessary
institutionalization, hospitalization, or interactions with law enforcement.
Beginning no later than eighteen (18) months after the Effective Date, the
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30
County will ensure the prompt notification of the applicable FSP provider when an
individual served by an FSP receives crisis intervention from another ACBHD
contracted provider, such as mobile crisis teams, or other crisis programs, so that
the FSP can respond to the crisis.
SERVICE TEAMS (INTENSIVE CASE MANAGEMENT)
Service Teams are intended to provide services to adults with serious mental illness to
decrease or diminish mental health symptoms in order for them to integrate into the
community and avoid patterns of psychiatric hospitalization. Service teams are intended
to serve adults ages 18 and above who have high utilization of emergency and/or
urgent behavioral health systems.
Service Teams were assessed for this initial report through interviews with ACBHD
staff, community-based provider staff and supervisors, reviewing the contracts between
ACBHD and the community-based providers, reviewing policies and procedures,
reviewing outcomes data provided by ACBHD, and reviewing two client records of
individuals receiving Service Team services. During this first review period, the
Independent Reviewer was not able to review additional records or to conduct a broad
sampling across the various ACBHD client populations to identify systemic patterns. In
addition, the Independent Reviewer was not able to interview clients receiving Service
Team services to confirm that they receive services consistent with the requirements.
Requirement: The County will maintain 2,168 slots to provide intensive case
management through Service Teams. The County will utilize these slots to serve
individuals 18 and older who meet Service Teams eligibility criteria and may also use
these slots for transitional age youth as appropriate.
ACBHD contracts with thirteen community-based providers for Service Teams for a total
of 2,228 slots. The Independent Reviewer will verify the sustainability and durability of
this requirement in the next report.
Requirement: The County will explore community needs and opportunities for
expanding Service Teams as appropriate.
The FSP assessment will review data related to Service Team utilization. Service Team
capacity and opportunity for expansion will be explored as appropriate.
Requirement: Service Teams will assist individuals in attaining a level of autonomy
within the community of their choosing. Service Teams will provide mental health
services, plan development, case management, crisis intervention, and medication
support; and will be available to provide services in the field where clients are located, in
office locations, and through the use of telephonic or other electronic communication
when clinically appropriate.
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31
Data provided by ACBHD indicated that for FY 2022-23, the frequency of contacts was
2.9 contacts per month. Evidence was found in the contracts with community-based
providers, policy and procedures, review of client records, and interviews with
community-based provider staff and supervisors that a variety of services are provided
to assist the client in attaining autonomy, and the services are provided in appropriate
locations. A review of the contracts with community-based providers listed out the
following services to be provided under Service Teams: mental health services, case
management/brokerage, crisis intervention, and medication support.
ACBHD provided the following outcomes data for these clients in the chart below. Of
clients who completed six consecutive months during the 12-month fiscal year, there
was a 78 percent reduction in psychiatric hospital or crisis stabilization unit per the data
provided by ACBHD. While this is not current data and it is unclear why the two fiscal
years were combined, the Independent Review will continue to monitor the outcomes
for future years and will provide a comparison in subsequent reports.
Discharge
Years
Discharge Percent Change
Incarceration
Percent Change
Hospital Days
Percent
Change in ED
Days
FY20/21
and
FY21/22
916 -74% -84% -13%
Requirement: Service Team clients will receive support and assistance to access, as
needed, temporary housing and permanent housing, through the CES and other
available programs.
Evidence was found in the contracts with community-based providers, policy and
procedures, review of client records, and interviews with community-based provider staff
and supervisors that assistance with housing needs is provided. However, the
Independent Reviewer was unable to confirm through broad records sampling and
direct client interviews that Service Teams are receiving support and assistance to
access temporary and permanent housing.
Summary of Service Team Findings
As stated previously, no substantial compliance was given for this initial report since the
Settlement Agreement requires substantial compliance for six months and this report
was produced only five months after the Effective Date of the Settlement Agreements.
Overall, there are four service commitments in the Service Teams (Intensive Case
Management) component of the Settlement Agreement. ACBHD received partial
compliance for three service commitments and not applicable for only one service
commitment. There were no non-compliant ratings given in this section.
First Six Months Report August 7, 2024
32
ACBHD achieved Partial Compliance for the following requirements:
1. The County will maintain 2,168 slots to provide intensive case management
through Service Teams. While ACBHD contracts with thirteen community-based
providers for Service Teams for a total of 2,228 slots, it is important to see that
slots are maintained for more than six months.
2. Service Teams will assist individuals in attaining a level of autonomy within the
community of their choosing. Service Teams will provide mental health services,
plan development, case management, crisis intervention, and medication
support; and will be available to provide services in the field where clients are
located, in office locations, and through the use of telephonic or other electronic
communication when clinically appropriate. The Independent Reviewer needs to
review more client records and interview clients who have received these
services.
3. Service Team clients will receive support and assistance to access, as needed,
temporary housing and permanent housing, through the CES and other available
programs. The Independent Reviewer may need to interview CES staff, interview
clients and review more client records for subsequent reports.
ACBHD achieved Not Applicable for the following requirement:
1. The County will explore community needs and opportunities for expanding
Service Teams as appropriate. The FSP Assessment will include Service Teams
utilization data and the due date for this is in the future.
OUTREACH, ENGAGEMENT, LINKAGES, AND DISCHARGE
PLANNING
The Settlement Agreement outlines service components related to outreach,
engagement, linkages, and discharge planning. Among other services, the services
under this section relate to connecting individuals with the services they need to avoid
unnecessary institutionalization and incarceration, and discharge planning from facilities
such as John George Psychiatric Hospital, Santa Rita jail, and Villa Fairmont
Rehabilitation Center.
Requirement: The County will maintain a 24/7 telephonic hotline (the ACCESS line or
its successor) to aid in implementing the provisions below.
The first service commitment in this service component is to maintain a 24/7 telephonic
ACCESS Line. This is also a DHCS requirement, and DHCS conducted test calls to the
ACCESS line during their triennial review. The seven test calls must demonstrate
compliance with California Code of Regulations, title 9, chapter 11, section 1810,
subdivision 405(d) and 410(e)(1). The results of the last triennial review were for FY
2022-23, DHCS made 7 test calls with the following results:
First Six Months Report August 7, 2024
33
• In Compliance – 5 calls
• Partial Compliance – 2 calls
Partial compliance was given by DHCS since the County did not provide information
about how to access specialty mental health services to the caller.
The MHSA Annual Plan Update (Draft) for FY24/25, identifies a number of recurring
themes as identified by numerous listening sessions. One theme identified was “access,
coordination and navigation to services” (Page 398).
Requirement: The County will make meaningful efforts to create a system to provide
real-time appointment scheduling, timely in-the-field assessments, and authorization of
services by ACCESS or its successor, in order to facilitate prompt and appropriate
connection to services following an eligible individual’s contact with ACCESS.
ACCESS staff collect demographic information, current symptoms, and historical
information from the caller and then utilize a screening tool to determine eligibility for
services. ACCESS teams do not complete the formal clinical assessment. Currently,
ACCESS writes up a referral and sends that referral to the community-based provider
who then contacts the client to schedule an intake appointment. The community-based
providers reported that they then complete the clinical assessment. No evidence was
found on real-time appointment scheduling, and no data on the timeliness, number, and
location of assessments completed. However, the County is making meaningful efforts,
which at present involve technological and other back-end improvements that would be
the foundation for the system changes and data collection.
ACBHD currently has a pilot underway with Pathways to Wellness where ACCESS
coordinates a call with Pathways to Wellness staff and connects the client to Pathways
to Wellness in real time. The pilot is in its first year and data will be collected on the
efficacy of this pilot.
The Independent Reviewer will assess additional evidence and provide more
information on the progress of these efforts in subsequent reports.
Requirement: When an individual with serious mental illness (1) is identified by the
County through section II.4.e, or (2) contacts (or another individual does so on his or her
behalf) the County (e.g., the ACCESS program or its successor) or an ACBHD
contracted entity for behavioral health services, the County or an ACBHD contracted
community provider will determine the person’s eligibility for community-based
behavioral health services and, unless the person can no longer be contacted or
declines further contact, will provide a complete clinical assessment of the individual’s
need for community-based behavioral health services (an “assessment”).
The Independent Reviewer reviewed the following:
• Two client records,
• Policy and procedures,
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34
• Contracts with community-based providers and
• Interviewed ACCESS staff.
Evidence was found regarding partial compliance with this requirement. However, the
Independent Reviewer will need to review additional client records and will report on this
in subsequent reports to ensure the requirement is being implemented in practice and in
a sustained and durable manner.
Requirement: Following such assessment, individuals determined to be eligible for and
in need of FSP or Service Team services will be assigned to an FSP or Service Team’s
caseload to commence the provision of services. As discussed above, the County uses
ACCESS to determine eligibility for community-based behavioral health services, and
ACCESS refers individuals out to community-based providers for the clinical
assessment.
ACCESS determines eligibility of the individual and then refers the case to the
appropriate community-based provider. ACBHD staff interviews plus the on-site review
confirmed that ACCESS does make appropriate referrals to community-based
providers. Community-based provider staff reported that they assign the case to the
appropriate staff member and then initiate services promptly. The Independent
Reviewer reviewed two client records and verified that the clinical assessment was in
the record and the appropriate level of care was determined during the assessment.
However, the Independent Reviewer will need to review additional client records and will
report on this in subsequent reports to ensure the requirement is being implemented in
practice and in a sustained and durable manner.
Requirement: This assessment and assignment process will be promptly completed,
and those services initiated in a prompt manner sufficient to reduce the risk of
prolonged and future unnecessary institutionalization, hospitalization, or incarceration.
Interviews with ACCESS staff plus the on-site review confirmed that ACCESS does
make appropriate referrals to community-based providers. ACBHD did provide a report
on when assessments are completed by the community-based provider and the number
of hours of service provided. The Independent Reviewer was not able to interview
clients to determine the length of time from their initial contact to ACBHD to when the
community-based provider contacted them to complete the intake and assessment.
Requirement: Beginning no later than six (6) months after the Effective Date, the
County will document all situations in which an eligible individual is assessed as in need
of FSP or Service Team services, but such FSP or Service Team services were not
immediately available and will conduct regular quality reviews to identify such situations.
Following a quality review, the County will take appropriate action, if any is indicated,
based on the results of the quality review, and the results will inform the County’s FSP
Assessment under Section II.2.c.
First Six Months Report August 7, 2024
35
Community-based providers, ACBHD staff, and ACBHD Senior Executive Team
reported that there have not been any situations where a FSP team or Service Team
were not available to take a case. It is also not tracked in the Quality Improvement Work
Plan, but the Settlement Agreement does not require this. Interviews with ACBHD staff
and community-based providers conducted during the on-site review reported that they
have always been able to accommodate the client’s needs for either FSP or Service
Team. ACBHD has reported that they conducted an internal meeting with Quality
Improvement, ACCESS, Utilization Management, and Adult and Older Adult System of
Care to review if any client was unable to be assigned to an FSP or Service Team and
there were no incidents to report. In future reports, the Independent Reviewer will
assess additional evidence to ensure the requirement is occurring in practice and is
being sustained in a durable manner.
Requirement: Within two (2) years of the effective date of the Agreement, the County
will develop, implement, and staff a System Coordination Team to improve linkages to
community-based services across the County’s behavioral health system. The System
Coordination Team will coordinate system care and improve transitions of care.
This requirement will be discussed in subsequent reports.
Requirement: The County will implement a system to identify and provide proactive
outreach and engagement to individuals with serious mental illness who are, for
reasons related to their serious mental illness, at risk of unnecessary institutionalization,
hospitalization, or incarceration. In order to do so, this system will focus on factors that
include, among others, whether individuals with serious mental illness have had
frequent contacts with crisis services (including PES), frequent hospitalizations for
mental health reasons, and/or frequent incarcerations (and, in the case of
incarcerations, received behavioral health services during an incarceration). The County
will connect such individuals, as needed, to FSPs, Service Teams, or other community-
based services. The County will use a culturally responsive, peer driven approach that
builds on the person’s strengths and goals and seeks to address the individual’s
concerns regarding treatment (including service refusals). Outreach and engagement
will include frequent, in person contact in the field in locations convenient to the person.
Outreach and engagement will include using the Familiar Faces program to identify and
connect with individuals who do not follow up regarding services after experiencing a
crisis. Beginning no later than six (6) months after the Effective Date, the County will
track progress in connecting individuals to needed services.
The Adult and Older Adult System of Care Director reported that the County has an
Outreach and Engagement (O&E) team. Mobile crisis staff reported that there are three
community-based providers who provide outreach and engagement services. The O&E
Team do engage with individuals that are not currently receiving any services. The
Interim Crisis Services System of Care reported that there is a Geriatric Assessment
Response Team (GART) that can receive referrals from the public, the calls will be
First Six Months Report August 7, 2024
36
screened for both clinical needs and the consumer’s health insurance coverage
according to professional best practices.
The ACBHD contract for those community-based providers requires that the staff
conduct the outreach in the client’s natural environment. Evidence was found in policy
and procedures along with interviews with community-based providers that individuals
are connected to FSP, Service Teams or appropriate community-based services as
needed. In future reports, the Independent Reviewer will assess additional evidence to
ensure the requirement is occurring in practice and is being sustained in a durable
manner.
ACBHD did provide their tracking log of high inpatient and subacute utilizers. The
Independent Reviewer will need to follow up on ACBHD’s system for tracking whether
individuals with serious mental illness have had frequent contacts with crisis services
(including PES), and/or frequent incarcerations and, in the case of incarcerations,
received behavioral health services during an incarceration.
ACBHD reported that Familiar Faces is a program that will conduct outreach and
engagement activities, and this program went live in FY 2019-20. The Independent
Reviewer will review this program in subsequent reports.
Requirement: The County will explore, collaborate with, and support as appropriate
programs that provide connection to community-based services as alternatives to
incarceration. The County will provide information and education to prosecutors, public
defenders, courts and law enforcement about available community-based services that
can provide alternatives to incarceration, arrest, and law enforcement contact, and will
coordinate with these entities to rapidly connect individuals to those services as
appropriate.
Evidence was found of information and education provided to, or coordination with,
criminal justice entities for rapid connection to community-based services. ACBHD
provided examples of training and educational material that are used to educate
providers about alternatives to incarceration, arrest and law enforcement contact. The
Forensic, Diversion and Re-entry Services Director reported that there are multiple
meetings with the Sherriff’s Office.
Requirement: The County will provide information and education to ACBHD-contracted
behavioral health providers about available community-based services that can provide
alternatives to unnecessary institutionalization and hospitalization and reduce risk of
unnecessary law enforcement contact and will coordinate with these entities to rapidly
connect individuals to those services as appropriate.
Evidence was found of information and education provided to, or coordination with,
criminal justice entities for rapid connection to community-based services. ACBHD
provided many examples of training material that are used to educate providers about
available services. Some of these training topics were as follows: overview of working
First Six Months Report August 7, 2024
37
with participants in the criminal justice field, ACT, crisis services, youth justice, and re-
entry mental health programs. Interviews with community-based provider staff confirmed
that there is coordination with ACBHD regarding rapid connection to community-based
services as an alternative to hospitalization or incarceration. The Independent Reviewer
will provide more information regarding this rapid connection process in a subsequent
review.
Requirement: The County will work with law enforcement to direct referrals to the In-
Home Outreach Team (“IHOT”).
ACBHD has the following four In Home Outreach Teams (IHOT):
• One Transitional Age Youth (TAY) County-wide team and
• Three adult teams based on region.
The TAY IHOT team is comprised of a clinician, two peer providers, and one family
member provider. The Adult IHOT teams are comprised of one licensed team lead, a
case manager, a peer provider and a family member provider. All teams provide family
members support and education. The purpose of IHOT is to outreach and engage
individuals who have historically been difficult to engage into services. IHOT also
provides linkages with services that address serious mental health issues and
substance use. Law enforcement may refer to IHOT as described in the IHOT
Operations Manual and in the ACBHD contract scope of work. In future reports, the
Independent Reviewer will assess additional evidence to ensure the requirement is
occurring in practice and is sustained in a durable manner.
IHOT (Adobe Services) reported the following challenges in the MHSA Annual Update
(Draft) for FY 24/25:
“If the client is homeless, major challenges have been locating said client, or
giving a referral from a source that has never met said client and cannot do a
warm introduction or provide accurate whereabouts. Overall, given the short
timeframe to introduce services and produce positive results can be unfeasible at
times due to inadequate rapport building and clients' distrust in mental health
resources and county systems, which often times stem from a history of
involuntary hospitalization and/or incarceration. These factors can lead to the
team struggling to find an ethical discharge plan and may result in clients being
enrolled in the program outside of set timeframes” (Page 242).
Requirement: The County will ensure that people with co-occurring SUD can access
and receive services, including through the development of two (2) substance use
mobile outreach teams, within two years of the Effective Date.
This requirement will be discussed in subsequent reports.
Requirement: In-Reach to, and Discharges to Community-Based Services from,
Medicaid Institutions for Mental Diseases (“IMDs”). “IMD” as used in this Settlement
Agreement, refers to Villa Fairmont Mental Health Rehabilitation Center, Gladman
First Six Months Report August 7, 2024
38
Mental Health Rehabilitation Center, and Morton Bakar Center. Within 12 months of the
effective date of this Agreement, the County will begin initial implementation of a
utilization review (“UR”) pilot program. The UR pilot program will be designed to ensure
that individuals are transitioned to and live in the most integrated setting appropriate to
the individual’s needs and to reduce the length of IMD stays where appropriate. As part
of the UR pilot program the County will review clinical records and engage in peer-to-
peer meetings to assess appropriateness for discharge in light of community-based
services appropriate to the individual.
This requirement will be discussed in subsequent reports.
Requirement: Promptly after an individual eligible for ACBHD services is admitted to an
IMD in the County, the individual will begin receiving discharge planning services. The
individual’s discharge plan will include transitioning the individual to the most integrated
setting appropriate to the individual’s needs, consistent with the individual’s
preferences. As part of assisting individuals to transition to the most integrated setting
appropriate, appropriate community-based services will be identified. Where applicable
and with the individual’s (and, when relevant, his or her legal representative’s) consent,
FSP and Service Team providers will participate in the discharge planning process.
Discharge begins at intake per community-based provider staff interviewed, and per the
ACBHD contract. ACBHD provided examples of contracts that require the placement be
of a less-intensive level of care and includes the appropriate referrals to community-
based providers. Community-based provider staff interviewed reported that they
participate in the discharge planning process. Interview with Adult and Older Adult
System of Care Director indicated that there is an acute care coordination meeting
every week. The purpose of this meeting is to review cases and to monitor the client’s
progress and transition to a different level of care, as appropriate. In future reports, the
Independent Reviewer will assess additional evidence, including individual client
interviews, and client records sampling, to ensure the requirement is occurring in
practice and is sustained in a durable manner.
Requirement: If the unavailability of FSP or Service Team services is preventing
discharge from an IMD to a community setting, then the director of ACBHD (or
designee) will be notified, and the County will work to arrange such services as promptly
as possible.
Community-based providers, ACBHD staff, and ACBHD Senior Executive Team
reported that there have not been any situations where a FSP team or Service Teams
were not available to take a case. While it is not required by the Settlement Agreement,
this issue is not tracked in the Quality Improvement Work Plan where any of these
situations could be monitored on a regular basis for a quality assurance perspective.
Interviews with ACBHD staff and community-based providers conducted during the on-
site review reported that they have always been able to accommodate the individual’s
needs for either FSP or Service Team.
First Six Months Report August 7, 2024
39
Requirement: The County will promptly notify ACBHD-contracted FSP and Service
Team providers when their clients are receiving care at an IMD, to ensure that the
provider promptly resumes services upon discharge, as appropriate.
Interview with Adult and Older Adult System of Care Director indicated that there is an
acute care coordination meeting every week. The purpose of this meeting is to review
cases and to monitor the client’s progress and transition to a different level of care, as
appropriate. In future reports, the Independent Reviewer will assess the notification
process and how services are resumed upon discharge.
Requirement: Linkages for Services Following Discharge from John George PES and
Inpatient. The Parties understand that John George is required to provide discharge
planning to and effectuate safe discharges of patients at John George PES and John
George inpatient in compliance with applicable laws, regulations, and contractual
obligations, including, but not limited to, 42 C.F.R. § 482.43 and California Health &
Safety Code §§ 1262 and 1262.5. The County will collaborate with John George to
support John George’s safe and effective discharges of eligible individuals from John
George PES and John George inpatient to community-based services as appropriate,
including through ACBHD’s critical care managers and contracted community-based
providers, with the goal of increasing the prompt connection to community-based
services for patients that are eligible and appropriate for community-based services.
The County will request that John George promptly notify the County when it identifies
someone who may be eligible for any such services.
Beginning no later than eighteen (18) months after the Effective Date, the County’s
role in this collaboration will include, to the fullest extent reasonably practicable: (1)
using available data to promptly identify individuals registered by John George who are
both (a) likely to be, for reasons related to their serious mental illness, at risk of
unnecessary institutionalization, hospitalization, or incarceration, and (b) likely to be
eligible for and in need of FSP or Service Team services; (2) upon identification, to the
extent that the individual has not yet been discharged, promptly coordinate with John
George to determine whether the individual is eligible for and in need of any such
services; and (3) if the individual is eligible for and in need of any such services and to
the extent that the individual has not yet been discharged, promptly connecting the
individual to an FSP or Service Team to commence engagement, which may include
participation in discharge planning and commencement of services upon the individual’s
discharge.
Community-based providers, ACBHD staff, and ACBHD Senior Executive Team
reported their relationship has improved with John George. The Adult and Older Adult
System of Care Director reported that they now have access to John George’s
electronic health record which indicates progress, and they receive client updates twice
a week now.
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40
John George has three units for a total of 69 beds and an additional 11 beds for
Psychiatric Emergency Services (PES) for a grand total of 80 beds. Overall, the ACBHD
Senior Executive team and ACBHD staff reported that their relationship with John
George Hospital has improved recently. ACBHD Senior Executive Team reported that
ACBHD staff are invited to participate in the discharge process.
There are portions of this requirement that are not due to begin until eighteen months
from the effective date of the Settlement Agreement and will be discussed in a
subsequent report.
Requirement: The County will request that John George Psychiatric Hospital invite and
actively include representatives of an individual’s FSP or Service Team (if any) in the
discharge planning process and, with respect to patients determined eligible for and in
need of such services under section II.4.k.ii above, invite and actively include
representatives of the County or a County-contracted community based service provider
in the discharge planning process. To the fullest extent reasonably practicable and
within the direct control of the County and its community-based service providers, and
with the individual’s consent, the County will ensure that: (1) representatives of the FSP
or Service Team are included in the discharge planning process for those individuals
who are assigned to or are clients of a County FSP or Service Team; and (2)
representatives of the County or a County contracted community-based service provider
are included in the discharge planning process for those individuals who are not
assigned to an FSP or Service Team but who have been identified as eligible for an FSP
or Service Team under section II.4.k.ii above. To the extent that John George routinely
does not include such representatives in the discharge planning process, the County
will seek to identify and reasonably address barriers to John George’s inclusion of such
representatives in discharge planning.
The ACBHD Senior Executive Team and ACBHD staff reported that their relationship
with John George Hospital has improved recently. ACBHD Senior Executive Team
reported that ACBHD staff are invited to participate in the discharge process. The Senior
Executive Team also reported that the goal is for prompt connection to community-
based services. There are two Critical Care Managers that assist with acute inpatient
care coordination between the following: acute and subacute, acute and crisis
residential, inpatient and outpatient, and discharge planning. John George attends the
weekly care coordination meeting and care conferences, as needed. The Independent
Reviewer will follow up on the attendance and frequency of meetings regarding the
discharge process.
The Adult and Older Adult System of Care Director reported that they are creating a
transition team to engage with the client in the hospital and to assist with their transition
back into the community. This new team is not operational yet. The Independent
Reviewer will continue to monitor this requirement and will include this in subsequent
reports.
First Six Months Report August 7, 2024
41
The chart below is the number of clients served based on data during FY 2022-23.
Service Modality Number of
Episodes
Number of
Clients
Crisis Stabilization 8,584 4,270
Hospital 2,304 1,564
Requirement: Beginning no later than eighteen (18) months after the Effective Date,
the County will use electronic health record and registration information provided to the
County by John George Psychiatric Hospital to promptly identify individuals with serious
mental illness who are discharged to the community and who are, for reasons related to
their serious mental illness, at risk of unnecessary institutionalization, hospitalization, or
incarceration in accordance with section II.4.e. and will comply with its obligations under
section II.4.c.
This requirement will be discussed in subsequent reports.
Requirement: The County will use programs designed to reach individuals who do not
follow up regarding services.
The Adult and Older Adult System of Care Director reported that the County has an
Outreach and Engagement(O&E) team. There are also three community-based
providers who provide outreach and engagement services. One example is from BACS,
a community-based provider, who has an Assertive Outreach Protocol for clients who
do not engage or follow-up for services. This protocol requires the community-based
provider staff to continue outreach and engagement efforts for minimum of 90 days from
the last date of service. In future reports, the Independent Reviewer will assess
additional evidence to ensure services are designed to achieve the outcomes described
in the above requirement.
Requirement: The County will collaborate with John George to ensure that John
George promptly notifies FSP and Service Team providers when their clients are
registered or admitted to receive John George PES or John George inpatient care, to
facilitate the FSP’s or Service Team’s prompt resumption of services upon discharge.
The Adult and Older Adult System of Care Director reported that they now have access
to John George’s electronic health record, and they receive client updates twice a week
now. Further, the new Transition of Care team will assist with notification of FSPs and
Service Teams when their clients are at John George. The Independent Reviewer will
monitor this requirement and will discuss this in subsequent reports.
Requirement: Linkages for Services Following Release from Santa Rita Jail. This
Agreement does not govern the provision of mental health services or treatment at
Santa Rita Jail and does not duplicate, modify, or override any provisions in the Babu v.
County of Alameda Consent Decree (including section III.I, “Discharge Planning,” page
49:13-51:18).The County will ensure that ACBHD collaborates with the County Sheriff’s
First Six Months Report August 7, 2024
42
office and will use its best efforts to identify and implement appropriate strategies to
improve warm handoffs of Behavioral Health Clients (as defined in the Babu consent
decree) who are eligible for ACBHD services.
The Forensic, Diversion and Re-entry Services Director reported that there are multiple
meetings with the Sherriff’s Office. For example, leadership meets twice a month, re-
entry staff meet weekly and suicide risk meets monthly. The Director reported that there
are two dedicated FSP teams that are through contracts with community-based
providers. There is also one re-entry team, and this team will refer to community-based
services. The Director also described the Community Assessment, Referral and
Engagement Services (C.A.R.E.S) program. This program diverts individuals away from
jail and the criminal justice system and into supportive services and referrals are from
law enforcement.
Requirement: Beginning no later than eighteen (18) months after the Effective Date,
the County will periodically (at least every six months) evaluate FSPs’ and Service
Teams’ (a) participation in discharge and reentry planning for their clients following
notification of incarceration, (b) participation in discharge and reentry planning for
incarcerated individuals referred to such provider, and (c) their success in re-engaging
or newly engaging their client upon release. This evaluation will include analysis of
timeliness, trends, and causes of identified problem areas. The Parties understand that
FSP and Service Team participation in discharge and reentry planning may be provided
through the use of telephonic or other electronic communication when clinically
appropriate or as necessary to respond to public health considerations.
This requirement will be discussed in subsequent reports.
Requirement: Beginning no later than six (6) months after the Effective Date, the
County will document all situations in which an individual identified by ACBHD as
eligible and in need of FSP or Service Team Services and such FSP or Service Team
services were not immediately available upon release and will conduct regular quality
reviews to identify such situations.
The ACBHD Senior Executive Team and community-based staff and supervisor
reported that there has not been a situation where services were not available.
However, this requirement was not due during this reporting period, it will be discussed
further in subsequent reports.
Requirement: With the goal of reducing risk of unnecessary institutionalization,
incarceration, and law enforcement contacts, the County will take appropriate action, if
any, based on the results of the evaluation in section II.4.i.ii. and the quality reviews in
section II.4.l.iii. Where appropriate, the results of the quality reviews under section
II.4.l.iii will inform the County’s FSP Assessment under section II.2.c.
This requirement will be discussed in subsequent reports.
First Six Months Report August 7, 2024
43
Requirement: The County will use programs designed to reach individuals who do not
follow up regarding services, consistent with section II.4.e.
The Forensic, Diversion and Re-entry Services Director reported that there is one re-
entry team who follows-up with these individuals. In future reports, the Independent
Reviewer will assess additional evidence to ensure services are designed to achieve
the outcomes described in the above requirement.
Summary of Outreach, Engagement, Linkages, and Discharge Planning Findings
As stated previously, no substantial compliance was given for this initial report since the
Settlement Agreement requires substantial compliance for six months and this report
was produced only five months after the Effective Date of the Settlement Agreements.
This is the largest service commitment in the Settlement Agreement. Overall, there are
twenty-six service commitments in the Outreach, Engagement, Linkages and Discharge
Planning component of the Settlement Agreement. ACBHD received partial compliance
for sixteen service commitments and a rating of not applicable for ten service
commitment. There were no non-compliant ratings given in this section.
ACBHD achieved Partial Compliance for the following requirements:
1. The County will maintain a 24/7 telephonic hotline (the ACCESS line or its
successor) to aid in implementing the provisions below. There is evidence to
support this requirement, but the Independent Reviewer needs to examine again
after six months.
2. The County will make meaningful efforts to create a system to provide real-time
appointment scheduling, timely in-the-field assessments, and authorization of
services by ACCESS, in order to facilitate prompt and appropriate connection to
services. While the County is making meaningful efforts on this requirement, the
Independent Reviewer will provide more information on the progress of these
efforts in subsequent reports.
3. When an individual with serious mental illness (1) is identified by the County
through section II.4.e, or (2) contacts (or another individual does so on his or her
behalf) the County (e.g., the ACCESS program or its successor) or an ACBHD
contracted entity for behavioral health services, the County or an ACBHD
contracted community provider will determine the person’s eligibility for
community-based behavioral health services and, will provide a complete clinical
assessment. The Independent Reviewer will need to review additional client
records and other information for subsequent reports.
4. Following such assessment, individuals determined to be eligible for and in need
of FSP or Service Team services will be assigned to an FSP or Service Team’s
caseload to commence the provision of services. The Independent Reviewer will
First Six Months Report August 7, 2024
44
need to review additional client records and other information for subsequent
reports.
5. This assessment and assignment process will be promptly completed, and those
services initiated in a prompt manner sufficient to reduce the risk of prolonged
and future unnecessary institutionalization, hospitalization, or incarceration. The
Independent Reviewer will need to review additional client records and other
information for subsequent reports.
6. The County will explore, collaborate with, and support as appropriate programs
that provide connection to community-based services as alternatives to
incarceration. The County will provide information and education to prosecutors,
public defenders, courts and law enforcement about available community-based
services that can provide alternatives to incarceration, arrest, and law
enforcement contact and will coordinate with these entities to rapidly connect
individuals to those services as appropriate. Evidence was found on the
collaboration and with providing education and training to the justice system.
However, the Independent Reviewer will need to verify that this process is
continuing and is maintained.
7. The County will provide information and education to ACBHD-contracted
behavioral health providers and will coordinate with these entities to rapidly
connect individuals to those services as appropriate. Evidence was found of
information and education provided to, or coordination with, criminal justice
entities for rapid connection to community-based services. But the Independent
Reviewer will need to obtain additional information on the rapid connection
process.
8. The County will work with law enforcement to direct referrals to the In-Home
Outreach Team (“IHOT”). While there is evidence of steps taken by ACBHD, the
Independent Reviewer will need to interview IHOT staff for a subsequent report.
9. Promptly after an individual eligible for ACBHD services is admitted to an IMD in
the County, the individual will begin receiving discharge planning services. The
individual’s discharge plan will include transitioning the individual to the most
integrated setting appropriate to the individual’s needs, consistent with the
individual’s preferences. While there was evidence of discharge planning, the
Independent Reviewer will need to examine this process more fully in
subsequent reviews.
10. If the unavailability of FSP or Service Team services is preventing discharge from
an IMD to a community setting, then the director of ACBHD (or designee) will be
notified, and the County will work to arrange such services as promptly, as
possible. There was evidence that ACBHD has always been able to provide FSP
or Service Team services, the Independent Reviewer will request additional
information on how ACBD tracks this requirement.
11. The County will promptly notify ACBHD-contracted FSP and Service Team
providers when their clients are receiving care at an IMD, to ensure that the
provider promptly resumes services upon discharge, as appropriate. While there
First Six Months Report August 7, 2024
45
is evidence of care coordination occurring, the Independent Reviewer will need to
explore this issue more fully in subsequent reports.
12. The County will request that John George Psychiatric Hospital invite and actively
include representatives of an individual’s FSP or Service Team (if any) in the
discharge planning process and, invite and actively include representatives of the
County or a County-contracted community based service provider in the
discharge planning process. There is evidence of the care coordination, the
Independent Reviewer will continue to monitor this requirement and will report on
it in subsequent reports.
13. The County will use programs designed to reach individuals who do not follow
up regarding services. While there is evidence to support the follow up regarding
services, the Independent Reviewer will need to interview the Outreach and
Engagement Team in a subsequent report.
14. The County will collaborate with John George to ensure that John George
promptly notifies FSP and Service Team providers when their clients are
registered or admitted to receive John George PES or John George inpatient
care, to facilitate the FSP’s or Service Team’s prompt resumption of services
upon discharge. The Independent Reviewer will monitor this requirement and will
discuss this in subsequent reports.
15. The County will ensure that ACBHD collaborates with the community’s office and
will use its best efforts to identify and implement appropriate strategies to
improve warm handoffs of Behavioral Health Clients (as defined in the Babu
consent decree) who are eligible for ACBHD services. There is evidence to
support this requirement, the Independent Reviewer needs to examine this
process for subsequent reports.
16. The County will use programs designed to reach individuals who do not follow up
regarding services, consistent with Section II.4.e. While there is evidence to
support compliance with this requirement, the Independent Reviewer will need to
interview O&E staff for subsequent reports.
ACBHD achieved Not Applicable for the following:
1. Beginning no later than six (6) months after the Effective Date, the County will
document all situations in which an eligible individual is assessed as in need of
FSP or Service Team services, but such FSP or Service Team services were not
immediately available and will conduct regular quality reviews to identify such
situations.
2. Within two (2) years of the effective date of the Agreement requires ACBHD to,
the County will develop, implement, and staff a System Coordination Team to
improve linkages to community-based services across the County’s behavioral
health system. The System Coordination Team will coordinate system care and
improve transitions of care.
3. The County will implement a system to identify and provide proactive outreach
and engagement to individuals with serious mental illness who are, for reasons
First Six Months Report August 7, 2024
46
related to their serious mental illness, at risk of unnecessary institutionalization,
hospitalization, or incarceration. Beginning no later than six (6) months after the
Effective Date, the County will track progress in connecting individuals to needed
services.
4. The County will ensure that individual’s with co-occurring SUD can access and
receive services, including through the development of two (2) substance use
mobile outreach teams, within two years of the Effective Date.
5. In-Reach to, and Discharges to Community-Based Services from, Medicaid
Institutions for Mental Diseases (“IMDs”). “IMD” as used in this Settlement
Agreement, refers to Villa Fairmont Mental Health Rehabilitation Center,
Gladman Mental Health Rehabilitation Center, and Morton Bakar Center. Within
12 months of the effective date of this Agreement, the County will begin initial
implementation of a utilization review (“UR”) pilot program.
6. The County will collaborate with John George to support John George’s safe and
effective discharges of eligible individuals from John George PES and John
George inpatient to community-based services as appropriate. Beginning no later
than eighteen (18) months after the Effective Date, the County’s role in this
collaboration will include, (1) using available data and likely to be eligible for FSP
or Service Team services; (2) upon identification, promptly coordinate with John
George; and (3) if the individual is eligible, promptly connecting the individual to
an FSP or Service Team.
7. Beginning no later than eighteen (18) months after the Effective Date, the
County will use electronic health record and registration information provided to
the County by John George Psychiatric Hospital.
8. Beginning no later than eighteen (18) months after the Effective Date, the
County will periodically (at least every six months) evaluate FSPs’ and Service
Teams’ (a) participation in discharge and reentry planning for their clients
following notification of incarceration, (b) participation in discharge and reentry
planning for incarcerated individuals referred to such provider, and (c) their
success in re-engaging or newly engaging their client upon release. This
evaluation will include analysis of timeliness, trends, and causes of identified
problem areas. The Parties understand that FSP and Service Team participation
in discharge and reentry planning may be provided through the use of telephonic
or other electronic communication when clinically appropriate or as necessary to
respond to public health considerations.
9. Beginning no later than six (6) months after the Effective Date, the County will
document all situations in which an individual identified by ACBHD as eligible and
in need of FSP or Service Team Services and such FSP or Service Team
services were not immediately available upon release and will conduct regular
quality reviews to identify such situations.
10. With the goal of reducing risk of unnecessary institutionalization, incarceration,
and law enforcement contacts, the County will take appropriate action, if any,
First Six Months Report August 7, 2024
47
based on the results of the evaluation in section and the quality reviews in
section II.4.l.iii.
CULTURALLY RESPONSIVE SERVICES
The Settlement Agreement outlines the service components under Culturally
Responsive Services which include the County continuing ensure that all services are
culturally responsive and are person-centered. In Alameda County, Culturally
Responsive Services is organized under the Office of Health Equity with a Director who
reports directly to the Behavioral Health Director. The Independent Reviewer was able
to interview this Director, the Behavioral Health Director and ACBHD’s Senior Executive
Team.
Requirement: The County will continue its ongoing efforts to ensure that all services
provided under this Agreement are culturally responsive and are person-centered. The
County will continue to provide and expand culturally responsive behavioral health
services, including through community-based and peer-run organizations, and will
continue to identify and implement culturally and linguistically appropriate and affirming
strategies and practices to help reduce behavioral health disparities across racial,
ethnic, cultural, and linguistic groups.
ACBHD developed a strategic plan that was issued on April 22, 2024, with seven
themes and strategic directions. There are two goals in this plan that are related to
Culturally Responsive Services. The first goal is to uplift community assets for
policy/program development and the second goal is to increase equitable care for
communities facing the greatest inequities through outreach, recruitment, and programs
and opportunities for improvement especially for diverse Asian, Black, and
LGBTQIA2S+ communities.
ACBHD has a Cultural Competence Plan (CCP), 2023. The plan describes the
following:
• Vision: We envision a community where all individuals and their families can
successfully realize their potential and pursue their dreams where stigma and
discrimination against those with mental health and/or alcohol and drug issues
are remnants of the past.
• Mission: To support and empower individuals experiencing mental health and
substance use conditions along their path towards wellness, recovery, and
resiliency.
• Values: Access, consumer and family empowerment, best practices, health and
wellness, culturally responsive, and socially inclusive.
The MHSA Annual Plan Update (Draft) for Fiscal Year 2024 through 2025 includes the
goal of being culturally responsive which is defined as follows:
First Six Months Report August 7, 2024
48
“We honor the voices, strengths, leadership, languages and life experiences of
ethnically and culturally diverse consumers and their families across the lifespan.
We value operationalizing these experiences in our service setting, treatment
options, and in the processes, we use to engage our communities” (Page 10).
The MHSA Annual Plan Update (Draft) for FY24/25, identifies several recurring themes
as identified by numerous listening sessions. One theme identified was “Access,
Coordination and Navigation to Services”. The plan lists two strategies and solutions
related to cultural competency which are as follows:
• Prioritize bilingual services to support multiple languages in the growing client
base and improve accessibility for diverse communities.
• Implement culturally sensitive and appropriate outreach strategies to effectively
engage diverse communities (Page 53).
Interviews with both ACBHD staff and community-based provider staff indicated that the
services provided are culturally responsive and person centered. The Independent
Reviewer was able to review a number of client records where the client’s goals are
identified and were developed in a manner consistent with a person-centered approach.
However, it is difficult to draw any substantial conclusions due to the small number of
client records reviewed and the lack of formal client interviews.
The MHSA Three Year Program and Expenditure Plan Fiscal Year 2023 through 2026,
states that three of the reoccurring themes in the community listening session were as
follows: “More services for the African American community across the lifespan;
supports and activities for the LGBTQ community, particularly the transgender
community of color and sex workers and; and the need for increased language
capacity” (Page 65).
Alameda has six threshold languages as defined by DHCS Information Notice #20-070.
The most prevalent threshold language is Spanish. The CCP includes a snapshot of
data from the FY2022-23, and the largest ethnic group served in their system are
Other/Unknown and White, followed by Black or African American. The smallest group
within their system of care is Alaska Native or American Indian. The CCP also states
that there is a “high penetration rate among African Americans, who receive care in the
most severe forms of mental health treatment. (Cultural Competency Plan, 2023, Page
8).
According to the External Quality Review Organization (EQRO) report for FY2023-24,
African American and Asian/Pacific Islander members are the only racial/ethnic groups
with penetration rates lower than statewide penetration rates. The EQRO report also
provided a breakdown for each ethnicity and penetration rate as follows:
ACBHD Mental Health penetration rate of Members Served by Race/Ethnicity, Calendar
Year 2022
First Six Months Report August 7, 2024
49
Race/Ethnicity
Total Members
Eligible
Number of
Members
Served
ACBHD
Penetration
Rate
Statewide
Penetration
Rate
Hispanic/Latino 137,869 5,005 3.63% 3.51%
Other 127,820 5,017 3.93% 3.57%
Asian/Pacific
Islander
99,830 1,433 1.44% 1.91%
African American 70,740 4,937 6.98% 7.08%
White 44,728 2,483 5.55% 5.45%
Native American 1,066 74 6.94% 5.94%
FY 2023-24 Medi-CAL Specialty Behavioral Health External Quality Review Alameda Final Report
ACBHD also conducts a Cultural Responsiveness Committee (CRC) and the
community-based providers also reported that the County staff, community-based
providers staff, and stakeholders attend these meetings. The Independent Reviewer did
review the minutes of the March 19, 2024, meeting which was facilitated by the Health
Equity Policy and Systems Manager. During the meeting, the CCP is discussed along
with announcements and upcoming events of interest.
In future reports, the Independent Reviewer will assess additional evidence, including
data, individual client interviews, and client records sampling, to ensure the requirement
is occurring in practice and is being sustained in a durable manner.
Requirement: The County will continue to operate the Office of Health Equity within
ACBHD, and the Division Director of the Office of Health Equity will continue to serve as
the departmental Health Equity Officer, reporting to the Director of ACBHD, and will
oversee the existing Office of Ethnic Services. The Health Equity Officer will continue to
work in collaboration with community stakeholders to promote social and behavioral
health equity reform and inclusion, and to ensure clients receive high quality and client
centered care that considers the whole person and all their needs.
ACBHD provided an organizational chart that indicates that the Director, Office of Health
Equity reports directly to the ACBHD Director. The Independent Reviewer interviewed
the Director, Office of Health Equity. This department also includes Ethnic Services,
Peer Support Services and Family Empowerment Services. The department also
oversees operations related to Patients’ Right Advocacy.
In December 2023, ACBHD conducted a listening session with the Executive Team at
the LGBTQ Center in Oakland and learned more about the needs of its clients and the
LGBTQ Community. This was reported in the MHSA Annual Plan Update (Draft) for FY
24/25 which included the following:
“They are seeing a need for more programs to address social isolation in the
elderly population. The housing being developed is not created with LGBTQ
concerns in mind and accommodations for the LGBTQ community are leading to
displacement from new developments. Also, needs for LGBTQ people in
homeless encampments need to be addressed due to rising threats and
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50
violence. HIV is an ongoing problem that is receiving less resources but still
needs to be addressed. Overall, the LGBTQ Center is looking to bring on a care
navigator and would like to continue to participate in county programs” (Page
441).
Requirement: No later than fifteen (15) months after the Effective Date of this
Agreement, the Health Equity Officer will host a stakeholder and community input
meeting. In order to deepen meaningful community stakeholder engagement, no later
than one month before the stakeholder and community input meeting, the Office of
Health Equity will make a dashboard publicly available on the Office of Health Equity’s
public internet website setting forth aggregated data metrics on the populations served
by ACBHD (including individual racial and ethnic groups broken down by geographic
area within the County) and various communities’ service needs (including racial and
ethnic groups’ needs for FSP, Service Team, and IHOT services in geographic areas
within the County.
ACBHD has already begun to work on the dashboard and expects to have it uploaded
to their website by February 2025. Subsequent reports will address this further.
Requirement: The Health Equity Officer will thoroughly review the feedback from the
stakeholder/community input meetings on how to improve culturally responsive services
in the County. The Health Equity Officer will periodically make recommendations to the
Director of ACBHD on how to improve culturally responsive services in the County and
coordinate with the County’s other diversity, equity, and inclusion programs and
activities.
This will be discussed in subsequent reports since this requirement is not due at this
time.
Requirement: The County will continue to support the African American Wellness Hub
capital facilities project, with the goal of aligning culturally relevant and community
focused services for Black/African American residents within the County’s service
delivery system. The African American Wellness Hub facility will serve as a hub and
coordinating center for a variety of behavioral health services, community-based
supports, and linkages for the Black/African American community in the County. The
County will provide opportunities for community and stakeholder engagement over the
course of this project to further the project’s focus on providing culturally inclusive,
respectful, and relevant supports to the County’s Black/African American clients and
community.
The County is to support the African American Wellness Hub and the Health Equity
Division Director reported that the County has found a building and they recently closed
escrow on the building. ACBHD conducted community listening sessions in April and
May of 2023. The African American Wellness Hub will serve as a focal point
designed to preserve and actualize the core understanding and best practices of African
American people with a focus on wellness. The County has dedicated $19 Million
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51
dollars towards this effort. The Independent Reviewer will continue to monitor this and
report on the progress in subsequent reports.
Requirement: The County has implemented and will continue to provide periodic and
ongoing trainings to all ACBHD staff and ACBHD-contracted community-based
providers regarding: culturally responsive services; trauma-informed care; inequities
across race, ethnicity, sex, sexual orientation, gender identity, and disability; anti-racism
and implicit bias. A primary intent of such trainings is to ensure the delivery of culturally
responsive services and to increase engagement across historically underserved
populations.
Training is provided upon hire and throughout the year. The ACBHD Health Equity
Division Director reported that training is under the purview of the Office of Ethnic
Services within ACBHD Department in collaboration with the Workforce and Education
Team. The Health Equity Division Director also reported that the County has a contract
with ONTRACK to provide the CLAS training and offers training each month. For the
community-based providers, the following language was found in their contract with
ACBHD: “Contractor shall maintain staffing with professional experience and expertise
in providing evidence-based, culturally, and linguistically appropriate services,
particularly for any designated priority populations that Contractor has agreed to serve.
Contractor shall ensure annual training of all applicable employees.”
The Independent Reviewer will request additional information such as training topics
and number of attendees for subsequent reports.
Summary of Culturally Responsive Services Findings
As stated previously, no substantial compliance was given for this initial report since the
Settlement Agreement requires substantial compliance for six months and this report
was produced only five months after the Effective Date of the Settlement Agreements.
Overall, there are six service commitments in the Culturally Responsive Services
component of the Settlement Agreement. ACBHD received partial compliance for three
service commitments and a rating of not applicable for three service commitments.
There were no non-compliant ratings given in this section.
ACBHD achieved Partial Compliance for the following requirements:
1. The County will continue its ongoing efforts to ensure that all services provided
under this Agreement are culturally responsive and are person-centered. While
there is evidence to support compliance with this requirement, the Independent
Reviewer will continue to monitor the County’s ongoing efforts and will report on
these efforts in subsequent reports.
2. The County will continue to operate the Office of Health Equity within D, will
report to the Director of ACBHD, and will oversee the existing Office of Ethnic
Services. The Health Equity Officer will continue to work in collaboration with
community stakeholders and to ensure clients receive high quality and client
First Six Months Report August 7, 2024
52
centered care that considers the whole person and all their needs. While there is
evidence to support compliance with this requirement, the Independent Reviewer
will need to continue to monitor the stakeholder engagement and will need to
interview clients who have received services.
3. The County has implemented and will continue to provide periodic and ongoing
training to all ACBHD staff and ACBHD-contracted community-based providers.
The primary intent of such training is to ensure the delivery of culturally
responsive services and to increase engagement across historically underserved
populations. While there is evidence of the training provided, the Independent
Reviewer will request additional information such as training topics and number
of attendees for subsequent reports.
ACBHD achieved Not Applicable for the following:
1. No later than fifteen (15) months after the Effective Date of this Agreement, the
Health Equity Officer will host a stakeholder and community input meeting. In
order to deepen meaningful community stakeholder engagement, no later than
one month before the stakeholder and community input meeting, the Office of
Health Equity will make a dashboard publicly available on the Office of Health
Equity’s public internet website.
2. The Health Equity Officer will thoroughly review the feedback from the
stakeholder/community input meetings on how to improve culturally responsive
services in the County.
3. The County will continue to support the African American Wellness Hub capital
facilities project, with the goal of aligning culturally relevant and community
focused services for Black/African American residents within the County’s service
delivery system. The County has found a building and they recently closed
escrow on the building.
SUMMARY AND RECOMMENDATIONS
This is the first initial report from the Independent Reviewer regarding the Settlement
Agreement between the County of Alameda and ACBHD with Disability Rights California
(DRC), and the United States Department of Justice (DOJ) which became effective on
January 31, 2024. ACBHD has been very cooperative in providing the information
requested by the Independent Reviewer.
A rating of partial compliance was given in 62.5 percent of the service commitments and
a rating of not applicable was given for 37.5 percent of the service commitments.
This is the first report on the progress towards compliance with the Settlement
Agreement and there has not been enough time for the County and ACBHD to
implement everything in the Settlement Agreement nor for the Independent Reviewer to
First Six Months Report August 7, 2024
53
gather and review all of the necessary evidence. As stated previously, the Settlement
Agreement defined substantial compliance when the requirement has been sustained
and durable for a period of no less than six months. Because the on-site review
occurred after four months of the effective date and the draft of this report was due in
five months, no substantial compliance ratings were given. Therefore, it should be noted
that in some cases, this is not a reflection of the County’s compliance with the
requirements.
The Independent Reviewer will continue to evaluate implementation of all provisions.
The Independent Reviewer will also verify if the requirements were sustained after six
months and durable in the next report for any of the partial compliance ratings given.
The Independent Reviewer will also monitor the implementation of any of the
requirements given a not applicable rating if the deadline is during the next report.
The next report is to be submitted 14 months after the effective date of the Settlement
Agreement. The Independent Reviewer would like to focus the next on-site visit on a
tour of John George, interviewing FSP participants, a ride along with the mobile crisis
team, reviewing additional client records, and touring other ACBHD contracted
community-based providers. The Independent Reviewer will also monitor the
implementation and results of both the Mobile Crisis Assessment and the FSP
assessment.
Recommendations:
1. ACBHD currently collects a lot of data, but data is not a requirement of the
Settlement Agreement. However, reviewing data can indicate compliance with a
requirement and thus plays an important role in the determination of compliance.
The Independent Reviewer will work with ACBHD to identify appropriate and/or
alternative sources of data and evidence and will examine if the data can be
collected for future reports to ensure the requirements are occurring in practice
and is being sustained in a durable manner.
2. ACBHD also identified the need to expand CSU, CRT, peer respite, and mobile
crisis teams. ACBHD will continue to monitor the implementation of Prop1 as
some of these facilities may qualify for funding. In addition, it will be important to
review the results of the Mobile Crisis Assessment to assist with expansion of
crisis services.
3. The crisis services continuum of care seems to be disjointed and not
coordinated. Along with the findings of the mobile crisis assessment, ACBHD
should consider ways to coordinate their services. This includes a determination
for which model of mobile crisis should respond to particular types of crisis
situations.
First Six Months Report August 7, 2024
54
4. ACBHD should monitor FSP services to make sure that the services are provided
with high fidelity to the ACT model and that the needed frequency, intensity, and
quality of services is being provided. The FSP assessment and implementation of
Prop1 may help with this issue.
5. The Settlement Agreement requires FSP participants to receive a housing
assessment. ACBHD should consider developing a formal housing assessment
with collaboration from their community-based providers, ACBHD could then
collaborate with CES to make sure their clients are receiving priority from CES.
6. ACBHD should examine the possibility of implementing real time scheduling
within their systems of care so that clients do not have to wait for a call back to
receive access to services. ACBHD currently has a pilot underway with Pathways
to Wellness where ACCESS coordinates a call with Pathways to Wellness staff
and connects the client to Pathways to Wellness in real time. The pilot is in its
first year and data will be collected on the efficacy of this pilot.
7. ACBHD should continue to work with John George and Santa Rita jail to ensure
a warm hand-off to community based services. The new transition team should
be able to assist with care coordination, but this team will not be implemented for
another year.
First Six Months Report August 7, 2024
55
Attachment 1: Ratings of Service Commitments
SERVICE COMMITMENT RATING3
1. Crisis Services
1.a. The County will continue to offer a countywide crisis system and expand
crisis intervention services.
PC
1.a.i. Maintain a 24/7 crisis hotline. The crisis hotline will provide screening and
de-escalation services on a 24/7 basis. No later than 18 months after the
Effective Date, the County will expand the 24/7 crisis hotline to provide triage and
the identification of full service partnership clients on a 24/7 basis.
NA
1.a.i. (2) The County will coordinate with entities responsible for managing
urgent and emergency care response lines, including but not limited to the crisis
hotline, 911, FSP warmlines, and 988 (when and if such coordination is
available), to ensure there is “no wrong door” for accessing appropriate crisis
services. The County will have and will implement protocols for when to conduct
warm handoffs from its crisis hotline to FSP warmline teams to provide
appropriate services. The County will respond to 911-dispatch inquiries in order
to facilitate an appropriate behavioral health response to crises.
PC
1.a.i.(3) The County will implement protocols and education efforts to ensure
appropriate deployment of County mobile crisis teams in response to calls
received through emergency response lines.
NA
1.a.ii.(1) Mobile crisis teams will provide a timely in-person response to resolve
crisis as appropriate. When clinically appropriate, mobile crisis services may be
provided through the use of telehealth.
PC
1.a.ii.(2) Mobile crisis services shall be provided with the purpose of reducing, to
the greatest extent possible, interactions with law enforcement during mental
health crisis, reducing 5150 and John Geoge psychiatric emergency services
(PES) placement rates, and increasing the use of voluntary community-based
services (including diversion, care coordination, transportation, and post-crisis
linkages to services).
PC
1.a.ii.(3) The County has recently expanded its mobile crisis capacity to nine (9)
mobile crisis teams and agrees to maintain this as a minimum capacity.
PC
1.a.ii. (4) The County shall complete an assessment of needs and gaps in mobile
crisis coverage, no later than one year after the execution of this Agreement, that
is designed to determine the amount and number of mobile crisis teams needed
to provide mobile crisis services consistent with this Agreement (the “Mobile
Crisis Assessment”). The Mobile Crisis Assessment will be informed by and will
appropriately take into account (i) community and stakeholder input; and (ii) all
necessary data and information sufficient to assess the need for crisis services in
the County, which the County will collect and analyze as part of the Mobile Crisis
Assessment process.
NA
1.a.ii.(5)The County will provide a draft of the design of the Mobile Crisis
Assessment to the Independent Reviewer (see section III.1.a of this Agreement)
for review, feedback, and comment, and will appropriately take into account such
feedback and comment before proceeding with the Mobile Crisis Assessment. As
part of this review, the Independent Reviewer will provide the draft to, and
consider input from, DRC and the United States. The assessment and
conclusions in the final Mobile Crisis Assessment will promptly be made available
to the public.
NA
3 Due to the temporal limitations of this report, a rating of substantial compliance was not yet possible.
First Six Months Report August 7, 2024
56
1.a.ii.(6) Based on the County’s Mobile Crisis Assessment, the County will
reasonably expand its mobile crisis services as needed in order to operate a
sufficient number of mobile crisis teams to provide timely and effective mobile
crisis response.
NA
1.a.ii.(7) FSPs will provide crisis intervention as set forth in section II2.m. in this
Agreement.
PC
1.a.ii.(8) Each mobile crisis team shall include at least one mental health
clinician.
PC
1.a.iii. Trained peer support specialist shall be part of the County’s crisis service
team and shall be included in outreach and engagement functions.
PC
1.b.i. Maintain 45 crisis residential treatment (CRT) beds. PC
1.b.ii. Within two years of the effective date of the Agreement, the County will
make all reasonable efforts to contract with one or more community-based
providers to add a mixture of 25 additional CRT and/or peer-respite beds.
NA
1.b.iii. A purpose of CRT facilities and peer-respite is to promptly deescalate or
avoid a crisis and reduce unnecessary hospitalization. CRT facilities and peer-
respite homes are intended to be used by people experiencing or recovering from
a crisis due to their mental health disability for short-term stays and to provide
support to avoid escalation of a crisis. CRT facilities and peer-respite homes are
unlocked.
PC
1.b.iv. Peer staff will be on-site 24/7 at peer-respite homes. Peer-respite homes
shall serve no more than 6 individuals at a time.
NA
1.b.v. Individuals shall not be required to have identified housing as a condition of
admission to a CRT facility.
PC
1.b.vi. CRT facilities and peer-respite homes shall be able to accept admissions
directly from mobile crisis.
PC
1.c. The County’s crisis system will be designed to prevent unnecessary
hospitalization, IMD admissions, law enforcement interactions, and incarceration.
PC
2. Full-Service Partnerships (FSP)
2. a. and b. The County offers FSPs through community-based providers that
provide services under the Community Services and Supports (“CSS”) service
category, in accordance with 9 C.C.R. §§ 3620, 3620.05, and 3620.10. Within
two years from the effective date, the County will add 100 FSP slots for adults
and transition aged youth for a total of 1,105 FSP slots for that population. The
County will utilize the FSP slots that are added under this Agreement to serve
individuals 16 and older who meet FSP eligibility criteria under 9 C.C.R. §
3620.05.
NA
2.c. Within one year from the Effective Date, the County will complete an
assessment of needs and gaps in FSP services for individuals ages 16 years and
older that is designed to determine the number of additional FSP slots needed to
appropriately serve individuals ages 16 and older who meet FSP eligibility criteria
under 9 C.C.R. § 3620.05 (the “FSP Assessment”).
NA
2.d. The FSP Assessment will be informed by and will appropriately take into
account all necessary and appropriate data and information, which the County
will collect and analyze as part of the FSP Assessment process, including but not
limited to: i. Community and stakeholder input, including from FSP and other
contracted providers, from organizations who make referrals for FSP services or
regularly come into contact with individuals who are likely eligible for FSP
services, and from individuals who receive or may benefit from FSP services; ii.
NA
First Six Months Report August 7, 2024
57
Data regarding utilization of crisis services, psychiatric inpatient services, and
FSP and other CSS services; indicators of eligibility for FSP; and numbers of
individuals who have completed FSP eligibility assessments, outcomes following
assessment, and length of time from identification to enrollment; iii. Analysis of
numbers and demographics of sub-populations who (a) were not connected to
FSP services despite multiple visits/admissions to PES, John George inpatient,
and/or IMDs, (b) declined to consent to FSP services, or (c) stopped engaging
with FSP services, and analysis of relevant barriers or challenges with respect to
these groups; and iv. Research, literature, and evidence-based practices in the
field that may inform the need for FSP services in Alameda County.
2.e. The County will provide a draft of the design and methodology of the FSP
Assessment to the Independent Reviewer for review, feedback, and comment,
and will appropriately take into account such feedback and comment before
proceeding with the FSP Assessment. As part of this review, the Independent
Reviewer will provide the draft to, and consider input from, DRC and the United
States. Following the FSP Assessment process, the County will provide a draft of
the FSP Assessment report to the Independent Reviewer for review, feedback,
and comment, and will appropriately take into account such feedback and
comment before finalizing the County’s FSP Assessment report. As part of this
review, the Independent Reviewer will provide the draft to, and consider input
from, DRC and the United States. The assessment and conclusions in the final
FSP Assessment will promptly be made available to the public.
NA
2.f. Based on the County’s FSP Assessment, the County will further reasonably
expand its FSP program as necessary in order to appropriately serve individual
ages 16 and older who meet eligibility criteria under 9 C.C.R. § 3620.05
consistent with their preferences.
NA
2.g. and h. As used in this Agreement, one “slot” (such as an FSP slot or a
Service Team slot) means the ongoing capacity to serve one individual at a given
time. FSP will provide services necessary to attain the goal identifies in each FSP
recipients’ Individual Services and Supports Plan (ISSP) which may include the
Full Spectrum of Community Services, as defined in 9 C.C.R. § 3620(a)(1).
PC
2.i. Consistent with 9 C.C.R. § 3620(a), (g), and (h), each FSP recipient will have
an ISSP that is developed with the person and includes the person’s
individualized goals and the Full Spectrum of Community Services necessary to
attain those goals. Each FSP recipient will receive the services identified in their
ISSP, when appropriate for the individual.
PC
2.j. Services provided through FSP will be flexible and the level of intensity will be
based on the needs of the individual at any given time, including the frequency of
service contacts and duration of each service contact. To promote service
engagement, services will be provided in locations appropriate to individuals’
needs, including in the field where clients are located, in office locations, or
through the use of telephonic or other electronic communication when clinically
appropriate.
PC
2.k. FSPs serve the individuals described in 9 C.C.R. § 3620.05. FSPs will
provide their clients services designed to reduce hospitalization and utilization of
emergency health care services, reduce criminal justice involvement, and
improve individuals’ ability to secure and maintain stable permanent housing in
the most integrated setting appropriate to meet their needs and preferences.
PC
2.l. FSP program will be implemented using high fidelity to the Assertive
Community Treatment (ACT) evidence-based practice, including that: (i.) FSP
PC
First Six Months Report August 7, 2024
58
programs are provided by a team of multidisciplinary mental health staff who,
together, provide the majority of treatment, rehabilitation, and support services
that clients need to achieve their goals. (ii.) FSP teams operate at a 1:10 mental
health staff to client ratio.
2.m. FSPs will promptly provide crisis intervention 24/7, including, as appropriate,
crisis intervention at the location of the crisis as needed to avoid unnecessary
institutionalization, hospitalization, or interactions with law enforcement.
Beginning no later than eighteen (18) months after the Effective Date, the
County will ensure the prompt notification of the applicable FSP provider when an
individual served by an FSP receives crisis intervention from another ACBH
contracted provider, such as mobile crisis teams, or other crisis programs, so that
the FSP can respond to the crisis.
NA
2.n. FSPs will provide or arrange for appropriate Individual Placement and
Support (IPS) supported employment services for FSP clients based on their
choice. IPS supported employment focuses on engaging a person in competitive
employment based on their individualized interests, skills, and needs.
PC
2.o. Housing: The Parties recognize that permanent, integrated, stable housing
with Housing First principles is critical to improving treatment engagement and
supporting recovery. (i.) FSP clients will receive a housing needs assessment,
and will receive support and assistance to secure and maintain, as needed,
affordable, (1) temporary housing, and (2) permanent housing, either directly
from the FSP or by referral by the FSP to the County Health Care Services
Agency’s Coordinated Entry System (“CES”), or through other County and
community resources.
PC
2.o.ii. As individuals with serious mental illness, FSP clients who are referred to
the CES will receive priority, with the goal of securing and maintaining permanent
housing.
PC
2.o.iii. If an FSP client is waiting for permanent housing, the FSP will, as needed,
promptly provide or secure temporary housing for the FSP client until permanent
housing is secured. Temporary housing provided under this Agreement shall be
stable and shall not be at a congregate shelter, except on an emergency basis.
PC
2.o.iv. and v. Permanent housing will be provided in the least restrictive and most
integrated setting that is appropriate to meet the needs and preferences. Nothing
in this section II.2.o is intended to override an FSP client’s preferences.
PC
3. Service Teams (Intensive Case Management)
3.a. The County will maintain 2,168 slots to provide intensive case management
through Service Teams. The County will utilize these slots to serve individuals 18
and older who meet Service Teams eligibility criteria and may also use these
slots for transitional age youth as appropriate.
PC
3.b. The County will explore community needs and opportunities for expanding
Service Teams as appropriate.
NA
3.c. Service Teams will assist individuals in attaining a level of autonomy within
the community of their choosing. Service Teams will provide mental health
services, plan development, case management, crisis intervention, and
medication support; and be available to provide services in the field where clients
are located, in office locations, and through the use of telephonic or other
electronic communication when clinically appropriate.
PC
First Six Months Report August 7, 2024
59
3.d. Service Team clients will receive support and assistance to access, as
needed, temporary housing and permanent housing, through the CES and other
available programs.
PC
4. Outreach, Engagement, Linkages, and Discharge Planning
4.a. The County will maintain a 24/7 telephonic hotline (the ACCESS line or its
successor) to aid in implementing the provisions below.
PC
4.b. The County will make meaningful efforts to create a system to provide real-
time appointment scheduling, timely in-the-field assessments, and authorization
of services by ACCESS or its successor, in order to facilitate prompt and
appropriate connection to services following an eligible individual’s contact with
ACCESS.
PC
4.c. When an individual with serious mental illness (1) is identified by the County
through section II.4.e, or (2) contacts (or another individual does so on his or her
behalf) the County (e.g., the ACCESS program or its successor) or an ACBH
contracted entity for behavioral health services, the County or an ACBH
contracted community provider will determine the person’s eligibility for
community-based behavioral health services and, unless the person can no
longer be contacted or declines further contact, will provide a complete clinical
assessment of the individual’s need for community-based behavioral health
services (an “assessment”).
PC
4.c.i. Following such assessment, individuals determined to be eligible for and in
need of FSP or Service Team services will be assigned to an FSP or Service
Team’s caseload to commence the provision of services.
PC
4.c.ii. This assessment and assignment process will be promptly completed, and
those services initiated in a prompt manner sufficient to reduce the risk of
prolonged and future unnecessary institutionalization, hospitalization, or
incarceration.
PC
4.c.iii. Beginning no later than 6 months after the Effective Date, the County will
document all situations in which an eligible individual is assessed as in need of
FSP or Service Team services, but such FSP or Service Team services were not
immediately available and will conduct regular quality reviews to identify such
situations. Following a quality review, the County will take appropriate action, if
any is indicated, based on the results of the quality review, and the results will
inform the County’s FSP Assessment undersection II.2.c.
NA
4.d. Within two years of the effective date of the Agreement, the County will
develop, implement, and staff a System Coordination Team to improve linkages
to community-based services across the County’s behavioral health system. The
System Coordination Team will coordinate system care and improve transitions of
care.
NA
4.e The County will implement a system to identify and provide proactive
outreach and engagement to individuals with serious mental illness who are, for
reasons related to their serious mental illness, at risk of unnecessary
institutionalization, hospitalization, or incarceration. In order to do so, this system
will focus on factors that include, among others, whether individuals with serious
mental illness have had frequent contacts with crisis services (including PES),
frequent hospitalizations for mental health reasons, and/or frequent
incarcerations (and, in the case of incarcerations, received behavioral health
services during an incarceration). The County will connect such individuals, as
needed, to FSPs, Service Teams, or other community-based services. The
NA
First Six Months Report August 7, 2024
60
County will use a culturally responsive, peer driven approach that builds on the
person’s strengths and goals and seeks to address the individual’s concerns
regarding treatment (including service refusals). Outreach and engagement will
include frequent, in person contact in the field in locations convenient to the
person. Outreach and engagement will include using the Familiar Faces program
to identify and connect with individuals who do not follow up regarding services
after experiencing a crisis. Beginning no later than six (6) months after the
Effective Date, the County will track progress in connecting individuals to needed
services.
4.f The County will explore, collaborate with, and support as appropriate
programs that provide connection to community-based services as alternatives to
incarceration. The County will provide information and education to prosecutors,
public defenders, courts and law enforcement about available community-based
services that can provide alternatives to incarceration, arrest, and law
enforcement contact and will coordinate with these entities to rapidly connect
individuals to those services as appropriate.
PC
4.g. The County will provide information and education to ACBHD-contracted
behavioral health providers about available community-based services that can
provide alternatives to unnecessary institutionalization and hospitalization and
reduce risk of unnecessary law enforcement contact and will coordinate with
these entities to rapidly connect individuals to those services as appropriate.
PC
4.h. The County will work with law enforcement to direct referrals to the In-Home
Outreach Team (“IHOT”).
PC
4.i. The County will ensure that people with co-occurring SUD can access and
receive services, including through the development of two (2) substance use
mobile outreach teams, within two years of the Effective Date
NA
4.j.i and ii. In-Reach to, and Discharges to Community-Based Services from,
Medicaid Institutions for Mental Diseases (“IMDs”). “IMD” as used in this
Settlement Agreement, refers to Villa Fairmont Mental Health Rehabilitation
Center, Gladman Mental Health Rehabilitation Center, and Morton Bakar Center.
Within 12 months of the effective date of this Agreement, the County will begin
initial implementation of a utilization review (“UR”) pilot program. The UR pilot
program will be designed to ensure that individuals are transitioned to and live in
the most integrated setting appropriate to the individual’s needs and to reduce
the length of IMD stays where appropriate. As part of the UR pilot program the
County will review clinical records and engage in peer-to-peer meetings to
assess appropriateness for discharge in light of community-based services
appropriate to the individual.
NA
4.j.iii. Promptly after an individual eligible for ACBHD services is admitted to an
IMD in the County, the individual will begin receiving discharge planning services.
The individual’s discharge plan will include transitioning the individual to the most
integrated setting appropriate to the individual’s needs, consistent with the
individual’s preferences. As part of assisting individuals to transition to the most
integrated setting appropriate, appropriate community-based services will be
identified. Where applicable and with the individual’s (and, when relevant, his or
her legal representative’s) consent, FSP and Service Team providers will
participate in the discharge planning process.
PC
4.j.iv. If the unavailability of FSP or Service Team services is preventing
discharge from an IMD to a community setting, then the director of ACBHD (or
PC
First Six Months Report August 7, 2024
61
designee) will be notified, and the County will work to arrange such services as
promptly, as possible.
4.j.v. The County will promptly notify ACBHD-contracted FSP and Service Team
providers when their clients are receiving care at an IMD, to ensure that the
provider promptly resumes services upon discharge, as appropriate.
PC
4.k.i. and ii. Linkages for Services Following Discharge from John George PES
and Inpatient. (i.) The Parties understand that John George is required to provide
discharge planning to and effectuate safe discharges of patients at John George
PES and John George inpatient in compliance with applicable laws, regulations,
and contractual obligations, including, but not limited to, 42 C.F.R. § 482.43 and
California Health & Safety Code §§ 1262 and 1262.5. (ii.) The County will
collaborate with John George to support John George’s safe and effective
discharges of eligible individuals from John George PES and John George
inpatient to community-based services as appropriate, including through ACBH’s
critical care managers and contracted community-based providers, with the goal
of increasing the prompt connection to community-based services for patients
that are eligible and appropriate for community-based services. The County will
request that John George promptly notify the County when it identifies someone
who may be eligible for any such services. Beginning no later than eighteen (18)
months after the Effective Date, the County’s role in this collaboration will
include, to the fullest extent reasonably practicable: (1) using available data to
promptly identify individuals registered by John George who are both (a) likely to
be, for reasons related to their serious mental illness, at risk of unnecessary
institutionalization, hospitalization, or incarceration, and (b) likely to be eligible for
and in need of FSP or Service Team services; (2) upon identification, to the
extent that the individual has not yet been discharged, promptly coordinate with
John George to determine whether the individual is eligible for and in need of any
such services; and (3) if the individual is eligible for and in need of any such
services and to the extent that the individual has not yet been discharged,
promptly connecting the individual to an FSP or Service Team to commence
engagement, which may include participation in discharge planning and
commencement of services upon the individual’s discharge.
NA
4.k.iii. The County will request that John George Psychiatric Hospital invite and
actively include representatives of an individual’s FSP or Service Team (if any) in
the discharge planning process and, with respect to patients determined eligible
for and in need of such services under section II.4.k.ii above, invite and actively
include representatives of the County or a County-contracted community based
service provider in the discharge planning process. To the fullest extent
reasonably practicable and within the direct control of the County and its
community-based service providers, and with the individual’s consent, the County
will ensure that: (1) representatives of the FSP or Service Team are included in
the discharge planning process for those individuals who are assigned to or are
clients of a County FSP or Service Team; and (2) representatives of the County
or a County contracted community-based service provider are included in the
discharge planning process for those individuals who are not assigned to an FSP
or Service Team but who have been identified as eligible for an FSP or Service
Team under section II.4.k.ii above. To the extent that John George routinely does
not include such representatives in the discharge planning process, the County
will seek to identify and reasonably address barriers to John George’s inclusion
of such representatives in discharge planning.
PC
First Six Months Report August 7, 2024
62
4.k.iv. Beginning no later than eighteen (18) months after the Effective Date, the
County will use electronic health record and registration information provided to
the County by John George Psychiatric Hospital to promptly identify individuals
with serious mental illness who are discharged to the community and who are, for
reasons related to their serious mental illness, at risk of unnecessary
institutionalization, hospitalization, or incarceration in accordance with section
II.4.e. and will comply with its obligations under section II.4.c.
NA
4.k.v. The County will use programs designed to reach individuals who do not
follow up regarding services.
PC
4.k.vi. The County will collaborate with John George to ensure that John George
promptly notifies FSP and Service Team providers when their clients are
registered or admitted to receive John George PES or John George inpatient
care, to facilitate the FSP’s or Service Team’s prompt resumption of services
upon discharge.
PC
4.l.i. Linkages for Services Following Release from Santa Rita Jail. This
Agreement does not govern the provision of mental health services or treatment
at Santa Rita Jail and does not duplicate, modify, or override any provisions in
the Babu v. County of Alameda Consent Decree (including section III.I,
“Discharge Planning,” page 49:13-51:18). The County will ensure that ACBHD
collaborates with the community’s office and will use its best efforts to identify
and implement appropriate strategies to improve warm handoffs of Behavioral
Health Clients (as defined in the Babu consent decree) who are eligible for
ACBHD services.
PC
4.l.ii Beginning no later than 18 months after the Effective Date, the County will
periodically (at least every six months) evaluate FSPs’ and Service Teams’ (a)
participation in discharge and reentry planning for their clients following
notification of incarceration, (b) participation in discharge and reentry planning for
incarcerated individuals referred to such provider, and (c) their success in re-
engaging or newly engaging their client upon release. This evaluation will include
analysis of timeliness, trends, and causes of identified problem areas. The
Parties understand that FSP and Service Team participation in discharge and
reentry planning may be provided through the use of telephonic or other
electronic communication when clinically appropriate or as necessary to respond
to public health considerations.
NA
4.l.iii. Beginning no later than six (6) months after the Effective Date, the County
will document all situations in which an individual identified by ACBHD as eligible
and in need of FSP or Service Team Services and such FSP or Service Team
services were not immediately available upon release and will conduct regular
quality reviews to identify such situations.
NA
4.l.iv. With the goal of reducing risk of unnecessary institutionalization,
incarceration, and law enforcement contacts, the County will take appropriate
action, if any, based on the results of the evaluation in section II.4.l.ii. and the
quality reviews in section II.4.l.iii.. Where appropriate, the results of the quality
reviews under section II.4.l.iii will inform the County’s FSP Assessment under
section II.2.c.
NA
4.l.v. The County will use programs designed to reach individuals who do not
follow up regarding services, consistent with Section II.4.e.
PC
5. Culturally Responsive Services
First Six Months Report August 7, 2024
63
5.a. The County will continue its ongoing efforts to ensure that all services
provided under this Agreement are culturally responsive and are person-
centered. The County will continue to provide and expand culturally responsive
behavioral health services, including through community-based and peer-run
organizations, and will continue to identify and implement culturally and
linguistically appropriate and affirming strategies and practices to help reduce
behavioral health disparities across racial, ethnic, cultural, and linguistic groups.
PC
5.b. The County will continue to operate the Office of Health Equity within ACBH,
and the Division Director of the Office of Health Equity will continue to serve as
the departmental Health Equity Officer, reporting to the Director of ACBH, and will
oversee the existing Office of Ethnic Services. The Health Equity Officer will
continue to work in collaboration with community stakeholders to promote social
and behavioral health equity reform and inclusion, and to ensure clients receive
high quality and client-centered care that considers the whole person and all their
needs.
PC
5.b.i. No later than fifteen months after the Effective Date of this Agreement, the
Health Equity Officer will host a stakeholder and community input meeting. In
order to deepen meaningful community stakeholder engagement, no later than
one month before the stakeholder and community input meeting, the Office of
Health Equity will make a dashboard publicly available on the Office of Health
Equity’s public internet website setting forth aggregated data metrics on the
populations served by ACBHD (including individual racial and ethnic groups
broken down by geographic area within the County) and various communities’
service needs (including racial and ethnic groups’ needs for FSP, Service Team,
and IHOT services in geographic areas within the County).
NA
5.b.ii. The Health Equity Officer will thoroughly review the feedback from the
stakeholder/community input meetings on how to improve culturally responsive
services in the County. The Health Equity Officer will periodically make
recommendations to the Director of ACBH on how to improve culturally
responsive services in the County and coordinate with the County’s other
diversity, equity, and inclusion programs and activities.
NA
5.c. The County will continue to support the African American Wellness Hub
capital facilities project, with the goal of aligning culturally relevant and
community focused services for Black/African American residents within the
County’s service delivery system. The African American Wellness Hub facility will
serve as a hub and coordinating center for a variety of behavioral health services,
community-based supports, and linkages for the Black/African American
community in the County. The County will provide opportunities for community
and stakeholder engagement over the course of this project to further the
project’s focus on providing culturally inclusive, respectful, and relevant supports
to the County’s Black/African American clients and community.
NA
5.d. The County has implemented and will continue to provide periodic and
ongoing trainings to all ACBHD staff and ACBHD-contracted community-based
providers regarding: culturally responsive services; trauma-informed care;
inequities across race, ethnicity, sex, sexual orientation, gender identity, and
disability; anti-racism and implicit bias. A primary intent of such trainings is to
ensure the delivery of culturally responsive services and to increase engagement
across historically underserved populations.
PC