Drug Medi-Cal Organized Delivery System Implementation Plan. Imperial County Behavioral Health Services

Transcription

1 Drug Medi-Cal Organized Delivery System Implementation Plan Behavioral Health Services

2 Contents Page Number Part I Plan Questions 2 Part II Plan Description: Narrative Description of the County s Plan 5 Section 1 Collaborative Process 5 Section 2 Client Flow 7 Section 3 Beneficiary Notification and Access Line 12 Section 4 Treatment Services 13 Section 5 Coordination with Mental Health 19 Section 6 Coordination with Physical Health 21 Section 7 Coordination Assistance 22 Section 8 Availability of Services 24 (a) The anticipated number of Medi-Cal clients 25 (b) The expected utilization of services 26 (c) The number and types of providers required to furnish the 27 contracted Medi-Cal services (d) Language capability for the county threshold languages 28 (e) Timeliness of first face-to-face visit, timeliness of services for 28 urgent conditions and access after-hours care (f) The geographic location of providers and Medi-Cal beneficiaries, 29 considering distance, travel time, transportation, and access for beneficiaries with disabilities (g) How will the county address service gaps, including access to 32 Medication Assisted Treatment (MAT) services (h) Appendix list of network providers 33 Section 9 Access to Services 33 Section 10 Training Provided 34 Section 11 Technical Assistance 35 Section 12 Quality Assurance 36 Section 13 Evidence-based Practices 42 Section 14 Regional Model 44 Section 15 Memorandum of Understanding 44 Section 16 Telehealth Services 45 Section 17 Contracting 45 Section 18 Additional MAT 47 Section 19 Residential Authorization 48 Section 20 One Year Provisional 49 1

3 P A R T I - P L A N Q U E S T I O N S This part is a series of questions that summarize the county s Drug Medi-Cal - Organized Delivery System (DMC-ODS) plan. 1. Identify the county agencies and other entities involved in developing the county plan. (Check all that apply) Input from stakeholders in the development of the county implementation plan is required; however, all stakeholders listed are not required to participate. County Behavioral Health Agency County Substance Use Disorder Agency Providers of drug/alcohol treatment services in the community Representatives of drug/alcohol treatment associations in the community Physical Health Care Providers Medi-Cal Managed Care Plans Federally Qualified Health Centers (FQHCs) Clients/Client Advocate Groups County Executive Office County Public Health County Social Services Foster Care Agencies Law Enforcement Court Probation Department Education Recovery support service providers (including recovery residences) Health Information technology stakeholders Other (specify) 2. How was community input collected? Community meetings County advisory groups Focus groups Other method(s) (explain briefly) 3. Specify how often entities and impacted community parties will meet during the implementation of this plan to continue ongoing coordination of services and activities. Monthly Bi-monthly Quarterly Other: Every two weeks 2

4 Review Note: One box must be checked. 4. Prior to any meetings to discuss development of this implementation plan, did representatives from Substance Use Disorders (SUD), Mental Health (MH) and Physical Health all meet together regularly on other topics, or has preparation for the Waiver been the catalyst for these new meetings? SUD, MH, and physical health representatives in our county have been holding regular meetings to discuss other topics prior to waiver discussions. There were previously some meetings, but they have increased in frequency or intensity as a result of the Waiver. There were no regular meetings previously. Waiver planning has been the catalyst for new planning meetings. There were no regular meetings previously, but they will occur during implementation. There were no regular meetings previously, and none are anticipated. 5. What services will be available to DMC-ODS clients upon year one implementation under this county plan? REQUIRED Withdrawal Management (minimum one level) Residential Services (minimum one level) Intensive Outpatient Outpatient Opioid (Narcotic) Treatment Programs Recovery Services Case Management Physician Consultation How will these required services be provided? All County operated Some County and some contracted All contracted. OPTIONAL Additional Medication Assisted Treatment Partial Hospitalization Recovery Residences Other (specify) 3

5 6. Has the county established a toll free 24/7 number with prevalent languages for prospective clients to call to access DMC-ODS services? Yes (required) No. Plan to establish by:. Review Note: If the county is establishing a number, please note the date it will be established and operational. 7. The county will participate in providing data and information to the University of California, Los Angeles (UCLA) Integrated Substance Abuse Programs for the DMC-ODS evaluation. Yes (required) No 8. The county will comply with all quarterly reporting requirements as contained in the STCs. Yes (required) No 9. Each county s Quality Improvement Committee will review the following data at a minimum on a quarterly basis since external quality review (EQR) site reviews will begin after county implementation. These data elements will be incorporated into the EQRO protocol: Number of days to first DMC-ODS service/follow-up appointments at appropriate level of care after referral and assessment Existence of a 24/7 telephone access line with prevalent non-english language(s) Access to DMC-ODS services with translation services in the prevalent non-english language(s) Number, percentage of denied and time period of authorization requests approved or denied Yes (required) No 4

6 P A R T I I P L A N D E S C R I P T I O N (Narrative) 1. Collaborative Process. Describe the collaborative process used to plan DMC-ODS services. Describe how county entities, community parties, and others participated in the development of this plan and how ongoing involvement and effective communication will occur. Behavioral Health Services (ICBHS) developed an internal DMC-ODS implementation committee composed of representation from Quality Management (QM), Adult Substance Use Disorder (SUD) Services, Adolescent SUD services, Youth and Young Adult (YAYA) Services Mental Health, Adult Services Mental Health, and Administration. The members of this committee included the assistant director; deputy director, behavioral health manager and administrative analyst for Adult Services; deputy director, behavioral health manager, program supervisor and administrative analyst for YAYA; and behavioral health manager and administrative analyst for QM. This committee met on a weekly basis to discuss all elements of the implementation plan and define tasks required as part of the implementation process. The committee identified a list of agencies, stakeholders, and individuals that would have a role or contribution in the implementation of DMC-ODS services. Informational brochures in English and Spanish were created that provide an overview of the DMC-ODS waiver and a series of community forums were scheduled in different areas of. Newspaper ads were posted inviting the community to participate in these forums and invitations were delivered to different community agencies, schools and stakeholders encouraging their participation. In addition, individual presentations were also held within ICBHS mental health and SUD clinics, other SUD providers, SUD treatment participants and agencies that were not available to participate in the community forums. Each presentation included an overview of DMC-ODS waiver services and a series of questions that assisted in engaging the community and stakeholders providing valuable input in the needs and priorities for. The survey questions were as follows: 1) In your opinion, what is the greatest need for related to Alcohol and Drug treatment services? 2) A. From the DMC-ODS treatment interventions described, what do you think is the most important? B. Please explain why. 3) What would you consider to be the greatest challenges/barriers in delivering these services? Location Availability of appointments Hours of service Bilingual staff Transportation 5

7 Confidentiality Negative views of people seeking services Other 4) What recommendations do you have to reduce the impact of these challenges/barriers? 5) In your opinion, how will implementation of this new system impact residents? 6) What do you recommend to make these services available to residents (Example: location, bilingual staff, office hours, etc.)? 7) Do you have other recommendations for the implementation of these services or additional comments? The list of groups and individuals that provided input during these community forums and presentations includes the following: Community Groups and Individuals Engaged for Implementation Plan Behavioral Health Services Imperial Valley College Imperial Valley LGBTQ Resource Center Imperial Valley Regional and Occupational Program Department of Social Services Children and Families First Commission Imperial Valley Food Bank Calexico Unified School District El Centro Elementary School District Probation U.S. Border Patrol Central Union High School District Office of Education Public Health Department of Corrections Sure Helpline Crisis Center Smart Recovery Group Participants Imperial Valley Medical Treatment Center (NTP) The DMC-ODS implementation committee reviewed and analyzed the data collected and incorporated the feedback as part of the implementation process. The major themes from the data collected that impacted the development of the plan are as follows: Major Themes from Community Forums and Presentations Family counseling and education Increase accessibility to residential facilities Increase services for adolescents and families Follow-up services to support recovery Expansion of service hours Transportation Vocational training Community outreach and education Prevention Services Case management services for community Increase focus on individual counseling Accessible location of services Home visiting services ICBHS will continue to provide stakeholders opportunities for involvement in the implementation process through ongoing meetings with agencies such as Public Health Department, 6

8 Probation, Department of Social Services, Methadone Clinic, residential facilities, law enforcement, school districts, ICBHS MH and SUD staff and other local agencies. Through these meetings, ICBHS will maintain stakeholders updated on the progress of the implementation plan and will continue to obtain input on how the process can be improved to better serve residents. 2. Client Flow. Describe how clients move through the different levels identified in the continuum of care (referral, assessment, authorization, placement, transactions to another level of care). Describe what entity or entities will conduct ASAM criteria interviews, how admissions to the recommended level of care will take place, how often clients will be re-assessed, and how they will be transitioned to another level of care accordingly. Include the role of how the case manager will help with the transition through levels of care. Also describe if there will be timeliness established for the movement between one level of care to another. Please describe how you plan to ensure successful care transitions for high-utilizers or individuals at risk of unsuccessful transitions. The goal of ICBHS is to provide timely access to medically necessary SUD services. Beneficiaries can access services through different pathways that include referrals from other agencies such as, Imperial County Probation, Department of Social Services, education, health care providers, or ICBHS MH. Beneficiaries can also access SUD treatment by contacting the 24-hour access number, contacting one of the SUD treatment facilities, or by walking in to one of the ICBHS SUD or MH clinics. An intake assessment appointment will be provided within seven (7) working days from the day the individual requests services at which time medical necessity criteria for SUD services will be determined. Beneficiaries, who meet medical necessity and ASAM criteria, will have access to a full continuum of SUD services based on ongoing assessment and identified need during the course of treatment. Please refer to Figure 1 Client Flow Chart. Initial Service Screening Upon request for services, individuals will be screened by an Access and Benefits Worker (ABW), who will ask a series of questions to determine insurance coverage and eligibility, demographic information, and the presenting problem(s). Once screened by the ABW, clients will be given an intake assessment appointment at the appropriate SUD outpatient clinic. Determination for the appropriate clinic will be based on findings from the initial access screening, geographic accessibility, threshold language needs, and individuals preference. ICBHS will develop procedures on the referral and screening process, which will be shared and discussed with ICBHS MH and SUD staff and referring agencies. The referral process will provide multiple points of entry for beneficiaries. Referrals can be generated from Community Based Agencies, primary care/ emergency department physicians or governmental agencies such as the Court System, Probation, Parole and School Districts. Additionally, a beneficiary may be able to access service through a self-referral. community agencies, and governmental organizations and may refer beneficiaries through the use of a Community Agency Referral Form which will be provided to these organizations or which will be available on the ICBHS 10

9 website. Primary Care Physicians will refer clients along with the Screening Brief Intervention and Referral (SBIRT). Self-referred beneficiaries can begin the screening process by calling the Access phone number which is available 24 hours per day/ 7 days per week. Additionally, beneficiaries can walk into clinics and request services. Upon receiving the referral, Access workers will contact or meet with the beneficiary to complete a screening and gather needed information to make arrangements to begin treatment services. In addition the eligibility information obtained, additional inquiry will be made about the reason for requesting services such as the type(s) of substance the client is using, the situation or crisis which motivated the request for services, and whether or not a crisis or urgent condition exists. This screening will allow the Access worker to make all the necessary arrangements to begin treatment services which includes a scheduled appointment for an intake assessment, at the appropriate regional clinic. Intake Assessment and Medical Necessity Determination Medical necessity for services must be determined as part of the intake assessment process and will be performed through a face-to-face session with the beneficiary. Beneficiaries attending the first appointment at a SUD outpatient clinic will receive a comprehensive bio-psychosocial intake assessment as well as a risk/severity rating and immediate needs profile based on the American Society of Addiction Medicine (ASAM) criteria. This assessment will be conducted by a licensed clinician or registered intern working under the supervision of a licensed clinician. Information gathered during the intake assessment includes presenting problem(s); family alcohol and drug and mental health history, social history, medical history and religious history; personal alcohol and drug use history; developmental history; personal/social history; legal history; medical and mental health history; other critical information. Based on the information gathered during the intake assessment, clinicians determine if the beneficiary meets medical necessity for SUD treatment. Beneficiaries must be diagnosed as having at least one Substance-Related and Addictive Disorder diagnosis, excluding Tobacco-Related Disorder and Non-Substance Related Disorders, from the Diagnostic and Statistical Manual (DSM) or, for beneficiaries under the age of 21, a risk for developing a SUD. After establishing a diagnosis and medical necessity, the ASAM criteria will be applied using the multidimensional assessment to determine a level of care placement. This information will also guide the recommended treatment plan. Beneficiaries who meet medical necessity and present a MH need, will be referred for additional MH evaluation. SUD treatment team staff, which may include a physician, case manager, and/or clinician, will work in collaboration with MH staff to ensure proper coordination for integrated MH services if appropriate. ICBHS will develop procedures that will define the process for the proper integration of MH treatment for those beneficiaries with co-occurring disorders. In the event that a beneficiary does not meet SUD medical necessity criteria, the clinician will assess for other immediate needs and will make the necessary referrals to other community agencies, including MH. If the beneficiary does not meet diagnostic criteria for SUD but is assessed as being at risk for developing a SUD, the client will be referred for Early Intervention Services, ASAM level 0.5, through a managed care plan. 10

10 Medical necessity qualification for ongoing receipt of services [except Narcotic Treatment Programs (NTP) services] will be determined at least every six months through the reauthorization process for beneficiaries determined by the medical director or clinician to be clinically appropriate. Reauthorization for NTP services will be conducted annually. Reassessment and Transition between Modalities Beneficiaries will receive on-going assessment using ASAM criteria throughout the course of treatment. Re-assessment can take place at any time and as deemed appropriate. At minimum, assessment and/or re-assessment will take place at the onset of each treatment modality and every ninety (90) days thereafter in conjunction with the required treatment plan. Beneficiaries will also be evaluated at the conclusion of the treatment modality for determination of the next level of care in the continuum of SUD treatment. Case managers, who are required to be a Licensed Practitioner of the Healing Arts (LPHA) or a certified substance abuse counselor (SAC), will work directly with the ICBHS SUD treatment team, other agencies involved in the beneficiary s treatment and contract providers to assist in the transition between treatment modalities. Case managers will work proactively by ensuring that transitions to other levels of care are effective, timely and complete, which will improve the beneficiaries safety and satisfaction. For beneficiaries who are high utilizers or at risk of unsuccessful transitions and require a higher level of care, ICBHS will follow the expedited referral process to ensure immediate transition within modalities. The assigned case manager will work closely with the beneficiary by providing more intensive services and increasing contacts with the beneficiary, if necessary, until the transition is complete. Case manager services may continue after this transition, if medically necessary, and to assist the beneficiary adhere to the recommended treatment. The case manager will also communicate with other treatment providers to ensure that attention is placed on assisting the client transition to the higher level of care successfully. Beneficiaries who will transition to a lower level of care will also continue to receive support by the treatment provider and assigned case manager to ensure progress is sustained and concerns regarding their recovery are addressed. This support may include increased case management contacts that will slowly decrease once the beneficiary demonstrates stability in the lower level of care, interventions to cope with triggers that may lead to relapse, connecting the beneficiary to health social supports and activities, and providing linkage to community services that will provide additional support through the SUD treatment. Beneficiaries will move through the continuum of care as individual progress takes place. Treatment plans will be individualized and timelines will be set based on the needs of the beneficiary. Considerations on the number of sessions for individual, group, and family counseling will be made based on evidence-based models and identified needs. ICBHS will abide by the requirements set by DHCS related to residential treatment and will work within the mandated maximum stay for adolescents and adults in residential facilities. Case managers will also take an important role in helping beneficiaries reach their optimal level of health, well-being and recovery by addressing their medical, psychosocial, behavioral, and spiritual needs. In addition, all ICBHS SUD case managers will be trained on evidence-based models that will address the beneficiaries SUD needs, help beneficiaries develop skills that enhance life functioning 10

11 and promote self-advocacy, self-care, and recovery. Case managers will focus on collaborating with beneficiaries to establish accountability and responsibility, help with transitions, create a proactive treatment plan at the start of each treatment modality, and will monitor and follow-up as needed for the beneficiary s success. Residential Evaluation and Authorization All beneficiaries seeking SUD treatment will receive an intake appointment in which a biopsychosocial assessment of the beneficiary will be conducted by a LPHA. The LPHA will use the ICBHS Intake Assessment tool that will incorporate all six elements of the ASAM Multidimensional Assessment. Beneficiaries who at the time of intake are assessed to meet the ASAM criteria for residential treatment, will be referred and assigned a case manager through the expedited referral process for immediate placement coordination in a contracted residential facility. Or, throughout the course of treatment, if the beneficiary is assessed to require a higher level of care, the treatment team will meet to discuss the case for appropriateness and referral to a residential facility. The treatment team will review the beneficiary s current functioning, response to treatment, and each ASAM dimension to determine severity and need for a higher level of care. A case manager will be assigned for coordination and facilitation of timely placement, follow-up and discharge planning. All prior authorization requests will be reviewed by the SUD Program Supervisor within 24 hours of request by the treatment provider. The SUD Program Supervisor will review the beneficiary s intake assessment, diagnosis, treatment history and the reasons for referral to determine approval or denial of request. Authorization and tracking of all residential treatment referrals will be conducted by ICBHS designated staff at each SUD outpatient clinic. ICBHS will grant a prior authorization for the first seven (7) days of residential treatment based on the results identified on the ASAM assessment. The residential treatment provider will have the responsibility to submit a request for authorization for up to a maximum of ninety (90) days on a continuous period for those adult clients who have been assessed and admitted into a residential facility. One extension of up to thirty (30) days beyond the maximum length of ninety (90) days may be authorized for one continuous length of stay in a one (1) year period. The residential treatment provider will also have the responsibility to submit a request for authorization for up to a maximum of thirty (30) days in one continuous period for adolescent clients who have been assessed and admitted to a residential facility. Reimbursement will be limited to two non-continuous thirty (30) day regimens in any one year period. One extension of up to thirty (30) days beyond the maximum length of stay may be authorized for one continuous length of stay in a one year period. Continuum of Care All SUD providers are expected to individualize treatment and use the full continuum of services available to beneficiaries to ensure clients receive the most appropriate care. Case management services will help assure clients move through the system and access other needed health and ancillary services to support their recovery. As beneficiaries complete primary treatment, they will be connected to recovery services to build connections within the recovery community and continue developing self-management strategies to prevent relapse. 10

12 Client Flow Chart Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver Referral Source Community Agencies Court Order Referral to Access Walk-in to Clinic Call to Clinic / Access Access Screening Appointment within 7 Days of Referral to Appropriate SUD Outpatient Clinic Referral to non-dmc Does Not Meet Medical Necessity but is SUD Outpatient Cli Does Not Referral Meet Medical to Community Clinician Completed Intake Services & Supports Assessment & ASAM Multidimensional Co-Occurring Mental Health Assessment follow-up for Integrated Mental M e e t s M e d i c a l N e c e s s i t y f o r S U D T r e a t m C l i n i c a l l y M a n a g e d W i t h d r a R e s i d e n t i a l Level 3.1 Level 3.3 Adults with Adolescent Cognitive Individual Group O u t p a t i e n Level 1 O t h e r S U D S e r v Withdrawal Management I n t e n s Services i v e O u t p Opioid/Narcotic Level 2.1 Treatment Services Individual Medication Assisted Group C o m p l e t i o n o f T r e a t m e n t D i s c h a R e c o v e r y S e r v i c e s Figure 1 - Client Flow Chart 11

13 3. Beneficiary Notification and Access Line. For the beneficiary toll-free access number, what data will be collected (i.e. measure the number of calls, waiting time, and call abandonment)? How will individuals be able to locate the access number? The access line must be toll-free, functional 24/7, accessible in prevalent non-english languages, and ADA-compliant (TTY). Review Note: Please note that all written information must be available in the prevalent non-english languages identified by the state in particular service area. The plan must notify beneficiary of free oral interpretation services and how to access those services. ICBHS will utilize the current toll-free access line as the beneficiary access line for DMC ODS services. The access line is available twenty-four (24) hours a day, seven (7) days a week and is available in English and the MHP s threshold language, Spanish. Language Line Services are available for interpretation in other languages. During business hours, the toll-free line is managed by the ICBHS Access Unit. After hours, the line is managed by trained on-call staff. The access line is ADAcompliant and all callers are also screened for crisis/urgent conditions and referred appropriately. The toll-free access line number and information on free oral interpretation and how to access those services is currently included in the informing materials that are available through the Access Unit and at each service area and contract provider service locations. All informing material is provided in English and the MHP s threshold language, Spanish. ICBHS also notifies beneficiaries of the availability of the toll-free number, free oral interpretation services and how to access those services through posters that are displayed at all service areas. The toll-free access line is also listed on brochures, forms, newspapers, phone books, social and local media. Each call requesting information about services, appointment requests or identified as crisis/urgent conditions are logged and the following data is collected: Caller s name Date of call Contact type (client request) Referred by Interpreter needed Presenting problem Appointment information Timeliness of Appointment Staff who answered call Information provided to caller/disposition of call 12

14 In addition, ICBHS ShoreTel phone system has the capability to capture data such as: number of calls received, hold waiting time, and length of call. Data collected will measure timeliness, access and urgent conditions. 4. Treatment Services. Describe the required types of DMC-ODS services (withdrawal management, residential, intensive outpatient, outpatient, opioid/narcotic treatment programs, recovery services, case management, and physician consultation) and optional (additional medication assisted treatment, recovery residences) to be provided. What barriers, if any, does the county have with the required service levels? Describe how the county plans to coordinate with surrounding opt-out counties in order to limit disruption of services for beneficiaries who reside in an opt-out county. ICBHS will provide the following types of required and optional services: D M C - O D S S e r v i c e s Service Type ASAM Level Required or Optional Provider A Early Intervention/ Screening, Brief Intervention, and Referral to Treatment (SBIRT).05 Provided in partnership with existing primary care provider or managed care provider Primary Care MDs Medi-Cal Managed Care Providers B Outpatient Services/ Outpatient Treatment Services 1 Required ICBHS Contract Provider C Intensive Outpatient Treatment Services (IOT) 2.1 Required ICBHS Contract Provider E Withdrawal Management Services (WM) 1-WM 3.2-WM 1 Level Required ICBHS Contract Provider F Residential Treatment Services 3.1, 3.3, Required Contract Provider (RTS) 3.7 G Opioid/Narcotic treatment OTP Required Contract Provider Program (NTP) Level 1 H Additional Medication Assisted Treatment (MAT) Services OTP Level 1 Optional ICBHS Contract Provider I Recovery Services N/A Required ICBHS J Case Management N/A Required ICBHS K Physician Consultation N/A Required ICBHS L Recovery Residence N/A Optional ICBHS Service Descriptions: A. Early Intervention (ASAM Level 0.5) Screening, Brief Intervention, and Referral to Treatment (SBIRT) for beneficiaries at risk for developing a SUD will be provided by Medi-Cal managed care providers, and local primary care providers. Beneficiaries at risk of developing a SUD or those with an existing SUD are identified and offered screening for adults, brief treatment as medically necessary, and, when indicated, a referral to treatment with formal linkage. 13

15 B. Outpatient Services (ASAM Level 1.0) Outpatient services consist of up to nine (9) hours per week of medically necessary services for adults and less than six (6) hours per week of services for adolescents. SUD providers will offer ASAM Level 1 services including: assessment, treatment planning; individual and group counseling; family therapy; patient education; medication services; collateral services; crisis intervention services; and discharge planning and coordination. Services may be provided in-person or by telephone in any appropriate setting in the community. Services listed above will be provided in an outpatient setting by ICBHS SUD staff. Staff providing services will consist of certified SACs and LPHAs. C. Intensive Outpatient Services (ASAM Level 2.1) Intensive outpatient involves structured programming provided to beneficiaries as medically necessary for a minimum of nine (9) hours and a maximum of nineteen (19) hours per week for adult clients. Adolescents are provided a minimum of six (6) and a maximum of nineteen (19) hours per week. Services include assessment, treatment planning, individual and/or group counseling, patient education, family therapy, medication services, collateral services, crisis intervention services, treatment planning, and discharge planning and coordination. Services may be provided in person or by telephone in any appropriate setting in the community. Services listed above will be provided in an outpatient setting by ICBHS SUD staff. Staff providing services will consist of certified SACs and LPHAs. D. Withdrawal Management Services (ASAM Levels 1-WM, 3.2-WM, 3.7, 4.0) Withdrawal Management services are provided as medically necessary to beneficiaries and include; assessment, observation, medication services, and discharge planning and coordination. These services will be provided in an outpatient setting by ICBHS. Staff providing services will be provided by licensed physicians with a specialty in addiction medicine. ICBHS will offer ASAM Level 1-WM: Ambulatory Withdrawal Management without Extended On-Site Monitoring at implementation. By end of Implementation Year 2 (IY2) ICBHS will assess the utilization and ASAM data to make a determination if the need exists for ASAM Level 3.2-WM: Clinically-Managed Residential Withdrawal Management and ASAM Level 2-WM: Ambulatory withdrawal management with extended on-site monitoring. If the need for these levels of Withdrawal Management exists, providers will be identified and attempts will be made to establish provider contracts. ICBHS will work with El Centro Regional Medical Center and Pioneers Memorial Hospital and other area service providers to assist beneficiaries to access Withdrawl Management 3.7 Medically- Monitored Inpatient Withdrawal Management) and Withdrawl Management WM (Medically-Managed Inpatient Withdrawal Management) when medically necessary. ICBHS will coordinate with these providers to ensure a successful 14

16 transition for beneficiaries through discharge planning. Discharge planning will ensure that beneficiaries are able to access less intensive levels of care available within the DMC-ODS. ICBHS will establish a MOU that outlines mutual responsibilities, referral, billing, and aftercare systems. In addition, ICBHS has contracts with two Acute Psychiatric Hospitals that will be utilized to address the need for ASAM level 3.7 and 4.0 and currently has a process in place for the placement and transportation of beneficiaries who are in need of this service. E. Residential Treatment Services (ASAM Levels 3.1, 3.3, 3.5, 3.7 and 4.0) Residential treatment is a 24 hour, non-institutional, non-medical, short-term service that provides residential rehabilitation services to youth, adult, and perinatal beneficiaries. Residential services are provided in facilities designated by DHCS as capable of delivering care consistent with ASAM Level 3.1: Clinically-Managed Low-Intensity Residential, ASAM Level 3.3: Clinically Managed Population-Specific High-intensity Residential Services (Adult only), ASAM level 3.5: Clinically- Managed High-Intensity Residential, ASAM Level 3.7: Medically Monitored Intensive Inpatient Services, and ASAM Level 4.0: Medically Managed Intensive Inpatient Services Beneficiaries are approved for residential treatment through a prior authorization process based on the results identified by the ASAM assessment All prior authorization requests for residential treatment 3.1, 3.5, and 3.7 will be reviewed by the SUD Program Supervisor within 24 hours of request by the treatment provider. The SUD Program Supervisor will review the beneficiary s intake assessment, diagnosis, treatment history and the reasons for referral to determine approval or denial of request. The residential treatment provider will have the responsibility to submit a request for authorization for up to a maximum of ninety (90) days on a continuous period for those adult clients who have been assessed and admitted into a residential facility. One extension of up to thirty (30) days beyond the maximum length of stay of ninety (90) days may be authorized for one continuous length of stay in a one year period. The residential treatment provider will have the responsibility to submit a request for authorization for up to a maximum of thirty (30) days on one continuous period for adolescent clients who have been assessed and admitted to a residential facility. Reimbursement will be limited to two non-continuous thirty (30) day regimens in any one year period. One extension of up to thirty (30) days beyond the maximum length of stay may be authorized for one continuous length of stay in a one year period. Under the Early Periodic Screening, Diagnostic and Treatment (EPSDT) mandate, beneficiaries under age of twenty-one (21) are eligible to receive all appropriate and medically necessary services needed to correct and ameliorate health conditions that are coverable under Section 1905(a) Medicaid authority. The DMC-ODS Pilot does not override any EPSDT requirements. Perinatal and criminal justice involved clients may receive a longer length of stay based on medical necessity. 15

17 Residential treatment services include assessment, treatment planning, individual and group counseling, client education, family therapy, collateral services, crisis intervention services, treatment planning, transportation to medically necessary treatment, and discharge planning and coordination. All providers are required to accept and support patients who are receiving medication-assisted treatment. For ASAM Level 3.7 and 4.0, ICBHS will work with El Centro Regional Medical Center and Pioneers Memorial Hospital to address the needs of beneficiaries with severe withdrawal. In addition, ICBHS has contracts with Alvarado Parkway Institute and Aurora Behavioral Health Psychiatric Hospitals. ICBHS has a process in place for evaluating individuals who present need for inpatient psychiatric care. The SUD clinical and administrative staff will work in collaboration with the Crisis and Referral Desk team who will coordinate placement and transportation for beneficiaries who are in need if inpatient psychiatric treatment. The SUD case manager will monitor the process of treatment, both at the local hospital and psychiatric hospital, will participate in the discharge planning and will ensure a successful transition to a lower level of SUD care. Residential services will be provided by contract providers. ICBHS currently has a contract with McAllister Institute, which is ASAM designated 3.1 and 3.5 and is in the process of visiting other residential facilities that have received an ASAM designation and are DMC certified or in the process of becoming certified for the purpose of developing additional contracts. ICBHS will ensure ASAM level 3.3 is available within 3 years of final approval of the County s implementation plan and will follow the County policy and process for selecting new providers. For clients in any residential treatment program, case management services will be provided to facilitate step down to lower levels of care and support. Based on the ASAM level designation, staffing will consist of certified substance abuse counselors, allied health professionals, LPHAs, physicians, and physician extenders. F. Opioid (Narcotic) Treatment Program (OTP/NTP, ASAM OTP Level 1) ICBHS will establish a contract with the local licensed Narcotic Treatment Program to offer services to beneficiaries who meet medical necessity criteria requirements. Services are provided in accordance with an individualized client plan determined by a licensed prescriber. Prescribed medications offered include methadone, buprenorphine, naloxone and disulfiram and other medication covered under the DMC-ODS formulary. There are two NTP clinics in, which are located in the city of El Centro and Calexico. These clinics have the ability to serve the SUD beneficiaries of. The contract with this NTP clinic will clearly define its responsibility to serve all beneficiaries who are referred for services. Services provided as part of an OTP include: assessment, treatment planning, individual and group counseling, patient education, medication services, collateral services, crisis intervention services, treatment planning, medical psychotherapy, and discharge services. Clients receive between fifty (50) and two hundred (200) minutes of counseling per calendar month with a therapist or 16

18 counselor, and when medically necessary, additional services may be provided. Staffing consists of a licensed physician, certified SACs, LPHAs. G. Additional Medication Assisted Treatment (MAT) Services (Optional, ASAM Level 1) ICBHS will offer medically necessary MAT services through ICBHS staff. Services will include; ordering, prescribing, administering, and monitoring of medication for SUD. MAT will expand the use of medications for beneficiaries with chronic alcohol - related disorders and opiate use. Medications will include: naltrexone, both oral (ReVia) and extended release injectable (Vivitrol), topiramate (Topamax), gabapentin (Neurontin), acamprosate (Campral), and disulfiram (Antabuse). Opiate overdose prevention: naloxone (Narcan) Opiate use treatment: buprenorphine-naloxone (Suboxone) and naltrexone (oral and extended release) (Note: methadone will continue to be available through the licensed narcotic treatment program) For reduction of alcohol craving: naltrexone, both oral (ReVia) and extended release injectable (Vivitrol), topiramate (Topamax), gabapentin (Neurontin), acamprosate (Campral) and disulfiram (Antabuse) Physician consultation will be provided to support implementation in areas such as medication selection, dosing, side effects management, adherence, and drug-drug interactions. Services listed above will be provided in an outpatient setting by ICBHS. Staff providing services will be provided by licensed physicians with a specialty in addiction medicine. In addition, a Licensed Vocational Nurse (LVN) will assist the physician if there is a need to order labs, communicate with pharmacies, and will follow up with the beneficiaries on a regular basis to ensure that side effects are under control and that they are following the recommended regimen. The LVN will also work in collaboration with case managers and LPHAs for treatment planning and for recommendations to a higher or lower level of care. H. Recovery Services (ASAM Dimension 6, Recovery Environment) Recovery services are available once a beneficiary has completed the primary course of treatment and during the transition process. These services will be available to beneficiaries whether they are triggered, have relapsed, or as a preventive measure to prevent relapse. Services will be provided in the context of an individualized treatment plan that includes specific goals. This may include the plan for ongoing recovery and relapse prevention that was developed during discharge planning when treatment was completed. Beneficiaries accessing recovery services are supported to manage their own health and health care, use effective selfmanagement support strategies, and use community resources to provide ongoing support. 17

19 Recovery services may be provided face-to-face, by telephone, or elsewhere in the community. Services may include: outpatient individual or group counseling to support the stabilization of the client or reassess the need for further care, recovery monitoring/ recovering coaching, peer to peer services and relapse prevention, WRAP development, education and job skills, family support, support groups, and linkages to various ancillary services. Recovery Services will be provided by ICBHS staff consisting of certified SACs and LPHAs. ICBHS is also in the process of working with HR and developing a job description for Peer Support Staff as this is not an existing position. Once this position is approved, Peer Support staff will also be used to provide Recovery Services to beneficiaries. Referral to recovery services can be made by any SUD treatment provider, which may include the case manager, Peer Support, LPHA, physician, or nurse. Appropriateness of referral will be evaluated by the SUD treatment team prior to the beneficiary s discharge to ensure proper coordination of care once the beneficiary has completed treatment. The beneficiary will also be able to request recovery services if he/she has relapsed, is triggered, or as a preventive measure to prevent relapse even after he/she has completed treatment. I. Case Management Services Case management services support beneficiaries as they move through the DMC-ODS continuum of care from initial engagement and early intervention, through treatment, to recovery supports. Case management services are provided for clients who may be pre-contemplative and challenging to engage, and/or those needing assistance connecting to treatment services, and/or those clients stepping down to lower levels of care and support. ICBHS will use a comprehensive case management model based on the ASAM bi-psychosocial assessment to identify needs and develop a treatment plan. Additionally, ICBHS will follow the SAMHSA/CSAT TIP 27 (Treatment Improvement Protocol) Comprehensive Case Management for Substance Abuse Treatment to establish Case Management Services Criteria based on the assessment, needs and location on the continuum of care and assign case management services as appropriate. ICBHS will be responsible for coordination and monitoring of case management services for SUD clients including the coordination of a system of case management services with physical and/or mental health in order to ensure appropriate level of care. Case management services are defined as a service that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. These services focus on coordination of SUD care and integration around primary care especially for beneficiaries with a chronic SUD, and interaction with the criminal justice system, if needed. Case management services may be provided face-to-face, by telephone and may be provided anywhere in the community. 18

20 Case management services may include: a. Comprehensive assessment and periodic reassessment of individual needs to determine the need for continuation of case management services. b. Transition to a higher or lower level SUD of care c. Development and periodic revision of a treatment plan that includes service activities. d. Monitoring service delivery to ensure beneficiary access to service and the service delivery system. e. Monitoring the beneficiary s progress. f. Patient advocacy, linkages to physical and mental health care, transportation and retention in primary care services. g. Case management shall be consistent with and shall not violate confidentiality of alcohol or drug patients as set forth in 42 CFR Part 2 and California law at DMC provider sites, and county locations. Case management will be provided by DMC provider staff consisting of certified SACs and LPHAs J. Physician Consultation The ICBHS Medical Director will be available for consultation with all DMC providers that are seeking expert advice on designing treatment plans for specific DMC ODS beneficiaries. These consultation services are to support DMC providers with complex cases which may address medication selection, dosing, side effects management, adherence, drug-drug interactions, or level of care considerations. Physician consultation services will only be billed and reimbursed to DMC providers. K. Recovery Residences Recovery Residences (RR) or sober living homes will be available by contract providers for beneficiaries who require housing assistance in order to support their health, wellness and recovery. There is no formal SUD treatment provided at these facilities however residents are required to actively participate in outside outpatient treatment and/or recovery supports during their stay. The maximum length of stay is one hundred eighty (180) days. On a case by case basis a determination will be made whether or not to extend the length of stay. ICBHS is developing standards for contracted sober living homes and will monitor these standards. Sober living homes are not reimbursable through Medi-Cal. Optional Service Levels Pending ASAM Utilization Review ICBHS will consider whether to offer additional optional services available under the waiver once baseline data on beneficiary ASAM service need and utilization has been collected and analyzed. If an unmet need for a service is determined, ICBHS will amend this plan to incorporate the additional service(s) and will initiate in a process to identify and develop contract providers. Service levels which ICBHS anticipates for possible expansion include: Withdrawal Management (ASAM 2-WM, 3.2-WM, 3.7-WM AND 4-WM). 19

21 Service Level Barriers ICBHS anticipates the following barriers to providing a number of services within the DMC-ODS continuum of care: start-up costs associated with starting new facilities and programming, facility location challenges, (including zoning, lease procurement, construction, hiring, training and retaining of qualified staff), DMC certification delays, geographic location and related beneficiary transportation barriers. Additionally, barriers exist that prevents the provision of residential services for adolescents due to the lack of ASAM certified providers. Coordination with Surrounding Counties ICBHS is surrounded by San Diego and Riverside Counties who are both opt-in counties. ICBHS will provide original DMC modalities to any beneficiary in an opt-out county seeking services within, coordinate with neighboring counties to ensure beneficiaries can access services easily and quickly, and will work together as needed, when a regional approach is required to deliver a component of the continuum of care (e.g. youth residential treatment). 5. Coordination with Mental Health. How will the county coordinate mental health services for beneficiaries with co-occurring disorders? Are there minimum initial coordination requirements or goals that you plan to specify for your providers? How will these be monitored? Please briefly describe the county structure for delivering SUD and mental health services. When these structures are separate, how is care coordinated? ICBHS provides SUD and MH services to residents of. Each program is supervised under a single executive management structure consisting of a director, assistant director, medical director, a deputy director and managers for youth and young adult services, and for adult services. SUD staff and programming are integrated into the organization, sharing the same policies and procedures, administrative support, and often facilities with mental health. The DMC-ODS provides further opportunity to fully align ICBHS programs and services not only for cases of co-occurring disorders, but to assure that there is no wrong door when an individual makes the decision to seek treatment and begin their recovery. Prior to the implementation of the Mental Health Services Act (MHSA), SUD and MH services were organized in separate departments with little interaction between staff and contract providers. Upon implementation of MHSA the two departments began collaborating on service delivery to individuals with co-occurring SUD and MH disorders. This collaboration eventually led to a reorganization that established ICBHS as a single administrative structure for both SUD and MH services. During this time period several changes in program systems have created a seamless method of responding to beneficiaries request for services. This began with the ICBHS Access Unit which now is responsible for service requests for both SUD and MH treatment requests. SUD assessments screen for mental illness and provide referral for further assessment and psychiatric evaluation when necessary. Likewise, MH assessments screen for and diagnose SUD conditions and also provide referrals to the 20

22 MHSA Full Service Partnership services. Care coordination and referral procedures have been created to maximize response time and inclusion of the beneficiary in treatment planning. Additionally, collaborative relationships have been established with the Self-Management and Recovery Training (SMART) Recovery community as well as the National Alliance on Mental Illness (NAMI). During the DMC-ODS planning process, it has been the intent of ICBHS to avoid the development of a separate system for service delivery, but rather, to integrate SUD services within structures of ICBHS. Using this approach, ICBHS can build upon the support structures that already exist, not duplicating existing systems, and broadening the existing infrastructure to further support residents seeking treatment for SUD. This includes expanding quality assurance and improvement functions by extending the oversight of the Quality Management Unit to include DMC-ODS programs and services, as well as to staff and contract providers. The experience and skill of quality review staff in cooperation with fiscal, technical, and administrative staff will prove invaluable during performance reviews, audits, reporting, and evaluations, assuring compliance within DMC-ODS requirements. This approach provides the support to conduct regular internal reviews and ongoing monitoring to test for compliance and help to achieve performance standards and benchmarks. Additionally, this creates opportunities for more holistic quality improvement measures that incorporate both SUD and MH practices, which will have greater impact on client outcomes when conducted within an integrated service delivery system. Currently, ICBHS coordinates services between programs for individuals with co-occurring disorders through coordinated treatment plans and services. Service teams remain in regular communication with one another since employees belong to the same organization and are often co-located sharing the same , calendaring, and telephone systems. All HIPAA and 42 CFR Part 2 requirements are met. Coordination with Physical Health. Describe how the county will coordinate physical health services within the waiver. Are there minimum initial coordination requirements or goals that you plan to specify for your providers? How will these be monitored? Physical health services will be coordinated primarily through collecting and monitoring health-related client specific information about medical history, current medical conditions and treatment. This will be done through the initial assessment process and updated during follow up visits as needed. A medical history is obtained at the first appointment via the medical information sheet which is reviewed and discussed with the client including the date of the last physical exam. The medical director will review the medical history sheet, medical records and communicate with the client s primary care provider regarding treatment, medications or other issues as needed. The medical director will order lab work for each client to obtain baseline information regarding their current status as needed. If necessary, a referral is made to local primary care physicians for further testing of Human Immune-Deficiency Virus (HIV), Hepatitis C and/or other Sexually Transmitted Diseases (STDs). 21

23 During the course of treatment, any changes in the client s health will be noted and reported to the medical director. If clients do not have a primary care provider, treatment staff will encourage the client to obtain a primary care doctor to attend to and monitor their healthcare needs. Referrals for medical needs will be made as necessary. Clinicas De Salud del Pueblo is a community outpatient medical clinic located in the major population areas within the county. A large segment of our population utilizes these clinics for routine medical care. Referrals will be made reciprocally between ICBHS and Clinicas de Salud del Pueblo. Imperial Valley Medical Clinic, a contract provider engages in Narcotic Treatment (methadone) services. Clients health care is monitored by the medical director for IV Medical Clinic. Referrals for continuing medical care are made to local healthcare resources. McAllister Institute, a contract provider for a social model residential detoxification and recovery services, requires the completion of a medical history and screening form. Any medical needs are addressed by taking residents to area health clinics for services. Minimum initial coordination requirements or goals for providers will emphasize maintaining up to date information on the client s health status. Additionally, providers will be expected to establish goals for beneficiaries to obtain or maintain a relationship with a primary care provider, provide education and awareness of health-related conditions, as well as, referrals to health care providers. This will be identified as a service for beneficiaries in contracts/ MOUs with ICBHS. Additionally, this will be identified as an area to be monitored by ICBHS contract compliance staff. Coordination Assistance. The following coordination elements are listed in the STCs. Based on discussion with your health plan and providers; do you anticipate substantial changes and/or need for technical assistance with any of the following? If so, please indicate which and briefly explain the nature of the challenges you are facing. Comprehensive substance use, physical, and mental health screening Beneficiary engagement and participation in an integrated care program as needed Shared development of care plans by the beneficiary, caregivers and all providers Collaborative treatment planning with managed care Care coordination and effective communication among providers Navigation support for patients and caregivers Facilitation and tracking of referrals between systems a) Comprehensive substance use, physical, and mental health screening / g) Facilitation and tracking of referrals between systems ICBHS currently provides comprehensive substance use and mental health screening by staff at the various clinical divisions within and has established Memorandums of Understanding (MOUs) with Clinicas De Salud Del Pueblo, Inc. and formerly with Public Health. Provision of services include the coordination of medical clearance examination for individuals participating in the ICBHS exercise program, tuberculosis testing, HIV testing, and other 22

24 sexually transmitted disease testing. The Memorandums of Understanding (MOU) also address protocols related to the facilitation and tracking of referrals between systems and the method of reimbursement. Additionally, ICBHS has MOUs with the two county Medi-Cal managed care health plans (California Health and Wellness and Molina Healthcare of California) which define coordination of mental health, and SUD services for Medi-Cal beneficiaries. Providers meet on a quarterly basis with ICBHS staff to discuss issues or concerns related to the coordination process. ICBHS will use this coordination infrastructure established in the aforementioned MOUs to build the DMC-ODS care coordination infrastructure with additional providers. Prior to the implementation of the DMC-ODS waiver, all ICBHS substance use treatment staff will receive thorough training on the treatment criteria for Addictive, Substance-Related, and Co- Occurring Conditions (ASAM Criteria). Once staff are trained, the ASAM criteria will be used in ensuring comprehensive screening is conducted on each individual presenting with substance use concerns. b) Beneficiary engagement and participation in an integrated care program as needed ICBHS has trained both SUD and MH staff in Motivational Interviewing (MI) and other evidencebased models which heavily emphasis engagement techniques. These techniques have been used within the divisions to promote the working alliance with individuals from the start of treatment. However, since the integration of services will include various outside contract providers, it is anticipated that training in MI and other engagement strategies among contract providers may be limited. For this reason, one challenge may be that contract providers may lack the necessary training in engagement strategies to increase the participation of individuals in an integrated care program. One way to address this would be to include the contract providers in internal ICBHS trainings related to engagement strategies. c) Shared development of care plans by the beneficiary, caregivers and all providers Currently, ICBHS has integrated SUD and MH treatment to the extent that employees from each program are co-located, refer to each program, and communicate amongst treatment team members from each program with the necessary releases of information. This has allowed for shared communication related to the individuals treatment needs and progress, including participating in treatment team meetings when needed. Additionally, providers from outside of ICBHS are not consistently involved in the development of care plans for all individuals. This will require collaboration between ICBHS and various providers while still adhering to HIPAA and 42 CFR. d) Collaborative treatment planning with managed care ICBHS is already actively engaged in collaborative treatment planning with the two managed care plans in. The adherence to current MOUs with California Health and Wellness and Molina Healthcare of California and quarterly meetings have been successful in the collaborative treatment planning with managed care. This system will continue to be followed and added to in 23

25 order to enhance the process. However, part of the initial implementation will require educating the managed care plans on the specific levels of care and referral and assessment protocols for the DMC-ODS. e) Care coordination and effective communication among providers With the established MOUs between ICBHS and Clinicas De Salud Del Pueblo, and the two managed care plans, a foundation already exists for care coordination and effective communication between providers. These established protocols will be the foundation for creating a comprehensive protocol for enhancing care communication and coordination amongst providers. However, one challenge anticipated with care coordination and effective communication among providers is ensuring that all providers understand the requirements related to 42 CFR, Part 2. This will also include the need to update forms, policies, procedures, and protocols to enable the communication necessary for effective care coordination and communication. This will be particularly challenging given the fact that records from each ICBHS program (SUD and MH) are currently kept separate and therefore, not easily accessible by treatment staff from each program. It will be necessary to ensure that the integration of records (while still adhering to HIPAA and 42 CFR) is prioritized to allow for easy accessibility of chart reviews by direct treatment staff for the purpose of delivering an integrated approach to treatment. Some technical assistance may be required in this area. f) Navigation support for patients and caregivers With the implementation of targeted case management and recovery services in the DMC-ODS, it is expected that individuals receiving services and their caregivers will be provided with effective navigation support with an emphasis on family education. There are currently no anticipated challenges in this area. 6. Availability of Services. Pursuant to 42 CFR , the pilot County must ensure availability and accessibility of adequate number and types of providers of medically necessary services. At minimum, the County must maintain and monitor a network of providers that is supported by written agreements for subcontractors and that is sufficient to provide adequate access to all services covered under this contract. In establishing and monitoring the network, describe how the County will consider the following: The anticipated number of Medi-Cal clients. The expected utilization of services by service type. The numbers and types of providers required to furnish the contracted Medi-Cal services. A demonstration of how the current network of providers compares to the expected utilization by service type. Hours of operation of providers. Language capability for the county threshold languages. Specified access standards and timeliness requirements, including number of days to first face-toface visit after initial contact and first DMC-ODS treatment service, timeliness of services for urgent 24

26 conditions and access afterhours care, and frequency of follow-up appointments in accordance with individualized treatment plans. The geographic location of providers and Medi-Cal beneficiaries, considering distance, travel time, transportation, and access for beneficiaries with disabilities How will the county address service gaps, including access to MAT services? As an appendix document, please include a list of network providers indicating, if they provide MAT, their current patient load, their total DMC-ODS patient capacity, and the populations they treat (i.e., adolescent, adult, perinatal). The anticipated number of Medi-Cal clients As of July 2015, had approximately 75,866 Medi-Cal beneficiaries according to local health officials. Prevalence estimates vary. Up to 14.2% of the Medicaid population meets the diagnostic criteria for a substance use disorder according to NSDUH ( ) National Survey of Drug Use and Health, 2013 American Community Survey), while the California Department of Health Care Services (DHCS Behavioral Health Needs Assessment, chapter 7, page 178) estimates 10.3% of the population meets criteria for a SUD. Using these prevalence estimates ICBHS projects between 10,773 and 7,814 Medi-Cal beneficiaries have a SUD and could benefit from treatment. SAMHSA data indicate 10.8 percent of those who needed treatment received treatment in a specialty program. Given this, ICBHS anticipates serving between 1,163 and 844 beneficiaries in the first year of implementation. The table below presents the actual beneficiary counts with prevalence and penetration high and low estimates for adults and youth for ICBHS. The Department of Health Care Services (DHCS) in the 2013 Behavioral Health Needs Assessment estimated the penetration rate at 7% for. This results in a caseload range of 754 to 547 beneficiaries. For planning purposes ICBHS will be using the SAMHSA methodology because with the implementation of the DMC-ODS there will be a more structured outreach and engagement processes as well as a full continuum of services that will be more responsive to the treatment needs of this population than has previously existed. Therefore, ICBHS will use an estimate high of 1,163 and an estimate low of 844. Medi-Cal Beneficiary Estimates Based on 2015 Actuals With Prevalence and Penetration Estimates by Adult and Youth Prevalence Penetration Pre-2014 Medi-Cal Adult Beneficiaries Total 14.2% 10.3% 10.8% High Low High Low 2015 Actual Medi-Cal Beneficiaries 75,866 10,773 7,814 1, Actual Medi-Cal Adult Beneficiaries 46,528 6,607 4, Actual Medi-Cal Youth Beneficiaries 29,388 4,173 3, Prevalence and Penetration Calculations Projected Over 5 Years 25

27 A c t u a l Percent Jun 2014 Oct 2015 FY P r o j e c t i o n FY FY FY Prevalence Est. Low 10.3% 7,814 7,892 7,971 8,051 8,131 Prevalence Est. High 14.2% 10,773 10,881 10,990 11,100 11,211 SAMHSA w/sud Dx High 1,163 1,175 1,187 1,199 1, % Receiving Tx Low

28 a) The expected utilization of services used a number of historical and forecasted approaches in determining service utilization and projections. The table below details services utilization reported from existing data collection systems. This information is based on actual treatment admissions for Fiscal Year and Fiscal Year During Fiscal Year , 93.76% of treatment admissions were for outpatient and nonresidential services. During Fiscal Year , 93.73% of the admissions were for outpatient and non-residential services. For Fiscal Year , 6.24% of the treatment admissions were in residential modalities. For Fiscal Year , 6.27% of the treatment admissions were in residential modalities. Medi-Cal Beneficiary SUD Treatment Admission by Modality FY FY14-15 Non Residential / Outpatient Treatment / Recovery Actual % Subtotal % Grand Total Actual % Subtotal % Grand Total Outpatient Drug Free % 55.38% % 59.08% Outpatient (Medications) 0 0 NTP Maintenance % 24.96% % 27.65% Outpatient Detoxification 0 0 Outpatient Detox (non-med) 0 0 Outpatient Detox (med) 0 0 NTP Detox % 13.42% % 7.00% Subtotal 1, % 1, % Residential Inpatient Detoxification (hospital) 0 0 Detoxification (non-hospital) 0 0 Residential (30 days or less) % 6.24% % 6.27% Residential (30 days or more) 0 0 Subtotal Grand Total 1, % 1, % 27

29 b) The number and types of providers required to furnish the contracted Medi-Cal Services The table below details the beneficiary high and low penetration estimates to establish the needed network capacity to meet beneficiary demand. Actual admission percentages multiplied by the high and low penetration of overall medical beneficiaries demonstrates results in projected caseloads. Medi-Cal Beneficiary SUD Treatment Admissions by Modality with Caseload Estimates for Current and Future Years Through FY F Y F Y Non-Residential Outpatient Actual % ODS Estimated ODS Estimated Actual % High Low High Low Treatment Recovery 1, , Outpatient Drug Free % % Outpatient (medication) NTP Maintenance % % Day Care Habilitative Outpatient Detox Outpatient Detox (non-med) Outpatient Detox (med) NTP Detox % % Subtotal 1, % 1, , % 1, Residential inpatient Detox (hospital) Detox (non-hospital) Residential (30 days or less) % % Residential (30 days or more) Subtotal % Total 1, % 1, , % 1, F Y F Y ODS Estimated Actual ODS Estimated Non-Residential Outpatient Actual % (projected % High Low High Low Treatment Recovery 1, , Outpatient Drug Free % * 54.22% Outpatient (medication) NTP Maintenance 347* 27.15% * 27.15% Day Care Habilitative Outpatient Detox Outpatient Detox (non-med) Outpatient Detox (med) NTP Detox 159* 12.44% * 12.44% Subtotal 1, % 1, , % 1, Residential inpatient Detox (hospital) Detox (non-hospital) Residential (30 days or less) 79* 6.18% * 6.18% Residential (30 days or more) Subtotal Total 1, % 1, , % 1, Figures marked with (*) indicate 1% growth from previous year. Actual figures are unknown. 1%) Currently, ICBHS has five Substance Abuse Counselors providing DMC services to the adolescent population and one Substance Abuse Counselor providing services to adults and older adults who 28

30 have a dual SUD and mental health diagnosis. To meet the estimated need for the ODS waiver ICBHS will contract with the number of providers necessary to meet estimated need at the time of implementation. ICBHS is in the process of recruiting the following additional providers: Adult SUD Services Outpatient, Intensive Outpatient, Case Management and Recovery Services: Eight certified Substance Abuse Counselors Six Licensed Practitioners of the Healing Arts Adolescent SUD Services Outpatient, Intensive Outpatient, Case Management and Recovery Services: Three certified Substance Abuse Counselors Six Licensed Practitioners of the Healing Arts Adolescent and Adult SUD Services Medication Assisted Treatment: One part-time physician One Licensed Vocational nurse Opioid (Narcotic) Treatment Program: ICBHS will contract with the local NTP clinic for these services Residential and Withdrawal Management: ICBHS will continue to utilize the services that are currently contracted and described in this plan and will develop additional contracts to meet the need of Beneficiaries. c) Language capability for the county threshold languages Currently, 80% of ICBHS employees are bilingual/bicultural and 64% of ICBHS employees provide interpretation services. ICBHS employees will be required to abide by the Behavioral Health Services language access policies specifically in providing interpretation and translation services to all clients. In addition, ICBHS employees providing or requiring interpretive services will be required to attend mandatory How to Work With Interpreters training to ensure proper use of interpreters in service provision. ICBHS through its Quality Management Unit will ensure that DMC providers comply with the language access requirements for its beneficiaries. ICBHS does not currently track the percent of bilingual employees working at contract facilities, but will begin tracking this as part of the ICBHS annual cultural competency plan. d) Hours of Operation of Providers Provider Adult El Centro SUD Clinic Hours of Operation Monday-Friday 8:00am to 5:00pm 29

31 Adult Brawley SUD Clinic Adult Calexico SUD Clinic Adolescent El Centro SUD Clinic Adolescent Brawley SUD Clinic Adolescent Calexico SUD Clinic Imperial Valley M edical Clinic Monday-Friday 8:00am to 5:00pm Hours to be determined Monday-Friday 8:00am to 5:00pm Monday-Friday 8:00am to 5:00pm Hours to be determined Monday-Friday 8:00am to 5:00pm (Narcotic Treatment Program) McAllister Institute 24 hours per day/ 7 days per week (Residential Treatment) f) Timeliness of first face-to-face visit, timeliness of services for urgent conditions and access afterhours care Type of Care T i m e l i n e s s o f C a r e Time Frame Non Urgent / Routine Appointment offered within seven (7) working days through scheduled appointments and walk-in assessments. Urgent Conditions Request for services for an urgent condition will be provided within one (1) hour of the request. Emergency Anyone who is experiencing a medical or Substance Use Disorder emergency will be directed to the nearest hospital for services. The ICBHS standard is for each beneficiary to be offered a first appointment within seven (7) working days of initial request for service for non-urgent services. To improve timely access to services for all beneficiaries, ICBHS will collect baseline data to identify problem areas and solutions, with the goal of all beneficiaries being offered an appointment within seven (7) working days of a request for non-urgent services. Urgent conditions require immediate attention but do not require inpatient hospitalization. Urgent conditions may be identified during the course of treatment, a scheduled intake assessment or during a walk in screening/assessment. ICBHS offers walk in assessments that are available Monday-Friday from 8am to 5pm at each regional clinic site or at the Assessment Center. Once ICBHS identifies the presence of a beneficiary s urgent condition, arrangements are made for an expedited appointment at one of the ICBHS regional clinics for SUD Services. Beneficiaries will have access to services afterhours through a toll free 800 phone number twenty-four (24) hours per day, seven (7) days per week. After hours calls are screened and triaged by an on-call certified substance abuse counselor for risk and appropriate referrals are made. 30

32 All beneficiaries experiencing a medical or SUD emergency will be directed to the nearest hospital for services. f) The geographic location of providers and Medi-Cal beneficiaries, considering distance, travel time, transportation, and access for beneficiaries with disabilities ICBHS currently has a total of eleven (11) SUD clinics located in the major population centers of. Adult Services has one outpatient SUD clinic located in El Centro and Adolescent Services has ten (10) clinics located in El Centro, Calexico and Brawley; nine of which are schoolbased clinics located in different high schools. Additional SUD clinics are currently being planned for development to ensure that services are accessible to underserved and unserved populations; especially those residing in the outline areas of. The development of these clinics will allow beneficiaries to have access to SUD services closest to their city of residence. Additionally, public transportation is available which provides transportation from the outlying cities to nearby bus stops. Public transit is handicapped accessible as well as each of the clinic sites. The following table is a list of DMC certified providers or in the process of seeking certification as an ICBHS DMC provider. Provider Number Provider Name Service Location 1303 Adolescent Outpatient Drug Free (ODF) Clinic 1309 Adult Outpatient Drug Free (ODF) Recovery Center Outpatient/ Intensive Outpatient Outpatient/ Intensive Outpatient 1310 Brawley Union High School Outpatient/ Intensive Outpatient 1311 Calexico High School Outpatient/ Intensive Outpatient 1312 Desert Valley High School Outpatient/ Intensive Outpatient 1315 Aurora High School Outpatient/ Intensive Outpatient 1318 Central Union High School Outpatient/ Intensive Outpatient 1319 Calexico High School 2 (9 th Grade) Outpatient/ Intensive Outpatient 1320 Valley Academy School Outpatient/ Intensive Outpatient 1321 Del Rio Academy School Outpatient/ Intensive Outpatient 1322 Calexico Academy School Outpatient/ Intensive Outpatient 1295 State Street, Suites El Centro CA S. 4 th Street, 2 nd Floor El Centro, CA N. Imperial Avenue Brawley, CA Encinas Avenue Calexico, CA Magnolia Street Brawley, CA Rockwood Avenue Calexico, A W. Brighton Avenue El Centro, CA Blair Avenue Calexico, CA E. Ross Avenue El Centro, CA I Street Brawley, CA Andrade Avenue, Rooms A&B Calexico, CA

33 Provider Number Provider Name Service Location Pending Adult ODF Brawley, Outpatient Outpatient/ Intensive Outpatient Pending Adult ODF Calexico, Outpatient Outpatient/ Intensive Outpatient Pending Adolescent ODF Brawley, Outpatient Outpatient/ Intensive Outpatient Pending Adolescent ODF Calexico, Outpatient Outpatient/ Intensive Outpatient To be determined To be determined To be determined To be determined Medi-Cal Certified Providers providing SUD services are shown by geographic location Adolescent ODF 1309 Adult ODF 1318 Central Union High School 1320 Valley Academy 1310 Brawley Union High School 1312 Desert Valley 1311 Calexico High School 1315 Aurora High School 1319 Calexico High School th 30