Imperial County Behavioral Health Services

Transcription

1 Imperial County Behavioral Health Services Mental Health Services Act Three-Year Program and Expenditure Plan Fiscal Year through Fiscal Year POSTED April 17, 2017

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3 This portrait was created by one of the consumers at the El Centro Wellness Center Program. This is available for public review and comment from April 17, 2017, through May 16, This document can be accessed at through the website s bulletin board. We welcome your feedback via phone, fax, or , or during the Public Hearing to be held on May 16, Public Hearing Information: Imperial County Behavioral Health Services 202 N. Eighth Street, El Centro, CA Training Room Second Floor Tuesday, May 16, 2017, at 12:00 p.m. Questions or comments? Please contact: Imperial County Behavioral Health Services 202 N. Eighth Street, El Centro, CA Phone: (442) Fax: (442) MHSA@co.imperial.ca.us

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5 Table of Contents Executive Summary MHSA County Compliance Certification MHSA County Fiscal Accountability Certification County Profile Workforce Needs Assessment MHSA Background Community Planning Process Requirements MHSA Three-Year Program Plan Community Services and Supports Full Service Partnership Youth and Young Adult Services Full Service Partnership Program Adult and Older Adult Services Full Service Partnership Program General Systems Development Wellness Center Outreach and Engagement Outreach and Engagement Program Transitional Engagement Supportive Services Program Prevention and Early Intervention Prevention Outreach Activities The Incredible Years Early Intervention Trauma-Focused Cognitive Behavioral Therapy Innovation First Steps to Success Program FY Through FY Three-Year Mental Health Service Act Expenditure Plan Funding Summary Community Services and Supports Component Worksheets

6 Prevention and Early Intervention Component Worksheets Innovations Component Worksheets Appendices Appendix I: Definition of Acronyms Appendix II: Stakeholder Comments Received

7 Executive Summary The Mental Health Services Act (MHSA) became a state law on January 1, 2005, after having been approved by California voters. The MHSA was designed to expand and transform California s mental health service systems by providing funds to reduce the long-term adverse impact of untreated severe mental illness and serious emotional disturbance. The goal of MHSA programs is to provide services that promote well-being, recovery, and self-help; prevent the long-term negative impact of severe mental illness; and reduce stigma. Services are culturally competent, easier to access, and more effective in preventing and treating severe mental illness. Using a whatever it takes approach, Imperial County Behavioral Health Services (ICBHS), through a stakeholder process that includes consumers, family members, and community partners, has developed and implemented various MHSA programs to meet the specific needs of Imperial County. As a result of this community planning process, the following programs and services will be available during : Community Services and Supports The largest component of the MHSA, Community Services and Supports programs focus on children and families, transition-age youth, adults, and older adults who suffer from severe mental illness or serious emotional disturbance. Programs provided through Community Services and Supports include: Youth and Young Adult Services Full Service Partnership Program The Youth and Young Adults Service Full Service Partnership (YAYA-FSP) Program provides services and supports to severely mentally ill (SMI) and seriously emotionally disturbed (SED) youth and young adults, ages 12 to 25. Services available to YAYA-FSP Program clients case management; rehabilitative services; wrap-like services; integrated community mental health and substance abuse treatment; crisis response; alternatives to juvenile hall; home and community re-entry from juvenile hall; youth and parent mentoring; supported employment or education; transportation; housing assistance; benefit acquisition; and respite care. The YAYA-FSP Program staff are trained to implement the following treatment models: Cognitive Behavioral Therapy; Trauma-Focused Cognitive Behavioral Therapy; Functional Family Therapy; Interpersonal Psychotherapy; Moral Reconation Therapy; Motivational Interviewing; Portland Identification and Early Referral Model; and Aggression Replacement Training. Additionally, equine therapy, health and exercise groups, general education development (GED) classes, and Tai Chi classes are available to YAYA-FSP Program clients. During the past two years, the YAYA-FSP Program has significantly increased its working collaboration with the Probation Department by enhancing mental health services provided to youth detained in Juvenile Hall and developing joint protocols for the treatment of youth who present mental health concerns while in the facility and upon discharge. As part of this increased collaboration, ICBHS assisted Probation staff in the development of a Suicide Prevention Plan that would guide Juvenile Hall and ICBHS staff on how to best manage those youth who present suicide risk while detained in the facility. The Suicide Prevention Plan ensures that both Juvenile Hall and ICBHS staff are provided with clear and detailed guidelines on how to best identify, protect, and treat youth at risk of suicide. Page 1

8 For, the YAYA-FSP Program will work toward: implementing evidence-based practices that are specific to diagnosis and population; improving access to services in the Calexico region; making facilities LGBT friendly and inviting; increasing referrals to equine therapy, Fitness Oasis, and Imperial Valley Regional Occupational Program; increasing consumers engagement; and decreasing consumers no-show rates to scheduled appointments. Adult and Older Adult Services Full Service Partnership Program The Adult and Older Adult Services Full Service Partnership (Adult-FSP) Program provides services and supports to SMI adults and older adults, ages 26 and older. Services available to Adult- FSP Program clients include case management; rehabilitative services; wrap-like services; integrated community mental health services; alcohol and drug services; crisis response; and peer support. The Adult-FSP Program provides clients linkage to the following: emergency shelter; permanent housing; emergency clothing; food assistance; SSI/SSA benefits application and/or appeals; DSS Cash Aid application; Section 8 Housing application; substance abuse treatment and/or rehabilitation referral; referrals to general physician and/or dentist; driver s license/id application; and/or immigration paperwork. Delivery of needed supports and services are provided in the home for older adults who are homebound, do not have transportation, or are unable to access public transportation. The Adult-FSP Program staff are trained to implement the following treatment models: Cognitive Behavioral Therapy; Cognitive Processing Therapy; Motivational Interviewing; Cognitive Behavioral Therapy-Anxiety Treatment; Cognitive Behavioral Therapy- Depression Treatment; and Moral Reconation Therapy. During FY , the Adult-FSP Program secured a building in Calexico to expand services to the adult and older adult population in this region. The clinic opened on March 6, The initial caseload will be approximately 120 Adult-FSP Program consumers, which is expected to increase to approximately 180 to 200 consumers within the first year. Additionally, during FY , the Adult-FSP Program began implementing Medication and Diagnosis Education Groups. These groups began in September 2016 in order to help educate consumers regarding their diagnosis and medications. In prior years, individuals were only referred to the Adult-FSP Program if they also met criteria for mental health services and targeted case management services provided by a mental health rehabilitation technician. Effective FY , all adult consumers who meet the FSP criteria will be served through the Adult-FSP Program and specific specialty mental health services will be assigned based on the individual s unique needs. For, the Adult-FSP Program will work toward: improving FSP screening protocols for new referrals as evidenced by an increase in the number of FSP consumers at each clinic site; reducing the number of Adult-FSP Program consumer crisis desk admissions and hospitalizations; providing services and supports that teach, empower, and assist clients in accessing services, avoiding homelessness, managing their independence, and improving safety and permanence at home, school, and in the community; providing Moral Reconation Therapy to consumers who have a history with the criminal justice system; increasing the number of Adult-FSP Program consumers with a co-occurring substance use disorder who are referred to and Page 2

9 receive substance abuse treatment; increasing the number of consumers who are referred to and attend the Medication and Diagnosis Education Groups; improving access to mental health services for LGBT individuals; and increasing the number of peer support staff and volunteers that work specifically with the Adult-FSP Program population. Wellness Center The Wellness Center, formerly known as the Recovery Center Program, is a network of consumers whose mission is to implement a wellness program of supportive resource services for adults with a significant and persistent mental health diagnosis. Currently, there are two Wellness Center facilities, one in El Centro and one in Brawley, that provide services that focus on social skills, recovery skills, encouragement, wellness, positive self-esteem, and community involvement. The Wellness Center has partnered with outside agencies to offer consumers educational classes and pre-employment, job readiness, and employment training, as well as assist them in obtaining a high school diploma or GED. Consumers also have access to computers and the internet to aid them in completing school assignments (i.e. research, homework, and projects). The Wellness Center staff includes a music instructor who provides group and individual voice and instrumental music instruction. Consumers are also offered the opportunity to attend classes on English as a second language, arts and crafts, Tai Chi, photography, self-esteem, life skills, cooking, embroidery/sewing, and computers. For, the Wellness Center will work toward: increasing the number of consumers who obtain a GED, certificates, and/or college degrees; increasing consumers participation in the exercise/fitness program and nutritional classes; increasing consumers independence and social connections by engaging them in their Wellness and Recovery Action Plan; increasing consumers participation in the life skills class, GED program, and Department of Rehabilitation services; implementing family psychoeducation groups; and engaging consumers in their overall mental health treatment and participation in the programs and groups offered at the Wellness Centers. Outreach and Engagement Program The Outreach and Engagement Program provides outreach services to unserved and underserved SED and SMI individuals in the neighborhoods where they reside, including those who are homeless, in order to reduce the stigma associated with receiving mental health treatment and increase access to mental health services. The program also provides education to the community regarding mental illness and symptoms, early identification of mental illness, and resources to improve access to care through local outreach. The program assists individuals in obtaining mental health treatment services from ICBHS by providing information pertaining to programs, services, and the intake assessment process; conducting home visits; scheduling intake assessment appointments; and providing transportation to intake assessment appointments when necessary. The Outreach and Engagement Program is also responsible for conducting outreach in order to ensure SED and SMI clients, and their family members, have the opportunity to participate in the community program planning process. For, the Outreach and Engagement Program will continue to work toward reducing the stigma associated with receiving mental health treatment and increasing access to mental health services. Page 3

10 Transitional Engagement Supportive Services Program the Transitional Engagement Supportive Services (TESS) Program provides outreach and engagement activities to unserved and underserved SED and SMI individuals over the age of 14. The TESS Program provides individualized mental health rehabilitation/targeted case management services to youth and young adults, adults, and older adults who have experienced a personal crisis in their life requiring involuntary or voluntary mental health crisis interventions services. In addition, the TESS Program provides supportive services to assist conservatees who have recently been released from LPS Conservatorship. These services assist the individual with reintegrating back into the community and provide a supportive environment including gaining entry into the mental health system. The TESS Program also assists AB 109, non-active, and active individuals who are referred to the McAlister Institute for 14-day drug and alcohol detox (adults) or 21-day drug and alcohol detox (adolescents). The TESS Program provides aftercare and follow-up services. Services available to clients at the TESS Program include: initial intake assessment; medication support; mental health services nurse and rehabilitation technician; targeted case management; and crisis intervention. The TESS Program provides linkage to variety of community resources, including, but not limited to: emergency shelter, clothing and food baskets; permanent housing; SSI/SSA benefits or appeal; DSS/Cash Aid; substance abuse treatment and/or rehabilitation referral; general physician, dentist, and/or optometrist; and other ICBHS program and community resources. The TESS Program is also responsible for implementing Phase I and Phase II of the Portland Identification and Early Referral (PIER) Model. For, the TESS Program will work toward: increasing efforts to engage homeless individuals; improving successful transfers to outpatient mental health services; increasing community outreach presentations to various community agencies and organizations; improving follow-up services for individuals who are hospitalized out-of-county and are not returning to Imperial County; and improving mental health service delivery for individuals scheduled to be released from the Imperial County Jail. Prevention and Early Intervention The intent of Prevention and Early Intervention programs is to engage individuals before the development of severe mental illness or serious emotional disturbance, or to alleviate the need for additional or extended mental health treatment by facilitating access to supports at the earliest signs of mental health problems. Programs provided through Prevention and Early Intervention include: Prevention -- The prevention component utilizes universal strategies that address the entire Imperial County population. These strategies include a parenting program, the Incredible Years, which addresses the needs of children/youth in stressed families, and outreach and education activities, which focus on the importance of early identification and intervention to reduce the negative outcomes that may result from untreated mental illness. The Incredible Years is a comprehensive evidence-based practice with a set of curricula designed to provide parents with the necessary skills to promote children s development in a positive environment, nurturing relationships, reducing harsh discipline, and fostering parents ability to promote children s social and emotional development. The program is focused on strengthening parenting competencies and fostering positive Page 4

11 parent-child interactions and attachments for children ages 2 through 12. Groups are provided by the Child Abuse Prevention Council free of charge in English and/or Spanish at non-traditional settings, such as schools, after school programs, churches, resource centers, or at the Child Abuse Prevention Council office. Referrals to the Incredible Years Program are made by community agencies or parents self-referral. Prevention activities also include those that are focused on providing information and education to children/youth, parents, family members, educators, administrators, and agencies or care providers of children and youth in order to identify individuals at risk of or who may be presenting early signs of mental illness or emotional disturbance in order to link them to treatment or other resources. Prevention activities are delivered to large or small groups in health fairs, career fairs, and school presentations without any prior screening of attendance for mental health treatment. For, the prevention component of the Prevention and Early Intervention Program will continue to focus on implementing universal prevention activities, which include providing the Incredible Years Parenting Program as well as outreach and education activities targeting unserved and underserved populations, in efforts to decrease the probability of children and youth developing mental disorders. Early Intervention -- Trauma-Focused Cognitive Behavioral Therapy Program The Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an early intervention program that addresses the needs of children and youth in the community who have been exposed to trauma. The TF-CBT Program is utilized as an intervention to treat children and adolescents, ages 4 to 18, who have been exposed to a traumatic experience. By providing prevention and early intervention activities, mental health becomes part of the wellness for individuals and the community, reducing the potential for stigma and discrimination against individuals with mental illness. The TF-CBT model is being implemented as an early intervention activity aiming to prevent mental illness from becoming severe and disabling. TF-CBT is being provided to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse; traumatic loss of a loved one; domestic, school, or community violence; or exposure to natural disasters (earthquakes), terrorist attacks, or war trauma. TF-CBT incorporates cognitive and behavioral interventions with traditional child abuse therapies that focus on enhancement of interpersonal trust and empowerment. All clients who are referred to the TF-CBT Program are thoroughly assessed to determine medical necessity. Prior to September 2016, if a client met medical necessity they were transferred to the Children s Outpatient Programs to for Specialty Mental Health Services (SMHS). As of September 2016, the TF-CBT Program began billing Medi-Cal for SMHS for clients who met medical necessity and were exposed to a traumatic event. SMHS services are being provided to children/youth who have been exposed to a traumatic experience to promote recovery and related functional outcome(s) for a mental illness in its emergence and preventing it from becoming severe and disabling. For, the early intervention component of the Prevention and Early Intervention Program will continue to focus on implementing the Page 5

12 TF-CBT Program in order to prevent the long-term negative effects of child traumatic stress and prevent the development of mental illness. Innovation Innovation programs provide opportunities to learn something new that has the potential to transform the mental health system. Innovation programs are novel, creative, and ingenious mental health approaches that promote recovery and resilience and lead to learning that advances mental health. Programs provided through Innovation include: First Steps to Success Program Imperial County s MHSA Innovation Plan was approved and adopted by the County Board of Supervisors on January 14, 2014, and approved by the California Mental Health Services Oversight and Accountability Commission during March The goal of the Innovation Plan is to develop and maintain an effective interagency collaboration between ICBHS and the local education system, with a defined system to provide mental health services in the school setting to young children, ages four to six, who are experiencing behavioral and emotional problems or are at risk of serious mental illness, and are an unserved or underserved population. Through the joint implementation of the evidence-based First Steps to Success (FSS) Program, ICBHS will be able to replicate and expand collaborative efforts to school districts countywide and, in the process, develop a strong and effective collaborative relationship. The FSS Program is an evidence-based, early intervention program that historically has been implemented by school personnel and focuses on the transitioning kindergarten (TK) and kindergarten population. In the Innovation Plan, mental health rehabilitation technicians, rather than school personnel, will be providing the interventions at school, serving as the behavior coach or interventionist where they will have daily interactions with the teachers. This provides classroom teachers with immediate access to services, consultation, and, when needed, information on other ICBHS resources. During the first year of the Innovation Plan, FY , seven TK/kindergarten classrooms at three schools implemented the FSS Program. During the second year of implementation, FY , 13 TK/kindergarten classrooms at three elementary schools implemented the FSS Program. In the current year, FY , an additional 13 TK/kindergarten classrooms in three elementary schools implemented the FSS Programs. A total of 33 classrooms in nine elementary schools, in five cities spread to six school districts in Imperial County, have implemented the FSS Program. ICBHS contracted with Clarus Research to conduct a comprehensive evaluation on the Innovation Plan for Imperial County. Based on the information provided by Clarus Research, the data does not indicate any noteworthy increases in referrals of kindergarten age children to mental health services since the Innovation Project was implemented. Clarus Research recommends utilizing additional time to gather further referral data to provide results and see if the collaboration has been firmly established through the implementation of a school-based intervention between ICBHS and the education system and to see if that collaboration has been successful in increasing access to mental health services, increasing awareness of mental health problems and available resources, reducing stigma, and improving the quality of services provided to young children in Imperial County. Page 6

13 On December 19, 2016, during the quarterly MHSA Steering Committee meeting, ICBHS presented to the stakeholders in attendance the recommendation to extend the Innovation Project for two additional years, making the Innovation Project a five year project. During the meeting, data gathered from Clarus Research was presented, as well as interest in implementing the FSS Program in three additional school districts, Westmorland, Holtville, and San Pasqual School Districts, as well as expanding to new classrooms in Calexico and Seeley School Districts. All attendees supported the proposal to extend the current Innovation Project an additional two years. For, the FSS Program will continue to be implemented in order to develop and maintain an effective interagency collaboration between ICBHS and the local education system. Additionally, the program will expand services to additional elementary schools and increase the number of TK/kindergarten children served. Page 7

14 MHSA COUNTY COMPLIANCE CERTIFICATION County/City: Imperial Three-Year Program and Expenditure Plan Annual Update Local Mental Health Director Name: Andrea Kuhlen Telephone Number: (442) Local Mental Health Mailing Address: Imperial County Behavioral Health Services 202 N. Eighth Street El Centro, CA92243 Program Lead Name: Andrea Kuhlen Telephone Number: (442) I hereby certify that I am the official responsible for the administration of county/city mental health services in and for said county/city and that the County/City has complied with all pertinent regulations and guidelines, laws and statutes of the Mental Health Services Act in preparing and submitting this Three-Year Program and Expenditure Plan or Annual Update, including stakeholder participation and nonsupplantation requirements. This Three-Year Program and Expenditure Plan or Annual Update has been developed with the participation of stakeholders, in accordance with Welfare and Institutions Code Section 5848 and Title 9 of the California Code of Regulations section 3300, Community Planning Process. The draft Three-Year Program and Expenditure Plan or Annual Update was circulated to representatives of stakeholder interests and any interested part for 30 days for review and comment and a public hearing was held by the local mental health board. All input has been considered with adjustments made, as appropriate. The annual update and expenditure plan, attached hereto, was adopted by the County Board of Supervisors on. Mental Health Services Act funds are and will be used in compliance with Welfare and Institutions Code section 5891 and Title 9 of the California Code of Regulations section 3410, Non-Supplant. All documents in the attached annual update are true and correct. Local Mental Health Director (PRINT) Signature Date Page 8

15 MHSA COUNTY FISCAL ACCOUNTABILITY CERTIFICATION 1 County/City: Imperial Three-Year Program and Expenditure Plan Annual Update Annual Revenue and Expenditure Report Local Mental Health Director Name: Andrea Kuhlen Telephone Number: (442) AndreaKuhlen@co.imperial.ca.us Local Mental Health Mailing Address: Imperial County Behavioral Health Services 202 N. Eighth Street El Centro, CA County Auditor-Controller / City Financial Officer Name: Douglas Newland Telephone Number: (442) DouglasNewland@co.imperial.ca.us I hereby certify that the Three-Year Program and Expenditure Plan, Annual Update, or Annual Revenue and Expenditure Report is true and correct and that the County has complied with all fiscal accountability requirements as required by law or as directed by the State Department of Health Care Services and the Mental Health Services Oversight and Accountability Commission, and that all expenditures are consistent with the requirements of the Mental Health Services Act (MHSA), including Welfare and Institutions Code (WIC) sections , 5830, 5840, 5847, 5891, and 5892; and Title 9 of the California Code of Regulations sections 3400 and I further certify that all expenditures are consistent with an approved plan or update and that MHSA funds will only be used for programs specified in the Mental Health Services Act. Other than funds placed in a reserve in accordance with an approved plan, any funds allocated to a county which are not spent for their authorized purpose within the time period specified in WIC section 5892(h), shall revert to the state to be deposited into the fund and available for other counties in future years. I declare under penalty of perjury under the laws of this state that the foregoing and the attached update/report is true and correct to the best of my knowledge. Local Mental Health Director (PRINT) Signature Date I hereby certify that for the fiscal year ended June 30,, the County/City has maintained an interestbearing local Mental Health Services (MHS) Fund (WIC 5892(f)); and that the County s/city s financial statements are audited annually by an independent auditor and that the most recent audit report is dated for the fiscal year ended June 30,. I further certify that for the fiscal year ended June 30,, the State MHSA distributions were recorded as revenues in the local MHS Fund; that County/City MHSA expenditures and transfers out were appropriated by the Board of Supervisors and recorded in compliance with such appropriations; and that the County/City has complied with WIC section 5891(a), in that local MHS funds may not be loaned to a county general fund or any other county fund. I declare under penalty of perjury under the laws of this state that the foregoing and the attached report is true and correct to the best of my knowledge. County Auditor-Controller / City Financial Officer (PRINT) Signature Date 1 Welfare and Institutions Code Section 5847(b)(9) and 5899(a) Three-Year Program and Expenditure Plan, Annual Update, and RER Certification (02/14/2013) Page 9

16 County Profile Imperial County is located in the southernmost region of California, bordering San Diego County to the west, Riverside County to the north, the State of Arizona to the east, and Mexico to the south. It extends over approximately 4,597 square miles and is comprised of seven incorporated cities (Brawley, Calexico, Calipatria, El Centro, Holtville, Imperial, and Westmorland) and seven unincorporated areas, some of which are located more than 45 minutes apart from each other. According to the 2010 U.S. Census Bureau, Imperial County s population was 174,528, growing by 22.6% since The county s demographic information is included in Table 1 below. Imperial County continues to have one of the highest unemployment rates in the state of California, with statistics from the U.S. Bureau of Labor Statistics illustrating an unemployment rate of 18.8% in December 2016, more than triple the state s average of 5.2% during the same time frame. Table 1 Imperial County Demographics (2010 U.S. Census) U.S. Census Demographic Category 2010 Results Population % of Total Gender Male 89, Female 84, Age 9 years 27, to 19 years 29, to 24 years 13, to 59 years 78, years 25, Ethnicity Hispanic or Latino 140, White 23, Black or African American 5, American Indian/Alaskan Native 1, Asian 2, Pacific Islander Other 1, The number of Medi-Cal eligible individuals in Imperial County was 78,264 during FY , per the Department of Health Care Services. Imperial County s threshold language is Spanish. In the Imperial County Behavioral Health Services Staff Cultural Competence Survey for FY , 84% of staff identified as Hispanic, 80% indicated they are fluent in Spanish, and 97% reported being culturally aware of the Hispanic culture. Page 10

17 Workforce Needs Assessment Imperial County Behavioral Health Services Occupational Category Although Imperial County continues to face obstacles in recruiting licensed medical professionals, there has been a slight increase in the number of licensed medical professionals hired since the last Workforce Needs Assessment that was completed in Since that time, one additional psychiatrist and six additional licensed vocational nurses have been employed. Imperial County has also seen a growth in the number of Associate Clinical Social Workers and MFT Registered Interns in the past few years. Recruitment for other licensed medical professionals such as nurse practitioner and registered nurse continue to be trying, especially for those from under-represented racial/ethnic groups. One obstacle to hiring licensed medical professionals is that the salaries for these positions are low compared to community standards. Private employers, including two local hospitals and two state prisons that are able to provide higher salaries, create recruitment challenges for the county for key licensed positions. Another obstacle is the physical environment of this rural area. Imperial County is an isolated desert region with a hot and dry climate that ranges from lows in the mid 30 s in January to highs of 110+ in July and August. The county s historical earthquake activity is also above California s state average, and is 2,508% greater than the overall U.S. average. Table 2 on the following page depicts Imperial County s current workforce by group and position. Page 11

18 Table 2 Imperial County Full Time Equivalent (FTE) Workforce by Group and Position Group and Positions Number of Current FTEs White/ Caucasian Imperial County Behavioral Health Services Race/Ethnicity of FTEs currently in the workforce African Asian/ Hispanic/ Native American/ Pacific Latino American Black Islander How many identify as fluent in Spanish? Unlicensed Mental Health Direct Service Staff: Mental Health Rehabilitation Specialist Mental Health Rehabilitation Technician Access & Benefits Worker Other Unlicensed Direct Service Staff Subtotal: Licensed Mental Health Direct Service Staff: Psychiatrist Licensed Psychiatric Technician Licensed Clinical Psychologist Licensed Clinical Social Worker Licensed Marriage & Family Therapist Associate Clinical Social Worker MFT Registered Intern Subtotal: Other Mental Health Direct Service Staff: Registered Nurse Licensed Vocational Nurse Subtotal: Managerial and Supervisory Staff: Management Supervising Clinical Psychologist Supervising Psychiatric Social Worker Supervisors Subtotal: Support Staff: Analysts, tech. support, quality assurance Clerical, administrative assistants Other support staff (non-direct services) Subtotal Total Mental Health Direct Service Staff: Total Managerial, Supervisory, & Support Staff: Multi or Other Total of all Staff: Page 12

19 Language Proficiency As seen in Table 2, Imperial County currently employs FTE employees. 53% of employees are direct service staff and 47% are managerial, supervisory, and support staff. 84% of employees identify as Hispanic/Latino, with 81% also identifying as being fluent in Spanish, Imperial County s threshold language. Further demographic breakdown may be seen in Chart 1 below: Chart 1: Imperial County Behavioral Health Workforce by Ethnicity 1% 3% 1% 0% 84% 11% White/Caucasian Hispanic/Latino African American/Black Asian/Pacific Islander Native American Multi/Other Chart 2: Imperial County Workforce Ethnicity by Major Group 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Direct Service Staff Managerial, Supervisory, & Support Staff Page 13

20 Moreover, when comparing the workforce by race/ethnicity to the populations receiving public mental health services, few disparities were found: Table 3 Imperial County Workforce vs. FY Med-Cal Beneficiaries Served FY Workforce Medi-Cal Workforce Beneficiaries Hispanic/Latino 82% 84% White/Caucasian 12% 11% African American/Black 3% 1% Asian/Pacific Islander 0.37% 3% Native American 0.81% 1% By collaborating with local universities and colleges, Imperial County has built a sustainable workforce of individuals who were born, raised, and educated locally, and thereby familiar with the cultures, values, and traditions that are specific to the community and its residents. Consumer and Family Member Employment Imperial County does not currently have positions that specifically include qualification statements in the job description requiring applicants with experience as a consumer or family member or express a preference for someone with such experience. The Staff Cultural Competence Survey conducted in April 2016 included a question that allowed staff to self-report being a consumer of mental health services. The survey results found below indicate the optional question regarding self-identified consumers was answered by 18 staff members, which is approximately four percent of the surveys returned. Table 4 FY Staff Cultural Competence Survey Function Self- Identified Consumer Administrative n=48 Direct Services n=217 Support Services n=170 Total n=435 # % # % # % # % Page 14

21 MHSA Background Imperial County Behavioral Health Services In November 2004, California voters passed Proposition 63, which became a state law entitled the Mental Health Services Act (MHSA). The MHSA is funded through a 1% tax on personal incomes of over $1 million. The MHSA was designed to expand and transform California s mental health service systems. It was enacted into law on January 1, The MHSA provides funding for services and resources that promote wellness, recovery, and resiliency for adults and older adults with severe mental illness and for children and youth with serious emotional disturbances and their family members. The MHSA aims to reduce the long-term adverse impact of untreated severe mental illness and serious emotional disturbance by expanding and transforming services that promote well-being, recovery, and self-help, and introduce prevention and early intervention strategies to prevent long-term negative impact of severe mental illness and reduce stigma. Services are culturally competent, easier to access, and more effective in preventing and treating severe mental illness. A core set of values apply to all MHSA activities: Promote wellness, recovery, and resilience; Increase consumer and family member involvement in policy and service development and employment in service delivery; Develop a diverse, culturally sensitive, and competent workforce in order to increase the availability and quality of mental health services and supports for individuals from every cultural group; Deliver individualized, consumer, and family-driven services that are outcome oriented and based upon successful or promising practices; and Outreach to underserved and unserved populations. MHSA funding was distributed to county mental health systems upon approval of their plans for each component of the MHSA. The MHSA is comprised of five major components. Each component addresses critical needs and priorities to improve access to effective, comprehensive, and culturally and linguistically competent county mental health services and supports. These components are: Community Services and Supports (CSS) The programs and services being identified by each county to serve unserved and underserved populations. Prevention and Early Intervention (PEI) Programs designed to prevent mental illnesses from becoming severe and disabling. Workforce Education and Training (WET) Targets workforce development programs to remedy the shortage of qualified individuals to provide services. Capital Facilities and Technological Needs (CF/TN) Addresses the infrastructure needed to support the CSS programs. Innovation Promotes recovery and resilience, reduces disparities in mental health services and outcomes, and leads to learning that advances mental health in California in the directions articulated by the MHSA. In March 2011, the signing of AB 100 into law by Governor Brown created immediate changes to the MHSA. The key changes eliminated the Department of Mental Health and the Mental Page 15

22 Health Services Oversight and Accountability Commission (MHSOAC) from their respective review and approval of county MHSA plans and expenditures. AB 1467, which was chaptered into law on June 17, 2012, requires that the annual update be adopted by the County Board of Supervisors and submitted to the MHSOAC. It also requires that the plans be certified by the county mental health director and the county auditor-controller. Page 16

23 Community Program Planning Process Imperial County Behavioral Health Services The Imperial County Behavioral Health Services (ICBHS) Director, in collaboration with the Mental Health Board, headed the administration of the MHSA community program planning process, as well as the development of the Three-Year Program and Expenditure Plan for FY through FY A Steering Committee that includes stakeholders is involved at all levels of the MHSA community program planning process. The MHSA Steering Committee meets on a quarterly basis to provide input and recommendations to the Department regarding the populations to be targeted for services under MHSA funding and evidence-based practices that would address issues and needs identified in the community. The committee is informed and directly involved by providing ongoing planning, monitoring, and oversight of the MHSA Program planning, development, and implementation. Stakeholders participating in the Steering Committee include consumers, family members, and peer supporters as well as representatives from law enforcement, education, veteran organizations, social services, community health agencies, and provider and system partners. Below is a list of agencies of which the stakeholders represent: Center for Family Solutions Child Abuse Prevention Council Clinicas de Salud del Pueblo Department of Social Services Imperial County Executive Office Imperial County Courts Imperial County Office of Education Imperial County Probation Department Imperial County Public Administrator s Office Imperial County Public Health Department Imperial County Sheriff s Office Imperial County Veterans Services Imperial Valley College Imperial Valley Drug Rehabilitation Center Imperial Valley LGBT Resource Center Imperial Valley Regional Occupational Program Mental Health Board Members National Alliance on Mental Illness Furthermore, adult consumers, transition-age youth consumers, and family members play an active role in the MHSA community planning process. All stakeholder meetings are held at the ICBHS El Centro Wellness Center in order to encourage consumer and family member attendance. Additionally, interpreter services are provided to ensure monolingual Spanish speakers are able to fully participate in the community program planning process. Page 17

24 The graphs below summarize the demographics of the stakeholders participating in the community program planning process to ensure they reflect the diversity of the County: Stakeholders by Age Stakeholders by Gender 100% 80% 60% 40% 20% 0% 79% 21% 0% % 60% 40% 20% 0% 71% 25% 4% Male Female Transgender 35% 30% 25% 20% 15% 10% 5% 0% Stakeholders by City 23% 15% 17% 8% 3% 33% Stakeholders by Language 100% 92% 80% 60% 40% 20% 8% *Other includes the cities of Heber, Holtville, Niland, Seeley, and Winterhaven 0% English Spanish Stakeholders by Race/Ethnicity 80% 70% 60% 50% 40% 30% 20% 10% 0% 4% American Indian/Alaskan Native 0% 0% Asian/Pacific Islander Black/African American 75% Hispanic/Latino 21% White Page 18

25 During FY , the MHSA Steering Committee met on the following dates: September 19, 2016 December 19, 2016 March 20, 2017 April 10, 2017 June 19, 2017 In order to ensure clients with serious mental illness and/or serious emotional disturbance, and their family members, have the opportunity to participate in the community program planning process, meeting flyers advertising the date, time, location, and purpose of each respective MHSA Steering Committee meeting are posted in the waiting areas of ICBHS clinics and are distributed to consumers, family members, and community members by the MHSA Outreach and Engagement Program s outreach workers. Moreover, the meeting information is also made available to the public through the ICBHS website. During FY , ICBHS continued a community planning process to identify needed supports and services for unserved and underserved populations. Outreach and engagement to underserved populations continued to expand through the scope of Let s Talk About It and Exprésate, the weekly-aired, locally produced and hosted behavioral health radio programs in English and Spanish, the County s threshold language. Informational shows continued to provide the community with program overviews, referral and access information, the populations each program serves, and contact information through broadcast on three separate local radio stations. KXO Radio provided internet podcast hosting of all the radio shows that aired. With this podcast storing, any community member, friend, neighbor, family member, as well as agency personnel from ICBHS or any community agency, can access the information and refer an individual to a particular topic that may apply to their recovery at any time. Moreover, anyone can search the archives and listen in support of their own interests and/or needs. The ongoing outreach and engagement to underserved populations identified in the MHSA processes received a variety of media and advertising support. The local English and Spanish newspapers and their internet sites, Imperial Valley Women s Magazine, and the local radio stations are targeted with program advertising. The shows have attracted a regular listenership and have established their voice as the local voice of radio wellness in the community. 30-Day Review Process The Three-Year Program and Expenditure Plan for was posted for a 30-day public review and comment period from April 17, 2017, through May 16, Circulation The Three-Year Program and Expenditure Plan for was posted for public access on the ICBHS website. In addition, it was distributed through the MHSA Steering Committee, the Cultural Competence Task Force, and the Mental Health Board, as well as to the public by the MHSA Outreach and Engagement Program s outreach workers. Advertisement for the Public Hearing was posted in the Imperial Valley Press, which is circulated throughout all regions of the county. Residents were able to provide feedback through a Public Comment Form that was both posted to the ICBHS website and distributed along with the Three-Year Program and Expenditure Plan. Page 19

26 ICBHS also facilitated informational outreach meetings to obtain public feedback regarding the Three-Year Program and Expenditure Plan for. Imperial County made these sessions available as follows: April 26, N. Eighth Street, El Centro, CA May 2, Main Street, Brawley, CA May 4, N. Eighth Street, El Centro, CA May 9, E. Third St., Calexico, CA Public Hearing After the 30-day public review and comment period, a Public Hearing was held by the Mental Health Board on May 16, The Mental Health Board also reviewed the Three-Year Program and Expenditure Plan for and made recommendations for revision, as appropriate. A summary and analysis of any substantive recommendations received during the public comment period and at the Public Hearing, including any substantive changes made to the Three-Year Program and Expenditure Plan in response to public comments, are documented and included as Attachment 1 to this plan. Page 20

27 Three-Year Program and Expenditure Plan Requirements In accordance with MHSA regulations, every county mental health program is required to submit a three-year program and expenditure plan and update it on an annual basis. This Three-Year Program and Expenditure Plan for Imperial County s MHSA programs is an overview of the work plans and projects being implemented as part of the series of service components launched with the passage of Proposition 63 in The passage of the MHSA provided Imperial County with increased funding, personnel, and other resources to support mental health programs for children, transition-age youth, adults, older adults, and families. The MHSA addresses a broad continuum of prevention, early intervention, and service needs, as well as the necessary infrastructure, technology, and training elements that support the County s public mental health system. The intent of the Three-Year Program and Expenditure Plan is to provide the community with a report on the various projects to be conducted as part of the MHSA. This report includes descriptions of programs and services to be implemented during FY through FY for the following MHSA components: Community Services and Supports (CSS) Prevention and Early Intervention (PEI) Innovation (INN) Page 21

28 MHSA Three-Year Program Plan Community Services and Supports Imperial County Behavioral Health Services Community Services and Supports (CSS) is the first and largest component funded under the MHSA. This component focuses on those individuals with serious emotional disturbances or mental illnesses for the following populations: Children and Families Transition-Age Youth Adults Older Adults To serve these four groups, counties are required to implement three components within their CSS programs: Full Service Partnerships Systems Development Outreach and Engagement Under the CSS component of the MHSA, counties can request three different kinds of funding to make changes and expand their mental health services and supports. Funding includes: Full Service Partnership Funds to provide all of the mental health services and supports a person wants and needs to reach his or her goals. General Systems Development Funds to improve mental health services and supports for people who receive mental health services. Outreach and Engagement Funds to reach out to people who may need services but are not receiving them. ICBHS has requested Full Service Partnership (FSP) funds for the Youth and Young Adult Services Full Service Partnership Program and the Adult and Older Adult Services Full Service Partnership Program. General Systems Development funds were requested for the Wellness Center and Outreach and Engagement funds were requested for the Outreach and Engagement Program and the Transitional Engagement Supportive Services Program. Full Service Partnership Youth and Young Adult Services Full Service Partnership Program The Youth and Young Adult Services Full Service Partnership (YAYA-FSP) Program consists of a full range of integrated community services and supports for youth and young adults, ages 12 to 25, including direct delivery and use of community resources. These services and supports include a focus on recovery and resiliency, shared decision-making that is client-centered, and maintenance of an optimistic therapeutic perspective at all times. Specifically, services include: case management; rehabilitative services; wrap-like services; integrated community mental health and substance abuse treatment; crisis response; alternatives to juvenile hall; home and Page 22

29 community re-entry from juvenile hall; youth and parent mentoring; supported employment or education; transportation; housing assistance; benefit acquisition; and respite care. The target populations for the YAYA-FSP Program are as follows: Seriously emotionally disturbed (SED) adolescents, ages 12 to 15, who, as a result of a mental disorder, have substantial impairment in at least two of the following areas: selfcare, school functioning, family relationships, or the ability to function in the community; and who are either at risk of or have already been removed from the home; or whose mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment; or who display at least one of the following: psychotic features, risk of suicide, or risk of violence due to a mental disorder. These individuals may also be diagnosed with a co-occurring substance abuse disorder. SED or severely mentally ill (SMI) transition-age youth, ages 16 to 25, who, as a result of a mental disorder, have substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or the ability to function in the community and are unserved or underserved and are experiencing either homelessness or are at risk of being homeless; aging out of the child and youth mental health system; aging out of the child welfare system; aging out of the juvenile justice system; have involvement in the criminal justice system; are at risk of involuntary hospitalization or institutionalization; or are experiencing a first episode of severe mental illness. These individuals may also be diagnosed with a co-occurring substance abuse disorder. SED adolescents, ages 12 to 15, and SED or SMI transition-age youth, ages 16 to 25, may also meet criteria for the YAYA-FSP Program if they have made recent suicidal attempts, gestures, and/or threats; have frequent Crisis & Referral Desk visits; have any recent psychiatric hospitalization(s); are currently in the juvenile justice system; and/or have a history of delinquent behaviors. Services available to clients at the YAYA-FSP Program include: Medication Support; Mental Health Services Nurse; Mental Health Services Therapy; Mental Health Services Rehabilitation Technician; Targeted Case Management; Intensive Care Coordination; Intensive Home Based Services; and, Crisis Intervention. Staff at the YAYA-FSP Program have been trained on the overall needs of individuals ages 12 to 25. The training provided to staff on treatment models currently being implemented at the YAYA-FSP Program include the following: Cognitive Behavioral Therapy (CBT): CBT is an evidence-based psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders including anxiety, Page 23

30 depression, and addiction. CBT is generally short-term and focused on helping clients deal with a very specific problem. During the course of treatment, people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. This treatment is being provided at the FSP clinic sites, as well as out in the field by both mental health rehabilitation technicians and clinicians. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): TF-CBT is a treatment for children and youth, ages 4 to 18, provided by clinicians at FSP clinic sites, that involves individual sessions with the client and parent as well as joint parent-child sessions. The goal of TF-CBT is to help address the biopsychosocial needs of children and youth, with Posttraumatic Stress Disorder (PTSD) or other problems related to traumatic life experiences, and includes active participation of their parents or primary caregivers. TF- CBT is a model of psychotherapy that combines trauma-sensitive interventions with cognitive behavioral therapy. Children and parents are provided knowledge and skills related to processing the trauma; managing distressing thoughts, feelings, and behaviors; and enhancing safety, parenting skills, and family communication. Cognitive Processing Therapy (CPT): CPT is a cognitive-behavioral therapy for PTSD and related conditions that focuses on thoughts and feelings. CPT is effective in treating PTSD across a variety of populations such as veterans who have experienced combat, sexual assault victims, and individuals who experienced childhood trauma, as well as other types of traumatic events. CPT provides a way to understand why recovery from traumatic events has been difficult and how symptoms of PTSD affect daily life. The focus is on identifying how traumatic experiences change thoughts and beliefs, and how thoughts influence current feelings and behaviors. This treatment is designed for adults ages 18 and over and is provided by clinicians at FSP clinic sites. Functional Family Therapy (FFT): FFT is a family-based treatment program for high-risk youth who are either at risk for or who manifest antisocial behavioral problems such as conduct disorder, oppositional defiant disorder, disruptive behavior disorder, violent acting-out, and substance abuse disorders. FFT targets youth between the ages of 11 and 18 from a variety of ethnic and cultural groups. Co-morbid behavioral or emotional problems, such as anxiety or depression, may also exist as well as family problems, such as communication and conflict issues. The FFT model allows for successful intervention through clinical practice that is flexibly structured, culturally sensitive, and accountable to youth, their families, and the community. FFT has a systematic, yet individualized, family-focused approach to juvenile crime, violence, drug abuse, and other related problems. FFT is a strength-based model that focuses on and assesses those risk and protective factors that impact the adolescent and his or her environment. FFT attempts to alleviate emotional disturbances, change maladaptive patterns of behavior, and encourage personality growth and development. FFT also pays specific attention to both intra-familial and extra-familial factors and how they present within and influence the therapeutic process. Interpersonal Psychotherapy (IPT): IPT is an evidence-based model utilized for the treatment of depression and other mood disorders being provided by clinicians at the FSP clinic sites. The model focuses on helping clients improve their interpersonal relationships or change their expectations about themselves. IPT also aims to aid clients in improving their social support system to better manage their current interpersonal distress, thus reducing psychological symptoms caused by these distressed Page 24

31 interpersonal relationships. IPT is a time-limited, dynamically informed psychotherapy that works with children ages nine and above and their families. Moral Reconation Therapy (MRT): MRT is a cognitive-behavioral counseling program, provided at alternative education schools, that combines education, group and individual counseling, and structured exercises designed to foster moral development in treatmentresistant clients. As long as clients judgments about right and wrong are made from low levels of moral reasoning, counseling them, training them in job skills, and even punishing them will have little long-lasting impact on their behavior. They must be confronted with the consequences of their behavior and the effect that it has had on their family, friends, and community. Poor moral reasoning is common within at-risk populations. MRT addresses beliefs and reasoning. It is a systematic, step-by-step group counseling treatment approach for treatment-resistant clients. The program is designed to alter how clients think and make judgments about what is right and wrong. The MRT system approaches the problem of treating resistant populations as a problem of low levels of moral reasoning. Moral reasoning represents how a person makes decisions about what he or she should or should not do in a given situation. Briefly, MRT seeks to move clients from hedonistic (pleasure vs. pain) reasoning levels to levels where concern for social rules and others becomes important. MRT research has shown that as clients complete steps, moral reasoning increases in adult and juvenile offenders. MRT systematically focuses on seven basic treatment issues: Confrontation of beliefs, attitudes and behaviors; Assessment of current relationships; Reinforcement of positive behavior and habits; Positive identity formation; Enhancement of self-concept; Decrease in hedonism and development of frustration tolerance; and, Development of higher stages of moral reasoning. Motivational Interviewing: Motivational Interviewing is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. Portland Identification and Early Referral (PIER) Model: The PIER Model is an evidencebased early detection and intervention model that focuses on the prodromal phase of a developing psychotic illness and advocates psychosocial interventions and drug treatments that are tailored to the individual. The objective of the PIER Model is to transition an individual identified with early severe mental illness into an evidence-based treatment model as quickly as possible to improve outcomes in treatment and allow for transition back into the community. Specific goals of the PIER Model include interrupting the very early progression of psychotic disorders and improving outcomes and Page 25

32 preventing the onset of the psychotic phase of severe mental illness like bipolar disorder, major depression, and schizophrenia. The emphasis of the PIER Model is on family psychoeducation and supported education and employment for the individual through the family s participation in a Family Workshop, Joining, and Multifamily Group. The groups provide an opportunity for the family to meet with clinical staff and five to six other PIER Model families to learn more about the illness process, ways to reduce stress, and how to move forward with their lives thus improving outcomes and preventing the onset of the psychotic phase of serious mental illness. Aggression Replacement Training (ART): ART is a cognitive behavioral intervention program to help children and adolescents, ages 12 to 18, improve social skill competence and moral reasoning, better manage anger, and reduce their aggressive behavior. The program is currently being provided at the Adolescent Habilitative Learning Program and consists of 10 weeks (30 sessions) of intervention training, provided in one-hour sessions, three times per week. Incremental learning, reinforcement techniques, and guided group discussions enhance skill acquisition and reinforce the lessons in the curriculum. The ART Program is a multi-modal intervention consisting of three components: Skills Streaming: Teaches a curriculum of Pro-Social, interpersonal skills that train on more effective alternatives to aggressive and violent behavior. Anger control training: Trains the youth on the use of effective responses when provoked. Moral Reasoning: Assists in instilling values that respect the rights of others and promotes the use of the skills learned in the first two components. Research has shown that students who develop skills in these areas are far less likely to engage in a wide range of aggressive and high-risk behaviors. Lessons in this program are intended to address the behavioral, affective, and cognitive components of aggressive and violent behavior. ICBHS has also entered into contracts with businesses and agencies in the community that can address the needs of the youth and young adults being served through the YAYA-FSP Program. The following are services currently being contracted by ICBHS and provided to clients: Equine Therapy: Animals Plus delivers horsemanship services to clients with emotional and/or behavioral impairments that promote development of the individual s life skills. These services lead the individual toward increased confidence, patience, and selfesteem. Youth and young adults, ages 12 to 25, are paired with horses whose personalities and behaviors challenge them to explore the concept of responsibility for one s behavior and choices, logical consequences, nurturing of others, self-evaluation, and control. Youth and Young Adults Exercise Program: Studies have shown that exercise improves mental health by reducing symptoms of anxiety, depression, and negative mood, and improving self-esteem and cognitive function. In order to combine the benefits of exercise with traditional mental health treatments, the YAYA-FSP Program provides an exercise program to promote health and wellness and guide participants to a healthier and more active lifestyle. Fitness Oasis Health Club and Spa provides youth and young Page 26

33 adult clients with severe mental illness and/or serious emotional disturbances with physical training and fitness guidance. Clients referred to Fitness Oasis Health Club and Spa can participate in Zumba, toning, and resistance training classes. Clients are also provided with education on healthy nutrition and the benefits of exercise. A MOU with Clinicas Del Salud Del Pueblo, Inc., was executed to provide an array of comprehensive primary health care services including a medical clearance examination for individuals participating in the exercise program. General Educational Development (GED) Classes: Imperial Valley Regional Occupational Program (IVROP) and ICBHS entered into a MOU to provide GED preparation classes and needed educational services to youth and young adults receiving mental health services at the YAYA-FSP Program. Tai Chi: A certified Tai-Chi instructor provides weekly classes to the youth at Juvenile Hall. Tai Chi Chaun is an exercise that brings the individual back to balance. Through Tai Chi classes, participants learn relaxation, mindfulness, and self-regulation techniques. Specialty mental health services are made available to all high-risk youth detained at Juvenile Hall who meet medical necessity criteria. Probation officers, Juvenile Hall staff, or Juvenile Hall nurses will refer to ICBHS Juvenile Hall Services any detained juvenile offenders who are displaying significant symptoms of severe depression, suicidal ideation, or self-destructive behavior. During the past two years, ICBHS has significantly increased its working collaboration with the Probation Department by enhancing mental health services provided to youth detained in Juvenile Hall and developing joint protocols for the treatment of youth who present mental health concerns while in the facility and upon discharge. As part of this increased collaboration, ICBHS assisted Probation staff in the development of a Suicide Prevention Plan that would guide Juvenile Hall and ICBHS staff on how to best manage those youth who present suicide risk while detained in the facility. The Suicide Prevention Plan ensures that both Juvenile Hall and ICBHS staff are provided with clear and detailed guidelines on how to best identify, protect, and treat youth at risk of suicide. In addition, the Probation Department contracted with Dr. Lisa Boesky for training on suicide prevention, Suicide Prevention Among Youth in Detention: What You Need to Know. Those in attendance included ICBHS and Probation management staff, supervisors, Juvenile Hall staff, and the ICBHS clinicians and psychiatrists assigned to provide treatment to youth in the facility. On September 15, 2013, ICBHS began the implementation of Intensive Care Coordination (ICC) and Intensive Home Based Services (IHBS) as required by Katie A. vs. Bonta. Youth and Young Adult clients, ages 12 to 21, who met Katie A. subclass criteria and accepted services were provided with intensive mental health services. On February 5, 2016, Mental Health Plans were informed that neither membership in the Katie A. class nor subclass was a prerequisite to consideration for receipt of ICC and IHBS. Therefore, a child or youth does not need to have an open child welfare case to be considered for receipt of these services. Currently, the YAYA-FSP Program is providing ICC and IHBS to three clients. The number of unduplicated clients served during FY , FY and FY (until January 2017) by the YAYA-FSP Program was 1,785. The cost per person was Page 27

34 $14,649. It is projected that the YAYA-FSP Program will serve up to 2,302 clients by the end of FY , with the cost per person projected to be $13,571. The charts below provide a demographic summary of the YAYA-FSP Program: Gender Age Female 36% Male 64% % % % Black 4% White 9% Race/Ethnicity Other 3% Hispanic 84% Language Other 5% Spanish 24% English 71% ( Other Alaskan Native/American Indian, Vietnamese, and Chinese) City ( Other includes Cantonese, Sign Language, and Vietnamese) Other 24% Calexico 20% Brawley 20% El Centro 36% ( Other includes the cities of Calipatria, Westmorland, Imperial, Holtville and other outlying cities.) Performance Outcomes As of January 2014, the YAYA-FSP Program started the implementation of a standardized method for measuring outcomes by specific disorder and the implementation of two general tools that measure overall functioning. For the general tools, all youth, ages 12 to 17, and their parents are administered the Youth Outcome Questionnaire Self Report (YOQ-SR) and Parent Report (YOQ-Parent Report) at the time of intake and annually thereafter. The Youth Outcome Page 28

35 Questionnaire is a tool for children and youth, ages 4 to 17, who are receiving mental health services, that is designed to measure treatment progress and track changes in functioning during the course of treatment. The areas of measurement include interpersonal distress, somatic symptoms, interpersonal relations, social problems, behavioral dysfunction, and other critical items. The Youth Outcome Questionnaire is also being used with those youth who are receiving ART, FFT, TF-CBT, MRT, and equine therapy, and those that are enrolled in the exercise program. The YAYA-FSP Program is also administering the Behavior and Symptom Identification Scale 24 (Basis 24) measurement tool to those consumers who are between the ages of 18 and 25. Basis 24 is being administered at the point of intake and annually thereafter. Basis 24 provides a complete patient profile and measures the change in self-reported symptom and problems difficulty over the course of time. Basis 24 measures the consumers' level of depression, functioning, interpersonal relationships, psychosis, substance abuse, emotional liability, and risk for self-harm. The following is a list of measurement outcome tools currently being implemented at the YAYA- FSP Program that are specific by diagnosis and age: Instrument Name Adult ADHD Self Report Scale (ASRS-v1.1) Behavior and Symptom Identification Scale (BASIS 24) Center for Epidemiologic Studies Depression Scale - Mood Questionnaire (CES-D) Conners 3 ADHD Index - Parent (3-P) Conners 3 ADHD Index - Parent Short (3-PS) Conners 3 ADHD Index - Self Report (3-SR) Disorder Age Group Areas of Measurement ADHD 18 + ADHD Symptoms in Adults General 18+ Depression and Functioning Emotional Liability Interpersonal Relationships Psychosis Self-Harm Substance Abuse Depression 12+ Depression ADHD 6-18 Aggression Executive Functioning Hyperactivity/Impulsivity Inattention Learning Problems Peer Relations ADHD 6-18 Aggression Executive Functioning Hyperactivity/Impulsivity Inattention Learning Problems Peer Relations ADHD 8-18 ADHD Combined ADHD Hyperactive-Impulsive ADHD Inattentive Aggression Conduct Disorder Executive Functioning Page 29

36 Conners 3 ADHD Index - Self Report Short (3-SRS) Conners 3 ADHD Index- Teacher (3-T) Conners 3 ADHD Index- Teacher Short (3-TS) Eyberg Child Behavior Inventory (ECBI) Generalized Anxiety Disorder Assessment (GAD-7) PTSD Checklist-Civilian (PCL-C) PTSD Checklist-Monthly (PCL-S) PTSD Checklist-Weekly (PCL-S) Patient Health Questionnaire (PHQ-9) General Psychopathology Hyperactivity/Impulsivity Inattention Learning Problems Oppositional Defiant Disorder Peer & Family Relations ADHD 8-18 ADHD Combined ADHD Hyperactive-Impulsive ADHD Inattentive Aggression Conduct Disorder Executive Functioning General Psychopathology Hyperactivity/Impulsivity Inattention Learning Problems Oppositional Defiant Disorder Peer & Family Relations ADHD 6-18 Defiance/Aggression Executive Functioning (Full Length Only) Hyperactivity/Impulsivity Inattention Learning Problems (Full Length Only) Peer/Family Relations ADHD 6-18 (Full Length Only) Defiance/Aggression Executive Functioning Hyperactivity/Impulsivity Inattention Learning Problems (Full Length Only) Disruptive Behaviors Peer/Family Relations 2-16 Behavior Problems Intensity Scale Frequency of Problems Problem Scale Parent s Tolerance Anxiety 18 + Panic Disorder Social Anxiety Post-Traumatic Stress Disorder PTSD 18 + PTSD Symptoms PTSD 18 + Measures PTSD Symptoms From the Past Month PTSD 18 + Measures PTSD Symptoms From the Preceding Week Depression Depression Page 30

37 UCLA Post Traumatic Stress Reaction Index - Parent (PTSD-RI-Parent) UCLA Post Traumatic Stress Reaction Index - Self Report (PTSD-RI-SR) Youth Outcomes Questionnaire Parent (YOQ-Parent) Youth Outcomes Questionnaire Self Report (YOQ-SR) PTSD 3-18 PTSD Symptoms PTSD 7-18 PTSD Symptoms General Tool 4-17 Behavioral Dysfunction Critical Items Interpersonal Distress Interpersonal Relations Social Problems Somatic General Tool Behavioral Dysfunction Critical Items Interpersonal Distress Interpersonal Relations Social Problems Somatic Information and scores for these measurement outcome tools are being submitted through the AVATAR electronic health record and it is expected that specific outcome reports for services provided at the YAYA-FSP Program will be available by the end of FY Program Goals and Objectives The following are the goals and objectives for the YAYA-FSP Program during FY through FY : Continue to implement evidence-based practices that are specific to diagnosis and population and promote recovery and resiliency. With the implementation of the measurement outcome tools, the YAYA-FSP Program has been able to gather information and produce outcome reports that demonstrate treatment progress over time that is client specific. Individual client services are being modified as necessary based on the data to ensure positive outcomes for clients. Furthermore, efforts will continue to be made in developing a system for data analysis that gathers outcome data that is team, unit, and Department specific to ensure the YAYA-FSP Program is keeping fidelity and meeting the goals set forth by the Department. To improve access to services for unserved or underserved areas by securing an additional building in the south-end of Imperial County in the city of Calexico. Achievement in this region will be measured by tracking the increase of consumers served in this area of Imperial County. It is anticipated that once this clinic has been established there will be a significant increase in caseload size. Continue to improve and make facilities LGBT friendly and inviting. In January 2014, several staff were trained on the LGBT population to ensure that staff are informed, sensitive, and culturally competent with this population. The YAYA-FSP Program has also ensured that clinical facilities are LGBT friendly by being designated as LGBT Safe Zones, as well as identified with a Safe Zone poster. This has been done to clearly communicate that clinics are welcoming and receptive locations for the LGBT Page 31

38 community. Objectives in this area are to continue to address and define the unmet needs for LGBT youth in the community. These efforts will include staff participation in LGBT community committees to contribute to making efforts to collect data to define the unmet needs of LGBT youth and their families. This information would help ICBHS to identify the type and extent of unmet needs, thus assisting in providing targeted services and directing resources to address the needs of LGBT youth. Increase referrals to equine therapy and improve outcomes in the areas of confidence, patience, and self-esteem. Consumers will then be able to demonstrate better behavior choices, understanding of logical consequences, nurturing of others, self-evaluation, and control. This increase in referrals will be promoted by the education of YAYA-FSP Program staff on the services and benefits of equine therapy, thus encouraging referrals. Increase of referrals will be measured by the number of referrals received and the YOQ- SR will provide information on consumers progress in the area of confidence, patience, and self-esteem per fiscal year. Improve consumers physical health by increasing the number of consumers referred to the YAYA-FSP exercise program at Fitness Oasis. This increase in referrals will be promoted by the education of YAYA-FSP Program staff on the services and benefits, thus encouraging referrals. The AVATAR system is now able to track individuals Body Mass Index (BMI), which will be calculated at the initial nursing assessment. Consumers that present a risk based on their BMI, or report a desire to improve their physical health, will be referred for a physical evaluation and to the exercise program, thus increasing referrals. Another strategy to increase referrals consists of collaborating with Fitness Oasis in offering the exercise program on site to those consumers attending Community School or currently in Juvenile Hall. Outcomes will continue to be measured by tracking the increase in the number of referrals per fiscal year. Continue to increase services through Imperial Valley Regional Occupation Program, which focuses on education performance and skill building, to increase the number of consumers who obtain a GED or a high school diploma. This increase in referrals will be promoted by the education of YAYA-FSP Program staff on the service and benefits, thus encouraging referrals. This will promote wellness, recovery, and self-sufficiency, and assist consumers with rebuilding a healthy and more independent lifestyle. The YAYA- FSP Program will continue to identify and make referrals to consumers whose emotional disturbances prevent them from maximizing their academic performance, thus in need of further academic assistance. Consumers will have access to computers and the internet to aid them in completing school assignments, as well as tutoring services that are sensitive to the unique needs of the YAYA-FSP Program consumer. Outcomes will be measured by tracking the number of consumers referred and the number of consumers who obtain a GED or a high school diploma per fiscal year. Increase consumers engagement to services and decrease the no-show rate through the use of motivational interviewing skills and outreach services. Additionally, the exploration of appointments with the nursing staff geared to education on the medication and diagnosis specific to the consumer to assist in the reduction of stigma and promoting the importance of medication compliance. Outcomes will be measured by tracking consumers attendance to appointments and tracking the decrease of the noshow rate. Page 32

39 These goals and objectives should be accomplished by FY , but continued improvement toward these goals will be expected through FY Adult and Older Adult Services Full Service Partnership Program The Adult and Older Adult Services Full Service Partnership (Adult-FSP) Program is consumerdriven, community focused, and promotes recovery and resiliency. The Adult-FSP Program provides a whatever it takes approach to ensure that all consumers receive the services and assistance that are needed. Services provided by the Adult-FSP Program staff include case management, rehabilitative services, wrap-like services, integrated community mental health, alcohol and drug services, crisis response, and peer support. This program serves all SMI adults who meet the following criteria: Their mental disorder results in substantial functional impairments or symptoms, or they have a psychiatric history that shows that, without treatment, there is an imminent risk of decompensation with substantial impairments or symptoms. This program also serves SMI adults with co-occurring disorders of substance abuse. Their mental functional impairment and circumstances may result in disabilities and require public assistance, services, or entitlements. In addition, adults and older adults must meet the following criterion: Adults (ages 26-59) must meet the criteria in either (a) or (b) below: a. They are unserved and: (1) Homeless or at risk of becoming homeless; (2) Involved in the criminal justice system (i.e., jail, probation, parole); or (3) Frequent users of hospital and/or emergency room services as the primary resource for mental health treatment. These individuals are identified subsequent to being placed on an involuntary hold (W&IC 5150). b. They are underserved and at risk of: (1) Homelessness; (2) Involvement in the criminal justice system (i.e., jail, probation, parole); or (3) Institutionalization (i.e., jail, psychiatric hospital, Institute for Mental Disease, Skilled Nursing Facility). Older Adults (ages 60 and older) must meet the criteria in either (a) or (b) below: a. They are unserved and: (1) Experiencing a reduction in personal and/or community functioning; (2) Homeless; (3) At risk of becoming homeless; (4) At risk of becoming institutionalized (i.e., jail, psychiatric hospital, Institute for Mental Disease, Skilled Nursing Facility); (5) At risk for out-of-home care (i.e., nursing home, assisted living facility, board and care); or (6) At risk of becoming frequent users of hospital and/or emergency room services as the primary resource for mental health treatment. These individuals are identified subsequent to being placed on an involuntary hold (W&IC 5150). Page 33

40 b. They are underserved and: (1) At risk of becoming homeless; (2) At risk of becoming institutionalized (i.e., jail, psychiatric hospital, Institute for Mental Disease, Skilled Nursing Facility); (3) At risk for out-of-home care (i.e., nursing home, assisted living facility, board and care); (4) Frequent users of hospital and/or emergency room series as the primary resource for mental health treatment. These individuals are identified subsequent to being placed on an involuntary hold (W&IC 5150); or (5) Involved in the criminal justice system (i.e., jail, probation, parole). The Adult-FSP Program provides a variety of services, in a culturally competent environment, to adults and older adults, ages 26 and older, in all of the adult outpatient clinic locations. Individuals eligible to receive services through the Adult-FSP Program benefit from receiving medication support, therapy, and mental health rehabilitation/targeted case management services, if needed. Additionally, the program s mental health rehabilitation technicians assist consumers with reintegrating back into the community through linkage of the following applicable services: emergency shelter; permanent housing; emergency clothing; food assistance; SSI/SSA benefits application and/or appeals; DSS Cash Aid application; Section 8 Housing application; substance abuse treatment and/or rehabilitation referral; referrals to general physician and/or dentist; driver s license/id application; and/or immigration paperwork. Adult-FSP Program staff promote recovery, resiliency, and hope through full community integration by offering the aforementioned rehabilitation services and linkage to eligible individuals. Additionally, for the older adult population, delivery of needed supports and services are provided at their homes if they are homebound, unable to access public transportation, or do not have transportation. Adult-FSP Program clinical staff have been trained in the following evidenced based models and are currently providing services using these models: Cognitive Behavioral Therapy (CBT): CBT is an evidence-based psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders including anxiety, depression, and addiction. CBT is generally short-term and focused on helping clients deal with a very specific problem. During the course of treatment, people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. Cognitive Processing Therapy (CPT): CPT is a cognitive-behavioral therapy for PTSD and related conditions that focuses on thoughts and feelings. CPT is effective in treating PTSD across a variety of populations such as veterans who have experienced combat, sexual assault victims, and individuals who experienced childhood trauma, as well as other types of traumatic events. CPT provides a way to understand why recovery from traumatic events has been difficult and how symptoms of PTSD affect daily life. The focus is on identifying how traumatic experiences change thoughts and beliefs, and how thoughts influence current feelings and behaviors. This treatment is designed for adults ages 18 and over. Page 34

41 Motivational Interviewing: Motivational Interviewing is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. Cognitive Behavioral Therapy-Anxiety Treatment (CBT-AT): CBT-AT is a therapy model used for adult clients with an anxiety related diagnosis. CBT-AT is based on assumptions that psychological disorders involve dysfunctional thinking. CBT-AT helps clients modify dysfunctional beliefs that help improve their overall mood and behaviors. It also involves a cognitive conceptualization of the disorder and of the particular client. CBT-AT uses a variety of helpful techniques and strategies to challenge unhelpful patterns of thinking that trigger or increase anxiety related symptoms. Behavior techniques, in particular, help address those behaviors which may be used to reduce anxiety or avoid it altogether, including: Engagement in healthy and pleasurable activities; Problem solving techniques; Utilization of helpful coping skills (relaxation techniques, PMR, etc.); Goal setting (short and long-term goal); and, Exposure and response prevention. This model will also help clients improve their interpersonal skills by: Increasing social support as avoidance may progressively decrease with the implementation of this model; Improve communication skills; Increase acceptance/comfort of anxiety; Reduce/eliminate avoidance behaviors which may lead to increased functional behaviors (ability to maintain job, make and maintain relationships with others, decrease avoidant behaviors which interfere with their overall social and interpersonal functioning); and, Assisting with problem solving in social situations and when encountering high levels of stress. This model consists of three major modules, which are four sessions each for a total of 12 sessions, that address the following areas: Thoughts Activities People Interactions Staff provide clients with psychoeducation prior to starting the CBT-AT module, as well as a relapse prevention component that is provided after the last module. The length of this therapy model is 14 to 16 sessions, which includes initial psychotherapy assessment, CBT, discussion of relapse, and termination phase. Cognitive Behavioral Therapy-Depression Treatment (CBT-DT): CBT-DT is a therapy model used for adult clients with a depression diagnosis. This model helps individuals change their unhealthy thoughts and behaviors to improve their mood and daily Page 35

42 functioning skills. This is a manualized model that focuses on cognitive restructuring to identify dysfunctional or distorted thoughts and develop balanced and realistic thinking through: Behavioral activation to increase daily behaviors; Pleasurable activities; Problem solving barriers; and, Goal setting. This model will also improve their interpersonal skills by: Increasing social support; Improving communication skills; and, Assisting with problem solving in social situations. This model consists of three major modules that address the following areas: Thoughts; Activities; and, People Interactions. Staff will provide psychoeducation prior to starting the modules, as well as a relapse prevention component that is provided after the last module. The length of this therapy model is 14 to 16 sessions to complete all modules, which includes the discussion of relapse and termination. Moral Reconation Therapy (MRT): MRT is a cognitive-behavioral counseling program, provided at alternative education schools, that combines education, group and individual counseling, and structured exercises designed to foster moral development in treatmentresistant clients. As long as clients judgments about right and wrong are made from low levels of moral reasoning, counseling them, training them in job skills, and even punishing them will have little long-lasting impact on their behavior. They must be confronted with the consequences of their behavior and the effect that it has had on their family, friends, and community. Poor moral reasoning is common within at-risk populations. MRT addresses beliefs and reasoning. It is a systematic, step-by-step group counseling treatment approach for treatment-resistant clients. The program is designed to alter how clients think and make judgments about what is right and wrong. The MRT system approaches the problem of treating resistant populations as a problem of low levels of moral reasoning. Moral reasoning represents how a person makes decisions about what he or she should or should not do in a given situation. Briefly, MRT seeks to move clients from hedonistic (pleasure vs. pain) reasoning levels to levels where concern for social rules and others becomes important. MRT research has shown that as clients complete steps moral reasoning increases in adult and juvenile offenders. MRT systematically focuses on seven basic treatment issues: Confrontation of beliefs, attitudes and behaviors; Assessment of current relationships; Reinforcement of positive behavior and habits; Page 36

43 Positive identity formation; Enhancement of self-concept; Decrease in hedonism and development of frustration tolerance; and, Development of higher stages of moral reasoning. The Adult-FSP Program experienced some barriers in implementing this model after staff were trained and is currently in the beginning stages of implementation by identifying those adult consumers that meet criteria for this service. It is expected that this model will be in full implementation by FY The number of unduplicated clients served by the Adult-FSP Program is approximately 175 per year for an approximate cost per person of $7,056. The charts below provide a demographic summary of the Adult-FSP Program: Black 5% Race/Ethnicity White 22% Other 2% Other 3% Language Spanish 17% Hispanic 71% English 80% ( Other Alaskan Native, Chinese, Japanese, and Vietnamese) Other 30% City Brawley 15% ( Other includes Sign Language and Vietnamese) % Age 60+ 9% % Calexico 15% El Centro 40% % % ( Other includes the cities of Calipatria, Heber, Holtville, Imperial, Westmorland, and other outlying cities.) Gender Female 41% Male 59% Page 37

44 During the last three years, the Adult-FSP Program has not been able to meet its goal of serving the expected number of consumers. After analyzing the barriers to meeting this goal, it was identified that consumers who did not meet the service necessity criteria for mental health services and targeted case management services provided by a mental health rehabilitation technician (MHRT) were not being referred to the Adult-FSP Program or were being discharged and provided services through a different clinic. Effective FY , all adult consumers who meet the FSP criteria will be served through the Adult-FSP Program and specific specialty mental health services will be assigned based on the individual s unique needs. If a consumer does not meet service necessity for MHRT services, the consumer will continue to receive other mental health services under the Adult-FSP Program. Mental health services and targeted case management services will be provided by the assigned nurse or clinician if the consumer does not present the need for services provided by a MHRT. By eliminating these barriers, the number of clients who will be served at the Adult-FSP Program will increase significantly. Performance Outcomes The Adult-FSP Program has continued to implement a standardized method for measuring outcomes by specific disorder, as well as continues to utilize the BASIS 24 at the point of intake and annually thereafter. The BASIS 24 provides a complete patient profile and measures the change in self-reported symptoms and problem difficulty over the course of time. The BASIS 24 also measures the client s level of depression, functioning, interpersonal relationships, psychosis, substance abuse, emotional liability, and risk for self-harm. Below is a list of measurement tools that are currently being implemented at the Adult-FSP Program. These tools are specific to diagnosis and include the age and areas that are measured for each tool: Instrument Name Disorder Age Group Areas of Measurement Adult ADHD Self Report Scale (ASRS-v1.1) Behavior and Symptom Identification Scale (Basis 24) Patient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder Assessment (GAD-7) Illness Management and Recovery Scale: Client Self- Rating (IMR) ADHD 18 + ADHD Symptoms in Adults General 18 + Depression and Functioning Interpersonal Relationships Psychosis Self-Harm Substance Abuse Emotional Liability Depression 60 + Depression Anxiety 18 + Panic Disorder Social Anxiety Post-Traumatic Stress Disorder Recovery 18 + No Domains Page 38

45 PTSD Checklist-Specific Civilian (PCL-C) PTSD Checklist-Specific Monthly (PCL-S) PTSD Checklist-Specific Weekly (PCL-S) PTSD 18 + PTSD Symptoms PTSD 18 + Measures PTSD Symptoms From the Past Month PTSD 18 + Measures PTSD Symptoms From the Preceding Week Information and scores for these measurement outcome tools are being submitted through the AVATAR electronic health record. During FY , the Adult-FSP Program expanded services to also include clients who are suffering from an anxiety or depressive disorder and are experiencing risk of homelessness or have become homeless. As a result, the Adult-FSP served an additional 40 consumers. The Adult-FSP Program has increased its efforts to make services accessible to the different areas of Imperial County. A building in the city of Calexico was secured at the beginning of FY and immediately began construction to meet the needs of the adult and older adult population. Construction is complete and the clinic is expected to open for services on March 6, The initial caseload will be approximately 120 Adult-FSP Program consumers. It is expected that the number of individuals served will increase to about 180 to 200 consumers within the first year. In an effort to help consumers maintain recovery, health, wellness, and self-sufficiency, the Adult-FSP Program began implementing Medication and Diagnosis Education Groups. A survey was conducted with consumers with the intent of determining trends or patterns in the use of crisis services and hospitalizations. Findings demonstrated that active clients who utilized crisis services and/or required hospitalization used these services for one of three reasons: they stopped taking prescribed medications; they increased use of illegal substances or alcohol; or they had increased interpersonal or familial conflict. In a review of charts it was determined that more could be done to educate clients regarding their diagnosis and medications so they would have greater insight and awareness in their role of managing their own health care. As a result, Medication and Diagnosis Education Groups began pilot testing in September Staff are working with consumers and clinic staff to encourage participation in these groups with the intent of expanding Medication and Diagnosis Education Groups within each of the clinic sites. Program Goals and Objectives The following are the goals and objectives for the Adult-FSP Program during FY through FY : Increase the number of FSP consumers at each clinic by providing training and education on the criteria for FSP services to those staff who make the initial contact with consumers to schedule an intake assessment appointment and to clinical staff who conduct assessments and determine treatment criteria. Page 39

46 Reduce the number of crisis desk admissions and hospitalizations by increasing the use of mental health interventions that assist consumers with decreasing or eliminating impairments in an important area of life functioning as a result of their mental illness. Provide services and supports that teach, empower, and assist clients in accessing needed services; reduce incidents or risk of homelessness; improve clients ability to manage independence and increase their ability to work or attend school; and improve safety and permanence at home, school, and in the community. Provide MRT services to consumers who have a history with the criminal justice system to help them increase moral reasoning, improve judgement and treatment adherence, and reduce recidivism. Increase the number of Adult-FSP Program consumers with a co-occurring substance use disorder who are referred to and receive substance use treatment. Decrease symptoms of mental illness by increasing the number of consumers who are referred to and attend the Medication and Diagnosis Education Groups and adhere to their recommended treatment. Improve access to mental health services for the LGBT community by increasing outreach efforts, having LGBT friendly clinics, and identifying specific LGBT factors at the time of initial intake assessment and annual assessment. Increase the number of peer support staff or volunteers that work specifically with the Adult-FSP population by engaging them into treatment and providing support and guidance to those who are receiving services. At least one peer support staff or volunteer will be recruited for each of the Adult-FSP clinics during the FY Page 40

47 General Systems Development Wellness Center The Wellness Center is a network of consumers whose mission is to implement a wellness program of supportive resource services for adults with a significant and persistent mental health diagnosis. Currently, ICBHS has two Wellness Center facilities, one in El Centro and one in Brawley. Services provided at the Wellness Centers focus on social skills, recovery skills, encouragement, wellness, positive self-esteem, and community involvement. The Wellness Centers address educational, employment, inter-personal, and independent living skills. Daily organized and structured activities are consumer-directed and geared to assist consumers towards recovery from mental illness and the restoration of a healthy and independent lifestyle. Consumers experience self-empowerment as they progress towards their recovery and reintegrate into the community. Services at the Wellness Centers are provided to unserved and underserved consumers who are 18 years of age and older, have been diagnosed with a mental health disorder, and are actively participating in services at one of the ICBHS mental health clinics. Through a series of mental health and other ancillary services, the Wellness Centers focus on promoting healthy living and prevention of the debilitating effects of mental illness. Because the program focus is geared to promote health through fitness, healthy nutrition education, psychological support, and vocational support through its program activities, the program s name will change from Resource Center to Wellness Center as of FY The purpose for changing the program name is to reinforce how the development of healthy living skills is the foundation for mental health wellness. The Wellness Centers are operated under a friendly and supportive atmosphere where consumers have an opportunity to build a Wellness and Recovery Action Plan (WRAP), set educational and employment goals, join a support group, and work on independent living skills. The services offered provide support and challenge consumers to develop self-sufficiency, selfdirection, and recognize their choices from available community resources and agencies. The Wellness Centers encourage family participation in the recovery process of each consumer afflicted by mental illness and drug abuse. The primary focus of the Wellness Center is to reinforce overall consumer wellness, promote recovery and resilience, teach healthy coping skills, and assist consumers in meeting personal goals. The average number of unduplicated consumers served at the El Centro and Brawley Wellness Centers is approximately 400 per year. The cost per person for the Wellness Centers combined for FY is $2,200 a year per person. The tables below provide a demographic summary of the Wellness Centers: Caseload - El Centro Caseload - Brawley FY FY FY FY FY FY Page 41

48 Caseload by Age - El Centro Caseload by Age - Brawley FY FY FY FY FY FY Caseload by Gender - El Centro Caseload by Gender - Brawley Female Male Female Male FY FY FY FY FY FY Caseload by Ethnicity - El Centro Caseload by Ethnicity - Brawley FY FY FY FY FY FY Page 42

49 The Wellness Center has partnered with outside agencies, such as the Department of Rehabilitation/Work Training Center, Imperial Valley College (IVC), Fitness Oasis Gym, Imperial Valley Regional Occupation Program, and Clinicas De Salud Del Pueblo, to offer consumers educational classes and pre-employment, job readiness, and employment training, as well as assist them in obtaining a high school diploma or GED. Consumers also have access to computers and the internet to aid them in completing school assignments (i.e. research, homework, and projects). The Wellness Center staff now includes a music instructor who provides group and individual voice and instrumental music instruction. Wellness Center staff provides bus vouchers and/or arrange for transportation through the ICBHS Transportation Unit based upon the consumer s specific transportation needs. Through the aforementioned agencies, consumers are also offered the opportunity to attend classes on English as a Second Language, Arts and Crafts, Tai Chi, photography, self-esteem, life skills, cooking (such as baking and/or cake decorating), embroidery/sewing, and computers. Performance Outcomes Outcome measurement tools are currently being implemented to measure progress made by clients who attend the Wellness Center. One of the tools implemented in this program is the Illness Management and Recovery Scale (IMRS), which is an evidence-based measurement tool used to assess different aspects of illness management and recovery for individuals. It is used to measure outcomes in individuals ages 18 and older who are diagnosed with disorders related to bipolar, psychosis, schizophrenia, depression, anxiety, or trauma. The IMRS is administered upon intake and quarterly thereafter. The IMRS scores focus on the following areas: Progress toward personal goals; Knowledge about symptoms, coping methods, and medication; Involvement of family and friends in treatment; Contact with people outside of family; Time in structured roles; Symptom distress; Impairment of functioning; Symptom relapse prevention; Psychiatric hospitalization; Coping; Involvement with self-help activities; Using medication effectively; Functioning affected by alcohol use; and, Functioning affected by drug use. The Wellness and Recovery Action Plan (WRAP) is also used to assist individuals in gaining insight into their mental illness and increase practice of specific strategies crucial in their recovery. The WRAP focuses on treatment planning and assessing recovery in individuals with severe mental illness. Major components of the WRAP include the following: Monitoring of dangerous symptoms and emotional feelings; Increasing wellness and create positive change; Encouraging the use of help skills into daily life; and, Helping develop and use support systems during time of need. Page 43

50 In addition, all consumers complete the Consumer Feedback Form, which provides the Wellness Center staff with information on consumers satisfaction and personal achievements. As a result of the numerous services provided at the Wellness Centers that focus on recovery, resilience, and overall wellness, six consumers graduated from IVC one of which transferred to the local San Diego State University (SDSU) campus and is in the process of obtaining a bachelor s degree. One consumer graduated with a bachelor s degree from SDSU. Four consumers graduated with certificates in Child Development, Human Relations, Emergency Medical Technician training, and Medical Assistant training. The Wellness Center also assisted 30 consumers with full-time and part-time job placements that include retail, fast food, and County employment. In addition, the Wellness Center has provided the opportunity to consumers to become official peer support volunteers. Currently, the program has four official volunteers and 22 unofficial volunteers. The Wellness Center consumers have also participated in music classes that include lessons on piano, singing, guitar, and other instruments. During February 2017, consumers finalized the production of their first CD, which includes Spanish and English songs performed by the consumers. They are currently in the process of producing a second CD. Program Goals and Objectives The following are the goals and objectives for the Wellness Center during FY through FY : Increase the number of consumers who obtain a GED, certificate, and/or college degree through their participation in the different vocational and educational programs provided at the Wellness Center. Improve clients overall physical health by increasing consumers participation in the exercise/fitness program and participation in nutritional classes. Progress will be measured by a decrease in consumers BMI and through consumers reported physical health improvement. Increase consumers independence and social connections by engaging them in their WRAP to strengthen their social supports and increase involvement in pleasurable and social activities. Increase consumers ability to maintain stable housing, maintain employment, and manage independent living through participation in IVROP life skills classes, the GED program, and linkage to the Department of Rehabilitation. Implement family psychoeducation groups to increase family participation in consumers treatment and build consumers significant supports. Maintain overall wellness, recovery, and self-sufficiency by engaging consumers in their overall mental health treatment and regular participation in the different programs and support groups provided at the Wellness Centers. Page 44

51 Outreach and Engagement Outreach and Engagement Program The Outreach and Engagement Program is an important component of the MHSA, as the program provides outreach and engagement services to unserved and underserved SED and SMI individuals in the areas where they reside. The goal of the program is to reduce the stigma associated with receiving mental health services and increase awareness and accessibility of the mental health services that are offered in Imperial County. The Outreach and Engagement Program provides education to the community regarding mental illnesses and their signs and symptoms; resources to help improve access to mental health care; and information regarding mental health services available through ICBHS. Staff provide outreach at many community locations such as local schools, homeless shelters, and self-help group meetings. Staff have completed presentations at the local LGBT Resource Center, the local Housing Authority, faith-based organizations, and community-based organizations. Additionally, the Outreach and Engagement Program assists individuals in obtaining services from ICBHS by providing education on how to initiate services and assistance in scheduling the initial intake assessment appointment. Staff also provide linkage to transportation services for the initial intake assessment appointment. Performance Outcomes During Calendar Year (CY) 2016, the Outreach and Engagement Program provided outreach to 11,041 individuals. The table and charts below provide a demographic summary of the individuals who have been provided with outreach services during this period Demographic Category 1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter Total % of Total Gender Female 2,824 1,183 1,104 1,620 6,731 61% Male 1, ,072 3,922 35% Other % Not Reported % Total 11, % Age Group 0 to 13 1, ,543 14% 14 to ,057 19% 26 to 59 1, ,764 34% ,323 21% Not Reported ,354 12% Total 11, % Ethnicity African American % Asian/Pacific Islander % Hispanic 2,908 1,684 1,419 2,507 8,518 77% Native American % White % Page 45

52 Multiethnic % Other % Not Reported % Total 11, % Outreach by Gender CY 2016 Outreach by Age Group CY % 60% 40% 20% 0% 61% 35% 1% 3% Female Male Other Not Reported 40% 30% 20% 10% 0% 14% 19% 34% 21% 12% 0 to to to Not Reported Outreach by Ethnicity CY 2016 Not Reported 8% Other Multiethnic 0.40% 0.90% White 8% Native American 1.60% Hispanic 77% Asian/Pacific Islander African American 0.60% 3.50% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Page 46

53 The goal of the Outreach and Engagement Program is to educate local unserved and underserved SED and SMI individuals and to encourage the utilization of mental health care by providing outreach at local schools, homeless shelters, substance abuse treatment facilities, self-help groups, low-income housing areas, faith-based organizations, and community-based organizations. During CY 2016, the Outreach and Engagement Program focused outreach efforts at 36 different sites, including, but not limited to: alternative education schools; El Centro Elementary School District; Grace Smith School; Women, Infant, and Children Program; Catholic Charities; the Center for Family Solutions; IVROP; Christ Community Church; the Methadone Clinic; Neighborhood House; Salvation Army; Villa de las Flores Apartments; Westmorland Family Apartments; Countryside Apartments, Islamic Center, Mexican Consulate, various parks in Imperial County, rural healthcare clinics, and Senior Centers. As a result of outreach and engagement efforts, 224 individuals were successfully linked to Imperial County Behavioral Health Services during CY Program Goals and Objectives For, the goals of the Outreach and Engagement Program will continue to be to reduce the stigma associated with receiving mental health treatment, and to increase access to mental health services. The objectives of the program are to engage unserved and underserved SED and SMI individuals through outreach in the community; educate the community about mental illnesses and available mental health resources; and increase awareness of the services available through ICBHS. Achievement of the program s goals will be measured directly by the number of individuals who are successfully linked to mental health treatment services at ICBHS as a result of outreach and engagement efforts. Transitional Engagement Supportive Services Program The Transitional Engagement Supportive Services (TESS) Program provides outreach and engagement activities to unserved and underserved SED and SMI individuals ages 14 and over. The TESS Program receives referrals from various agencies and programs, such as local community agencies, PIER Model, individuals who have been discharged from Lanterman- Petris Short Act (LPS) Conservatorship by the courts, acute care psychiatric hospitals, the ICBHS Crisis and Referral Desk (CRD), and the Imperial County Jail and State of California Department of Corrections Rehabilitation. The objective of the TESS Program is to provide supportive services while individuals transition to outpatient mental health treatment. The TESS Program provides individualized mental health rehabilitation/targeted case management services to youth and young adults, adults, and older adults who have experienced a personal crisis in their life requiring involuntary or voluntary mental health crisis intervention services. These services assist the individual with reintegrating back into the community by linking the individual to educational and employment programs, housing related assistance programs, drug and alcohol services, and linkage to outpatient mental and/or medical services. Additionally, the TESS Program assists AB 109, non-active, and active individuals who are referred to either the McAlister Institute for 14-day drug and alcohol detox (adults) or 21-day drug and alcohol detox (adolescents), or a sober living home. The TESS Program provides aftercare and follow-up services, with the objective of assisting the individual in accessing mental health and substance abuse related treatment upon release from the McAlister Institute Detox Program or sober living home. Page 47

54 The TESS Program is also responsible for implementing Phase I and Phase II of the PIER Model, which consists of outreach and engagement (Phase I) and in-depth assessment (Phase II) using the Structured Interview for Prodromal Syndromes (SIPS) to determine prodromal or first episode criteria for the PIER Model. Individuals and their families receive Phase III Treatment of the PIER Model through the YAYA-FSP Program. Through a Community Service Worker (CSW), the TESS Program provides outreach and engagement services to unserved and underserved populations. The TESS CSW contacts local community shelters to establish contact with potential consumers living in such facilities and educates local community shelter staff and potential consumers regarding the services offered by ICBHS. The TESS Program also continues to work in collaboration with various community entities such as El Centro Regional Medical Center and Pioneers Memorial Hospital Emergency Room staff to identify individuals who are exhibiting psychiatric symptoms in order to educate them on the referral process and continuity of care offered by ICBHS. Additionally, via the community referral process, the TESS Program receives referrals from West Shores High School in the outer Northern region of Imperial County, El Centro Police Department, Veteran s Affairs, Imperial County Department of Social Services Children & Family Services and Adult Protective Services, IVROP, IVC, Planned Parenthood of Imperial Valley, Calexico Clinicas de Salud del Pueblo, the Mexican Consulate, Adult Day Out Programs, Healthpeak Home Health Care, Imperial County Victim Witness, Sure Helpline Crisis Center, the ICBHS Assessment Center, Imperial County Probation Department, Federal Parole El Centro Office, California Department of Corrections and Rehabilitation, and local physicians offices all with the goal to expand accessibility to mental health services to the unserved and underserved. The TESS Program also provides educational information on the importance of mental health treatment, recovery, and accessibility to services by conducting community presentations and attending local community health fairs. Individuals are linked to the ICBHS Youth and Young Adults Services or Adult Services Divisions for continuation of care. As a result of outreach and engagement efforts, the TESS Program has been able to link individuals into outpatient mental health treatment to prevent decompensation and/or higher levels of care. Services available to clients at the TESS Program include: Initial Intake Assessment; Medication Support; Mental Health Services-Nurse; Mental Health Services- Rehabilitation Technician; Targeted Case Management; and Crisis Intervention. The TESS Program provides linkage to a variety of community resources, including, but not limited to: Emergency shelter; Permanent housing; Emergency clothing; Emergency food baskets; SSI/SSA benefits application or appeal; DSS/Cash Aid; Substance abuse treatment and/or rehabilitation referral; Page 48

55 General physician, dentist, and/or optometrist; and, Other ICBHS programs and community resources. The TESS Program assists in expediting services to individuals that, after prescreening evaluation, have been found to be in imminent need of services due to high risk of decompensation or homelessness, or in need of linkage to community resources. The TESS Program has a 30 day time frame to complete the expedited mental health services process and integrate the client to outpatient treatment via the intake process, which consists of an initial intake assessment, initial nursing assessment, and initial psychiatric assessment. The number of individual clients served during FY , FY and FY (until January 2017) by the TESS Program was 1,474. The average cost per person was $1,508 from July 1, 2016, to present. The charts below provide a demographic summary of the TESS Program: Female 48% Gender Male 52% Spanish 22% Language English 78% Other 37% Calexico 16% City El Centro 27% Brawley 20% White 21% Black 4% Race/Ethnicity Other 5% Hispanic 70% ( Other includes the cities of Calipatria,Heber,Holtville, Imperial, Westmorland, and other outlying cities.) Performance The TESS Program % % % % Age % % ( Other includes Alaskan Native, Vietnamese, Chinese, and other Asian.) % Outcomes administers the BASIS Page 49

56 24 outcome measurement tool to establish a baseline of symptoms and impairments to those clients age 18 years and older. The areas of measurement include depression/functioning, relationships, self-harm, emotional liability, psychosis, and substance abuse. The BASIS 24 is administered at the time of initial intake assessment and is re-administered on an annual basis. During FY , the TESS Program completed 509 BASIS 24, 400 in FY , and 310 to date during FY The TESS Program incorporated the YOQ-SR and YOQ-Parent Report as a result of the expansion of TESS Program services to target the youth and young adult population, ages 14 to 17. For the general tools, all youth, ages 14 to 17, and their parents are administered the YOQ- SR and YOQ-Parent Report at the time of initial intake assessment and annually thereafter. The tool is designed to measure treatment progress and tracks changes in functioning during the course of treatment. The areas of measurements include interpersonal distress, somatic symptoms, interpersonal relations, social problems, behavior dysfunction, and other critical items. During FY , the TESS Program completed 79 Youth Outcome Questionnaires, 76 in FY , and 48 to date during FY The TESS program has utilized the Structured Interview for Prodromal Syndromes (SIPS) assessment for individuals who are experiencing their first psychotic episode and/or prodromal psychotic symptoms. The SIPS is a tool used for youth and young adults, ages 14 to 25, who are receiving mental health services. The tool is designed to see if the individual meets criteria for the PIER Model by asking specific, probing questions about the onset, frequency, duration, and intensity of symptoms in four scaled areas: positive symptoms, negative symptoms, disorganization symptoms, and general symptoms. Each scaled area includes sub-sets; usual thought content/delusional ideas, suspiciousness/persecutory, grandiose ideas, perceptual abnormalities/hallucinations, and disorganized communication. The TESS Program completed 27 SIPS during FY and 22 SIPS to date during FY The following is a list of measurement outcome tools currently being implemented at the TESS Program that are specific by age: Instrument Name Behavior and Symptom Identification Scale (BASIS 24) Youth Outcomes Questionnaire Parent (YOQ Parent) Youth Outcomes Questionnaire Self-Report (YOQ SR) Disorder Age Group Areas of Measurement General 18 + Depression and Functioning Interpersonal Relationships Psychosis Substance Abuse Emotional Liability Self-Harm General Tool 4-17 Interpersonal Distress Somatic Interpersonal Relations Social Problems Behavioral Dysfunction Critical Items General Tool Interpersonal Distress Somatic Interpersonal Relations Social Problems Behavioral Dysfunction Critical Items Page 50

57 Structured Interview for Prodromal Syndromes (SIPS) Psychotic Disorders Imperial County Behavioral Health Services Usual Thought Content/Delusional Ideas Suspiciousness/Persecutory Grandiose Ideas Perceptual Abnormalities/Hallucinations Disorganized Communication Information and scores for these measurement outcome tools are being submitted through the AVATAR electronic health record. The TESS Program continues to focus on outreach efforts to establish relationships with agencies that might identify and refer individuals experiencing some of the early warning signs of a mental illness and/or experiencing a crisis situation. During FY through FY , the TESS Program conducted 41 outreach presentations to various community agencies within Imperial County, such as Department of Social Services; Brawley, Calexico, El Centro, and Holtville School Districts; IVC; National Arizona University; California Department of Corrections and Rehabilitation; El Centro Regional Medical Center; Pioneers Memorial Hospital; Sure Helpline Crisis Center; Imperial County Probation Department; Planned Parenthood; IVROP; Veterans Affairs; and AmeriCorps. The TESS Program received a total of 196 community referrals as a result of these outreach efforts. Additionally, the TESS Program has been working in collaboration with the Imperial County Jail and has been participating in quality assurance meetings for the Imperial County Jail Medical Services on a quarterly basis. Since the integration of the County Jail referral process into the TESS Program, administrative staff from ICBHS and the County Jail have been meeting on a monthly basis to develop effective ways to improve the delivery of mental health services and/or other community services to individuals who are reintegrating into the community. Since January 11, 2016, there have been a total of 72 County Jail referrals. From those 72 referrals, 47 individuals were successfully linked to outpatient mental health services. Currently there are 23 individuals waiting to be released from the County Jail and transition back into the community. Individuals referred to ICBHS while at the County Jail receive outreach and engagement services that begin 90 days prior to release with the goal of planning an effective discharge plan and initiate mental health treatment. The TESS Program is currently in the process of establishing a protocol for a clinician through the TESS Program to complete an initial intake assessment 30 days prior to an individual s discharge from the County Jail, which will promote plan development, treatment planning, and effective transition to the community with the assistance and support of a MHRT. The TESS Program also continues to work in collaboration with the Imperial County Jail psychiatric nurse prior to an individual s release. The psychiatric nurse, in conjunction with correctional/probation officers, identify potential clients and consults with the TESS Program MHRT with the objective of initiating outreach and engagement services. Once potential clients are identified, the TESS MHRT will conduct a prescreening evaluation with the individual. Based on reported information, the TESS MHRT will determine if the individual may benefit from further mental health assessment by coordinating an initial intake assessment to determine medical necessity for mental health services. For individuals actively receiving psychiatric treatment while incarcerated, the TESS MHRT will participate in psychiatric teleconference calls as part of the engagement process. In addition, the TESS MHRT provides psychoeducation on symptoms and behaviors, normalization, and identification of needed community resources. These involve accessing community resources and services and linkage to mental health and/or drug and alcohol services. The TESS MHRT also has access to County Jail records allowing the MHRT Page 51

58 to obtain information pertaining to an individual s release date or court date, which assists in expedited coordination of services. The TESS Program developed a MOU with IVROP to facilitate MRT groups to adult offender populations suffering from a substance use disorder, dual diagnosis or mental illness. As a cognitive behavioral approach, MRT seeks to increase the individual s awareness on the impact of skillful decision making by enhancing appropriate behavior through the development of higher moral reasoning. As a result, programs that have implemented MRT have shown a significant reduction in the rates of recidivism. Since the implementation of MRT in the County Jail on September 19, 2016, there has been one male group and one female group, both of which meet twice a week. The male groups were implemented from September 19, 2016, to November 9, 2016, and had seven participants that completed seven MRT Steps. The female group started on November 15, 2016, and is currently in progress. There are a total of 10 participants that have completed up to Step 11. In an effort to engage homeless individuals and increase the accessibility of mental health services to the unserved/underserved populations, the TESS Program participates in the Imperial Valley Homeless Task Force and enrolls individuals in the Projects for Assistance in Transition from Homelessness (PATH) Program. The PATH Program is designed to support the outreach to, engagement of, and delivery of services to eligible individuals who are homeless or at risk of homelessness that are hardest to reach and most difficult to engage with yet unknown severity of mental illness and/or co-occurring substance abuse disorders. Additionally, the TESS Program continues to work in collaboration with homeless shelters to educate on mental illness, accessibility of services, and stigma reduction. The TESS Program continues to expand its services by providing outreach, engagement, and assessment services to determine criteria for the PIER Model. The PIER Model is an evidencebased early detection and intervention model that focuses on the prodromal phase of a developing psychotic illness and advocates psychosocial interventions and drug treatments that are tailored to the individual. The objective of the PIER Model is to transition an individual identified with early severe mental illness into an evidence-based treatment model as quickly as possible to improve outcomes in treatment and allow for transition back into the community. Specific goals of the PIER Model include interrupting the very early progression of psychotic disorders and improving outcomes and preventing the onset of the psychotic phase of severe mental illness like bipolar disorder, major depression, and schizophrenia. The emphasis of the PIER Model is on family psychoeducation and supported education and employment for the individual through the family s participation in a Family Workshop, Joining, and Multifamily Group. The groups provide an opportunity for the family to meet with clinical staff and five to six other PIER Model families to learn more about the illness process, ways to reduce stress, and how to move forward with their lives thus improving outcomes and preventing the onset of the psychotic phase of serious mental illness. Since the implementation of the PIER Model, there have been 35 individuals meeting criteria under prodromal or first episode psychosis. From those 35 individuals, 12 individuals and their families are currently participating in PIER Model services through three different treatment cohorts: Cohort One an English group, which consists of four families; Cohort Two a Spanish group, which consists of five families; and Cohort Three a Spanish group, which consists of three families. There are currently 13 individuals and their families in the process of starting PIER Model services. The remaining 10 individuals decided not to continue and were discharged from services. Page 52

59 In addition to the above, the TESS Program also worked toward successfully linking individuals to mental health services. The following is a comparison of the number of individuals served through the TESS Program with the number of successful transfers to outpatient mental health services: During FY , the TESS Program served 554 individuals, of which, 140 (25%) were successfully transferred to outpatient mental health services. During FY , the TESS Program served 427 individuals, of which, 248 (58%) were successfully transferred to outpatient mental health services. During FY to date, the TESS Program has served 493 individuals, of which,176 (36%) were successfully transferred to outpatient mental health services. During FY , the TESS Program reduced the original 60-day timeframe to linking individuals to outpatient treatment teams to a 30-day timeframe by transferring mental health services immediately after the completion of the initial intake assessment. This involved collaborating with the outpatient treatment team and assigning a MHRT upon transfer and completion of the initial nursing assessment and initial psychiatric assessment. On November 30, 2016, the TESS Program began following through with the linkage to mental health services from initial intake up to the initial psychiatric assessment. It was observed that the level of engagement and commitment into treatment was most effective when individuals maintained the same MHRT as they transitioned from the TESS Program to outpatient mental health services. It is expected that there will be an increase in the overall number of successful transfers at the end of FY The following is a breakdown of the distribution of mental health services within ICBHS for FY : TESS Program Successful Transfers 1% 2% 1% 35% Youth and Young Adult Services Adult and Older Adult Services Children Services 61% Conservatorship San Pasqual FRC From the 493 TESS Program referrals to date in FY , 176 were successfully linked to outpatient mental health services; 21 were screened out from ICBHS medical necessity criteria; and 80 are still in the process of being linked to mental health services and/or community resources. During this time frame, 216 individuals have been discharged from the TESS Program due to non-compliance or being unable to locate (60); pre-registration status (53); no care needed (10); relocated out of county (47); declined services (45); indefinite placement (1). Page 53

60 TESS Program: Referral Outcome Overview Successful Linkages to Mental Health Outpatient Clinics: 176 Screened Out: 21 Unsuccessful Linkages: 216 Pending: 80 Total TESS Referrals: 493 The TESS Program goals for FY through FY were the following: 1. Reduce disparities in services provided to individuals residing in racially and ethnically diverse communities. 2. Reduce homelessness, hospitalizations, incarcerations, and stigma associated with mental illness. 3. Increase collaboration in the level of engagement in racially and ethnically diverse communities and strengthen local communities capacity to identify target populations and promote their inclusion in the mental health services delivery system. Through the abovementioned efforts, the TESS Program continues to successfully provide outreach and engagement services to communities in Imperial County, reducing stigma and disparities, increasing interagency collaboration to serve unserved and underserved populations, and linking individuals in need of treatment to mental health services. Program Goals and Objectives The following are the goals and objectives for the TESS Program during FY through FY : Increase efforts to engage homeless individuals by increasing accessibility of mental health services to the unserved or underserved population; improve delivery of services to those who are homeless or at risk of homelessness that are hardest to reach and most difficult to engage with unknown severity of mental illness and/or co-occurring substance use disorders; improve collaboration with homeless shelters to educate on mental illness and services available in the community; and continue to identify and make referrals to the TESS Program by having a CSW make contact with local shelters and meet with potential clients to successfully link them to mental health services. The TESS Program will continue to work on improving successful transfers to outpatient mental health services by linking clients to outpatient clinics within the 30 day time frame. By expediting services, individuals will be scheduled for an initial intake assessment within three days, for those who are discharged from the CRD and/or inpatient hospital, or seven days, if referred by community referral, of contact. Once the initial intake assessment is conducted, individuals will have an initial nursing assessment and initial psychiatric assessment for medication support scheduled within the three week time frame. This 30 day process of expediting services will prevent individuals from decompensating and being readmitted to the CRD. Continue to increase community outreach presentations to various community agencies and organizations within Imperial County in order to increase referrals and linkages to mental health services. The TESS Program will remain focused on providing Page 54

61 presentations to non-profit organizations, social services agencies, school districts, health clinics, shelters, local physician offices, law enforcement agencies, local hospitals, home health agencies, the Mexican Consulate, and colleges, with the objective of expanding accessibility to mental health services and drug and alcohol services. Improve follow-up services for those individuals that are hospitalized out-of-county and are not returning to Imperial County in order to decrease out-of-county hospitalization readmissions. The TESS Program will assist hospital social workers to ensure follow-up care is implemented by coordinating placement, scheduling mental health outpatient appointments, and changing county Medi-Cal codes to assist individuals in accessing services in their county of residence. Continue to improve mental health service delivery at the Imperial County Jail by conducting initial intake assessments for those individuals who are scheduled to be released. Upon release, the TESS Program will assist in expediting services in order for those individuals to have an initial nursing assessment and an initial psychiatric assessment for medication support. Additionally, MHRT services will be provided to support individuals in reintegrating back into the community. The TESS Program will work on outcome measurements to track referrals to the TESS program to provide outreach and successful transfers to outpatient mental health services. Page 55

62 Prevention and Early Intervention Imperial County Behavioral Health Services The intent of Prevention and Early Intervention (PEI) programs is to move to a help first system in order to engage individuals before the development of severe mental illness or serious emotional disturbance, or to alleviate the need for additional or extended mental health treatment by facilitating access to supports at the earliest signs of mental health problems. To facilitate accessing services and supports at the earliest signs of mental health problems and concerns, PEI builds capacity for providing mental health early intervention services at sites where people go for other routine activities (e.g., health providers, education facilities, community organizations). This integration allows mental health to become part of the wellness for individuals and the community, reducing the potential for stigma and discrimination against individuals with mental illness. Prevention Outreach Activities The prevention component of PEI utilizes a universal strategy that addresses the entire Imperial County community, focusing on providing outreach and educating on the effects and symptoms of trauma and the importance of identification and early intervention. Prevention services attempt to bring awareness to community members on issues commonly experienced by children who have experienced trauma, such as poor self-esteem, difficulty trusting others, mood instability, and self-injurious behaviors, including substance abuse. Services are delivered to large or small groups in health fairs, career fairs, and school presentations, without any prior screening of attendance for mental health treatment. Prevention activities are provided by a number of PEI Program staff, including master level clinicians, MHRTs, the program supervisor, and the program manager. Other outreach and prevention services include individual discussions with school personnel and distribution of informational materials, such as flyers on available services in community events, publishing of articles in the local newspaper and magazine, and radio shows on the ICBHS weekly radio show program Let s Talk About It. The articles and radio shows incorporate topics such as effects of trauma, bullying, anxiety, and depression in children and youth; respectful behaviors and empathy; and available resources. PEI Program staff provided prevention information to students, school administrators and faculty, and community agencies at the following locations during July 2014 through January 2017: Prevention Activities Provided to School Administrators and Staff: Number of Presentations Location 8 Calexico Unified School District 2 Calipatria School District 7 El Centro Elementary School District 2 Heber Union School District 2 Seeley Union School District 1 San Pasqual Valley Unified School District Page 56

63 Prevention Activities Provided to Students: Number of Presentations Location 21 Elementary Schools - Countywide 9 Middle/Junior Highs - Countywide 18 High Schools - Countywide Prevention Activities Provided to Parents: o Number ) of Presentations Location 5 Brawley Elementary School District 8 Calexico Unified School District 7 El Centro Elementary School District 1 Seeley Union School District 5 Elementary Schools - Countywide 3 Middle /Junior Highs - Countywide 17 Migrant Head Start 3 United Families 1 Calexico Neighborhood House 1 Family Tree House 1 Brawley Family Resource Center 1 Clinicas de Salud Prevention Activities Provided to Community Agencies: Number of Presentations Location 5 Let s Talk About It Radio Show 2 Countywide SARB 1 Amaris Ministries 1 Imperial Valley LGBT Resource Center Imperial Valley Regional Occupational 1 Program PEI Program staff provided prevention presentations on the topics listed below during July 2014 through January The number of attendees have been collected in small groups; however, it has not always been possible to obtain specific numbers of attendees participating in larger groups such as those participating in school rallies or health fairs, or number of individuals listening to the radio show. Prevention Presentations for Fiscal Year : Number of Presentations: 37 Approximate Number Served: 437 Topics # Target Population # of Groups Location # Bullying 9 Children 6 School Districts 5 Mental Health 7 Youth 1 Elementary Schools 13 Parenting 9 Parents 10 Middle/JH Schools 3 TFCBT/Trauma 11 School Admin/Staff 10 High Schools 5 Self-Harming 1 Comm. Members 3 Community Agencies 11 Page 57

64 Prevention Presentations for Fiscal Year : Number of Presentations: 95 Approximate Number Served: 3,066 Topics # Target Population # of Groups Location # Bullying 10 Children 22 School Districts 30 Mental Health 48 Youth 14 Elementary Schools 23 Parenting 26 Parents 33 Middle/JH Schools 10 TFCBT 6 School Admin/Staff 12 High Schools 13 Self-Harming 2 Comm. Community 5 Members Agencies 19 Suicide Prevention 3 Prevention Presentations for from July 2016 to January 31, 2017: Number of Presentations: 22 Approximate Number Served: 356 Topics # Target Population # of Groups Location # Bullying 4 Youth 5 School Districts 7 Mental Elementary 16 Parents 10 Health Schools 4 Parenting 2 School Middle/JH 2 Admin/Staff Schools 1 Comm. Members 2 High Schools 5 Community Agencies 5 Approximately 15% of staff time is dedicated to PEI Program outreach activities and it is projected that this same percentage will continue for the next three years. Therefore, based on the numbers obtained for the past three years, the cost for prevention activities per child/youth is estimated at $142. This cost includes outreach activities conducted by master level clinicians, MHRTs, the program supervisor, and the program manager, as well as linkage and referral services to the child/youth and their parents/legal guardians for additional mental health resources. The PEI Program outreach activities have assisted in bridging the gap in the community by establishing collaborative efforts with local agencies, such as the Department of Social Services and the education system, that provide services to local residents. These partner agencies have become familiar with the PEI Program s early intervention component, as well as ICBHS outpatient services, and are assisting in facilitating community members access of appropriate services by making referrals when needed. The continuous receipt of referrals from these agencies and the acceptance of services by parents are a testimony of the success of PEI Program outreach activities. For, the program is expected Page 58

65 to continue providing prevention and outreach services using the universal prevention strategy to continue educating and informing Imperial County residents of the effects of trauma and the importance of timely identification and early intervention in an effort to decrease the development of serious mental illness. Program Goals and Objectives The following are the goals and objectives for the outreach prevention component of the PEI Program during : Provide universal prevention activities through outreach and education by providing information and presentations to the community at large on trauma, the effects of trauma, the importance of identification and early intervention, and available resources. Conduct outreach activities in the community that would generate referrals for the PEI Program target populations and improve access to the unserved and underserved populations of Imperial County. Provide information on outreach activities to community stakeholders during the quarterly MHSA Steering Committee meetings, which are attended by local stakeholders, including families of children and those who represent local unserved and/or underserved populations and their families. The Incredible Years During FY , ICBHS begin implementing the Incredible Years (IY) parenting program to address the needs of one of the identified priority populations, Children/Youth in Stressed Families. The IY program is a comprehensive evidence-based model with a set of curricula designed to provide parents with the necessary skills to promote children s development in a positive environment; encourage nurturing relationships; reduce harsh discipline; and foster parents ability to promote children s social and emotional development. The IY model is conducted as a group of up to 12 parents with two trained facilitators. The model involves 10 to 14 two-hour weekly meetings. Parenting skills are taught through a combination of video vignettes, role playing, rehearsals, homework, and group support. The IY program was the selected parenting program as this model meets the needs of the community, focusing on strengthening parenting competencies and fostering positive parent-child interactions and attachments for children ages 2 through 12. Additionally, this model meets the linguistic and cultural needs of the community as the program materials are available in both English and Spanish. California Evidence-Based Clearinghouse for Child Welfare ( has given the Incredible Years model its highest rating of 1, indicating it is well supported by research evidence. The implementation of Incredible Years by the Child Abuse Prevention Council (CAPC) started in November The groups were provided free of charge in English and/or Spanish to families residing in Imperial County and were delivered in non-traditional settings such as schools, after school programs, churches, resource centers, or at the CAPC office. Referrals to the CAPC for the IY Program are made by community agencies, including the Department of Social Services, the Probation Department, and local school districts, or parents self-referral. Page 59

66 During FY , the CAPC conducted a total of 24 parenting groups, 15 groups in Spanish and 9 groups in English, serving a total of 326 parents. Below is the demographic information for the group participants: Gender # Age # Ethnicity # Total Served: 326 Marital Status # Status # Referral Source For the current FY , from July 2016 through January 2017, the CAPC conducted a total of 20 parenting groups, 13 groups in Spanish and 7 groups in English, serving a total of 201 parents. Below is the demographic information for the group participants: Gender # Age # Ethnicity # Total Served: 201 Marital Status # Status # Referral Source Female Hispanic 304 Married 161 Non- Mandated 238 Self 141 Male Caucasian 12 Single 91 Mandated 88 CPS African American 7 Divorced 45 ICBHS Other 3 Other 29 Court 45 *Other 20 *Other includes (Schools/CFS/Probation) Female Hispanic 191 Married 91 Non- Mandated 154 Self 66 Male Caucasian 8 Single 56 Mandated 47 CPS African American 2 Divorced 33 ICBHS Other 21 Court 10 *Other 82 *Other includes (Schools/CFS/Probation) Based on the numbers obtained for FY and FY , the cost per parent is approximately $463. This cost includes training seven CAPC staff, as well as other expenses related to providing IY groups to parents. For, ICBHS is planning on continuing to contract with the CAPC for the provision of IY parenting groups free of charge to parents in Imperial County. PEI Program staff continues to collaborate with the El Centro Elementary School District (ECESD) in implementing the IY Program. ECESD started offering an IY parenting group in February 2016 to parents whose children were attending any of the 12 schools in ECESD. PEI Program staff collaborated with the ECESD facilitators by co-facilitating the IY parenting groups in a school setting, both in English and in Spanish. In February 2017, ECESD started a new IY parenting group with the assistance of PEI Program staff in co-facilitating the group. PEI Program staff have conducted several outreach activities in the community to promote and generate referrals for the IY parenting groups targeting the PEI Program populations. Through the training, planning, implementation, and co-facilitation of the IY Program, ICBHS has been # # Page 60

67 developed and continue to grow a strong, collaborative relationship with local schools, the CAPC, and the community in general. Performance Outcomes The CAPC provides parents with a pre- and post- outcome tool to measure their parenting skills. The Parenting Practices Interview (PPI) tool measures parents ; hard discipline, appropriate discipline, inconsistent discipline, clear expectations, positive parenting, and monitoring. For items 1 and 2, a lower post-score compared to the pre-scores demonstrate reduction in inconsistent and harsh discipline. For items 2, 4 and 5, a higher post-score compared to the prescore demonstrates improvement of appropriate discipline, clear expectations, and positive parenting. Below is the outcome data obtained for FY and FY through January 2017: FY PPI Harsh Discipline (98) Appropriate Discipline (112) Inconsistent Discipline (42) 19 Clear Expectations (21) Positive Parenting (105) Pre Post FY PPI Harsh Discipline (98) Appropriate Discipline (112) Inconsistent Discipline (42) 21 Clear Expectations (21) Positive Parenting (105) Pre Post Page 61