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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 August 1, 2024, through March 31, 2025
Submitted By: Karen Baylor, Ph.D., LMFT
April 2025
Second Report April 14, 2025
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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.
The Settlement Agreement’s definition of Substantial Compliance refers to substantial
compliance for a period of no less than six (6) months. The first on-site review occurred
after four months of the Effective Date of the Settlement Agreement and the second on-
site review occurred ten months after the Effective Date. The second report reflects an
assessment of the County’s progress from the previous report and identifies any areas
where work is in progress or still needs to be completed.
A draft of this report was submitted to the parties on February 28, 2025. 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 Independent Reviewer and the parties agreed to extend the review
period by an additional seven days. The finalized report is submitted to the parties and
made public, with any redactions necessary under California or Federal Law.
The Settlement Agreement identified the following five service commitments:
1. Crisis Services
2. Full Service Partnerships
3. Service Teams (Intensive Case Management)
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 ACBHD’s progress and implementation of these five areas.
Second Report April 14, 2025
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METHODOLOGY
Since the effective date of the Settlement Agreement, the Independent Reviewer has
met every other week with the DOJ and DRC, every other week with Alameda County’s
counsel, and once a month with ACBHD Deputy Directors. This was done to keep the
parties apprised of the activities of the Independent Reviewer, County progress, and to
identify any challenges or barriers.
On October 7, 2024, the Independent Reviewer emailed ACBHD a request for
documents, including client records, a list of staff and clients to be interviewed, and a list
of facilities to be toured.
During the months of August 2024 through March 2025, the County uploaded
documents to the file sharing site. All these documents were reviewed by the
Independent Reviewer and helped form the Independent Reviewer’s interview questions
for the on-site review.
The Independent Reviewer requested a random sample of ten client records from the
following service categories:
• ACCESS
• Adult Full Service Partnership (FSP)
• Service Teams
• John George Psychiatric Hospital
• Institutes for Mental Diseases (IMD)
• Clients recently released from Santa Rita Jail
The methodology for the random selection of client records was provided to the
Independent Reviewer.
The Independent Reviewer utilized the initial report and the same protocol from the first
review that was developed based on the Settlement Agreement with feedback from the
parties. The parties previously agreed with the use of the protocol. This protocol
included all 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, and client interviews. 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 Independent Reviewer conducted an on-site review in Alameda County from
December 3, 2024, through December 6, 2024. During that on-site review the
Independent Reviewer interviewed County staff, toured five contract providers and
interviewed 17 of their staff, interviewed 16 county staff, and interviewed eight clients.
Limitations of the second review included conducting the interview of clients over Zoom.
ACBHD requested the community based provider to determine which clients were
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available to be interviewed. The Independent Reviewer requested two interviews: one
with Service Team clients and the other with Adult FSP clients. The session with the
FSP clients was hard to hear due to a connectivity issue. It is also more difficult to
engage clients over Zoom. The clients were also very positive about the services they
were receiving and had no issues or complaints with their current provider.
During the December 2024 on-site review, ACBHD staff accommodated a schedule
change, scheduling a tour of the new Forensic Peer Respite facility and rescheduling a
tour of Sally’s Place. Unfortunately, the La Familia staff had the wrong set of keys and
were not able to open the doors of the facility. The Independent Reviewer was given a
tour of the grounds and was able to look into the windows of the facility. This facility is
scheduled to open in the first quarter of 2025 and another tour may be scheduled for a
future on-site review. The tour of Sally’s Place occurred on 1/22/2025.
Throughout 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.
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. ACBHD served
a total of 25,638 clients for fiscal year 2023 to 2024.
The organization of ACBHD remains the same from the previous report and there were
no changes in the organizational structure.
SUMMARY OF RATINGS
The five service commitment areas are from the finalized Settlement Agreement. Each
service commitment was given a rating based on the evidence that is comprised of
documentation, protocols, contracts, data, client records and other related documents,
received from ACBHD and from interviews with staff, clients, and community-based
provider staff.
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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 I.
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.” (Page 20)
The Partial Compliance, Non-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. In
other cases, a rating of Partial Compliance was given where the information and
documentation requested and reviewed to date is consistent with a finding of
compliance, but the Independent Reviewer has identified additional areas of
inquiry to be explored in a subsequent reporting period to confirm substantial
compliance.
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.
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
occurs in practice but also that it is sustained and in a durable manner. A rating was
provided when there were several sources of evidence regarding the requirement.
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The following is a summary table of the overall ratings regarding compliance with the
Settlement Agreement.
Summary of Rating Per Service Commitment for the Second Report
SERVICE COMMITMENT SC PC NC NA TOTAL
1. Crisis Services 14 1 0 5 20
2. Full Service Partnership 2 8 0 6 16
3. Service Teams (Intensive Case Management) 2 1 0 1 4
4. Outreach, Engagement, Linkages, and
Discharge Planning
8 6 0 12 26
5. Culturally Responsive Services 4 0 0 2 6
Totals 30 16 0 26 72
Percent of Each Rating for Reporting Period
Ratings First
Report
Second
Report
Substantial Compliance 0* 42%
Partial Compliance 62.5% 22%
Non-Compliance 0 0
Not Applicable 37.5% 36%
Total 100% 100%
*Due to the temporal limitations of the initial report, a rating of substantial compliance was not
possible.
CRISIS SERVICES
The Settlement Agreement outlines the service components under crisis services which
includes the County providing a county wide crises 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. During this review, the Independent Reviewer
interviewed the Interim Director, the Crisis Services Division Director, ACCESS
Supervisor, and Mobile Crisis staff.
Requirement: The County will continue to offer a countywide crisis system and expand
crisis intervention services as follows: refers to the subsequent requirements which are
discussed below.
The County continues to offer a countywide crisis system. The County continues to
contract with providers for crisis intervention services and crisis support services, Crisis
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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 continue to be provided by County staff and through contracts with
providers. Specifically, the County either provides or contracts with the following for
services:
• ACBHD Crisis System of Care works closely with the ACCESS staff and provides
mobile crisis services.
• Crisis Stabilization Units which are provided through a contract with Amber
House (Bay Area Community Services/BACS) and John George Psychiatric
Emergency Services (PES). There are plans with La Família to open another
CSU in Hayward in July 2027.
• 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.
The chart below indicates the number of crises calls and the location of the call for
Fiscal Year 2022-23 and Fiscal Year 2023-24.
Region Crisis City Number of Calls
FY 22/23
Number of Calls
FY23/24
1. North Alameda 129 150
1. North Albany 24 23
1. North Berkeley 286 260
1. North Emeryville 54 62
1. North Oakland 3,511 4,080
1. North Piedmont 17 18
2. Central Castro Valley 104 108
2. Central Hayward 1,083 1,164
2. Central San Leandro 726 769
2. Central San Lorenzo 56 109
3. South Fremont 334 235
3. South Newark 84 76
3. South Union City 153 140
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4. East Dublin 75 109
4. East Livermore 130 164
4. East Pleasanton 77 76
5. Out of County Out of County 807 834
6. Unknown Unknown 25 24
The chart indicates that the calls are received from all over the county but most of the
crisis calls continue to be from Oakland and Hayward.
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.
Beginning no later than 18 months after the Effective Date, the crisis hotline will have a
clinician available to support crisis hotline services 24/7.
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 of Alameda County
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).
ACCESS staff determines eligibility for specialty mental health services at the time of
the initial telephone call and the determination is based on medical necessity as defined
by the State Department of Health Care Services. ACBHD’s policy titled “Adult/Older
Adult Outpatient Level of Care Determination states the following: “Individuals new to
ACBH services are initially assessed to determine if they meet medical necessity.”
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 65).
There are two future deadlines in this requirement which will be discussed in future
reports.
Second Report April 14, 2025
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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.
Crisis Support Services of Alameda County operates the 988 system for the county.
The Executive Director of Crisis Support Services reported that 988 is available in
Alameda County and has telephone and text capability 24/7. The purpose of 988 is to
provide crisis intervention and suicide prevention services. There is also a website titled
988 Alameda County where an individual may receive support. 988 of Alameda County
is an Accredited Crisis Center. The Annual Report from the Crisis Support Services of
Alameda County for the Fiscal Year 2023-24, reported that they responded to 38,288
calls.
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. At the last
conference, they had panels that included the following topics:
• Providing support after suicide loss
• Safety planning for non-clinicians supporting youth in crisis
• Assessing suicide risk
• Using phone and text collaborative approach to suicide
• Using client centered data collection to build rapport and improve
assessment
• How to access mobile crisis teams.
ACBHD continues to meet 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 for Fiscal Year 2023 to 2024.
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. The MET Team and the Mobile Crisis Team may be accessed by the crisis
telephone number or by 911. The CATT Team may be accessed by 911 or 988.
Referrals from 988 are directed to ACCESS. 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 for Fiscal Year 2023 to
2024. 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 this year to track the crisis contacts and the assignment to an
FSP Team, Service Team, or to a community-based provider.
ACBHD provided a copy of the warm hand-off procedure from a contracted community-
based provider. The procedure requires the community-based provider staff to contact
the client within 24 hours of receiving the referral and offer an intake/assessment
appointment within one week of receiving the referral. Another contract for a community
based provided had the following requirement: “Assist individuals in a mental health
crisis in obtaining the right services at the right time”. The Independent Reviewer
examined another contract with a community based provider that stated: “Upon
receiving a referral from ACCESS, Contractor shall provide assertive outreach to secure
treatment engagement.” The Independent Reviewer also reviewed several morning
reports from Crisis Services Hotline sent to ACCESS.
The Independent Reviewer needs to examine more fully ACBHD’s protocols for
conducting warm handoffs from the crisis line to FSP warmline teams.
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 provided a number of power point presentations regarding crisis services, a
description of mobile crisis services and data relating to the individuals served by mobile
crisis. In interviews with the mobile crisis staff during the initial and the second on-site
review, staff reported that the mobile crisis teams are deployed by geographical
location. During the second on-site review, the Independent Reviewer was able to
observe the mobile crisis staff listening into police scanners in order to be prepared for
possible deployment. ACBHD provided the policy and procedure for the crisis services
on-duty clinician protocol and mobile crisis team daily procedures. This policy and
procedure outlines when a mobile crisis response is indicated and the utilization of the
dispatch tool to determine the response. ACBHD also provided the Dispatch Screening
Tool that is used which also includes the dispatch decision.
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.
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ACBHD reported that the number of mobile crisis teams has recently expanded from 14
teams to 17 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.
• 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) pairs a clinician with an
Emergency Medical Technician. These teams focus on crisis intervention and
medical clearance. This service operates 24 hours a day and 7 days a week.
ACBHD has 12 of these teams.
CATT data reflect timely response and reported that the response time is 38.37
minutes, which is the 90th percentile despite varying conditions across the County.
However, the Independent Reviewer previously heard complaints during on-site reviews
that it can take a long time for mobile crisis to respond. Per the Settlement Agreement,
mobile crisis is to provide timely response. The Independent Reviewer did review a
recent contract with the CATT service that requires the community based provider to
report response time to ACBHD. Monitoring data on response time is well-established in
the field as an important performance metric for mobile crisis services.2
ACBHD staff continued to state during 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.
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.
The chart below shows the number of involuntary holds (5150) for the past two fiscal
years and some clients may have had more than one episode:
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.
2 National Guidelines for Behavioral Health Crisis Care (samhsa.gov) at page 50-51.
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Service Clients
FY 22/23
Episodes
FY 22/23
Clients
FY 23/24
Episodes
FY 23/24
5150 by clinician 13 13 * *
5150 Danger to Others 238 271 167 180
5150 Danger to Self 255 267 161 169
Gravely Disabled 241 271 204 217
* Data was redacted due to ACBHD privacy protocols
This chart indicates that the highest number of 5150’s during both fiscal years continues
to be a 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.
The statements made in the initial report regarding mobile crisis services continue to be
accurate for the second report. For example, 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 has now added
reporting response times requirement into the contracts for the community based
providers.
ACBHD is taking steps to begin to monitor MCT/MET response times and is aiming for
implementation in Summer 2025. Because there has not been six months since the
expansion of the mobile crisis teams, the Independent Reviewer will monitor and report
on the sustainability in subsequent reports.
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 to reduce
interactions with law enforcement, reduce 5150s and increase use of community based
services. Evidence of this was found in the interviews with mobile crisis staff and the
crisis system of care management staff and a review mobile crisis program information.
ACBHD recently expanded the number of mobile crisis teams from 14 to 17 with the
greatest increase in the number of CATT teams.
The Independent Reviewer did request a ride-along with the mobile crisis staff for the
second on-site review. However, no crisis calls were received during the time allotted on
the Independent Reviewer’s schedule.
There was an overall decrease in all the 5150 categories from Fiscal Years 2022/23 to
Fiscal Year 2023/24. ACBHD did identify the following as possible reasons for an overall
decrease in the number of 5150’s:
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• Collaboration with diversion sites such as Amber CSU, CRTs, Sobering and
detox facilities and improved outreach and engagement activities
• Increased usage of the Stanley Brown Safety Planning tool during mobile crisis
interventions
• Updates to Crisis Intervention Training for first responders
• Advertising of 988
• Additional mobile crisis team for East County
• Quarterly Crisis Services System of Care presentation for various stakeholders.
ACBHD continues to provide mobile crisis services with the purpose of achieving the
above stated outcomes as demonstrated by the review of documents and interviews
with ACBHD staff and community based provider staff.
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.
ACBHD reported that it either operated or contracted for the following 17 mobile crisis
teams:
• MCT - 3 teams serving north, south and east county
• MET- 2 teams serving Oakland and Hayward
• CATT – 12 teams service entire county with staging posts in Oakland, San
Leandro, Hayward, Livermore, and Fremont
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 Draft Mobile Crisis
Assessment was provided on January 31, 2025. The findings were as follows:
“The assessment found that ACBH needs a minimum of 2.5 – 5 additional FTE
Mobile Crisis Teams from the baseline identified in this assessment in order to meet
the estimated mobile crisis need, based on the Crisis Now benchmark that 32% of
known crisis events are responded to by mobile crisis intervention.” (Page 24)
The Mobile Crisis Assessment also noted that ACBHD has already added or plans to
add four additional mobile crisis teams which is outlined below.
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
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 final version of the Mobile Crisis Assessment was provided on January 31, 2025.
The Mobile Crisis Assessment is also posted on ACBHD’s website.
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The Mobile Crisis Assessment stated the following: “This assessment was informed by
necessary data and information sufficient to assess the need for crisis services, as well
as community and stakeholder input. The assessment results in an estimate of the
amount and number of mobile crisis teams needed to provide timely, in-person mobile
crisis coverage county-wide”. (Page 3)
Requirement: 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.
ACBHD contracted 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.
The final version of the Mobile Crisis Assessment was provided on January 31, 2025.
The Mobile Crisis Assessment is also posted on ACBHD’s website.
Requirement: 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 findings of the Mobile Crisis Assessment are as follows:
The assessment also identified existing gaps in mobile crisis coverage. Based on
mobile crisis team operating hours and time of mobile crisis calls in FY23-24,
mobile crisis coverage is needed overnight and on weekends. Mobile crisis
coverage is also needed in North County, particularly Oakland. Males and Black
and African American individuals also appeared less likely to participate in mobile
crisis services and were more likely to be admitted to crisis receiving centers.
Based on ACBHD’s mobile crisis team expansion of 4 FTE mobile crisis teams,
including 2 overnight CATT teams and an MCT East County team, the County
has fulfilled the addition of 2.5 – 5 FTE mobile crisis teams necessary to address
mobile crisis needs. (Pages 27-28)
During the Mobile Crisis Assessment, ACBHD further expanded the number of mobile
crisis teams as follows:
• MCT: ACBH implemented a fourth team in March 2024
• CATT: ACBHD implemented two new teams in partnership with ACBH, Bonita
House and Falck in May 2024, and November 2024
• CATT: ACBHD plans to implement another team in 2025.
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When implementation is completed, ACBHD will have expanded the number of mobile
crises teams and meets the recommendations outlined in the Mobile Crisis Assessment.
Because the expansion has not been in effect for more than 6 months, the Independent
Reviewer will review the sustainability of the expansion in subsequent reports.
Requirement: FSPs will provide crisis intervention as set forth in section II2.m in this
Agreement.
During the initial 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.
For the second review, the Independent Reviewer interviewed several community based
provider staff, reviewed FSP client records and interviewed clients receiving FSP
services. All agreed that FSP provides crisis intervention services.
Because this requirement is tied to section II2.m of the Settlement Agreement and that
requirement has a deadline in the future, this requirement will be reviewed in
subsequent reports.
Requirement: Each mobile crisis team shall include at least one mental health clinician.
As described above, the Mobile Crisis Teams continue to include 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. The
Independent Reviewer interviewed three peer support specialists during the second on-
site review. They reported that they are part of the crisis services teams and described
their role as being partners with the clinicians. The peers stated that some of their work
activities include responding to crisis calls with the mobile crisis team, collecting
collateral information during a crisis event, and providing crisis intervention services.
Requirement: The County will provide crisis residential services. Maintain 45 crisis
residential treatment (CRT) beds.
The current number of CRT beds continues to be at the same number of beds as
reported in the first report.
Second Report April 14, 2025
16
CRT Facility Community-Based Provider Number of Beds
Amber House BACS 16
Woodroe House BACS 16
Jay Mahler Telecare 16
TOTAL 48
ACBHD has met this requirement and has sustained this requirement for more than six
months per the Settlement Agreement.
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 second on-site review, the Independent Reviewer was able to tour Woodroe
Place and Jay Mahler and interview their staff. These facilities are unlocked. The
Independent Reviewer reviewed client records who had received CRT services,
community-based contracts scope of work and the community-based 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 tour of Sally’s Place occurred on 1/22/2025. The Independent Reviewer interviewed
the staff, toured the facility and spoke to two clients. The facility had a warm, homelike,
and welcoming atmosphere and it was unlocked. The staff reported that the maximum
length of stay is 14 days.
Data collected in FY 2023-24 showed a slight increase in the number of clients who
received CRT services compared to FY 2022-23: 698 clients compared to 663 clients,
respectfully.
Outcome Number of
Clients
FY 22/23
Percentage
FY22/23
Number of
Clients
FY 23/24
Percentage
FY 23/24
Admitted to hospital 48 7% 50 7%
Connected to CBS 140 21% 123 18%
Second Report April 14, 2025
17
Discharged to other
facilities
130 20% 155 22%
Detention to Santa Rita
Jail
20 3% 22 3%
This chart indicates a slight increase in the number of clients discharged to other
facilities from last fiscal year. Overall, there was not a significant change from one fiscal
year to another.
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. As discussed above, the tour of Sally’s Place occurred on
1/22/2025. The Independent Reviewer interviewed the staff, toured the facility and
spoke to two clients. The staff reported that peer staff are on-site 24/7. The tour of the
facility confirmed that it is a six bed facility.
Requirement: Individuals shall not be required to have identified housing as a condition
of admission to a CRT facility.
The Independent Reviewer previously reviewed client records of clients who had
received CRT services, community-based contract’s scope of work and the community-
based providers Operation Manual. During the second on-site review the Independent
Reviewer toured Woodroe Place and Jay Mahler and interviewed staff. Both ACBHD
staff and community-based provider staff confirmed that housing continues not to be a
condition for admission to CRT.
Requirement: CRT facilities and peer-respite homes shall be able to accept admissions
directly from mobile crisis teams.
Admissions to CRT may be made directly by MCT. This was confirmed by ACBHD staff
and community provider staff.
Requirement: The County’s crisis system will be designed to prevent unnecessary
hospitalizations, IMD admissions, law enforcement interactions, and incarceration.
For the initial report, 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. For the
second review, the Independent Reviewer interviewed ACBHD staff and mobile crisis
staff. ACBHD did provide a policy and procedure and a daily checklist for the on-duty
clinician for the mobile crisis team. The role of the on-duty clinician is to triage the crisis
calls received and determine the most appropriate response from Crisis Services using
the Dispatch Tool. ACBHD provided a copy of the Dispatch Screening Tool which
includes the following:
Second Report April 14, 2025
18
• a screen for medical issues,
• a safety assessment,
• screen for under the influence of substance and alcohol,
• reason for the call
• screen for location safety, and
• dispatch decision.
The dispatch decision consists of whether the mobile crisis team will be dispatched with
or without law enforcement, which mobile crisis team is dispatched, or if the mobile
crisis team was not dispatched and why.
ACBHD previously identified the need to expand CSU, CRT, peer respite, and mobile
crisis teams. ACBHD has already expanded the number of mobile crisis teams as
follows:
• MCT: ACBHD implemented a fourth team in March 2024.
• CATT: ACBHD implemented three new teams in partnership with ACBH, Bonita
House and Falck in May 2024, and November 2024 with the third in 2025.
ACBHD also 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.
Summary of Crisis Services Findings
Overall, there are twenty service commitments in the Crisis Services component of the
Settlement Agreement. ACBHD received substantial compliance for 14 service
commitments, a rating of partial compliance for one requirement, and a rating of not
applicable rating for five service commitments. There were no non-compliant ratings
given in this section.
ACBHD achieved Substantial Compliance for the following requirements:
1. The County will continue to offer county wide crisis system and expand crisis
intervention services. There was evidence through data, community based
provider contracts and interviews with ACBHD staff and community based
provider staff that the requirement for offering a county wide crisis system has
been met.
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. Evidence was found from ACBHD regarding protocols
and education efforts regarding crisis services, including a description of mobile
crisis services and data relating to the individuals served by mobile crisis.
3. Mobile crisis services shall be provided with the purposes of reducing, to the
greatest extent possible, interactions with law enforcement during a mental health
Second Report April 14, 2025
19
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 through interviews on the purpose of mobile crisis
services. The Independent Reviewer interviewed mobile crisis staff, the crisis
system of care management staff, reviewed mobile crisis program information,
and related data.
4. The County has recently expanded its mobile crisis capacity to nine (9) mobile
crisis teams and agrees to maintain this as a minimum capacity. ACBHD reported
that it operates 14 mobile crisis teams and has expanded to 17 teams.
5. 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”). ACBHD contracted with the Indigo Project to conduct the Mobile
Crisis Assessment, and the final version was provided on January 31, 2025.
6. The County will provide a draft of the design of the Mobile Crisis Assessment to
the Independent Reviewer. The Indigo Project submitted a draft of the
methodology for this assessment in May 2024. The final version of the Mobile
Crisis Assessment was provided on January 31, 2025. The Mobile Crisis
Assessment is also posted on ACBHD’s website.
7. Each mobile crisis team shall include at least one mental health clinician. There
was evidence that 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.
8. Trained peer support specialists shall be part of the County’s crisis services team
and shall be included in outreach and engagement functions. The Independent
Reviewer interviewed the peer support specialists who are part of the County’s
crisis services teams.
9. The County will provide crisis residential services. Maintain 45 crisis residential
treatment (CRT) beds. ACBHD has met this requirement and has sustained this
requirement for more than six months with plans to expand the number of CRT
beds.
10. A purpose of CRT facilities and peer-respite homes is to promptly deescalate or
avoid a crisis and reduce unnecessary hospitalization. Evidence was found
through tours of the facilities, reviews of contracts with community based
providers, community-based providers Operation Manual and through interviews
with ACBHD staff and community provider staff.
11. 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. Evidence was found on the tour of the
peer-respite home and through interviews with the staff and clients.
Second Report April 14, 2025
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12. Individuals shall not be required to have identified housing as a condition of
admission to a CRT facility. Evidence was found through a review client records,
community-based contract’s scope of work, the community-based providers
Operation Manual, tours of the facilities and interviews with staff.
13. CRT facilities and peer-respite homes shall be able to accept admissions directly
from mobile crisis teams. Evidence was found through interviews with ACBHD
staff and community provider staff.
14. The County’s crisis system will be designed to prevent unnecessary
hospitalization, IMD admissions, law enforcement interactions, and incarceration.
Evidence was found through interviews of ACBHD staff, community-based
provider staff, reviewed policy and procedures and community-based Operations
Manual.
ACBHD achieved Partial Compliance for the following:
1. 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 Independent Reviewer needs to
examine the protocol for conducting warm handoffs and will report findings in a
subsequent report.
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. 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.
3. 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.
4. FSPs will provide crisis intervention as set forth in section II2.m in this
Agreement.
5. 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.
Second Report April 14, 2025
21
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.
FSP services were assessed for the second report through interviews with ACBHD staff,
community-based provider staff and the supervisor of FSP programs, reviewed client
records and interviewed four clients currently receiving FSP service.
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 continues to contract with community-based providers for the provision of FSP
services. ACBHD provided the contract’s scope of work, and the Independent Reviewer
conducted interviews with ACBHD staff and community-based provider staff.
The addition of 100 additional slots has a deadline of two years from the effective date
of the Settlement Agreement and is not applicable at this time. ACBHD is complying
with this requirement in advance of the Settlement Agreement’s timeline: 50 slots were
added in January 2024 and another 150 additional slots were added in December 2024.
The Independent Reviewer will continue to monitor this and will report on
implementation in subsequent reports.
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”).
The Draft FSP Assessment was provided to the Independent Reviewer on January 28,
2025, and thus met the one year deadline for completing an assessment. The
Independent Reviewer sent the draft to the DOJ and DRC the next day. The Draft FSP
Assessment included individuals ages 18 and older who met FSP eligibility criteria.
Second Report April 14, 2025
22
Individuals ages 16 and 17 are included in the Children’s FSP programs and ACBHD
stated that it was not possible for them to provide the data.
Because the FSP Assessment has not been finalized, the Independent Reviewer will
provide an update on this in subsequent reports.
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;
and iv. Research, literature, and evidence-based practices in the field that may inform
the need for FSP services in Alameda County.
The Draft FSP Assessment included the data described above along with community
and stakeholder feedback. The Draft FSP Assessment stated the following:
“This assessment also considers an analysis of any demographic
or other variables that may influence participation in FSP
programming as well as the challenges and barriers in identifying,
referring, engaging, and serving individuals who need an FSP-level
of care. This assessment is informed by local service utilization
data, community and stakeholder input, and available literature
and evidence-based practices and results in an estimate of FSP
slots needed to appropriately serve individuals who meet FSP
eligibility criteria.” (Page 3)
The FSP Assessment has not been finalized, and the Independent Reviewer will
continue to monitor and will report on the progress in subsequent reports.
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
Second Report April 14, 2025
23
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.
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 the 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 Independent Reviewer did meet with the Indigo Project on 12/6/2024. The Draft
FSP Assessment was provided to the Independent Reviewer on January 28, 2025, and
was sent to the DOJ and DRC the following day. The Independent Reviewer provided
feedback to ACBHD on March 19, 2025, that was based on the Independent Reviewer’s
review and the DOJ and DRC’s feedback.
The FSP Assessment has not been finalized, and the Independent Reviewer will
continue to monitor and will report on the progress in subsequent reports.
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.
The FSP Assessment has not been finalized, and the Independent Reviewer will
continue to monitor and will report on the progress 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. FSPs 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).
Evidence was found regarding the definition of one slot through interviews with ACBHD
and community provider staff and review of contracts with the community providers. The
Independent Reviewer reviewed client records of clients receiving FSP services,
interviewed four clients currently receiving FSP services in a virtual setting. Based on
that information, it is determined that FSPs are in fact providing the necessary services.
The Independent Reviewer will need to review additional client records and conduct
additional interviews and will report on the sustainability and durability in subsequent
reports.
Second Report April 14, 2025
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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.
The Independent Reviewer previously reviewed ACBHD’s policies and procedures for
FSP. For the second report, the Independent Reviewer reviewed 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. In addition, the
Independent Reviewer interviewed four clients receiving FSP services in a virtual setting
to confirm that they receive services consistent with their wishes. Clients spoke of being
reminded of and then transported to their psychiatric appointments, receiving food and
clothing, and assistance with finding housing. Clients reported the importance of staying
on their medications and how the services were helping them with that goal.
The Independent Reviewer will need to interview more clients and review more records
since the sample size was small, to determine sustainability and durability. The
Independent Reviewer will continue to monitor and will report on this in subsequent
reports.
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 previously reviewed ACBHD’s policy and procedures for
FSP. For the second report, the Independent Reviewer reviewed client records for
clients receiving FSP services. Client records indicated that a variety of services were
being provided in several settings, and were based on client preference.
The Independent Reviewer also interviewed four clients receiving FSP services in a
virtual setting. The clients reported that their FSP staff did work with them on setting
their goals per the client’s preference. Clients also verified that services are flexible and
provided at the frequency and location of their choosing.
However, the Independent Reviewer also reviewed ACT Fidelity Assessments for the
FSP providers and learned that several FSP providers were not meeting the High
Fidelity rating with frequency or intensity of services. Several FSP providers received
scores of 2 or 3 out of 5, and many of the assessments recommended that FSP
providers increase their average number of face-to-face visits per week. In addition,
many of the assessments also recommended that the FSP providers increase the
number of minutes they are spending with clients per week.
Second Report April 14, 2025
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Data provided by the County also demonstrates that, on average, FSP providers are
only meeting with their clients once a week, but High Fidelity requires 3 or more face to
face contacts per week.
The chart below indicates the top locations where FSP services were provided for the
Fiscal Year 2022-23 and for FY 2023-24.
Treatment Location
# Clients
FY22-23
# Clients
FY23-24
Field 1,072 1,078
Office 1,128 1,067
Telephone 1,073 762
Client’s Home 815 672
Telehealth 549 587
Other Community Location 225 333
Group/Boad and Care * 302
Inpatient - Psychiatric 286 282
Satellite Office ** 214
Health/Primary Care 145 128
Psychiatric Residential 133 124
Inpatient (non-psychiatric) * 77
School 53 67
Community Mental Health * 66
Skilled Nursing Facility * 63
Unknown Location * 48
Prison/Correctional Facility 52 45
Homeless/ER Shelter 32 41
Temp Lodging (hotel, camp) * 38
Emergency Room * 36
SUD Residential * 34
Public Health Clinic * 24
FQHC * 17
* Not reported | ** Data was redacted due to ACBHD privacy protocols
This chart indicates that the majority of services are being provided in the field and at
the office. There was a slight increase in the number of field based services and office
based services but there was a decrease in the number of home visits. While there was
a decrease in the number of telephone calls, this is due to ACBHD splitting out the data
from a telephone service provided to the client versus when a call was made but the
client was not available. The actual total of calls made whether the client was available
or not was 1,370.
Second Report April 14, 2025
26
The Independent Reviewer will need to interview more clients and review more records
since the sample size was small, to determine sustainability and durability. The
Independent Reviewer will continue to monitor and will report on this in subsequent
reports.
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 previously reviewed ACBHD’s policy and procedures for
FSP services. ACBHD contract language includes the following for community based
providers providing FSP services:
A. Program Goals - Contractor shall provide services to accomplish the following
goals:
i. Improve the ability of clients to achieve and maintain an optimal level of
functioning and recovery;
ii. Improve the ability of clients to secure and maintain stable permanent housing
in the least restrictive and most integrated living situation appropriate to meet their
needs and preferences;
iii. Reduce criminal justice involvement and recidivism;
iv. Reduce client hospitalizations and utilization of emergency health care
services for mental health and physical health issues;
v. Ensure that clients obtain and maintain enrollment in health insurance and
other public benefits programs for which they are eligible;
vi. Connect clients with ongoing primary healthcare services and coordinate
healthcare services with clients’ primary care providers;
vii. Increase educational and/or vocational attainment among clients;
viii. Help clients to increase their monthly income and financial assets;
ix. Increase client participation in meaningful activities;
x. Decrease social isolation among clients; and
xi. Assist and empower clients to transition into the least intensive level of service
appropriate to meet their needs.
Performance Improvement Activities Contractor shall provide Performance
Improvement Activities to accomplish the following goals:
i. Improve client access to care;
ii. Increase quality;
iii. Improve outcomes;
iv. Ensure program accountability; and
v. Increase program efficiencies.
The Independent Reviewer reviewed client records, interviewed four clients in a group
virtual setting currently receiving FSP services, and interviewed community-based
Second Report April 14, 2025
27
provider staff. All indicated that services are designed to reduce hospitalization and the
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 2023 to 2023. For comparison, data from Fiscal Year 2022-23 is in
parentheses.
Housing
Status
At
Admission
Percent
Admission
At
Discharge
Percent
Discharge
Independent 75 (73) 31% (31%) 74 (72) 31% (30%)
Unknown or
other 46 (45) 19% (19%) 58 (54) 24% (23%)
Homeless 58 (56) 24% (24%) 48 (48) 20% (20%)
Group
Housing 46 (45) 19% (19%) 32 (32) 13% (14%)
Medical
Facility * * 13 (13) 5% (5%)
Justice
Related * * * *
Rehabilitation * * * *
* Data was redacted due to ACBHD privacy protocols.
There was little to no change from one fiscal year to the other. This chart indicates that
the largest percentage of clients who received FSP services continue to be 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.
ACBHD reported that there was a reduction in hospitalization days, incarceration days
and sub-acute days for eight out of the nine programs. The ACBHD ACT Review Guide
stated the following:
“The goal of the ACT Fidelity review is to continue to observe positive trends in
the metrics of service provision and reductions in hospitalization and jail days.
ACBH will continue to track the outcome data that is collected from the Fidelity
Review process and offer technical support as needed to assist the teams with
implementing the ACT model. The overall goal is to improve the lives of the
individuals supported.” (Page 2)
The Independent Reviewer will need to interview more clients and review more records
since the sample size was small, to determine sustainability and durability. The
Independent Reviewer will continue to monitor and will report on this in subsequent
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,
Second Report April 14, 2025
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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: toured two community-
based providers of adult FSP services, interviewed five community-based provider staff
from the two FSP community-based providers visited and reviewed client records.
For the initial review, the Independent Reviewer completed the following:
• Reviewed ACBHD’s FSP policy and procedures,
• Reviewed ACBHD community-based provider contracts scope of work for the
provision of FSP services, and
• 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).
ACBHD staff and community-based provider staff reported that the FSP program design
in Alameda County is based on the ACT model. Previously, community based providers
staff reported that ACBHD conducts a fidelity assessment of the ACT model annually.
For the second report the Independent Reviewer was able to review the 2024 fidelity
review assessment from nine programs providing FSP services. The programs were
assigned an overall total fidelity score, and those scores translated to a description of
fidelity. The results of the community based providers are as follows:
• Two providers scored high fidelity,
• Six providers scored moderately high fidelity, and
• One provider scored moderate fidelity.
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.
The Independent Reviewer was able to confirm through the fidelity assessment results,
client records sampling, and individual client interviews that FSP programs are being
implemented using high fidelity to the ACT evidence-based practice.
Second Report April 14, 2025
29
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
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 the initial
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.
ACBHD’s policy titled “24/7 Coverage Requirements for Children, TAY, Adult and Older
Adult Full Service Partnerships” states the following:
Each FSP will have a telephone number that is answered by a live person
available to the clients/families of the program after hour crisis needs 24 hours a
day, 7 days a week. A direct care staff member working in the FSP will be on-call
to respond to urgent client/family needs 24 hours a day, 7 days a week to provide
field or phone-based crisis interventions as appropriate.
For the second report, the Independent Reviewer reviewed client records and
interviewed four clients receiving FSP services. The clients reported that crisis services
are provided when necessary.
This requirement is not due at this time and will be reviewed and discussed in
subsequent report. This requirement
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. Previously, ACBHD provided two client records where IPS
services were provided, that indicated that employment services were being provided.
Community-based provider staff reported that ACBHD conducts an annual IPS fidelity
assessment.
ACBHD provided three IPS Supported Employment Fidelity reports. These reports can
result in a rating of Exemplary Fidelity, Good Fidelity, Fair Fidelity, and Not Supported
Second Report April 14, 2025
30
Employment depending upon the total points received for the requirements with a
maximum of five points per requirement. The results were as follows:
• one provider received a Good Fidelity rating
• two providers received a Fair Fidelity rating
ACBHD also provided two IPS Quality Improvement Reports for two community based
providers. These reports are not fidelity reports but can be used between fidelity reviews
when annual reviews are not possible. The intent of these quality improvement reviews
is as follows: to provide a roadmap that will help IPS programs provide effective
services and to provide a snapshot of current practices”.
ACBHD contracts with community based providers to deliver IPS services based on the
client’s individualized interests, skills, and needs. The Settlement Agreement does not
require an IPS fidelity score only that ACBHD arranges for supported employment
services for FSP clients based on their choice. ACBHD does conduct fidelity
assessments on an annual basis and also conducts quality improvement reviews with
their contracted community based providers. ACBHD is monitoring their providers on
the delivery of supported employment services and making the appropriate
recommendations for improvement.
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). Evidence of housing needs and
wishes of the client was found in the client records. Client interviews also revealed that
their housing wishes were reported.
The Independent Reviewer interviewed two staff from CES during the on-site review.
They reported that client voice is important and that they utilize the Housing First Model.
The policy and procedures for CES were provided and it states the following:
“The Coordinated Entry process uses specific Assessments to obtain information
about both the immediate and long-term needs of persons and households
seeking services. Portions of these assessments are weighted and assigned
points leading to a score which is used, along with eligibility information, for
placing participants on queues for referral to crisis and housing resources.
Because of the lack of sufficient resources, prioritization in the Alameda County
system is based on a range of factors to determine who among the population
experiencing homelessness has the greatest number or level of critical needs
Second Report April 14, 2025
31
and/or lesser likelihood of being able to become rehoused without assistance.
Factors that are considered include age and size of household, current and past
housing situations, length of time homeless, disabilities and health conditions,
barriers to rehousing such as past housing loss and criminal legal interactions,
and risk of or vulnerability to exploitation and violence. Factors used for crisis
prioritization are a subset of those used for housing prioritization.” (Page 11)
During the second on-site review, the Independent Reviewer heard in numerous
interviews with ACBHD staff, community-based provider staff and clients that permanent
housing continues to be 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).
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.
• Provide emergency housing lasting a minimum of 6 months, followed by long-
term supportive housing.
Second Report April 14, 2025
32
• 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).
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.
ACBHD provided the following data regarding the client’s housing at the beginning of
FSP services and when the client discharges from FSP services for Fiscal Year
2023/24.
Housing Status At
Admissions
At
Discharges
Independent 75 74
Unknown or Other 46 58
Homeless 58 48
Group Housing 46 32
Medical Facility * 13
Justice Related * 12
Rehabilitation * *
* Data was redacted due to ACBHD privacy protocols
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. This includes the coordination with the relevant
County entities 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 ACBHD’s activities with
respect to housing are confined to obligations with the FSP and Service Team clients.
It is noteworthy that ACBHD was awarded $14,040,909 from DHCS for Round 3 of the
Behavioral Health Bridge Housing Program. The Independent Reviewer will continue to
examine the issue of both temporary housing and permanent housing in subsequent
reports.
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 staff from CES reported that there are a number of priority factors based on the
assessment that determine if the client is placed in the housing queue. While FSP
clients are not identified as a priority factor, many clients are given priority based on
Second Report April 14, 2025
33
their diagnosis, current housing, income, and psychiatric history. The CES also reported
that they do try to solve the problem of the client’s immediate housing needs, but that
locating permanent housing can take years to complete.
As described above, the policy and procedures for CES were provided and it states the
following:
“The Coordinated Entry process uses specific Assessments to obtain information
about both the immediate and long-term needs of persons and households
seeking services. Portions of these assessments are weighted and assigned
points leading to a score which is used, along with eligibility information, for
placing participants on queues for referral to crisis and housing resources.
Because of the lack of sufficient resources, prioritization in the Alameda County
system is based on a range of factors to determine who among the population
experiencing homelessness has the greatest number or level of critical needs
and/or lesser likelihood of being able to become rehoused without assistance.
Factors that are considered include age and size of household, current and past
housing situations, length of time homeless, disabilities and health conditions,
barriers to rehousing such as past housing loss and criminal legal interactions,
and risk of or vulnerability to exploitation and violence. Factors used for crisis
prioritization are a subset of those used for housing prioritization.” (Page 11)
The Independent Reviewer will continue to examine the issue of both temporary
housing and permanent housing in subsequent reports.
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.
The ACBHD Senior Executive Team previously reported that the County Housing
Department used to be under ACBHD, but it was moved to the Alameda County Health,
Office of the 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, now known as the Alameda County Health Office of Housing and
Homelessness.
The community based providers previously reported that they can locate temporary
housing for their FSP clients by using hotel vouchers. Both the community based
providers and the FSP clients interviewed reported that FSP staff do work to locate
temporary housing for their clients. This was also found in the client records for the
clients receiving FSP services.
Second Report April 14, 2025
34
The Independent Reviewer needs to examine this requirement further with regard to
locating housing promptly and that the temporary housing is stable. It is also important
to verify the transition from temporary housing to permanent housing since it is difficult
to find permanent house in the county.
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.
Given the challenges in locating permanent housing in Alameda County, The
Independent Reviewer will continue to monitor the efforts of ACBHD to provide
permanent housing. The Independent Reviewer needs to examine further the
requirement for least restrictive and most integrated setting appropriate to meet the
client’s needs and preferences.
Summary of Full Service Partnership Findings
Overall, there are sixteen service commitments in the Full Service Partnership section.
There were two service commitments that received a rating of substantial compliance,
eight with 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 Substantial Compliance for the following requirements:
1. 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. Evidence was found with review of ACBHD’s FSP policy and procedures,
review of contracts, review of ACBHD’s ACT training materials. interviews of
community-based provider staff, tour of the facilities, and a review of the 2024
fidelity review assessment reports.
2. 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. Evidence was found in
client records, interviews with community-based provider staff, and a review of
the IPS Supported Employment Fidelity reports.
Second Report April 14, 2025
35
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 will need to review additional client records and conduct additional
interviews and will report on the sustainability and durability in subsequent reports.
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 goals.
Each FSP recipient will receive the services identified in their ISSP, when appropriate
for the individual. The Independent Reviewer will need to review additional client
records and conduct additional interviews and will report on the sustainability and
durability in subsequent reports.
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. The
Independent Reviewer will need to review additional client records and conduct
additional interviews and will report on the sustainability and durability in subsequent
reports.
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.
5. 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. Evidence was found in
the client files, interviews with clients and interviews with community based provider
and ACBHD staff. ACBHD staff provided the housing and homeless dashboard that
is based on the episode date at admission and at discharge. However, with both on-
site reviews, staff and clients report that permanent, safe housing is very difficult to
find in Alameda County.
6. 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 interviewed CES staff who stated the FSP clients do not
receive priority, many clients are given priority based on their diagnosis, current
Second Report April 14, 2025
36
housing, income, and psychiatric history. The CES also reported that locating
permanent housing can take years to complete. The Independent Reviewer will
continue to monitor this requirement.
7. 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. The
Independent Reviewer needs to examine this requirement further with regard to
finding housing promptly and that the temporary housing is stable. It is also important
to verify the transition from temporary housing to permanent housing since it is
difficult to find permanent house in the county.
8. 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 needs to continue to examine the issue of
both temporary housing and permanent housing the least restrictive and most
integrated setting 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.
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”). While the Draft FSP
Assessment was completed within the established deadline, it has not been
finalized. of 1,105 FSP slots for that population.
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, 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,
Second Report April 14, 2025
37
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.
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. 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.
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
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 provide
support to individuals considered to need a lower level of case management and
support interventions than those receiving FSP services. Service teams are intended to
serve adults ages 18 and above who have high utilization of emergencies and/or urgent
behavioral health systems.
Second Report April 14, 2025
38
Service Teams were assessed for this second report through review of contracts with
community based providers, interviews with ACBHD staff, community-based provider
staff and supervisors, reviewing client records, interviewing clients receiving this
service, and reviewing data provided by ACBHD.
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 continues to contract with thirteen community-based providers for Service
Teams for a total of 2,228 slots and plans to maintain this level of service. The
Independent Reviewer verified the sustainability and durability of this requirement
through review of ACBHD contracts, interviews with community based provider staff,
review of client records, and interview of clients.
Requirement: The County will explore community needs and opportunities for
expanding Service Teams as appropriate.
The Draft of the FSP Assessment was an opportunity to explore community needs
regarding FSP and Service Teams services. The Draft includes data from Service
Teams and included the Service Team staff as subject matter experts. ACBHD provided
a tracking log of the number of clients being served by the community based providers.
There is capacity with the community based providers to incorporate FSP clients who
are ready to step down to a lower level of care.
Because the FSP Assessment has not been finalized, the Independent Reviewer will
examine this further in subsequent reports.
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; (any county data on this) 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 was able to interview four service team clients in a virtual
group setting. The clients reported that they are receiving services that are flexible and
that assist with their autonomy. They reported that they did not have to wait for services
to begin. They reported that they receive help with their housing, food and clothing.
They also received help with their medication and with staying on their medication. The
staff will call to remind the client of a scheduled appointment and will provide
transportation to the appointment. The staff also help clients with finding a job and will
help the clients with writing their resume. If the client has a crisis after regular business
hours, the staff are available to provide crisis intervention services. They reported that
the staff will also come to their house to check on them. One client stated that the
Second Report April 14, 2025
39
Service Teams are “my lifeline”. Overall, all of the clients had very positive things to say
about the services they were receiving.
Data of services provided by ACBHD indicated that for FY 2023/24, the frequency of
contacts was 2.7 per month. In comparison FY 2022-23, the frequency of contacts was
just slightly higher with 2.9 contacts per month. Previous evidence included a review of
the contracts with community-based providers, policy and procedures, and interviews
with community-based provider staff and supervisors. ACBHD provided contracts with
community based providers which required the services as follows: “Assist clients in
attaining a level of autonomy within the community of their choosing”.
The chart below are the top treatment locations for Fiscal Year 2023-244
Treatment Locations Number of
Clients
Office 1,567
Telephone 1,220
Field 1,039
Patient’s Home 623
Telehealth 587
Location Unknown/Other 114
Other Community Location 171
Group/Board and Care Home 152
Health/Primary Care 132
Satellite Office 138
Skilled Nursing Facility 50
Community Mental Health Center 61
Psychiatric Inpatient 56
Inpatient (Non Psychiatric) 36
Homeless/ER Shelter 21
Psychiatric Residential Treatment 27
Court 17
Public Health Clinic 14
Emergency Room Hospital *
ACBHD provided outcomes data for these clients who completed six consecutive
months during the 12-month fiscal year. The results were a 79 percent reduction in
psychiatric hospital or crisis stabilization unit when comparing unduplicated days from
the 12 months prior to the fiscal year to the current 12-month fiscal year.
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.
* Data was redacted due to ACBHD privacy protocols
Second Report April 14, 2025
40
Client interviews and a review of client records confirmed that they receive assistance in
finding housing and with maintaining housing. Clients reported that they will receive
rental assistance if it is needed in order to maintain their housing. Previous 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 are provided. In addition, ACBHD
recently added up to $60,000 per fiscal year (depending on size of the Service Teams)
to assist individuals who needed housing assistance via client support expenditure
funding.
However, because housing is such a complex issue, the Independent Reviewer would
like to examine the support and assistance for temporary and permanent housing
further.
Summary of Service Team Findings
Overall, there are four service commitments in the Service Teams (Intensive Case
Management) component of the Settlement Agreement. ACBHD received substantial
compliance for two service commitments, a rating of partial compliance for one of the
service commitments, and a rating of not applicable for one of the service commitments.
There were no non-compliant ratings given in this section.
ACBHD achieved Substantial Compliance for the following requirements:
1. The County will maintain 2,168 slots to provide intensive case management
through Service Teams. ACBHD continues to contract with thirteen community-
based providers for Service Teams for a total of 2,228 slots. These slots have
been maintained for over 6 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 reviewed
client records and interviewed clients who have received these services who
confirmed that these services were provided.
ACBHD achieved Partial Compliance for the following:
1. 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 interviewed CES staff, interviewed clients
and reviewed client records which provided evidence of the services being
provided.
Second Report April 14, 2025
41
ACBHD achieved Not Applicable for the following:
1. The County will explore community needs and opportunities for expanding Service
Teams as appropriate.
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.
ACBHD does maintain a 24/7 telephonic ACCESS Line. ACBHD’s 24/7 telephone
number is posted on their website. ACBHD staff answer the telephone calls during the
day and then the telephones are rolled over to Crisis Support Services of Alameda
County. The ACCESS telephone number is available on the county’s website.
The Independent Reviewer previously interviewed ACCESS staff and the ACCESS
Supervisor. The Independent Reviewer interviewed the ACCESS Supervisor during the
second on-site review and reviewed ACCESS client records.
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 continue to 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 complete the clinical assessment.
ACBHD is making meaningful efforts to provide real-time appointments, which at
present involve technological and other back-end improvements that would be the
foundation for system changes and data collection. In addition to information previously
provided, ACBHD has recently received County Board of Supervisors approval to
explore a sole source agreement with Epic Systems Corporation (EPIC) for electronic
Second Report April 14, 2025
42
health record and billing operations software. The Epic project will be conducted in four
(4) main phases:
Phase I: Develop ACBHD and Santa Rita Jail requirements and finalize the Epic
contract for Board of Supervisor review and approval in the Fall of 2025.
• Phase II: On or around January 2026, project preparation will begin followed by Epic
implementation.
• Phase III: With a target date of July 2027 for an official Epic Go-Live, followed by a six
(6) month stabilization period.
• Phase IV: ACBHD will evaluate opportunities and timing to implement Epic in
remaining ACBH Departments.
ACBHD currently has a pilot underway with Pathways to Wellness where ACCESS
coordinates a call with Pathways to Wellness staff and provides the client with a warm
handoff to Pathways to Wellness in real time. There are two ACCESS Clinical Review
Specialists (CRSs) dedicated to this pilot and have a collaborative relationship with the
intake staff at Pathways to Wellness. The CRSs conduct a warm hand off from the
ACCESS line to Pathways to Wellness. The pilot is ongoing, and data is being collected
on the efficacy of this pilot. ACBHD plans to review the data over an extended period of
time to determine if clients who are transferred to Pathways to Wellness have better
outcomes and/or follow through with connecting to services than through their regular
process.
The Independent Reviewer needs to obtain an update on the technological and other
back-end improvements for providing real-time appointments. The Independent
Reviewer also will review any outcomes from the Pathways to Wellness pilot for
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”).
For the second report, the Independent Reviewer reviewed client records from ACCESS
and interviewed the ACCESS supervisor. The Independent Reviewer had previously
reviewed the following for the initial report:
• Policy and procedures,
• Contracts with community-based providers and
• Interviewed ACCESS staff.
Second Report April 14, 2025
43
ACCESS staff determines eligibility for specialty mental health services at the time of
the initial telephone call and the determination is based on medical necessity as defined
by the State Department of Health Care Services. ACBHD’s policy titled “Adult/Older
Adult Outpatient Level of Care Determination states the following:
Individuals new to ACBH services are initially assessed to determine if they meet
medical necessity. After medical necessity has been met, a Clinical Review
Specialist within the ACCESS unit works with the person and his/her/their
supports if appropriate to identify biopsychosocial needs, strengths, and cultural
factors relevant to their recovery process. The ACBH Adult/Older Adult Level of
Care Determination Tool is completed during this process. This information is
used to determine the most appropriate level of care and service provider. (Page
4).
The ACCESS Supervisor stated that ACCESS does not conduct the assessment but
sends a referral to the appropriate community based provider. ACBHD provided
samples of the referrals from ACCESS which the Independent Reviewer was able to
review. The interviews with the community based provider staff confirmed that they
conduct the assessment.
The Independent Reviewer only examined the process for individuals referred by
ACCESS to community based providers. The Independent Reviewer will need to review
the other part of this requirement which is as follows: identified by the County through
section II.4.e” or who “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 Independent Reviewer will review additional ACCESS
client records to verify the sustainability and durability of this requirement for
subsequent reports.
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 continues to determine eligibility of the individual and then refers the case to
the appropriate community-based provider. ACBHD staff interviews and the review of
ACCESS client files confirmed that ACCESS does make appropriate referrals to
community-based providers. ACBHD also provided samples of the referrals from
ACCESS. ACBHD provided a copy of the monthly ACCESS Capacity and Referral
Report which lists each program name and current vacancies in each program.
The contract with ACBHD and the community based provider states the following:
“Upon receiving a referral from ACCESS, Contractor shall provide assertive outreach to
secure treatment engagement.”
Second Report April 14, 2025
44
The chart below reflects data from Fiscal Year 2022-23 regarding access to providers.
Number
of
Referrals
Number of
Referrals
Connected to Care
Percent of
Referrals
Connected to
Care
Number
of Clients
Number of
Clients
Connected
to Care
Percent of
Clients
Connected
to Care
629 448 71.22% 597 428 71.69%
This chart is only for level one care (i.e. Outpatient) based on the Level of Care
Determination Tool. The other levels of care are not indicated which are higher levels of
care. The chart indicates that out of 597 clients referred to outpatient, 71.69 percent
were connected to treatment services.
The Independent Reviewer will need to examine the number of referrals for FSP or
Service Teams and then how many were connected to those services. The Independent
Reviewer also needs to examine the assignment process further with the community
based providers.
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 interviewed eight clients who
reported that they did not have to wait to complete the intake and assessment and for
services to begin.
ACBHD provided a copy of the warm hand-off procedure from a contracted community-
based provider. The procedure requires the community-based provider staff to contact
the client within 24 hours of receiving the referral and offer an intake/assessment
appointment within one week of receiving the referral. The Independent Reviewer
examined another contract with a community based provider that stated: “Upon
receiving a referral from ACCESS, Contractor shall provide assertive outreach to secure
treatment engagement.”
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.
Second Report April 14, 2025
45
The initial report indicated that there have not been any situations where an FSP Team
or Service Team were not available to take a case. This was reported by the community-
based providers, ACBHD staff, and ACBHD Senior Executive Team. However, ACBHD
staff reported that this has occurred in the past several months. They reported that
ACCESS now has a way to identify when there are no FSP Team or Services Team
available in their electronic health records. Their data system can generate a weekly
report that is distributed to the managers for review. The staff also reported that they
meet on a weekly basis with the Adult and Older Adult System of Care to review the
report. The goal of this meeting is to identify other resources for the client while they are
waiting for an FSP Team or Service Team. The ACCESS Supervisor has requested that
the number of days on the waiting list be added to the report. The Supervisor also
stated that the client remains on the report until they have been officially connected to
either an FSP Team or Service Teams. The Supervisor also stated that the report is too
new to identify any trends at this point.
Because this situation has just started to occur, the Independent Reviewer will need to
monitor this and will report on the status in subsequent reports.
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 is not due yet and 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.
Previously, 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.
Second Report April 14, 2025
46
The O&E Team engages with individuals that are not currently receiving any services.
The Interim Director of 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 screened for both clinical needs and the consumer’s health insurance
coverage according to professional best practices.
The ACBHD continues to contract for those community-based providers and continues
to require that the staff conduct the outreach in the client’s natural environment.
Previously, 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. ACBHD also provided the policy and
procedures for the Crisis Connect/Post-Crisis Follow-Up Team. This policy provides
guidance on the responsibilities and procedures for O&E teams in conducting in-
reaching, referrals, and follow-up for consumers not connected to existing ACBHD
services.
ACBHD provided a power point presentation on their outreach and engagement plan
which was implemented 9/9/2024. ACBHD implemented the following three teams:
• Crisis Connect/Post Crisis Follow-up Team (CC/PCFT): Six-person team who
provide in-reach at JGP and anywhere else in the county to individuals in need of assessment for and linkage to ongoing Behavioral Health/SUD care and other
social services.
• Adult Recovery, Outreach and Connection Program (ADROC): Short-Term (90-day) Intensive Case Management for adults, age 25 and older, who are not
already connected to the system of care, appear to be experiencing a mental health crisis, and/or have received care in a sobering/detox center, crisis
stabilization unit, crisis residential treatment, or inpatient psychiatric hospital.
• Transitional Age Youth Recovery, Outreach and Connection Program (TAYROC):
Short-Term (90-day) Intensive Case Management Program for individuals, ages
16 through 24, who are not connected to the system of care, appear to be
experiencing a mental health crisis, and/or have received care in a sobering and
detox center, crisis stabilization unit, crisis residential treatment, or inpatient
psychiatric hospital.
CC/PCFT provides face-to-face in-reach at PES and inpatient units at John George
Psychiatric Hospital from 8:30 am to noon Monday through Friday and also receive
direct referrals from John George Psychiatric Hospital social workers. CC/PCFT
conducts brief screening with clients and will refer clients back to existing provider if
they are already linked to services.
For clients that need more support and are not already connected, CC/PCFT will do a
warm hand off to the ADROC and TAYROC team who provide face-to face, in-reach to
PES and inpatient units at John George Psychiatric Hospital at least once daily, Monday
through Friday from 11:30am to 3:00pm. ADROC and TAYROC can work with the
individuals post discharge for up to 90 days. The in-reach process aims to engage
Second Report April 14, 2025
47
clients, understand their needs, facilitate a smooth transition to other ongoing
community-based services, and provides linkage and support during the post-crisis
period.
Individuals who are reluctant to consent to services and are at risk of re-hospitalization
will be referred to IHOT by CC/PCFT via ACCESS. Goals of these teams are as follows
and determined by data, documentation and disposition:
• Number of clients assigned to Service Team,
• Reduce Crisis SOC Recidivism, and
• Continuous participation is services for 6 to 12 months.
ACBHD did provide their tracking log of high inpatient and subacute utilizers. ACBHD
reported that the Familiar Faces was a grant funded program, and the grant has
expired. However, the Familiar Faces program has been incorporated into existing
programs described above.
The Independent Reviewer needs to examine how ACBHD is focusing on the factors
identified and how those factors will assist the identification of the population that should
receive outreach and engagement services. The Independent Reviewer will also
examine how ACBHD is tracking the progress of connecting individuals to appropriate
services. The Independent Reviewer will continue to monitor the outreach and
engagement plan that was implemented less than six months.
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.
Previously, 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 Independent Reviewer interviewed the Forensic, Diversion, and Re-entry
Services Director during both the initial and the second on-site review. The Forensic,
Diversion and Re-entry Services Director reported that there are regular multiple
meetings with the Sherriff’s Office. The Forensic Director also reported that there are re-
entry teams that work with the individual within 72 hours of booking to assist the
individual with treatment services.
The Independent Reviewer will need to examine how ACBHD coordinates with the
above entities to rapidly connect individuals to those services as appropriate.
Second Report April 14, 2025
48
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.
Previously, evidence was found of 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. 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 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 Forensic, Diversion and Re-entry Services Director reported that they work closely
with the Sheriff’s Office to coordinate referrals to the community based providers. The
Forensic, Diversion and Re-entry Services Director also reported that they have a
standing meeting with the offices of the District Attorney and Public Defender regarding
referrals to the Behavioral Health Court. The Forensic, Diversion and Re-entry Services
Director stated that in collaboration with the Superior Court of Alameda County, they
have a pilot at the jail for pre-trial diversion which began on 4/1/2024. ACBHD provided
a report on the number of people served.
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,
• Three adult teams based on region, and
• A pilot team was added to conduct intensive in reach at Washington Hospital
(Fremont) for persons who are familiar faces of the Emergency department.
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 for 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.
The Independent Reviewer interviewed three IHOT staff during the second on-site
review. The IHOT staff confirmed that they work with law enforcement and also receive
referrals from ACCESS and crisis residential treatment programs.
Second Report April 14, 2025
49
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
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.
The Independent Reviewer interviewed the Adult and Older Adult System of Care
Director during the second on-site review. This Director reported that the pilot has been
implemented, and it has been successful. The Director reported that they meet monthly
with community based providers to review each client nearing discharge. This Director
also provided the Independent Reviewer with an example of the utilization review from
Morton Bakar. Some of the categories listed in this report include the following: planned
next steps towards discharge, barriers to discharge, and stability. This Director reported
that the county is seeing shorter lengths of stays in the IMDs since the implementation
of the utilization review. For example, the length of stay at Villa Fairmont Mental Health
Rehabilitation Center was an average of 120 to 130 days. This length of stay has been
reduced to approximately 90 days.
The Independent Reviewer will continue to monitor the utilization review pilot and will
provide an update 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 include appropriate referrals to community-based
providers. Community-based provider staff interviewed continue to report that they
Second Report April 14, 2025
50
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.
The Independent Reviewer will review additional client records and will tour an IMD
facility and will report on this in subsequent reports.
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.
It was previously reported that this situation had not occurred. However, within the last
several months, ACBHD staff are starting to see this occur. ACBHD implemented a
process to track this occurrence within their IT system. The ACCESS Supervisor
reported that there are meetings with the FSP teams and the ACCESS staff every week.
This Director also reported that this same group meet quarterly to review any trends.
This Director reported that they do refer the client to another service while waiting for a
slot to open in a FSP team. One barrier that has resulted in FSP being unavailable is
workforce shortages and there is high turnover with this position.
Since this situation has only recently occurred, the Independent Reviewer will continue
to monitor and will follow up in a subsequent report.
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
continues to be 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. The implementation of the utilization management
pilot has also assisted with this process. This Director also reported that the Adult/Older
Adult System of Care has created three new positions to assist with transitions of care
into and out of acute inpatient and IMD settings and they are currently in the hiring
process.
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,
Second Report April 14, 2025
51
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.
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. ACBHD staff and
community provider staff continue to report that the relationship with John George
continues to improve. They primarily point to the John George Psychiatric Hospital
Social Worker at John George who communicates with ACBHD and community provider
staff on a daily basis to coordinate care. ACBHD Senior Executive Team reported that
ACBHD staff are invited to participate in the discharge process.
The Independent Reviewer was given a tour of the Inpatient facility and the Psychiatric
Emergency Services facility. The Independent Reviewer also interviewed John George
Psychiatric Hospital staff along with the Forensic Psychologist, Social Worker, and the
Chair, Department of Psychiatry. The Independent Reviewer reviewed 20 client records.
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 use this
real-time access for care coordination purposes.
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
Second Report April 14, 2025
52
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.
ACBHD Senior Executive Team previously reported that ACBHD staff are invited to
participate in the discharge planning 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 Psychiatric Hospital attends the weekly care
coordination meeting and care conferences, as needed. The John George Psychiatric
Hospital Social Worker reported that she regularly communicates with the community
based providers regarding discharge. The staff of the community based providers also
confirmed this.
The Adult and Older Adult System of Care Director reported that they are creating a
transition team to assist with their transition back into the community.
The chart below shows the number of clients served at John George Psychiatric
Hospital based on data for the last two fiscal years.
Service Modality FY 2022-23
Number of
Episodes
FY 2022-23
Number of
Clients
FY 2023-24
Number of
Episodes
FY 2023-24
Number of
Episodes
Crisis Stabilization 8,584 4,270 8,404 4,274
Hospital 2,304 1,564 2,535 1,714
The number of clients admitted to the crisis stabilization unit remained roughly the same
from one fiscal year to the other. The number of clients served at the inpatient hospital
and the number of episodes slightly increased from FY 2022-23 to FY 2023-24.
Since this requirement incorporates II.4.k.ii which is not yet due, the Independent
Reviewer will review this requirement and will report on the implementation in a
subsequent report.
Second Report April 14, 2025
53
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.
Previously, the Adult and Older Adult System of Care Director reported that the County
has an Outreach and Engagement(O&E) team. The outreach and engagement teams
were described in a previous requirement. 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.
The Independent Reviewer interviewed three staff from the IHOT team. The staff
confirmed that they are trying to engage a client within 90 days. The staff reported that
there are peer counselors, and a family advocate who also provide outreach and
engagement to the clients who do not follow up for services. The peer counselors
reported that they try to meet the client where they are at and treat them with respect.
Thy also reported that the lack of permanent stable, safe housing is the biggest
challenge.
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 previously reported that they have
access to John George Psychiatric Hospital’s electronic health record, and they use this
real-time access for care coordination purposes. ACBHD staff and the Social Worker at
John George Psychiatric Hospital confirmed that they do collaborate when clients are
admitted facilitating prompt resumption of services upon discharge. Further, the new
Transition of Care team will assist with notification of FSPs and Service Teams when
their clients are at John George Psychiatric Hospital.
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.
Second Report April 14, 2025
54
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
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 previously 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 prevention 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 refers to
community-based services. The Director also described the Community Assessment,
Referral and Engagement Services (C.A.R.E.S) ACT Court. This program diverts
individuals away from jail and the criminal justice system into supportive services and,
per legislation, referrals can be made by various entities, including law enforcement.
The Independent Reviewer interviewed the Forensic, Diversion and Re-entry Services
Director during the second on-site review. This Director confirmed that their re-entry
teams start working with the individual within 72 hours of booking. The purpose is to
coordinate re-engagement with services upon release or to initiate new referrals for
ongoing behavioral health services in the community. The re-entry team provides
support to individuals to provide a warm handoff to services. This Director also stated
that if the individual refuses services, the team tries 3 times to engage the individual into
services.
The chart below, indicates that for Fiscal Year 2023 to 2024, only 18.84% of the
individuals discharged were served in a new or existing community based provider
within 30 days of jail discharge.
Number of
MHS Clients
Released and
Served in MHS
in the Previous
Year
Number of
MHS Clients
Served in New
Community
Based Episode
Within 30 Days
of Jail
Discharge
Percent of
MHS Clients
Served in New
Community
Based Episode
Within 30 Days
of Jail
Discharge
Number of
MHS Clients
Served in New
or Existing
Community
Based Episode
Within 30 Days
of Jail
Discharge
Number of
MHS Clients
Served in New
or Existing
Community
Based Episode
Within 30 Days
of Jail
Discharge
3,126 333 10.65% 697 22.3%
The Independent Reviewer needs to examine ACBHD’s best efforts to identify and
implement appropriate strategies to improve warm handoffs to individuals for
appropriate services.
Second Report April 14, 2025
55
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.
It was previously reported that this situation did not occur. However, within the last
several months, ACBHD staff are starting to see this occur. ACBHD also implemented a
process to track this occurrence within their IT system. As stated previously, the Adult
and Older Adult System, Forensic Reentry system, and ACCESS meet weekly and
review individuals who need FSP or Service Team level of care to make assignments to
open slots and assign interim services until slots become available. The Adult and Older
Adult Systems of Care Director reported that there are monthly meetings with the FSP
Teams and the ACCESS staff every week. This Director also reported that this same
group meet quarterly to review any trends. This Director reported that they do refer the
client to another service while waiting for a slot to open in a FSP team. The Forensic,
Diversion and Re-entry Services Director reported that referrals for FSP are sent to
ACCESS. The Forensic, Diversion and Re-entry Director reported that they are piloting
the use of tablets to assist with the coordination and warm handoff for the individuals
being released.
Since the situation of unavailability of FSP or Service Teams has only recently occurred,
the Independent Reviewer will continue to monitor and will follow up in a subsequent
report.
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.
The Forensic, Diversion and Re-entry Services Director reported that supervisors and
managers are now conducting chart reviews on a regular basis. This Director reported
Second Report April 14, 2025
56
that they also review the re-entry plans and provide training to the community based
provider staff. One example of a change as a result of the quality reviews was to list
medications on the re-entry plan. ACBHD did provide the assessment form and the re-
entry form to the Independent Reviewer.
There is also the Multi-Disciplinary Forensic Team (MDFT) comprised of Alameda
County law enforcement agencies, Alameda County District Attorney’s Office, Alameda
County Behavioral Health Care and allied service providers. The goal of MDFT is to
provide assistance to individuals diagnosed with mental illness, substance abuse, and
co-occurring disorders. MDFT is committed to reducing recidivism by assisting these
individuals in obtaining psychiatric evaluation, treatment, and ongoing services leading
to recovery and the wellness of the individual and the greater community.
This requirement incorporates service commitments II.4.l.ii and II.4.l.iii which are not
due yet, the Independent Reviewer will examine the action taken by ACBHD and report
on the results in subsequent reports.
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 previously reported that there is
ACBHD re-entry team based at the county jail who follows-up with these individuals.
Two behavioral health clinicians are available to assist individuals in navigating services
after they are released from jail. This Director confirmed that their re-entry teams start
working with the individual within 72 hours of booking. The purpose is to coordinate re-
engagement with services upon release. The re-entry team provides support to this
individual to provide a warm handoff to services. This Director also stated that if the
individual refuses services, the team tries 3 times to engage the individual into services.
Summary of Outreach, Engagement, Linkages, and Discharge Planning Findings
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 substantial
compliance for eight service commitments, a rating of partial compliance for six service
commitments and a rating of not applicable for 12 service commitments. There were no
non-compliant ratings given in this section.
ACBHD achieved Substantial 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. ACBHD does maintain a
24/7 telephonic ACCESS Line and the number is posted on their website.
Second Report April 14, 2025
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Evidence was found during the on-site reviews, interviews of ACBH staff and
supervisor, and in reviewing client records.
2. 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.
Evidence was found in contracts, community based provider procedures, client
records, interviews with ACCESS staff, interviews with clients, and the on-site
review.
3. 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 in the
information and education materials, training documents, and interviews with
ACHBD staff. There are regular meetings with the police department, and there is
a pilot at the jail for pre-trial diversion.
4. The County will work with law enforcement to direct referrals to the In-Home
Outreach Team (“IHOT”). Evidence was found in the interviews with the IHOT
staff, review of training materials, review of policy and procedures and review of
data collected.
5. 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. Evidence of
care coordination was found in interviews with ACBHD staff, review of client
records, and a weekly meeting to review cases that monitor the client’s progress
and transition to a different level of care, as appropriate.
6. The County will use programs designed to reach individuals who do not follow up
regarding services. Evidence was found in interviews with ACBHD staff including
the IHOT team, training materials, policies and procedures, and community
based outreach and engagement teams.
7. 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. Evidence was found in interviews with ACBHD staff, John
George Psychiatric Hospital staff and with ACBHD having access to John George
Psychiatric Hospital’s electronic health record, and they use this real-time access
for care coordination purposes.
8. The County will use programs designed to reach individuals who do not follow up
regarding services, consistent with Section II.4.e. Evidence was found in
interviews with ACBHD staff and through documents regarding the re-entry
teams.
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ACBHD achieved Partial Compliance for the following requirements:
1. 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 following an eligible individual’s contact with ACCESS. The Independent
Reviewer needs to obtain an update on the technological and other back-end
improvements for providing real-time appointments along with any outcomes
from the Pathways to Wellness pilot for subsequent reports.
2. 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 needs to review the other part of this
requirement and will review additional ACCESS client records to verify the
sustainability and durability of this requirement in the next report.
3. 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
need to examine the number of referrals for FSP or Service Teams and then how
many were connected to those services. The Independent Reviewer needs to
examine the assignment process further with the community based providers.
4. 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. The Independent Reviewer needs to
examine how ACBHD coordinates with the above entities to rapidly connect
individuals to those services as appropriate.
5. 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. Evidence of discharge planning was found in interviews
with community-based provider staff, and in contracts with community based
providers. The Independent Review needs to review client records and tour an
IMD facility.
6. 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.
Second Report April 14, 2025
59
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 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
Independent Reviewer needs to examine ACBHD’s best efforts to identify and
implement appropriate strategies to improve warm handoffs to individuals for
appropriate services
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
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. 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.
7. 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
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60
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.
8. 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.
9. 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.
10. 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.
11. 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,
12. 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.4.1.ii and the quality reviews in
section II.4.l.iii. Evidence was found in interviews with ACBHD staff, review of
documents, supervisors and managers conducting chart reviews, the federal
monitor quarterly chart reviews and with the Multi-Disciplinary Forensic Team.
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CULTURALLY RESPONSIVE SERVICES
The Settlement Agreement outlines the service components under Culturally
Responsive Services which include the County continuing to ensure that all services are
culturally responsive and person-centered. In Alameda County, Culturally Responsive
Services are organized under the Office of Health Equity with a Director who reports
directly to the Behavioral Health Director. During the second on-site review, the
Independent Reviewer was able to interview the Director, Office of Health Equity.
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.
Alameda has six threshold languages as defined by DHCS Information Notice #20-070.
The most prevalent threshold language is Spanish. The other five threshold languages
are as follows: Cantonese, Farsi, Mandarin, and Vietnamese.
ACBHD developed a strategic plan dated May 13, 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), December 2024 Plan Update. 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.
• Values: ACBHD’s values reinforce our commitment to not only recognize the
cultural, linguistic, and ethnic diversity of our community but also actively
integrate cultural competency and humility into our services. By living the
following values, we aim to create a system that supports and empowers all
beneficiaries to achieve equitable health and wellness outcomes.
• Access: We value collaborative partnerships with peers and consumers, families,
service providers, agencies, and communities, where every door is the right door
for welcoming people with complex needs and assisting them along their journey
toward wellness, resilience, and recovery.
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• Consumer and Family Empowerment: We value, support, and encourage
individuals and their families to exercise their authority to make decisions,
choose from a range of available options, and develop their full capacity to think,
speak, and act effectively in their own interest and on behalf of others they
represent.
• Best Practices: We value clinical excellence through best practices, promising
community driven ideas, and effective outcomes, including prevention and early
intervention strategies, to promote well-being and optimal quality of life. We value
business excellence and responsible stewardship through revenue maximization
and the wise and cost-effective use of public resources.
• Health & Wellness: We value the integration of psychological, emotional, spiritual
and physical health care to promote the wellness and resilience of individuals
recovering from the multi-dimensional effects of mental illness and substance use
disorders.
• Culturally Responsive: We value the integration of psychological, emotional,
spiritual, and physical health care to promote the wellness and resilience of
individuals recovering from the multi-dimensional effects of mental illness and
substance use disorders.
• Socially Inclusive: We value advocacy and education to eliminate stigma,
discrimination, isolation, and misunderstanding of persons experiencing mental
illness, trauma, and substance abuse disorders. We support social inclusion and
the full participation of our clients, consumers, patients, and family members to
achieve fuller lives in communities of their choice – where they can live, learn,
love, work, play, and pray in safety, security, and acceptance.
The CCP, December 2024 Plan Update reported the following regarding workforce
capacity and needs:
The ACBHD aims to be intentional in its recruitment and retention efforts, given
Alameda County’s diversity and ongoing labor challenges in the behavioral health
sector. Through the needs assessment, the ACBHD wanted to understand the
diversity of the workforce and the existing strategies to recruit and retain a diverse
workforce.
Finding 1: Hiring and recruiting staff reflective of the client population is both a
priority and a challenge for community-based providers.
Finding 2: There is a shortage in bilingual and racially diverse staff, especially
clinicians. Providers spoke to the critical need for enhanced linguistic diversity
and cultural competence within the workforce.
Finding 3: Providers who participated in the needs assessment reported
experiencing challenges in meeting the complex health and social needs of their
clients, which can contribute to burnout.
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Finding 4: Providers expressed support for the critical role that the family and
peer workforce can play in meeting their clients’ needs and reported engagement
efforts. (Pages 135-140)
The CCP, December 2024 Plan Update did identify the following issues from survey
respondents and focus group participants the following:
In noting gaps in the behavioral health system, respondents mentioned concerns
around language capacity and the system’s limited ability to support people who
do not speak English. For programs serving those with severe mental illness,
community members mentioned a need for more family input for treatment and a
better understanding of the Health Insurance Portability and Accountability Act.
Community input highlighted the need for more centralized resources for people
experiencing homelessness and increased the quality and cultural
responsiveness of services for the African American/Black community. (Page 59).
The MHSA Annual Plan Update (Draft) for Fiscal Year 2024 through 2025 includes the
goal of being culturally responsive which is defined as follows:
“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 conducted between October 2023 through
January 2024. 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).
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).
ACBHD provided contracts with their community based providers which stated the
following: “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.”
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Interviews with both ACBHD staff and community-based provider staff previously
indicated that the services provided are culturally responsive and person centered. The
Independent Reviewer was able to review over fifty client records where the client’s
goals are identified and were developed in a manner consistent with a person-centered
approach. The Independent Reviewer also interviewed eight clients in a virtual group
setting, and they confirmed that services are provided in a culturally responsive and
person-centered manner. Clients spoke about receiving culturally appropriate services
surrounding the holidays such as their traditional meals.
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
reviewed the minutes for four committee meetings in 2024. These meetings are
facilitated by the Health Equity Policy and Systems Manager. During the meeting, the
CCP is discussed along with updates from the various culturally responsive advisory
committees, announcements of trainings and upcoming events of interest.
The CCP, December 2024 Plan Update has a section on strategies and efforts for
reducing racial, ethnic, cultural, and linguistic mental health disparities. The plan stated
that: “We are intentional in our efforts to reduce mental health disparities and create a
more equitable and inclusive behavioral health system.” (Page 61). This section in the
Plan includes the following:
• Identified unserved/underserved target populations with disparities,
• Identified disparities within target populations,
• Strategies/objectives/actions/timelines,
• Additional strategies/objectives/actions/timeline and lessons learned, and
• Planning and monitoring of identified strategies/objectives/actions/timelines to
reduce mental health disparities.
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 previously provided an organizational chart that indicates that the Director,
Office of Health Equity, reports directly to the ACBHD Director. This division also
includes the Office of Ethnic Services, the Office of Peer Support Services, the Office of
Family Empowerment Services, Health Equity Policy, Community Relations, and
Workforce Education and Training (WET). The division also oversees operations related
to Patients’ Right Advocacy. The Independent Reviewer interviewed the Director, Office
of Health Equity during the second review.
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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
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).
The CCP, December 2024 Plan Update lists out the number of coalitions/committees
with stakeholder participation to provide feedback to the department. Some of these
coalitions/committees are as follows:
• ACBH Pride Coalition,
• Asian American, Native Hawaiian, and Pacific Islander Advisory (AANHPI)
Committee for Health and Wellness,
• African American Steering Committee for Health and Wellness,
• First 5 Help Me Grow,
• Latinx/Latino Advisory Committee for Health and Wellness, and
• Mental Health Association for Chinese Communities.
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 completed the dashboard, and it is uploaded to their website. ACBHD hosted a
stakeholder and community meeting on March 6, 2025, to obtain their feedback.
Subsequent reports will address this further as the deadline is 15 months after the
effective date of the Settlement Agreement.
Requirement: The Health Equity Officer will thoroughly review the feedback from the
stakeholder/community input meetings on how to improve culturally responsive services
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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.
Previously, the Health Equity Division Director reported that the County found a building,
and Escrow has closed on the building. 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 clients and community members with a focus on wellness.
The County has dedicated $19 Million dollars to this effort. ACBHD provided evidence of
multiple listening sessions with stakeholders. At the Board of Supervisors meeting on
9/17/2024, the Board approved the following:
• The initial project budget for the African American Wellness Hub Project in the
amount of $5,000,000;
• The use of Alameda County Health, Behavioral Health Department funds for the
initial project budget for the African American Wellness Hub Project, in the
amount of $5,000,000;
• Authorized the Director of the General Services Agency or her designee to issue
Task Order No. 20115, in the amount of $3,866,861, with Vanir Construction
Management, Inc., for the program and project management services for the
African American Wellness Hub.
The Health Equity Division Director stated that the plan from the County’s General
Services is to tear down the existing building on the land and to build a new building.
This Director reported that they meet with the stakeholders on an as needed basis.
Some examples of the stakeholder meetings include topics such as CARE Court and
Prop 1 implementation. This Director also reported that the county continues a
commitment to this project.
Second Report April 14, 2025
67
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 Culturally and Linguistically Appropriate Services (CLAS)
training and offers training each month. For the community-based providers, the
following language was found in their contract with ACBHD: “Contractor shall ensure
annual training of all applicable employees, volunteers, board members, owners, and/or
agents who are providing and/or supporting services under this Agreement on
Administrative and Compliance Requirements, in areas including but not limited to:
documentation standards, billing requirements, Culturally and Linguistically Appropriate
Standards (CLAS), Annual Compliance/Code of Conduct, and Health Insurance
Portability and Accountability Act (HIPAA)/Privacy and Security.”
The CCP, December 2024 Plan Update stated the following:
Steps to Provide Required Cultural Competence Training to 100% of Staff Over
Three-Year Period: To ensure that all staff complete the required Cultural
Competence Training, ACBHD requires compliance for all internal staff. Each
contracted provider is required to abide by contractual obligations. Completion of
required cultural competency training is reviewed annually by ACBHD staff.
Per the executed contract: Provider, Program and Staff Information Contractor
shall submit any needed updates to provider, program and staff information, as
well as attestation of accuracy of information on file by the 15th of each month as
requested by ACBH to complete required publications, submissions and
monitoring including but not limited to Provider Directory and Network Adequacy
Reporting. Contractor’s submission shall include but not be limited to
Contractor’s cultural and linguistic capabilities in service delivery and
documentation of staff completion of cultural competence training and shall be in
accordance with the format specified by ACBH and the California Department of
Health Care Services (DHCS).
The Health Equity Division Director reported the following activities to ensure that the
training requirements are met:
1. Sign-in sheets are collected at the training and reviewed as part of compliance.
Second Report April 14, 2025
68
2. Each contract with a community based provided is required to provide CLAS
training to all direct service staff and managers who are providing or supporting
services through this Agreement. The staff are to complete at least four CLAS
training courses annually. The community based provider submits the following
information by July 10th of the following fiscal year to the ACBHD Office of Ethnic
Services:
a. An electronic survey that demonstrates Contractor’s implementation of
CLAS Standards,
b. A list of CLAS trainings attended by staff and managers who are
providing or supporting services through this Agreement; and
c. A summary or copy of a plan to further implement CLAS Standards
throughout the organization.
3. The Office of Ethnic Services conducts a survey at the end of each year to
assess and confirm attendance, plans and adherence to CLAS standards each
year. A copy of the survey results was provided for review.
4. QA/QI team performs audits and the CLAS standard portion of the contract is
assessed.
Trainings also include an evaluation form to be completed if CEUs are to be issued.
Some trainings do include a post test. In addition, the Health Equity Division Director
reported that they currently collect attendance at the class, but that ACBHD is moving
toward a more efficient process where each CLAS training has an electronic sign-
in sheet. This process will allow for the normalization of collected information. Office of
Ethnic Services is also moving toward collecting data on ACBHD hosted CLAS
trainings via the internal announcement portal in FY 2025-26.
ACBHD provided an EXCEL sheet summarizing the topic of the training, date of the
training, who attended, and the attendees’ organization for review. Some of the trainings
were as follows: Trauma informed and culturally responsive practices working with
Asian American, Native American, and Pacific Islander clients, CLAS standard and
stigma discrimination reduction in behavioral health, and Mental health services with
Latinx populations.
Summary of Culturally Responsive Services Findings
Overall, there are six service commitments in the Culturally Responsive Services
component of the Settlement Agreement. ACBHD received substantial compliance for
four service commitments, and a rating of not applicable for two service commitments.
There were no non-compliant ratings given in this section.
ACBHD achieved Substantial Compliance for the following requirement:
1. The County will continue its ongoing efforts to ensure that all services provided under
this Agreement are culturally responsive and are person-centered. ACBHD provided
evidence of their strategic plan, the CCP plan, and minutes of the CC committee
Second Report April 14, 2025
69
meetings. Review of contracts with community based providers and interviews with
community based provider staff and with clients also confirmed that services provided
are culturally responsive and person-centered.
2. The County will continue to operate the Office of Health Equity within ACBHD, 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 centered care that
considers the whole person and all their needs. There is evidence to support
compliance with this requirement through interviews with ACBHD staff, community
provider staff, and the CCP December 2024 Plan Update minutes of the Cultural
Responsiveness committee.
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 continues to support the African American Wellness Hub with
finding a building and General Services work to build a new building. ACBHD provided
the approval of project by the Board of Supervisors, listening sessions from the
stakeholders, a YouTube video regarding the African American Wellness Hub and
interviews with ACBHD staff.
4. 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. ACBHD
provided the following evidence: trainings occur on a regular and sustained basis,
procedure to ensure all staff are attending these training courses and a list of training
topics.
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.
Second Report April 14, 2025
70
SUMMARY AND NEXT STEPS
This is the second 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 substantial compliance was given in 42 percent of the service commitments,
a rating of partial compliance was given in 22 percent and a rating of not applicable was
given for 36 percent of the service commitments.
The draft of the second report was issued on February 28, 2025. Per the Settlement
Agreement, 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 will continue to evaluate implementation of all provisions.
The Independent Reviewer will also verify if the requirements were sustained after six
months and are durable 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 20 months after the effective date of the Settlement
Agreement.
Second Report April 14, 2025
71
Attachment I: Ratings of Service Commitments
SERVICE COMMITMENT RATING3
1. Crisis Services First
Report
Second
Report
1.a. The County will continue to offer a countywide crisis system and
expand crisis intervention services.
PC SC
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. Beginning no later than 18
months after the Effective Date, the crisis hotline will have a clinician
available to support crisis hotline services 24/7.
NA 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 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 SC
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 NA
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 SC
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 SC
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
NA SC
3 Due to the temporal limitations of this report, a rating of substantial compliance was not yet possible.
Second Report April 14, 2025
72
the need for crisis services in the County, which the County will
collect and analyze as part of the Mobile Crisis Assessment process.
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 SC
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 NA
1.a.ii.(7) FSPs will provide crisis intervention as set forth in section
II2.m. in this Agreement.
PC NA
1.a.ii.(8) Each mobile crisis team shall include at least one mental
health clinician.
PC SC
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 SC
1.b.i. Maintain 45 crisis residential treatment (CRT) beds. PC SC
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 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 SC
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 SC
1.b.v. Individuals shall not be required to have identified housing as a
condition of admission to a CRT facility.
PC SC
1.b.vi. CRT facilities and peer-respite homes shall be able to accept
admissions directly from mobile crisis.
PC SC
1.c. The County’s crisis system will be designed to prevent
unnecessary hospitalization, IMD admissions, law enforcement
interactions, and incarceration.
PC SC
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
NA NA
Second Report April 14, 2025
73
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.
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 PC
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. 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.
NA NA
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 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 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
PC PC
Second Report April 14, 2025
74
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).
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 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 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 PC
2.l. FSP program 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.
PC SC
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 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 SC
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)
PC PC
Second Report April 14, 2025
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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.
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 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 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 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 SC
3.b. The County will explore community needs and opportunities for
expanding Service Teams as appropriate.
NA 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 SC
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 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 SC
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 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
PC PC
Second Report April 14, 2025
76
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”).
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 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 SC
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 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 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 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.
NA NA
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
PC PC
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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.
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 SC
4.h. The County will work with law enforcement to direct referrals to
the In-Home Outreach Team (“IHOT”).
PC SC
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 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 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 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 designee) will be notified, and the County will
work to arrange such services as promptly, as possible.
PC NA
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 SC
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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 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
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Second Report April 14, 2025
79
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.
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 NA
4.k.v. The County will use programs designed to reach individuals
who do not follow up regarding services.
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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.
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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.
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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 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 NA
4.l.iv. With the goal of reducing risk of unnecessary
institutionalization, incarceration, and law enforcement contacts, the
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Second Report April 14, 2025
80
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.
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.
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5. Culturally Responsive Services
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 SC
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.
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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 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 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,
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Second Report April 14, 2025
81
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.
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.
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