Cntra Csta Cunty Behaviral Health Divisin Alchl and Other Drugs Services Request fr Interest Wrk Plan Instructins Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver Substance Use Disrder Cntinuum f Care Treatment and Other DMC-ODS Required Services ASAM Levels 3.1 Residential Services & 3.2 Withdrawal Management February 2017 Entity Identificatin (Cver) Name f Entity: Please type in the name f the entity perfrming services under this RFI. Mailing Address: List the mailing address f the entity's administrative ffices. Cntact Persn: The individual wh will be the cntact persn with the Cunty fr matters relating t this RFI. Please list the Telephne number, Fax number and e-mail address fr the cntact persn. Federal Tax Id Number: List the entity s Federal tax ID number. ASAM Level f Care: Indicate the ASAM level f care fr the services described in this wrk plan. Within any level f care, a separate budget and wrk plan must be submitted fr services prvided t wmen and/r fr yuth. In the grid belw the Entity Identificatin infrmatin, please enter the fllwing infrmatin regarding the services t be prvided. Service Site: List the addresses (street and city) f each facility in which services fr the prpsed level f care will be prvided. Facility NPI: Enter the HIPAA Natinal Prvider Identifier fr each facility where services will be prvided. Regin Served: List the cmmunity r gegraphic area yur agency will serve (i.e. Richmnd, Cncrd, Antich, West Cunty, etc.). Caselad Characteristics: Describe the peple yu intend t serve at each facility in terms f their distinguishing characteristics, i.e., age, gender, ethnicity, LGBTQ, etc. Hurs f Service Availability: List the days f the week and the times that the services will be prvided at each facility. Cntra Csta Cunty DMC-ODS Waiver 1
Wrk Plan Sectin A Administrative and Supprt Staff Budget Wrk Plan Sectin B Direct Service Staff Budget Clumn 1 (Psitin Title) The Administrative and Supprt Staff categry includes thse persns whse respnsibilities are directed twards prgram management r peratins. It wuld include executive directrs, accunting staff, billing clerks, etc. Direct Service Staff are thse psitins r prtins f psitins which are devted t direct cntact with the recipients f yur services, e.g., cunselrs, case managers, etc. Fr Clumn 1 in Budget Sectins A & B, please list the title nly f each staff persn as apprpriate. It is pssible that the same individual culd have dual respnsibility and be listed in bth categries. In this situatin, the same Psitin Title must be used in each Sectin. The title used will depend n the persn's primary respnsibilities within the rganizatin and nt just thse duties reflected in this wrk plan. Clumn 2 (FTE): List the decimal prprtin f a 40-hur wrk hur which each staff persn spends n DMC services. The frmula is: (hurs wrked per week) / 40 = 1 FTE. Fr example, 20 hurs per week translates t.50 FTE, 10 hurs per week t.25, 8 hurs t.20. Clumn 3 (Hurly Rate): Enter the hurly pay rate exclusive f benefits fr each individual listed in Clumn 1. Clumn 4 (Treatment): List the amunt f salary and benefit expenditures allcated t treatment services and cvered by DMC reimbursement. Clumn 5 (Rm & Bard): List the amunt f salary and benefit expenditures, if any, that are dedicated t rm and bard csts. Clumn 6 (Ttal): The cells in this clumn cntain frmulas and autmatically calculate the ttals f the Treatment and Rm & Bard amunts in each rw. In each sectin (A&B) list the aggregate amunt expended fr taxes and benefits fr the psitins listed. Wrk Plan Sectin C: Staff Prductivity Mdel There are three rws fr a quantitative listing f yur rganizatin s plicy regarding direct service staff invlvement in direct client services. These are: Paid Leave (Hliday, Vacatin, Sick, Persnal, etc.) Direct Service Hurs Prgram Supprt Hurs (Prep. Time, Travel, Staff Meeting, Training, Cmmunity Meetings, etc.) On the basis f the 2,080 hurs fr which a psitin is budgeted within the verall rganizatin, please list in the apprpriate cell the number f hurs that staff n average, are expected t devte t each categry. Cntra Csta Cunty DMC-ODS Waiver 2
Wrk plan Sectin D Operating Expenses Budget Clumn 1 (Cde): List the cde that will crrespnd with the Expense Categry t be added t the sheet. Clumn 2 (Expense Categry): Descriptive titles fr the mst frequently encuntered line items are printed n the frm. There are additinal blank lines t list expense categries nt included n the frm. Clumn 3 (Treatment): List the amunt f expenditures allcated t treatment services and cvered by DMC reimbursement. Clumn 4 (Rm & Bard): List the amunt f expenditures, if any, that are dedicated t rm and bard csts. Clumn 5 (Ttal): The cells in this clumn cntain frmulas and autmatically calculate the ttals f the Treatment and Rm & Bard amunts in each rw. Please Nte: The residential services budget and wrk plan frms cnsist f 2 separate spreadsheets. The spreadsheet titled Residential Facility Rent Allcatin (Attachment C) must be cmpleted fr each residential facility incrprated by a given level f care budget and wrk plan. Instructins fr this frm are cntained n the first page r that spreadsheet. Wrk plan Sectin E Budget Summary This sectin summarizes the Salaries & Benefits Categry Subttals (Rws 1 & 2) and verall Salaries & Benefits Ttal (Rw 3). These ttals are ppulated in the table by frmulas. Hwever, if the rganizatin will be charging an indirect rate, please enter that amunt in Rw 6. Wrk Plan Sectin F Staffing Please utilize the table belw t cmplete the Staffing spreadsheet: Clumn Jb Title Name FTE Gender Ethnicity Language Instructins List the jb title f each psitin allcated t the services t be prvided under this RFI. Every psitin budgeted in Sectins A and B must be included. If vlunteers are included, please enter the wrd, VOLUNTEER. List the name f each persn in the psitin listed in the first clumn. If the psitin is vacant, please enter the wrd, VACANT in place f the name. With the exceptin f FTE and Psitin Qualificatins, the remaining cells may be left blank. In this clumn, indicate the prprtin f a 40-hur wrk week devted t DMC services (i.e., the number f hurs wrked per week divided by 40 - fr example, 20 hurs per week =.5 FTE; 8 hurs per week =.2 FTE). Male, Female, r Other Race, Ethnicity r natinal rigin List all languages ther than English in which the staff listed is Cntra Csta Cunty DMC-ODS Waiver 3
Prficiency * Psitin Qualificatins Tenure Mst recent TB Test Date * Date f First Aid Training * Date f Last CPR Training * Type f License, Certificate r Registratin * Effective Date Expiratin Date prficient. Briefly list the licensure, educatinal, r experiential prerequisites fr each psitin. This clumn requests infrmatin relative t the psitin, and nt the persn currently filling it. Indicate the number f mnths the persn has been emplyed in that psitin within yur rganizatin. List the date the staff member s mst recent TB test result. The result must be negative. List the date f the mst-recently cmpleted First Aid training. List the date f the mst recently cmpleted CPR training. List type f credential the staff member has btained that is pertinent t the psitin. If n credential f any kind is required, state N/A in the clumn. List the effective date that the credential listed in the previus clumn. List the expiratin date f the credential listed fr the staff member. * Dcumentatin may be requested by AODS. Attach an rganizatin chart shwing lines f supervisin. If apprpriate, attach rganizatin plicies fr the use f vlunteers in the prgram. These plicies at a minimum shuld address qualificatins, recruitment, selectin, cde f ethics, training, scheduling and supervisin. Wrk Plan Sectin G: Outpatient Services Prjectin (ASAM Levels 1.0 & 2.1) This sectin lists the quantitative descriptin f the services t be prvided. The instructins explain the frm by sectin. Level f Care Static Capacity (Slts): Please indicate the maximum number f clients that culd be receiving services at yur facility at any given time. This will be determined by the number f beds in the facility r the cmbined caselad size f staff delivering services. Perinatal prgrams are requested t indicate capacity fr wmen and children separately. Ttal Unduplicated New Participants: This is an estimate f the number f persns receiving services in yur prgram fr the first time in the FY 17-18 cntract year. The number des nt include participants r caselad carried ver frm the prir fiscal year nr persns wh leave services and return within the Fiscal year. Persns frmerly clients in previus years may be included in the estimate. Type f Service: Services listed in this sectin are thse defined in the DMC-ODS Waiver Special Terms and Cnditins. Please nte that, the rw titled Individual Cunseling includes nt nly individual cunseling per se but als ther services prvided in a ne-n-ne sessin Intake, Cllateral Services, Crisis Interventin Services, Treatment Planning and Discharge Planning. Case Management and Recvery Supprt are t be listed separately. Cntra Csta Cunty DMC-ODS Waiver 4
FTEs: The figures t be entered in this clumn are ttal Direct Service Staff FTEs allcated t each Type f Service. The ttal f this clumn must equal the FTE clumn ttal in Sectin B. Direct Service Staff Hurs: This figure is the amunt f staff hurs spent directly interacting with prgram participants in the perfrmance f DMC billable services. This figure des nt include the time spent in writing case ntes, in case cnference, clinical supervisin r ther supprt activities. The number entered here must be cnsistent with the Sectin C Staff Prductivity Mdel Number f Bed Days: A bed day is defined as a 24-hur perid f client participatin in residential services. Payment Rate per Bed Day: Enter the cst per unit based upn factring in all csts assciated with the treatment f a beneficiary each day within the facility. The fllwing additinal clumns are utilized fr the Case Management and Recvery Services sectins nly: Number f Sessins: Fr Outpatient Services, this deliverable refers t specific ccurrences f the service types t be prvided. This is the number f times the direct service activity will be cnducted by staff in FY 17-18. This is distinct frm client visits. A visit is smething the client des. A sessin is smething staff des. Sessin Duratin (Minutes): Enter the duratin f each type f service. Number f Client Visits: This is an estimate f the number f times clients will participate in the services listed. Payment Rate per 15 Minute Unit based n the csts assciated with the cmplete budget is required fr each service type. Cntra Csta Cunty DMC-ODS Waiver 5
Service Definitins The fllwing definitins f services prvided in ASAM 3.1 Residential Treatment and 3.2 Withdrawal Management levels f care are excerpted frm the DMC-ODS Special Terms and Cnditins. Case Management and Recvery Services can be prvided in either level f care. Residential Treatment (ASAM Level 3.1) is a nn-institutinal, 24-hur, nn-medical, shrtterm residential prgram that prvides rehabilitatin services t beneficiaries with a substance use disrder diagnsis when determined by a Medical Directr r Licensed Practitiner f the Healing Arts (LPHA) as medically necessary and in accrdance with an individualized treatment plan. Residential services are prvided t nn-perinatal and perinatal beneficiaries. These services are intended t be individualized t treat the functinal deficits identified in the ASAM Criteria. In the residential treatment envirnment, an individual s functinal cgnitive deficits may require treatment that is primarily slwer paced, mre cncrete and repetitive in nature. The daily regimen and structured patterns f activities are intended t restre cgnitive functining and build behaviral patterns within a cmmunity. Each beneficiary shall live n the premises and shall be supprted in their effrts t restre, maintain and apply interpersnal and independent living skills and access cmmunity supprt systems. Prviders and residents wrk cllabratively t define barriers, set pririties, establish gals, create treatment plans, and slve prblems. Gals include sustaining abstinence, preparing fr relapse triggers, imprving persnal health and scial functining, and engaging in cntinuing care. Residential services are prvided in a DHCS, r fr adlescents Department f Scial Services, licensed residential facilities that als have DMC certificatin and have been designated by DHCS as capable f delivering care cnsistent with ASAM treatment criteria. Residential services can be prvided in facilities f any size. Residential services fr adults may be authrized fr up t 90 days in ne cntinuus perid. Reimbursement will be limited t tw, nn-cntinuus regimens fr adults in any ne-year perid (365 days). Based upn medical necessity, ne extensin f up t 30 days beynd the maximum length f stay f 90 days may be authrized fr ne cntinuus length f stay in a ne-year perid (365 days). Perinatal clients may receive a lnger length f stay based n medical necessity. Perinatal clients may receive lengths f stay up t the length f the pregnancy and pstpartum perid (60 days after the pregnancy ends.) Residential services fr adlescents may be authrized fr up 30 days in ne cntinuus perid. Reimbursement will be limited t tw nn-cntinuus 30-day regimens in any ne-year perid (365 days). One extensin f up t 30 days beynd the maximum length f stay may be authrized fr ne cntinuus length f stay in a ne-year perid (365 days). The cmpnents f Residential Treatment Services are (see Residential Services fr definitins): Intake Individual and/r Grup Cunseling Patient Educatin Family Therapy Medicatin Services Cllateral Services Crisis Interventin Service Treatment Planning Cntra Csta Cunty DMC-ODS Waiver 6
Transprtatin Services: Prvisin f r arrangement fr transprtatin t and frm medically necessary treatment. Discharge Services Withdrawal Management (ASAM Level 3.2) services are prvided in a cntinuum f Withdrawal Management (WM) services as per the five levels f WM in the ASAM Criteria when determined by a Medical Directr r Licensed Practitiner f the Healing Arts as medically necessary and in accrdance with an individualized client plan. Each beneficiary shall reside at the facility if receiving a residential service and will be mnitred during the detxificatin prcess. Medically necessary habilitative and rehabilitative services are prvided in accrdance with an individualized treatment plan prescribed by a licensed physician r licensed prescriber, and apprved and authrized accrding t the state f Califrnia requirements. The cmpnents f withdrawal management services are: Intake: The prcess f admitting a beneficiary int a substance use disrder treatment prgram. Intake includes the evaluatin r analysis f substance use disrders; the diagnsis f substance use disrders; and the assessment f treatment needs t prvide medically necessary services. Intake may include a physical examinatin and labratry testing necessary fr substance use disrder treatment. Observatin: The prcess f mnitring the beneficiary s curse f withdrawal. T be cnducted as frequently as deemed apprpriate fr the beneficiary and the level f care the beneficiary is receiving. This may include but is nt limited t bservatin f the beneficiary s health status. Medicatin Services: The prescriptin r administratin related t substance use disrder treatment services, r the assessment f the side effects r results f that medicatin, cnducted by staff lawfully authrized t prvide such services within their scpe f practice r license. Discharge Services: The prcess t prepare the beneficiary fr referral int anther level f care, pst treatment return r reentry int the cmmunity, and/r the linkage f the individual t essential cmmunity treatment, husing and human services. Case Management: Cunties will crdinate case management services. Case management services can be prvided at DMC prvider sites, cunty lcatins, and reginal centers r as utlined by the cunty in the implementatin plan. The cunty will be respnsible fr direct crdinatin f all f the case management activities. In Cntra Csta Cunty, the prvider will be required t participate in weekly clinical case cnferences t ensure client mvement acrss levels f care and bidirectinal crdinatin with mental health, primary health care and the managed care plan. Services may be prvided by a Licensed Practitiner f the Healing Arts r certified cunselr. Cunties will be respnsible fr crdinating case management services fr the SUD client. Cunties will als crdinate a system f case management services with physical and/r mental health in rder t ensure apprpriate level f care. Case management services are defined as a service that assist a beneficiary t access needed medical, educatinal, scial, prevcatinal, vcatinal, rehabilitative, r ther cmmunity services. These services fcus n crdinatin f SUD care, integratin Cntra Csta Cunty DMC-ODS Waiver 7
arund primary care especially fr beneficiaries with a chrnic substance use disrder, and interactin with the criminal justice system, managed care plan, mental health and primary health care if needed. Case management services may be prvided face-t-face, by telephne, r by telehealth with the beneficiary and may be prvided anywhere in the cmmunity. Case management services include: Cmprehensive assessment and peridic reassessment f individual needs t determine the need fr cntinuatin f case management services; Transitin t a higher r lwer level SUD f care; Develpment and peridic revisin f a client plan that includes service activities; Cmmunicatin, crdinatin, referral and related activities; Mnitring service delivery t ensure beneficiary access t service and the service delivery system; Mnitring the beneficiary s prgress; Patient advcacy, linkages t physical and mental health care, transprtatin and retentin in primary care services; and, Case management shall be cnsistent with and shall nt vilate cnfidentiality f alchl r drug patients as set frth in 42 CFR Part 2, and Califrnia law. Recvery Services: Recvery services are imprtant t the beneficiary s recvery and wellness. As part f the assessment and treatment needs f Dimensin 6, Recvery Envirnment f the ASAM Criteria and during the transfer/transitin planning prcess, beneficiaries will be linked t applicable recvery services. The treatment cmmunity becmes a therapeutic agent thrugh which patients are empwered and prepared t manage their health and health care. Therefre, treatment must emphasize the patient s central rle in managing their health, use effective selfmanagement supprt strategies, and rganize internal and cmmunity resurces t prvide nging self-management supprt t patients. Services are prvided as medically necessary. Beneficiaries may access recvery services after cmpleting their curse f treatment whether they are triggered, have relapsed r as a preventative measure t prevent relapse. Recvery services may be prvided face-t-face, by telephne, r by telehealth with the beneficiary and may be prvided anywhere in the cmmunity. In Cntra Csta Cunty, the prvider will be required t participate in weekly Clinical Recvery Oriented case cnferences t ensure that clients wh have cmpleted treatment benefit frm a range f system wide available activities acrss the cunty. The cunty is seeking innvative ideas that are available as and when needed by clients. Strategies shuld be gender, culturally and linguistically centered, including LGTBQ, hmeless, c-ccurring, yuth, wmen with children and lder adults, etc. The cmpnents f Recvery Services are: Cntra Csta Cunty DMC-ODS Waiver 8
Outpatient cunseling services in the frm f individual r grup cunseling t stabilize the beneficiary and then reassess if the beneficiary needs further care; Recvery Mnitring: Recvery caching, mnitring via telephne and internet; Substance Abuse Assistance: Peer-t-peer services and relapse preventin; Educatin and Jb Skills: Linkages t life skills, emplyment services, jb training, and educatin services; Family Supprt: Linkages t childcare, parent educatin, child develpment supprt services, family/marriage educatin; Supprt Grups: Linkages t self-help and supprt, spiritual and faith-based supprt; Ancillary Services: Linkages t husing assistance, transprtatin, case management, individual services crdinatin. Cntra Csta Cunty DMC-ODS Waiver 9
ADDITIONAL INSTRUCTIONS If, relative t the ttal budget, Administrative and Supprt Staff csts are abve 15%, please attach a justificatin fr these expenses. If Indirect Csts are charged, please attach a cpy f yur agency s cst allcatin plan and a clear descriptin f hw charges specific t this budget were calculated. Indirect csts must be apprtined by a methdlgy that cnfrms t the standards set by OMB Unifrm Guidance. Please rund all csts t the nearest dllar. The cunty may revise yur budget numbers slightly t crrect fr runding errrs. Any adjustments made t budget figures r service levels will nt exceed in the aggregate the cst f ne unit f service. If yu re-create these frms n yur wn spreadsheets, please d nt change the line item numbering n the Services & Supplies sectin f the budget. Cntra Csta Cunty DMC-ODS Waiver 10
Budget & Wrk Plan Checklist Sectin/Requirement OK Fllw-Up Actin Required Entity Identificatin (Cver) Service Site Regin Served Caselad Characteristics Hurs f Service Availability Sectin A Persnnel - Administrative and Supprt Staff Sectin B Persnnel - Direct Staff Services Sectin C Prductivity Sectin D Operating Expenses Sectin E Budget Summary Sectin F Staffing Sectin G fr Level 1.0 and/r 2.1 Weekly Schedule f Activities (Level 2.1 Only) Org Chart Vlunteer & Persnnel plicies Daily Schedule fr Residential and IOP levels f care Cmments: Cntra Csta Cunty DMC-ODS Waiver 11