The County of Sonoma Department of Health Services Behavioral Health Division

The County of Sonoma Department of Health Services Behavioral Health Division Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver Implementation Plan August 2016 Prepared by: Sonoma County Behavioral Health Division Please send questions to: michael.kennedy@sonoma-county.org

FOREWORD The County of Sonoma is comprised of 26 departments and agencies that provide a full range of services to the community. Sonoma County government has a history of providing excellent and responsive public service while operating under sound fiscal principles. Sonoma County encompasses over 1,700 square miles and is located between the commerce-driven San Francisco Bay Area and the spectacular beauty of northern California. The county s diverse economy includes a world class wine region, stunning natural resources, and dozens of tourist destinations. Sonoma County is home to 519,042 people (2015 - US Census), with approximately 33 percent of the population residing in Santa Rosa. Sonoma County plays a dual role to residents, providing municipal services such as law enforcement and fire protection to unincorporated areas and providing the day-to-day operation of state and federally mandated programs. As a general-law county, Sonoma County abides by state laws that determine the number and duties of county elected officials. The county is divided into five districts that are approximately equal in population size. Each district has an elected Supervisor. District boundaries are adjusted every ten years following the release of federal census data. Protecting the health and well-being of individuals and the community is the fundamental responsibility of the Sonoma County Department of Health Services (DHS). Thanks to the hard work of approximately 715 Health Services staff and our community partners, DHS provides a broad range of innovative programs and services designed to promote, develop and sustain the health of individuals, families, and communities. The department is comprised of three operational divisions (Behavioral Health, Public Health, and Health Policy, Planning & Evaluation) as well as an administrative unit that provides general administrative support. The Sonoma County Behavioral Health Division (SCBH) is the largest of DHS s three operational divisions accounting for approximately 60 percent of the department s total $159 million annual budget. The division has over 300 staff who are assigned to over 35 different programs within SCBH who are charged with providing behavioral health services to the residents of the County of Sonoma. SCBH s total operational budget is split approximately 50%-50% between its internal county run programs and the funding it allocates to its community based contracted partners. The mission of SCBH is to promote recovery and wellness to Sonoma County residents. SCBH embraces a recovery philosophy that promotes the ability of a person with mental illness and/or a substance use disorder to live a meaningful life in a community of his or her choosing, while striving to achieve his or her full potential. The principles of a recoveryfocused system include: self-direction, individualized and person-centered care, empowerment and shared decision-making, and a holistic approach that encompasses mind, body, spirit, and community; strengths-based, peer support; and focus on respect, responsibility, and hope. SCBH fosters a collaborative approach by partnering with clients, family members, and the community to provide high quality, culturally responsive services. The division provides mental health and substance use disorder services across the service spectrum, from prevention, early intervention and treatment, to aftercare and recovery. 1 P age

SCBH provides these services directly or through partnerships with community based agencies. SCBH directly administers specialty behavioral health (mental health and/or substance use disorder) treatment services to Sonoma County residents whose behavioral health needs are determined to be medically necessary. Sonoma County Behavioral Health provides oversight, quality assurance, training, and site monitoring for contracted services. 2 P age

PART I PLAN QUESTIONS This part is a series of questions that summarize the county s 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) Human Services, SUD Advisory Board, SUD Provider Network 2. How was community input collected? Community meetings County advisory groups Focus groups Other method(s) (explain briefly) Ongoing Provider meetings and individual meetings with Providers 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: Per State Suggestion, this narrative response is incorporated into Part 2, Question 1 3 P age

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 (MAT) * Partial Hospitalization Recovery Residences Other (specify) * = SCBH is currently in the process of assessing additional MAT See Question #18 below 4 P age

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: 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 5 P age

PART II PLAN DESCRIPTION (Narrative) In this part of the plan, the county must describe DMC-ODS implementation policies, procedures, and activities. General Review Notes: Number responses to each item to correspond with the outline. Keep an electronic copy of your implementation plan description. After DHCS and CMS review the plan description, the county may need to make revisions. When making changes to the implementation plan, use track changes mode so reviewers can see what has been added or deleted. Counties must submit a revised implementation plan to DHCS when the county requests to add a new level of service. Narrative Description 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. Review Note: Stakeholder engagement is required in development of the implementation plan. Sonoma County Behavioral Health (SCBH) participates in a number of ongoing community-based planning, collaboration, and coordination meetings. These meetings include the following: Substance Use Disorders Providers Meeting Youth Services Coordinating Council Criminal Justice Council Community Corrections Partnership Alcohol and Other Drugs Advisory Board Mental Health Board Redwood Community Health Coalition Monthly Monthly Monthly Quarterly Monthly Monthly Monthly In addition to these ongoing opportunities for collaboration, SCBH established the DMC Advisory Committee. The Advisory Committee was comprised of representatives from key provider organizations, County Probation, consumer representatives, and SCBH staff. The group met on three occasions to be oriented to the waiver and to provide input to SCBH regarding current strengths and weakness of the current system of care, opportunities for improvement, and recommendations for managing system capacity and access. 6 P age

SCBH staff met individually with each of the key provider organizations to determine their capacity to participate in the DMC-ODS development and to hear their ideas about expansion of services and capacity. SCBH staff also met with the local Medi-Cal managed care organization, Partnership Health Plan of California, to discuss their existing benefits/services and to discuss care coordination and the required memorandum of understanding. Once SCBH s plan is approved, these groups and organizations will be actively involved in the implementation of the system of care. As outlined above, SCBH staff participates in a number of ongoing community planning and coordination meetings that include criminal justice, community health centers, youth services in collaboration with education and human services, mental health advocates, substance use disorders advocates, substance use disorders providers, and health centers. At each of these ongoing meetings, participants were given an orientation to the DMC-ODS waiver and engaged in discussion about implementation of the waiver in Sonoma County. In addition, SCBH maintained regular communication with provider organizations in our partnership in managing the existing system of care. SCBH used these existing and ongoing forums to gather input regarding the development and implementation of the DMC-ODS Plan. SCBH has a long history of collaboration with the health centers in our area. We ve developed working relationships involving coordination of care and bi-directional referral. It is our intention to continue and build on these existing procedures to facilitate access to care for individuals with substance use disorders. We met with representatives of the health centers to get input for this plan. Moving forward, SCBH will continue to use existing meetings, forums, workgroups, and committees to discuss the implementation of the DMC-ODS once the plan is approved. In addition, a DMC Advisory Committee will act as a steering committee for the implementation of the plan. Membership will be expanded to include members from SCBH, SCBH SUD contract providers, the health centers, and Partnership Health Plan of California. 2. Client Flow. Describe how clients move through the different levels identified in the continuum of care (referral, assessment, authorization, placement, transitions to another level of care). Describe what entity or entities will conduct ASAM criteria interviews, the professional qualifications of individuals who will conduct ASAM criteria interviews and assessments, 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 and who is providing the case management services. Also describe if there will be timelines 7 P age

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. Clients currently enter the existing services through multiple access points represented by contracted providers and through services offered by local health centers. With the implementation of the DMC-ODS, SCBH will expand its mental health Access Team and integrate substance use disorder screening, ASAM assessment, authorization, referral, and care coordination. Partnership Health Plan already supports Screening, Brief Intervention, and Referral to Treatment (SBIRT) services through local health centers. It is possible that as a result of receiving these services, the individual will seek additional substance use disorders services. In addition, providers and SCBH receive referrals from criminal justice partners and will screen these individuals as well. As part of the Sonoma County DMC-ODS, individuals seeking and/or in-need-of SUD services can first enter the system through four primary means which include the following: I. SCBH Screening/Call Center; II. SCBH Crisis Programs Detox and/or CSU; III. Contract Providers; or IV. The division s Mobile Crisis Services Upon initially presenting, individuals will receive a brief screening by a licensed and/or SUD certified staff. Each individual will first be screened by a consistent and validated screening tool. SCBH is working with its different stakeholders to identify an evidencedbased screening tool (ex, CAGE assessment tool) that will be used. Should the screening show a need for substance use disorders services, the individual will be scheduled for a full ASAM assessment to be completed by the SCBH Access Team. All assessments will be completed using the Continuum software developed by the American Society of Addiction Medicine. Continuum provides a structured, researchbased assessment process. Once completed, the Continuum assessment software provides a suggested level of care. Continuum will be integrated with Sonoma County s electronic health record Sonoma Web Infrastructure for Treatment Services (SWITS). The software will capture the suggested level of care and the actual level of care offered to the individual. Differences between suggested and actual LOC are determined by the presiding clinician and result from factors not addressed in the ASAM but possibly revealed through clinical intervention. These identified differences will require supervisor review by a clinical supervisor and will be documented in the client file. Individuals who are in a Behavioral Health Crisis will be immediately referred to the division s Turning Point Orenda Detox program or the Crisis Stabilization Unit (CSU). 8 P age

SCBH utilizes three Mobile Crisis Service programs. These programs are described as follows: Crisis, Assessment, Prevention, & Education (CAPE) Team: CAPE is a prevention and early intervention strategy specifically designed to intervene with transition age youth ages, 16 to 25, who are at risk of or are experiencing first onset of serious psychiatric illness and its multiple issues and risk factors: substance use, trauma, depression, anxiety, self-harm, and suicide risk. The CAPE Team aims to prevent the occurrence and severity of mental health problems for transition age youth. The CAPE Team is staffed by SCBH licensed and license-eligible mental health clinicians. CAPE is onsite at fifteen Sonoma County high schools. CAPE provides crisis response and training in mental health issues to Santa Rosa Junior College, Sonoma State University, Family Justice Center, Positive Images, and VOICES. The CAPE Team has five essential components: Mobile Response to schools by licensed mental health clinicians with youth who may be experiencing a mental health crisis. Screening and Assessment of at-risk youth in high schools and colleges. Training and Education for students, selected teachers, faculty, parents, counselors, and law enforcement personnel to increase awareness and ability to recognize the warning signs of suicide and psychiatric illness. Peer-based and Family Services, including increasing awareness, education and training, and counseling and support groups for at-risk youth and their families. Integration and Partnership with existing school and community resources, including school resource officers, district crisis intervention teams, student and other youth organizations, health centers, counseling programs, and family supports including National Alliance on Mental Illness and Sonoma County Behavioral Health. Mobile Support Team (MST): The MST is operated by SCBH and is staffed by specially trained licensed behavioral health professionals, post-graduate registered interns, a certified substance use specialist and follow up by consumers and family members. The MST operates during peak activity hours and days as informed by ongoing data review and coordination with law enforcement agencies. MST staff responds to law enforcement requests. Once the scene is secured, the MST provide mental health and substance use disorders interventions to individuals experiencing a behavioral health crisis, including assessment, and placing the individual on an involuntary hold, if needed. MST staff provides crisis intervention, support and referrals to medical and social services as needed. Staff also conducts follow up support visits to individuals and their families in an effort to mitigate future crisis. Services are provided in English and Spanish. 9 P age

Community Intervention Program (CIP): The purpose of the CIP is to provide outreach to disparate populations (those who have been historically underserved by mental health services) in an effort to engage people from these populations into mental health services. CIP focuses its activities on reaching, identifying, and engaging unserved individuals and communities in the mental health system, and reducing disparities identified by Sonoma County. The MHSA community planning process prioritized the following populations for outreach and engagement: People who are homeless People who abuse substances Veterans People experiencing a recent psychiatric hospitalization Ethnic and cultural populations in particular, Latinos Individuals from the Lesbian, Gay, Bisexual, Transgendered, Queer, Questioning and Intersex (LGBTQQI) Community People who are geographically isolated CIP conducts outreach activities where these populations congregate and/or already receive other services. They do this by: Direct Services: Co-locating CIP staff in organizations that provide other services to these populations Contracted Services: Providing funding to organizations that serve these populations so they can hire their own staff The following diagram illustrates the flow of clients, depending on each individual s behavioral health need(s), within the SCBH system of care. Diagram 1: SCBH Client Flow 10 P age

Running parallel and in conjunction with the County s implementation of the DMC-ODS, SCBH is in the process of a system redesign that will incorporate a Care Coordination model. In this model, there will be a single point of entry into the Sonoma County behavioral health system of care which will be the SCBH Access program. Each client in the system will be assigned to a SCBH care coordinator (case manager) who will follow the client as they move into care and as they transition between levels of care. The care coordinator will act as a consistent ally for the client. The care coordinator will collaborate with treatment providers in determining client progress and ability to transition between levels of care or the need to provide additional or more intensive services. Clients will be reassessed (ASAM) by SCBH staff every 90 days or at the completion of each service. When high-utilizers are identified they will be flagged, triggering a more intensively structured case management approach, possibly including more frequent check-ins, assignment to peer support, or referral to Sober Living Environment. 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 times, 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 a particular service area. The plan must notify beneficiaries of free oral interpretation services and how to access those services. The SCBH Access line is currently included in the informing materials that are available and will be part of the Sonoma County DMC-ODS in English and Spanish (Sonoma s sole State-identified threshold language) at each of the SCBH programs as well as contract providers. In addition, the Access line is listed in the local phone book as well as the County s website. The DMC-ODS beneficiary access line will be incorporated with the existing ADA compliant access line for mental health services. This 800# connects callers with the SCBH Access Team and interpreter services are available for non-english speaking individuals. All calls are answered by a staff member who determines if the caller needs emergency services. If the call is urgent or emergent, the call will be transferred to available staff immediately. For routine inquiries, contact information will be entered into the automated system and transferred to an available Access Team member. If there is no Access Team member immediately available, the caller will be told that an Access Team member will call sometime that day. As Access staff become available, they will return calls saved in the cue. The automated phone system tracks: Time taken to answer the call; Total number of calls; The abandonment rate 11 P age

Starting on April 1, 2016, SCBH contracted with Optum for after hours and weekend phone coverage for the Access line. This contract with Optum has resulted in the SCBH Access Line being available 24/7/365. The Optum phone center is staffed by licensed clinicians during non-business hours (ex. nights, weekends and holidays). SCBH and Optum have developed protocols for dealing with emergency calls as well as a process for answering routine calls and providing information to beneficiaries. Optum tracks the following: Number of total calls; Number of calls answered; Average number of minutes per call; Call back rate; Number of calls referred for emergency services; Number of calls abandoned; Number of calls abandoned after 45 seconds; Percentage of calls abandoned after 45 seconds; Average seconds to answer; and Hang-up calls recorded 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, 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. Review Note: Include in each description the corresponding American Society of Addiction Medicine (ASAM) level, including opioid treatment programs. Names and descriptions of individual providers are not required in this section; however, a list of all contracted providers will be required within 30 days of the waiver implementation date. This list will be used for billing purposes for the Short Doyle 2 system. The SCBH DMC-ODS will include the following types of services: i. Withdrawal Management (ASAM Level 1): Habilitative and rehabilitative services when determined by the Medical Director as medically necessary and in accordance with an individualized client plan. The Withdrawal Management services are intake, observation, medication services and discharge services. For clients in Withdrawal Management, case management will be provided to coordinate care with ancillary service providers and facilitate transitions between levels of care. 12 P age

ii. Residential Services (ASAM LEVEL 3.1 and 3.5): The County of Sonoma currently provides through contracted CBO s a non-institutional 24-hour nonmedical, short term (30 days or less) or long-term (31 days or more) program that provides rehabilitative services. SCBH will work with its CBO network to expand capacity as demand for service increases as a result of the DMC-ODS. Rehabilitative services consist of intake, individual and group counseling, client education, safeguarding medications, collateral sessions with non-professional significant people in the client s life, crisis intervention services, treatment planning, and transportation and discharge services. The program involves the family or other supports in services whenever possible. Beneficiaries must receive a minimum of twenty (20) hours of services (not counting transportation services) per week. The Medical Director must determine the medical necessity for Residential Services and this level of care must be part of the individualized client plan. Case Management will be provided to collaborate care and transfer clients between levels of care. Additionally, perinatal residential substance abuse services including intake, admission physical examinations and laboratory tests, medical direction, treatment planning, individual and group counseling services, parenting education, body specimen screens, medication services, collateral services, and crisis intervention services, will be provided by staff that are lawfully authorized to provide and/or order these services within the scope of their practice or licensure. A client assessed as meeting criteria for ASAM levels 3.7 or 4.0 will be assigned an SCBH Care Coordinator and referred to local Emergency Departments. If sufficiently stabilized, the client will be reassessed and stepped down into the appropriate SCBH level of care. If the client is hospitalized, the SCBH Care Coordinator will monitor, and if appropriate, coordinate and integrate SUD services (most likely via individual counseling) until the client is discharged. Post discharge, the client will be reassessed and stepped down into the appropriate SCBH level of care. SCBH is exploring the possibility of developing a Level 3.7 program within our system of care. iii. Intensive Outpatient Services (ASAM Level 2.1): Consist primarily of counseling and education about addiction-related problems, with specific components including intake, individual counseling, group counseling, family therapy, client education, medication services, collateral services, crisis intervention services, treatment planning and discharge services. The Medical Director must determine medical necessity and this level of service must be a part of the individualized client plan. Case Management will be provided to collaborate care and transfer clients between levels of care. A day treatment program may prevent or minimize the need for a more intensive level of treatment. It may also function as a step-down from inpatient care or partial hospitalization or as transitional care following an inpatient or partial hospitalization stay to facilitate return to the community. 13 P age

Intensive Outpatient Treatment services shall be provided in 15 minute increments to any DMC eligible beneficiaries for at least nine hours a week for adults, and 6-19 hours per week for adolescents. The treatment schedules can be flexible for instance, adult treatment can be provided in various combinations of 15 minute units that total nine hours a week. Effective January 1, 2015, group size is limited to no less than two (2) and no more than twelve (12) clients at the same time. iv. Outpatient Services (ASAM Level 1): Offer comprehensive, coordinated, and defined services that may vary in level of intensity. Outpatient programs may address a variety of needs, including, but not limited to, situational stressors, family relations, interpersonal relationships, mental health issues, life span issues, psychiatric illnesses, and substance use disorders and other addictive behaviors. These services consist of intake, assessment, individual and group counseling, client education, collateral services, crisis intervention services, treatment and discharge planning. Outpatient Services consist of two types of sessions: Group counseling sessions shall focus on short-term personal, family, job/school, and other problems and their relationship to substance abuse or a return to substance abuse. Services shall be provided by appointment. Each beneficiary shall receive at least two group counseling sessions per month unless waived by a physician. Groups shall be conducted with no less than four (4) and no more than ten (10) clients at the same time, prior to December 31, 2014. Effective January 1, 2015, group size is no less than two (2) and no more than twelve (12) clients at the same time. Individual counseling shall be limited to intake crisis intervention, collateral services, and treatment and discharge planning. Services occur in 15-minute increments. The Medical Director must determine medical necessity and this level of service must be a part of the individualized client plan. Case Management will be provided to collaborate care and transfer clients between levels of care. v. Narcotic Treatment Program (ASAM OTP LEVEL 1): Services are provided in facilities licensed by the California Department of Health Care Services (DHCS) and accredited by a federally approved accreditation provider. The medically necessary services are provided in accordance with an individualized treatment plan determined by a licensed physician or their licensed designee and approved and authorized according to Title 9 CCR Regulations. Services are directed at reducing or eliminating the use of illicit drugs, criminal activity, and/or the spread of infectious disease while improving the quality of life and functioning of the beneficiaries served. The treatment services consist of intake, individual and group counseling, client education, medication services, collateral services, crisis intervention services, treatment planning, medical psychotherapy and discharge services. Beneficiaries can be concurrently enrolled in Outpatient, Intensive Outpatient (IOP) or Residential while receiving Narcotic Treatment Program 14 P age

Services (NTP). As described in question #19 below, SCBH currently utilizes methadone, and is adding Buprenorphine, Naloxone, and Disulfiram as MATs that will be available to clients at our two contracted NTP providers. vi. vii. viii. Recovery Services (ASAM Dimension 6 Recovery Environment): As part of the assessment and treatment needs of Dimension 6, Recovery Environment of the ASAM Criteria and during the transfer/transition planning process, beneficiaries will be linked to applicable medically necessary recovery services. Beneficiaries may access recovery services after completing their course of treatment whether they are triggered, have relapsed or as a preventative measure to prevent relapse. Recovery services will include outpatient individual or group counseling; recovery monitoring/coaching; peer-to-peer assistance; linkages to services to enhance education and job skills; and linkages to support groups and ancillary services. Case Management Services: Will be utilized to assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. These services focus on coordination of substance use disorder care, integration with primary care and mental health, and interaction with the criminal justice system, if needed. Case management services also will be utilized to serve the historically more challenging to engage population with complex needs, such as frequent utilizers of multiple health, criminal justice and social services systems, and older adults with co-occurring physical health and substance use issues. It is expected that case management services for these highly complex populations will occur outside of a formal treatment episode. Other case management services expected to take place outside of a formal treatment episode include linking beneficiaries with recovery support services. The case management services include: comprehensive assessment and periodic reassessment of individual needs to determine the need for continuation of case management services; transition to a higher or lower level of care; development and periodic revision of a client plan; communication, coordination, referral and related activities; monitoring service delivery to ensure beneficiary access to services; monitoring the beneficiary s progress; client advocacy; linkages to physical and mental health care; and transportation. Case management shall be consistent with and shall not violate confidentiality of alcohol or drug clients as set forth in 42 CFR Part 2, and California law. Case management services can be provided at DMC provider sites, county locations, hospitals, health centers and other community-based sites appropriate for providing these services to the beneficiary. Services may also be home-based, if deemed clinically appropriate. While approved DMC providers can provide case management services to a beneficiary while in treatment at the certified program, the SCBH Access Team will be responsible for coordinating the overall case management level of care, including providing any case management services outside of a treatment episode and overseeing all care coordination activity in the DMC-ODS. Physician Consultation: Services that are designed to assist DMC physicians with seeking expert advice on designing treatment plans and supporting DMC providers with complex cases. These cases may address medication selection, 15 P age

dosing, side effect management, adherence, drug-drug interactions, or level of care considerations. When needed, physician consultation services will be provided through the County s CSU, Access Team (County or Contracted psychiatrist) and/or when beneficiaries are placed into treatment. SCBH has developed a substantial network of SUD providers which it has contracted with for many years. SCBH is responsible for administering and monitoring the provision of publically funded contracted SUD services within the County of Sonoma. The services offered are both Drug Medi-Cal and non-drug Medi-Cal. Approximately 52% of the total SCBH SUD budget for FY 16/17 is allocated to SUD service contracts. All providers contracted with SCBH to provide SUD services are required to maintain appropriate licensure/certification including DHCS SUD licensure, Community Care licensure (Adolescent Residential), Accreditation (NTP), DEA licensure (NTP), and Drug Medi-Cal Certification (as applicable). All contracted providers are required vis-à-vis language included in their executed contracts to comply with Federal, State, and local requirements. Language regarding the standards and evidence-based practices that meet the DMC-ODS quality requirements will be added to each SUD contractor s agreement as the DMC-ODS is implemented within the County of Sonoma. For Medi-Cal beneficiaries receiving Drug Medi-Cal services within the County of Sonoma, services are offered/provided to beneficiaries when determined medically necessary. Through the County s DMC-ODS expansion, clients will receive an ASAM and, if indicated, will be referred and authorized through the SCBH Access program. The purpose of the Access program is to improve access to behavioral health services for residents of Sonoma County. Individuals seeking care are able to quickly receive a screening (ASAM), and when indicated be referred and authorized for appropriate levels of care as determined by the ASAM multidimensional assessment continuum of care screening process to the network of SUD services available throughout Sonoma County. Individuals can be screened either in person or over the phone. While the primary purpose of the Access Team is to assist the Medi-Cal beneficiary into care, the Access Team provides links to other community resources for any caller. Through the California Behavioral Health Directors Association and other state level associations, committees, workgroups and collaborations, SCBH has established strong working relationships with surrounding counties. SCBH will continue to offer and make available its original DMC modalities to any beneficiary from an opt-out county seeking services within Sonoma County. When beneficiaries from opt-out counties are determined to require expanded services, SCBH will coordinate with the beneficiary s county of residence in order to help ensure that the beneficiary may access services as seamlessly and quickly as possible. As needed, SCBH will work with its regional county partners to ensure the availability and delivery of services to those individuals that are entitled to expanded DMC-ODS services. Sonoma County s DMC-ODS will include withdrawal management (social model residential detoxification), residential services, intensive outpatient services, outpatient services, narcotic treatment services (including Methadone provision, as well as all 16 P age

required MAT services - Buprenorphine, Disulfiram, and Naloxone), recovery residences (such as Sober Living Environments - SLE), and recovery services. SCBH is anticipating adding 40 SLE beds, equating to 14,600 bed days annually to its SUD system of care. Individuals will be able to be placed in these SLEs for up to 6 months per episode. Services include supervised/monitored board & care as well as education services, individual and group treatment (field based DMC outpatient provided by contractor), aftercare services, as well as ancillary supportive services such as vocational training. As previously noted, SBIRT services are and will be available in the DMC-ODS. 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? Sonoma County Department of Health Services has an integrated Behavioral Health division that provides mental health and substance use disorders services. As the Mental Health Plan, SCBH provides Specialty Mental Health Services (SMHS) to Medi- Cal adult beneficiaries with serious and persistent mental illness and to children and youth beneficiaries with severe emotional disturbances. SMHS are provided by SCBH staff and community based contractors. Currently, the majority of substance use disorders services are provided by community based substance use treatment providers. With the implementation of the DMC-ODS, SCBH will look to expand both SCBH and contractor operated substance use treatment services, including case management. This expansion will complement services provided by contractors and fill in the gaps. Partnership HealthPlan of California (PHC) administers the Medi-Cal Managed Care Plan in Sonoma County and is responsible for providing the mental health benefit for beneficiaries with mild or moderate mental health issues and SBIRT: Screening, Brief Intervention and Referral to Treatment for beneficiaries to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. PHC contracts with Beacon Health Strategies (Beacon) to provide these services. In Sonoma County, private non-profit Federally Qualified Health Centers (FQHCs), private individual providers, and non-profit community based organizations have contracted with Beacon to provide this Medi-Cal benefit. Since the inception of the Affordable Care Act, PHC and SCBH have worked collaboratively to ensure excellent continuity of care for Sonoma County beneficiaries. As a result, SCBH and Beacon have developed system-wide strategies to ensure a seamless bi-directional referral process between SCBH and Beacon to meet the changing needs of beneficiaries and to ensure the beneficiaries needs are addressed with the appropriate level of treatment. The system-wide strategies include: 17 P age

Co-Locating SCBH staff in community health centers to screen and assist beneficiaries with transfers of care whether the beneficiary is stepping up a level of care from the community health center to SCBH or down in level of care from SCBH to the community health centers; Assisting Beacon to engage SCBH specialty mental health services community based contractors to become Beacon network providers. Whether a beneficiary is stepping up in level of care from a community based nonprofit to SCBH or stepping down a level of care from SCBH to a community based nonprofit, the beneficiary will maintain the continuity of their treatment provider while the provider would claim to another Medi-Cal source; Instituting a telephonic warm hand off with beneficiaries so they may be screened for any level of care through either Beacon or SCBH Call Centers and transferred seamlessly to the appropriate authorizing source; and Creating an agreed upon algorithm that supports level of care need. In conjunction with SCBH s implementation of the DMC-ODS, SCBH is in the process of a system redesign that will incorporate a Care Coordination model. The Substance Abuse and Mental Health Services Agency (SAMHSA) calls Care Coordination The cornerstone of health care redesign efforts including primary and behavioral health integration. The Care Coordination model brings together various providers in various disciplines to coordinate health services, client needs, and information to help better achieve the goals of treatment and care and improve client satisfaction. SCBH s Care Coordinators will work with beneficiaries across conditions, services, providers, and settings. The Access program currently screens children, youth, and adults seeking specialty mental health services. The SCBH Access program Call Center will serve as the single point of entry into the SCBH system of care for mental health and substance use disorders services. With the implementation of the DMC-ODS, SCBH will expand its mental health Access program Call Center to integrate substance use disorder ASAM screening as well. Beneficiaries seeking substance use disorders services will be able to call into the SCBH Access program Call-Center where staff will conduct a brief clinical screening to determine if the beneficiary meets Medical Necessity based on the current DSM and will apply the ASAM criteria to make the appropriate level of care recommendation(s) for individuals seeking substance use disorder treatment. Currently, the SCBH Access program uses an adapted evidence based, culturally responsive, strengths based, Child and Adolescent Needs and Strengths (CANS) for children and youth under the age of 18 and the Adult Needs and Strengths Assessment (ANSA) to screen for mental health needs. The CANS and ANSA are multi-purpose tools developed to support decision making, including level of care and service planning. With the implementation of DMC-ODS, the Access program will integrate the use of the ASAM to screen individuals who are seeking substance use disorders services. The ASAM is an evidence based, culturally responsive, strengths based biopsychosocial assessment also used to support decision making for service planning, treatment, and level of care. Both of these tools offer a quick screening for all dimensions of behavioral health needs. 18 P age

Beneficiaries seeking substance use disorders services will be able to call into the SCBH Access program Call-Center. Staff at Access includes licensed clinicians (MFT, LCSW); registered interns that are supervised by a licensed clinician (MFTi or ASW); or Registered and Certified AOD Counselors. These staff will conduct a brief clinical screening to determine if the beneficiary meets Medical Necessity based on the current DSM and will apply the ASAM criteria to make the appropriate level of care recommendation(s). Based upon the findings of the screening, SCBH staff will determine whether there is sufficient information to make a referral to the appropriate ASAM level of care or whether a face-to-face assessment shall be scheduled. Beneficiaries scheduled for a face-to-face assessment will be offered the first available assessment appointment per a daily capacity report provided by substance use disorders treatment agencies in the SCBH network of providers. This single point of entry practice will ensure beneficiaries with co-occurring disorders will also receive a screening for mental health issues and conversely that individuals seeking mental health services will be screened using the ASAM to determine level of care needed. Furthermore, providing a central access point for referrals will allow SCBH to monitor referrals, timeliness to treatment, and beneficiary progress. Once the determination is made for the need for mental health and/or substance use disorders services, each beneficiary will be assigned to an SCBH Care Coordinator. The Care Coordinator will follow the client as s/he moves into care and as s/he transition between levels of care. The Care Coordinator will act as a consistent ally for the client and assist them in moving between levels of care. The Care Coordinator will collaborate with treatment providers across conditions, services, providers, and settings determine beneficiary progress and ability to transition along the continuum of care. Contracts with DMC-ODS providers will include screening, assessment, and care coordinator requirements including but not limited to: Screening and assessment procedures for referral into treatment; Procedures for ongoing monitoring of timeliness to services; Procedures for linking beneficiaries to other necessary services including mental health treatment services through SCBH or Beacon and physical health care; and/or Procedures for ongoing monitoring of service efficacy. Contractors will also be required to participate in annual audits, including self-audits, quality review and utilization review audits. Sonoma County Department of Health Services has an integrated Behavioral Health Division that provides mental health and substance use disorders services. The service system design ensures monitoring along the service spectrum. Through the Access Call Center, beneficiaries will be screened for co-occurring disorders. Beneficiaries seeking substance use disorders services will receive a screening for mental health issues, and conversely, individuals seeking mental health services that are determined through their MH assessment to have a SUD issue will receive an ASAM to determine the substance use 19 P age

disorders level of care required. In other words, someone calling the access call center seeking out SUD services will be screened for possible MH needs as well. A person who calls the access center seeking MH services will not be screened for SUD but a full ASAM assessment will be conducted if the MH assessment reveals SUD needs. Beneficiaries with co-occurring disorders will be assigned a Care Coordinator who will re-assess clients at six month intervals and work with them across services, providers, and treatment settings. 6. Coordination with Physical Health. Describe how the counties 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 care for Medi-Cal beneficiaries in Sonoma County is provided by seven independent private nonprofit FQHCs, an Indian Health Service (IHS) health center, and Kaiser Permanente (Kaiser). These physical health care providers have over 20 separate service sites and clinics scattered throughout Sonoma County s nine cities and 1,768 square miles. Each of these community health centers provides physical health services to Medi-Cal beneficiaries through contract with Partnership HealthPlan of CA and behavioral health services through Beacon. While each of the seven FQHCs, the IHS, and Kaiser has its own model of coordinating with SCBH mental health and substance use disorders services, all organizations highly value collaboration and coordination of care. SCBH already has coordinated systems in place to ensure smooth bi-directional referrals that connect beneficiaries to the level of care, and service they need. SCBH will capitalize on these current methods used to coordinate physical health care within the waiver through expansion and replication. Imbedding community health center satellite clinics into substance use disorders treatment programs; and Co-locating substance use disorders contract providers in community health centers. SCBH will expand current structures to include ASAM screenings, referral, assessment, and level of care for treatment. Under DMC-ODS, beneficiaries will have an assigned Care Coordinator who will facilitate coordination with physical health. All SCBH contract providers will have goals and requirements for coordination with physical health in DMC- ODS contracts. DMC-ODS contracts will include a series of care coordination requirements including, but not limited to: Screening and assessment procedures and tools to identify physical health issues (within the scope of practice), and determining if the beneficiary has a primary care provider; 20 P age