Beatrice W. Readel, LCSW Director Development …archive.mhsoac.ca.gov/Counties/Innovation/docs/InnovationPlans/INN...May 29, 2010 · The Innovation plan was made available for public

Beatrice W. Readel, LCSW Director [email protected]

Anne Robin, MFT Assistant Director [email protected]

Sue McGuire, ASW, MSW Development & Compliance Mgr [email protected].

Tracie Riggs, EA Fiscal Manager [email protected]

Tuolumne County Behavioral Health Dep;;;:a~rt=m::.e::n:;.;t:.... _

May 29, 2010

MHSOAC 1300 17th St., Suite 1000 Sacramento, CA 95811 Attn: Sheri Whitt

The County of Tuolumne County Behavioral Health Department (TCBD) is submitting the Mental Health Services Act (MHSA) Innovation component for Tuolumne County. As requested please find enclosed an original signed Innovation component. One electronic copy has been submitted to MHSOAC ([email protected]).

The Innovation plan was made available for public review and comment for a 30-day period as part of Tuolumne County's Behavioral Health Advisory Board Public Hearing on May 5, 2010 at 5pm, posted electronically for 30 days on our Tuolumne County Behavioral Health website, and distributed to Tuolumne County's MHSA Leadership Council, Tuolumne County Behavioral Health Advisory members, and interested community residents.

We look forward to your review and approval of our MHSA Innovation Plan.

Sincerely,

~~ Tracie Riggs Director of Behavioral Health Services for Tuolumne County

Behavioral Health Adm 2 S. Green St., Sonora, CA 95370 Phone: (209) 533-6245 Fax: (209) 588-9563 Mono Clinic 2 South Green St., Sonora, CA 95370 Phone: 209-588-9528 Fax: (209) 533-5411 Cabezut Clinic 2 South Green St., Sonora, CA 95370 Phone: 209-533-3553 Fax: (209) 536-9356 Peer Help Center, 2 South Green St., Sonora, CA 95370 Phone: (209) 533-6695 Fax: (209) 588-2781 David Lambert Drop In Center, 347 West Jackson, Sonora, CA 95370 Phone: (209) 533-4879

mailto:[email protected]




Tuolumne County

Tuolumne County Behavioral Health www.tcbehavioralhealth.com

Mailing Address: 2 South Green St. Sonora, CA 95370

24 hour crisis line: (209) 533-7000


Sue McGuire, ASW, MSW Quality/Managed Care Manager [email protected].

Tracie Riggs Fiscal Manager [email protected]

Business locations and contact information:

Behavioral Health Admin. 105 Hospital Rd. Sonora, CA 95370 Phone: (209) 533-6245 Fax: (209) 588-9563

CAIP (Crisis Assessment & Intervention Program) 105 Hospital Rd. Sonora, CA 95370 Phone: (209) 533-7000

(800) 630-1130 Fax: (209) 533-7007

Mono Clinic 197 Mono Way Sonora, CA 95370 Phone: (209) 533-5400 Fax: (209) 533-5411

Cabezut Clinic 12801 Cabezut Rd. Sonora, CA 95370 Phone: (209)-533-3553 Fax: (209) 533-8259

Lambert Community Center 347 West Jackson St. Sonora, CA 95370 Phone: (209) 533-6695

(209) 533-4879 Fax: (209) 588-2781

Behavioral Health Department

March 29, 2010

NOTICE OF INITIATION OF 30-DAY PUBLIC REVIEW PERIOD RE: MHSA INNOVATION COMPONENT PLAN

Dear Community Members and Stakeholders,

Tuolumne County Behavioral Health Department is holding a 30-day public review and comment period for the Mental Health Services Act (MHSA) Innovation Component Plan. This review period begins March 29, 2010 and ends April 30, 2010. A public hearing is tentatively planned at our Behavioral Health Advisory Council Meeting of May 5, 2010. The meeting will take place at Tuolumne County Behavioral Health Department’s Conference Room at 105 Hospital Road, Sonora, California.

The Innovation Plan outlines a learning project that will contribute to the transformation process of our mental health system of care. A Public Comment Form is available at the end of this document. Please review our Plan and send comments, and/or questions to the staff member noted below:

MHSA Innovation Plan: Public Comments submitted to: Susan Sells, MHSA Coordinator

[email protected] Telephone: (209) 533-6245

Standard Mail: Tuolumne County Behavioral Health Department Attn: MHSA Innovation

2 South Green Street Sonora, California 95370

Sincerely,

Beatrice Readel

Beatrice Readel, LCSW Executive Director





Tuolumne County Behavioral Health Department

Tuolumne County Behavioral Health www.tcbehavioralhealth.com

Mailing Address: 2 South Green St. Sonora, CA 95370

24 hour crisis line: (209) 533-7000


Sue McGuire, ASW, MSW Quality/Managed Care Manager [email protected].

Tracie Riggs Fiscal Manager [email protected]

Business locations and contact information:

Behavioral Health Admin. 105 Hospital Rd. Sonora, CA 95370 Phone: (209) 533-6245 Fax: (209) 588-9563

CAIP (Crisis Assessment & Intervention Program) 105 Hospital Rd. Sonora, CA 95370 Phone: (209) 533-7000

(800) 630-1130 Fax: (209) 533-7007

Mono Clinic 197 Mono Way Sonora, CA 95370 Phone: (209) 533-5400 Fax: (209) 533-5411

Cabezut Clinic 12801 Cabezut Rd. Sonora, CA 95370 Phone: (209)-533-3553 Fax: (209) 533-8259

Lambert Community Center 347 West Jackson St. Sonora, CA 95370 Phone: (209) 533-6695

(209) 533-4879 Fax: (209) 588-2781




EXHIBIT A

INNOVATION WORK PLAN COUNTY CERTIFICATION

County Name: Tuolumne County

County Mental Health Director

Name: Tracie Riggs

Telephone Number: (209) 533-6245

E-mail: [email protected]

Mailing Address: 2 South Green Street Sonora, California 95370

Project Lead

Name: Susan Sells, MHSA Coordinator


E-mail: [email protected]

Mailing Address: 2 South Green Street Sonora, California 95370

I hereby certify that I am the official responsible for the administration of public community mental health services in and for said County and that the County has complied with all pertinent regulations, laws and statutes for this Innovation Work Plan. Mental Health Services Act funds are and will be used in compliance with Welfare and Institutions Code Section 5891 and Title 9, California Code of Regulations (CCR), Section 3410, Non-Supplant.

This Work Plan has been developed with the participation of stakeholders, in accordance with Title 9, CCR Sections 3300, 3310(d) and 3315(a). The draft Work Plan was circulated for 30 days to stakeholders for review and comment and a public hearing was held by the local mental health board or commission. All input has been considered with adjustments made, as appropriate. Any Work Plan requiring participation from individuals has been designed for voluntary participation therefore all participation by individuals in the proposed Work Plan is voluntary, pursuant to Title 9, CCR, Section 3400 (b)(2).

All documents in the attached Work Plan are true and correct.

5/19/10 Director Health DirectorlDesignee) Date Title



EXHIBIT B

INNOVATION WORK PLAN Description of Community Program Planning and Local Review Processes

County Name: Tuolumne County Work Plan Name: Building a Life at Home

Innovation Plan

Instructions: Utilizing the following format please provide a brief description of the Community Program Planning and Local Review Processes that were conducted as part of this Annual Update.

1. Briefly describe the Community Program Planning Process for development of the Innovation Work Plan. It shall include the methods for obtaining stakeholder input. (suggested length – one-half page)

The Community Program Planning Process consisted of a range of focus groups and key informant interviews that generated valuable input specific to Tuolumne County’s Mental Health Services Innovation Plan. Presentations to NAMI Chapter members, Tuolumne County Behavioral Health Advisory Board, and the Tuolumne County Mental Health Leadership Council were held in February, and a focus group made up of consumers participating at the Peer Help Lambert Center occurred in March. Other critical key stakeholders interviewed over this two month period included representatives from the Tuolumne County Adult Protective Services, Public Guardian, Probation, Children's Welfare Services, Omsbudsman, County Council, and Sheriff Departments. The Sonora Police Chief provided input for this plan, as well as representatives that provide advocacy and outreach services to the Spanish-speaking and Native American residents in our community. Because the Innovation component of the MHSA is different from other components of the Tuolumne County MHSA (CSS, PEI and WET) in that its primary focus is learning rather than service delivery, the MHSA Coordinator made sure that the attendees of both focus groups and key informant interviews were made aware of this novel approach to plan development.

Priorities and discussions generated between 2004 and 2008 and documented from the CSS, PEI and WET planning processes were revisited and shared when interviewing individuals and groups in February, and March of this year. Input shared included summaries from both the PEI and WET planning processes in 2007 and 2008 - which had been obtained through a large community forum with 70 residents in attendance; five community stakeholder meetings averaging a total of 50 participants each; 45 focus groups and key informant interviews; and 375 surveys completed. Input from the CSS community planning process completed in 2004 and 2005 was also summarized and shared. The CSS planning strategy resulted in excess of 1,100 individuals participating in the planning process and providing nearly 6,000 comments regarding mental health needs, impacts, and issues facing Tuolumne County.

Enclosure 3

2. Identify the stakeholder entities involved in the Community Program Planning Process.

The following stakeholder entities were involved in Tuolumne County’s MHSA Innovation Component Commmunity Planning Process:

Tuolumne County Mental Health Leadership Council, Tuolumne County Behavioral Health Advisory Board

Tuolumne County NAMI Chapter Board and Members NAMI Housing Director

Peer Help Center staff and volunteers A focus group of consumers participating at the Peer Help Lambert Center Tuolumne County Behavioral Health staff and clinicians

Outreach and Engagement advocates/case managers representing both the Spanish-speaking and Native American residents Representatives from Tuolumne County Sheriff Department, Public Guardian, Probation, Adult Protective Services, Children's Welfare Services, and County

Council Director of Ombudsman Program Police Chief, Sonora Police Department

3. List the dates of the 30-day stakeholder review and public hearing. Attach substantive comments received during the stakeholder review and public hearing and responses to those comments. Indicate if none received.

Copies of the MHSA Innovation Plan were made available to all stakeholders through the following methods: • Electronic format: the Tuolumne County Behavioral Health Department website: www.tuolumnecounty.ca.gov • Print format was available at the Tuolumne County Behavioral Health Department, the Tuolumne County Peer Help Support Center, and the Tuolumne County Library • The Tuolumne County MHSA Innovation Plan was e-mailed to Tuolumne County Behavioral Health Advisory Council, and the MHSA Leadership Council • Plans were e-mailed or mailed to all persons who requested a copy • An informational flyer was sent to stakeholders regarding the Plan’s availability, including where to obtain it, where to make comments, and where/when the public hearing would be held

The 30 day review was from March 29th to April 30th , 2010. The Public Hearing was held on May 5, 2010 at 5:00 pm at The Tuolumne County Behavioral Health Department located at 105 Hospital Road, Sonora, CA in the Community Conference Room.

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Enclosure 3

May 5, 2010 Public Hearing Comments:

Question #1 - During the public hearing a question was raised by a community resident about seniors being represented on the Innovation "Building a Life At Home" Task Force. Answer: there would be a representative from the Ombudsman Program on the Task Force for this population.

Question #2 - There was clarification requested about what it means to “bring them home”. Answer: It was explained that Tuolumne County Behavioral Health Department's Innovation Project plans to use NAMI housing, the MHSA housing project or locate small studio apartments or a room to rent in a house here in Tuolumne County, with subsidy funds made available for both housing and transportation. With the support of comprehensive managers and peer recovery wellness and resiliency services, it is felt these people could live productive and independent lives.

Question #3 - Another question raised was “how are people selected?” Answer: There would be a staff team made up of the three case managers, an LPS case manager , and three clinical managers who would decide which people would be the most appropriate to bring back to the County. Bringing clients home not only saves money, but is better for the client.

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2010/11 ANNUAL UPDATE EXHIBIT F5 INN NEW PROGRAM DESCRIPTION

County: Tuolumne

Program Number/Name: “Building a Life at Home” Innovation Plan

Date: March 25, 2010

Select one of the following purposes that corresponds to Increase access to underserved groupsthe Innovation’s key learning goal. Please note that while Increase the quality of services, including better outcomesthe program might embody all four purposes, a learning Promote interagency collaborationgoal cluster around a single Essential Purpose. Increase access to services

1. Describe which of the four essential purposes of Innovation is most relevant to your learning goal and why is this purpose a priority for your county.

Throughout both the MHSA Innovation and CSS community planning process, family members and peers raised concerns and complaints about the high number of severely mentally ill residents that are conserved and placed in out- of -county residential facilities. Family member and familiar peer networks are unable to provide support and assistance to help persons with mental illness to be active members in the community in which they themselves have chosen or desire to live. – Tuolumne County rates for LPS conservatorships have been consistently higher per capita then two thirds to three-fourths of the counties in California. Rates have stayed consistently high over the years (34 in 2007/2008, 23 in 2008/2009, and 27 in this fiscal year). A major factor in the high conservatorship ratio is due to long term consecutively renewed LPS conservatorships for consumers who have become dependent on residing in facilities outside our community in neighboring counties. These somewhat permanent relocations and renewed conservatorships are, in part, attributed to stigma and barriers associated with concerns and attitudes about persons suffering from severe mental illness and their ability to live successfully and independently in the rural community setting. For Innovation planning, we have interviewed key stakeholders representing diverse organizations, systems, and representatives. The organizations represented included the Public Guardian’s Office, Adult Protective Services, Child Welfare Services, Law Enforcement (Police and Sheriff Departments), Probation, Ombudsman, and Tuolumne County Behavioral Health Department staff. Additionally, outreach and engagement consultants that represent the needs of both the Spanish-speaking and Native American residents, along with NAMI family members and consumers were included. These persons and organizations collectively contribute or embody the resources that would be necessary to prevent the need to conserve severely mentally ill residents in long term residential facilities and provide collective support in the community. It was discovered that there are strong, diverse and negative systemic cultural attitudes and beliefs that may affect our community’s decision makers about what is best for severely mentally ill peers. There are two core attitudes incorporated into this belief system. First is the view that severely mentally ill clients must be placed in long term residential placement as they are unable to meet their basic needs or develop independence from caretakers. Secondly, that keeping persons suffering from severe mental illness in facilities will protect the community, based on vague fears and stigma attributed to perceived dangerous behaviors arising from mental illness which has often been dramatically promoted in the media. One contributing factor for these community attitudes and beliefs is the previous reliance on an acute locked psychiatric unit (as part of the Tuolumne General Hospital) to stabilize severely mentally ill residents. Inpatient care has been synonymous with appropriate treatment for the mentally ill since 1988. Our Board of Supervisors closed this unit on December 31, 2008 due to the prohibitive rising costs of inpatient service provision. In response, Tuolumne County Behavioral Health Department developed a strengthened outpatient system including a 23 hour crisis stabilization program, and augmented after hours walk-in service, and crisis and assessment service integration with the new systems. This more intensive outpatient model functions as the successor system from the involuntary locked inpatient

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treatment for acute psychiatric needs to a voluntary accessible crisis management system. Many residents and community agencies were concerned that closing the acute psychiatric unit reflected a decline or weakening in our department’s commitment to our peers and family members, when in fact it reflected a move toward more efficient, less restrictive and ultimately more effective practices to serve people in the community environment. Along with the 23-hour crisis stabilization and walk-in services, the Peer Help Center activities have been strengthened with MHSA funds and have included the employment and contracting of peers as a powerful model in the recovery process. In the last six months, there has been a 31% increase in local peer participation in a range of activities, including six peer run support groups at the Center.

Despite these successful changes and enhancements, our community’s culture (attitudes and beliefs) mitigates against bringing consumers home to live independently with family and peers who are available for support and assistance. Overall, these core attitudes and beliefs need to be addressed so that peers who have been institutionalized out of county can return home to participate successfully in the commitment to peer recovery, wellness and resilience activities and to benefit from families and friends who can be available to provide the community support network needed for healthy living.

For these reasons, we are proposing an Innovation strategy to develop an effective community collaborative partnership that will work together to improve and strengthen coordination and collaboration and reduce stigma between mental health and the varied stakeholders. We are excited to share that we have received agreement from all the key stakeholders who participated in our initial planning and interview to join in a Task Force, and will also include two case manager consultants that provide outreach and engagement to both Spanish-speaking families and Native American residents. This is our essential purpose - to learn if better ways of collaborating with our community (who hold many diverse beliefs) can over time address cultural attitudes, improve services for our mentally ill residents, reduce stigma, and create a more active community engagement that supports mental health peer recovery, wellness and resilience strategies. Our Innovation Plan is titled “Building a Life at Home”. This Innovation Plan hopes to create new planning processes across a range of social service agencies, new training and education practices and approaches, and ultimately new treatment and recovery services or interventions that improve mental health services for our mentally ill residents in Tuolumne County. It is important to note that effective community collaborations that have formed to address community concerns is not a new concept to Tuolumne County, but the type of interagency collaboration we propose in this plan is innovative related to the severely mentally ill population that has been viewed as the predominantly sole responsibility of the Tuolumne County Behavioral Health Department. For many years our community has collaborated on coalitions directed toward teen drug and alcohol abuse prevention, and suicide prevention issues– but the critical difference is that these community-wide collaborations have always had common agreement across all the members from the start about how to work together to impact and lessen a mutually agreed upon community issue and/or problem. Our proposed Task Force does not necessarily agree on the nature of the problems or solutions specific to our severely mentally ill residents. The collaboration we propose will utilize the successful building strategies currently used in the non-mental health focused community coalitions (Tuolumne County Suicide Prevention Task Force, YES Coalition supporting youth drug and alcohol prevention strategies). These strategies will be adopted for our current Innovation project. We plan to bring the community representatives and key stakeholders to the table including those who have expressed strong differences –many who are adamantly opposed or skeptical of the peer recovery, wellness and resilience models. These key community stakeholders representing strong and diverse beliefs have never met regularly to discuss and reach census on how best to provide services and support our community’s severely mentally ill clients. Key stakeholders have agreed to participate on this newly formed Task Force to discuss, listen

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to and evaluate the diverse range of community beliefs and perspectives specific to addressing the needs of mentally ill residents in our community and reconsidering the practice of long term out of county institutional placement and diversion. We hope to learn that, if successful, stigma can be reduced by directly addressing the cultural attitudes and beliefs through unifying key organizational decision makers with peers and family members and Behavioral Health staff on the Task Force. Also, we hope to demonstrate the Task Force members can work together over a three year period to effectively assess, engage and substantiate that the interventions proposed will be effective alternatives to residential housing out of county. Supportive interventions will be assessed by this Task Force to evaluate whether consumers can transition out of long term residential homes and return to our community to live successfully as members of the community over time. The Task Force will also assess the initiation of supportive intervention to reduce the number of first time and repeat placements of mentally ill consumers currently living in the county who are at risk of higher or more restrictive levels of care. The Task Force will document and track what worked and did not work with this plan, including assessing and documenting the community services that work well for people with mental health disabilities (i.e. are job training and placement activities effective, are public transportation opportunities accessible to peers?). What we learn by the end of the project will be shared with both our community and other rural counties faced with similar issues and barriers throughout California.

2. Describe the INN Program, the issue and key learning goals it addresses, and the expected learning outcomes, State specifically how the Innovation meets the definition of Innovation to create positive change; introduces a new mental health practice; integrates practices/approaches that are developed within communities through a process that is inclusive and representative of unserved and underserved individuals; makes a specific changeto an existing mental health practice; or introduces to the mental health system a community defined approach that has been successful in a non-mental health context.

Innovation Project Description: The Building a Life at Home Project proposes an innovative collaboration between our existing Behavioral Health Department, consumers and families, representatives of Spanish-speaking and Native American residents, and key and diverse stakeholders representing organizations and systems (Public Guardian, Adult Protective Services, Law Enforcement, Probation and Ombudsman programs) who all play a part in the decision to conserve severely mentally ill residents in long term residential in and out-of-county facilities or who would refer community members for more restrictive services. Our Innovation Plan meets the definition of Innovation as the project introduces our local mental health system to a community defined approach of collaboration that has been successful in a non-mental health context. We hope to ultimately create positive change with a process that is inclusive and representative of unserved and underserved individuals. We propose to form a Task Force that meets regularly to address community- issues related to the mentally ill (addressing fears, concerns, and hopes) and alternatives to restrictive higher level placements.. This type of collaboration has never existed before in our county specific to behavioral health issues for the conserved population, as the prevailing community attitudes have been that mentally ill issues are the sole responsibility of Tuolumne County Behavioral Health Department and its’ professionals.. The “Building a Life at Home” Task Force will oversee the development, implementation, and assessment of best practice case management and peer recovery and resiliency strategies that target mentally ill consumers currently living at home but requiring a higher level of care, and mentally ill peers residing in residential facilities in and out of county that need to return home to live safe and independent lives. While the clinical practices we propose to pilot are not philosophically new, the composition, structure, diverse attitudes and beliefs, and role of the newly formed community collaborative with regard to oversight and assessment to these practices is innovative to our community, and crucial to our goal to change community attitudes, cohesion and engagement over time.

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Task Force members will create and engage in a process to explore and make a commitment to establish alternatives to long-term institutionalization. Specific Task Force activities will include: Developing a collaborative structure to guide the three year learning project, ensuring that

relevant government agencies, consumers, and family members, and representatives of Spanish-speaking and Native American residents are actively participating;

Developing formal collaborative agreements to guide the Task Force and three year learning project (i.e. number of collaborative members who sign a Memorandum of Understanding as a commitment to the collaborative process);

Guiding, assessing and selecting the learning project’s relevant data needed for both process and outcome evaluation to assess changes in attitudes of Task Force members and community over time, and how to best communicate results specific to what works and does not work with the project’s service model interventions (e.g. document anecdotal stories specific to personal experiences, successful service methods applied over three year period, peer recovery success stories, use of blogging, videotaping, and/or pictures to share project activities, Task Force participation in regular site visits?);

Offering ongoing training and outreach to Task Force members, as well as the staff from members’ organizations and advocacy groups and the community at large regarding stigma and mental illness, as well as information about intensive case management and peer recovery services implemented as part of this project.

The heart of our Innovation Project addresses the learning goal “Can we change/shift cultural attitudes and beliefs in community systems over time in Tuolumne County from the current standard that institutionalization of severely mentally ill is best for the consumer and safest for community - to the understanding that consumers can live at home independently and safely, with recovery, wellness and resilience services available as needed, and that the consumers can become contributing members of our community?. What is the best way to organize and structure the Task Force to produce this kind of significant change in understanding, attitude, engagement, and ultimately service delivery? Over time, can we reduce the high number of permanent conservatorships by marshalling the cooperation, resources and expertise of consumers, families of consumers, and all county and community agencies that respond to or are involved with the necessity and determination to place our severely mentally ill residents in long-term out-of-county residential facilities? And… is there stigma related attitudes about severely mental ill clients that can be addressed through an ongoing Task Force?

Through the key informant interviews we have received agreement from all critical partners that they are willing to attend regular meetings as Task Force over the next three years.

The primary learning goals of this project are:

1. To determine the best way to develop a new approach to organizing, structuring and convening a community Task Force to increase awareness, agreement, cooperation, collaboration, and implementation of a better way to deliver services in Tuolumne County for individuals with serious mental illness and their families; and in the process successfully address the understanding, attitudes and beliefs among members of the Task Force and , the agencies and social networks they represent;

2. To determine if there is a corresponding change in community understanding, attitudes, collaboration, engagement, and cohesion regarding positive treatment options within Tuolumne County for people with serious mental illness and their families;

3. To determine if fewer mentally ill in crisis are placed in out of county residential facilities, and/or are allowed to return home more quickly with client-driven peer support services and

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case management assistance as a result of the project’s development of increased cooperation, collaboration and awareness through a Task Force,; and if the number of permanent conservatorships can be reduced over a three year period;

4. To determine if this innovative collaboration can be replicable in our community to address other difficult cultural differences locally specific to mental health, and is this project replicable for other small rural counties in California if successful in aiding a transformation of our local cultural beliefs about the abilities of the mentally ill to live at home.

A pilot of integrated case management and peer recovery services is proposed as part of the strategy to change our understanding, culture and attitudes. This service component of the project will be implemented while forming and supporting the new Building a Life at Home Task Force. This service component of the Innovation Plan is not conceptually new, though innovative in the degree of peer support integration planned and critical to our learning goal of changing cultural beliefs and attitudes. We know that change is difficult - as it contradicts well-developed views and the medical and public health models currently in place. Change often questions the common practice of protection against anticipated negative effects of problems rather than empowerment to deal with them; reversing these tendencies requires change from a focus on problems to a focus on human growth and development. For this reason, and with support, buy-in and guidance from the newly formed Task Force, we hope to demonstrate to our community that best practice case management and peer support activities can be safe alternatives to out-of-county residential facilities and reduction of permanent conservatorships, in order to successfully affect change in our community understanding over time. We have prepared members of the newly formed Task Force that our plan may not succeed by the end of the grant period.

The service component for this project , as currently envisioned, is as follows: Hire three new full time case management staff, including a nurse case manager and with a preference for peers. All three case managers will be trained in the Peer Recovery, Wellness and Resilience model – to ensure that peers are empowered with training and help as needed, as well as assistance developing and/or strengthening current Peer Support Systems for individuals transitioning from crisis or short-term hospitalization and/or residential care (e.g. a community-based team to provide encouragement and support after crisis events with follow-up calls and reminders for appointments). The new staff will not be asked to impose a structure of support in the peer community population, but instead would support these volunteers in leadership roles to help strengthen peer support systems already in place. Case managers will also work closely with the Tuolumne County Behavioral Health LPS Conservatorship Case Manager to bring conserved peers back into Tuolumne County, and coordinate closely with the Full Partnership Services (FSP) staff to ensure effective continuum of care services and team support as needed to those peers transitioning from a higher level of care. Funds would also be budgeted to help subsidize housing and transportation costs for consumers returning to live in the county from residential and acute settings both in and out of county. Shared housing models could be developed, where four to six consumers share a home close to resources, with intensive case management support offered as needed. Training in basic daily living skills (budgeting, shopping and preparing meals, managing money, doing housework, prioritizing daily tasks, accessing community resources, medication usage, etc.) could be offered, with the goal for newly conserved consumers and peers at risk to be able to take care of their needs and be self-sustaining over time. This new case management model will ensure that peers are assessed quickly during home visits in order to help identify symptoms, implement early stabilization and avoid hospitalizations. The newly hired nurse case manager would help educate peers in monitoring medication, and would selectively monitor and track medication usage All case managers would educate peers identified as at risk of a higher level of care by assessing/identifying warning symptoms of their disease and assisting with setting

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goals for the ongoing recovery process. They can also help peers to advocate and communicate clearly with their primary physicians about their medical needs. New services would be provided for three years, with the goal of bringing home 6 consumers by the end of each year (saving the BHD budget $135,000 each year for three years, totaling $405,000 by end of year three), with a total of 18 of the 27 conservators stabilized and living independently (or in less restrictive environments) by the end of year three. Funds saved from placements could help to sustain the new case management staff positions over time, and provide ongoing transportation and housing funds to consumers. This intensive case management model for consumers at risk of placement would also reduce future conservatorship costs. Additionally, it is anticipated that 30% of the new staff’s time specific to case management could be Medi-Cal billable – ensuring additional funds to sustain these activities.

As a result of developing and implementing and assessing this innovative, county-wide comprehensive Task Force – and implementing best practice intensive case management and strengthening our peer recovery, wellness and resiliency community - it is our hope that a number of positive changes and learning outcomes will result:

1. The community’s understanding shifts over time, so that members believe that mentally ill residents can live safely and independently at home with ongoing case management services and strong peer community support,

2. Increased level of cooperation, confidence and mutual understanding will occur among Task Force members regarding peer recovery, wellness and resiliency strategies, thereby building

3. community capacity to better support our mentally ill consumers, 4. Changes may occur in administrative processes/organizational practices of Task Force

agencies specific to permanent conservatorships county-wide, 5. There will be fewer severely mentally ill placed out of county in residential care, and more

consumers living safely and independently in our community with community-based peer support and case management services available as needed,

6. As peers will be brought home from residential facilities out of county over a three year period, there will be an increase in consumers involved in peer support community programs and activities, as well as an increase in families, friends, and Task Force members involved and engaged with peers in our community,

7. Ongoing education and training will be available regarding stigma and mental illness, as well as information about intensive case management and peer recovery services implemented as part of this project, and this will change the extent to and ways that Task Force members and agencies they represent (as well as other community members) will engage with consumers and families, which will lead to changes in information, attitudes and behaviors toward mentally ill consumers in Tuolumne County.

If successful at the end of the three year plan period, the Building a Life at Home Task Force will continue to meet and collaborate, and intensive case management and peer driven support services will continue and be self-sustaining, due to savings from cost of residential care.

2a. Include a description of how the project supports and is consistent with the applicable General Standards as set forth in CCR, Title 9, Section 3320.

This Innovation work plan incorporates the six standards applicable to all MHSA activities: #1 Community Collaboration – Community Collaboration is a key to the development of this Innovation Project. The Building a Life at Home Task Force represents an interagency collaboration between peers, families of peers, agencies and organizations who all play a part in the decision to conserve severely mentally ill residents in long term residential out-of-county facilities. This project initiates and

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strengthens collaboration and linkages in our community. #2 Cultural Competence –This plan demonstrates cultural competency and capacity to improve overall health outcomes for all residents of Tuolumne County with serious mental illness. An active Task Force, with representatives of both the Spanish-speaking and Native American residents, as well as peers and families of peers will assess and oversee culturally relevant intensive case management, and peer support services as an alternative to long term residential placement for local consumers. #3 and #4 Client and Family Driven Mental Health System – This plan includes the ongoing involvement of consumers and family in roles such as, but not limited to, program development, task force participation, case management services, and peer recovery, wellness and resiliency services. Both peers and the local chapter of NAMI family members have agreed to participate on the Building a Life at Home Task Force. #5 Wellness and Family Driven Mental Health System – This plan’s intent is to increase resilience and promote recovery and wellness for peers with serious mental illness who are currently in residential facilities by bringing them home safely over time, as well as peers who are currently at risk of higher levels of care in our community. Our project will provide targeted peers with a continuum of care ranging from specialty intensive case management mental health services with a focus on peer recovery best practices, to peer support services and programs. This plan addresses overall health and wellness for mentally ill residents in Tuolumne County. #6 Integrated Service Experience – Through a stronger collaboration with interagency Task Force members, this plan will encourage and provide support to help peers with access to a full range of peer recovery and support services that includes Peer Help Center’s PRIDE Support Groups; Benefits Specialist; Senior Peer Counseling; Mother Lode Job Training; Food Bank; NAMI and MHSA Housing opportunities; Teen Center for transition age youth; Meals on Wheels; Lifeline; Energy and Weatherization Services; Catholic Charities outreach and engagement; and more. Engaging peers in community support services will help to ensure they receive the help and assistance needed to live safely and independently when they return back into our community. 2b. If applicable, describe the population to be served, number of clients to be served annually, and demographic

information including age, gender, race, ethnicity, language spoken, and situational characteristic(s) of the population to be served.

Our target population to be served will be 60 or more severe mentally ill peers who have experienced at least one hospitalization and/or psychiatric emergency visit and/or a placement in residential facilities in and out of the county. Description of the population to be served is as follows: Age: 2% youth 17, 3% -transitional age youth, 80% - adults, and 15% - older adults. Gender: 47% - male, and 53% - female. Race: 89% - white, 4% - Native American, 2% - Black, and 5%- unreported. Primary Language: 100% -English, Ethnicity: 92% - non-Hispanic, 4% - Mexican/Mexican American and 4% - unreported. 1. Describe the timeframe of the program. In your description include key actions of the time line and milestones

related to assessing your Innovation and communicating results significance and lessons learned. Provide a brief explanation of why this timeline will allow sufficient time for the desired learning to occur and to demonstrate the feasibility of replicating the Innovation.

June, 2010 Anticipated DMH/MHOAC approval July, 2010 – June, 2013 Innovation Project three year project period July –September 2010 Form Interagency Task Force, and with Task Force members set dates

for meetings, define purpose, role and level of oversight with Innovation Project; develop a collaborative structure to guide the three year learning

Project; develop formal collaborative agreements; assess and select the learning project’s relevant data needed for both process and outcome

evaluation to assess changes in attitudes of Task Force members and community over time, and how to best communicate results specific to what works and does not work with the project’s service model

interventions. July -September 2010 Initiate project service model, hire and train case managers, develop

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strategies with Peer Help Center staff and volunteers to support and strengthen Peer Support/ Recovery services; and develop

trainings for Task Force members, as well as the staff from members’ organizations and advocacy groups, regarding stigma and mental illness.

October- December 2010 With Task Force, provide a preliminary assessment and evaluation of early project implementation activity.

Sept., 2010 – June, 2013 Full implementation of service component of Innovation Plan (Case management and Peer Support/Recovery services in place).

July, 2011 Medi-Cal Feasibility Study completed for first year service activities January, 2011 – June, 2013 Make project adjustments as necessary based on Task Force process

evaluation assessments. January 2011 Mid year process evaluation of Task Force effectiveness and services

provided to date, and then evaluation of project every six months until end of project.

May - July 2013 Full evaluation/assessment of Innovation Project, including effectiveness of Task Force, case management and peer recovery services, and rates

of permanent conservatorships and out of county residential facilities placements – determination of efficacy and feasibility or replication and

dissemination of results.

We are confident that this three year timeline will allow sufficient time to learn if we change/shift cultural attitudes and beliefs in community systems over time in Tuolumne County; and over time reduce the high number of permanent conservatorships. We also anticipate that the project period will allow us the time needed to provide a full evaluation/assessment of the Innovation Project to disseminate results, and determine the project’s efficacy and feasibility for other small counties in California. 2. Describe how you plan to measure the results, impacts, and lessons learned of your Innovation, with a focus on

what is new or changed. Include in your description how the perspectives of stakeholders will be included in assessing and communicating results.

We hope to learn from this project if we can change/shift cultural attitudes and beliefs in community systems over time in Tuolumne County from the current standard that institutionalization of severely mentally ill is best for the consumer and safest for community - to the understanding that consumers can live at home independently and safely, with recovery, wellness and resilience services available as needed, and that the consumers can become contributing members of our community. Additionally, we hope to learn the best way to organize and structure the Task Force to produce significant change in understanding, attitude, engagement, and ultimately service delivery; and if we can reduce the high number of permanent conservatorships by the end of our three year project.

To capture change in Task Force attitudes and beliefs, we will develop attitudinal pre and post surveys prior to forming the Task Force – to ensure we have baseline data from inception of project. Once the Building a Life at Home Task Force is formed, the members and staff will together plan and design both process and outcome evaluation strategies in the first three months of project implementation to assess and communicate results of the project’s short and long term goals over time (see primary learning goals listed under question #2 above) - as part of a comprehensive evaluation to measure the results, impacts and lessons learned from this project. Data collection methods to assess both the ongoing involvement and support of Task Force members, as well as the success of the project’s service component could include (but are not be limited to): pre and post attitudinal surveys of Task Force members; documentation of Task Force members’ participation at regular meetings, peer recovery activities and site visits; documentation

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of trainings provided to agencies and organizations; and anecdotal stories collected of peer recovery successes, possible use of blogging, videotaping, and/or pictures to share project implementation strategies. The data collected will be analyzed on an ongoing basis to evaluate and modify the implementation, as needed.

Ultimately, the Task Force’s engaged and active review, assessment and direct involvement of the project’s service component; attitudinal surveys indicating a shift in cultural attitudes and beliefs toward peer recovery, wellness and resilience models; as well as the overall reduction of conserved mentally ill residents institutionalized out of the county– but living successfully at home – will determine the success of this project, and whether this project can be replicated in other rural counties in California.

Data, outcomes, and the experience in learning during the course of implementation will be shared regularly at the Task Force meetings, as well as on a minimum of an annual basis with a diverse group of stakeholders to gather their input and feedback and make changes to project implementation. The Building a Life at Home Task Force members will also provide feedback regularly to the Tuolumne County Behavioral Health Department Advisory Board, MHSA Leadership Council, on our Tuolumne County Behavioral Health and Network of Care websites, and finally through the Board of Supervisors at the end of the three years. A full evaluation report will be completed during the final year of the Build a Life at Home project using the measurements designed in the first three months of project implementation. The results will be shared with Task Force members, stakeholders, and throughout the community to share learning and gather input regarding efficacy of the project and long term funding strategies.

3. Please provide a Budget Narrative that includes the entire budget for each Innovation Program, and also provide for each Innovation Program projected expenditure dollar amount by each fiscal year during the program time frame. (For Example, Program 01-XXXX, the entire project is $1,000,000. The first year projected amount will be $250,000, the second year projected amount is $250,000, the third year is $250,000 and the fourth year is $250,000.) Please also describe briefly the logic for this budget; how your proposed expenditures will allow you to test your model and meet your learning and communication goals. Please also describe briefly the logic for this budget; how your proposed expenditures will allow you to test your model and meet your learning and communications goals.

The Innovation budget will include support a portion of the MHSA Coordinator (10% FTE) to oversee the project process and outcome evaluation and facilitate the Task Force meetings and strategies, and a Clinical Program Manager (20% FTE) to supervise the project's service component staff as well as provide support and assistance with the “Building a Life at Home” Task Force.

In addition to these two positions, the department will also budget for two Recovery Counselors and one Nurse Case Manager, for a total of $195,000 each year. Travel expenses are another important component of the Innovation budget, as half of the target population currently reside in residential facilities primarily outside the county, and staff will be required to travel extensively in county to provide support to peers in crisis. Mileage is estimated using the county mileage per diem rate of $.50 per mile. Transportation subsidies will also be provided as needed for clients, estimated at $50 per client, per month.

The department estimates that 20-30% of the case manager time will be billable to Medi-Cal. The first year will be at a much lower rate as we collaborate with other county agencies to bring our conserved clients home, once they are home they each will receive intensive case management from the individuals listed above. The three case managers will also provide

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crisis services to clients who require a higher level of care, therefore negating the need for placement within a residential care facility.

As the clients are brought home, the placement costs will decrease, the savings from bringing these clients home will allow us to continue with the program beyond the first three years. It is estimated we will bring home six clients in the first year, estimated savings as a result of bringing these clients home is $135,000. For each year we bring clients back home, we reduce the cost of out of county placement, resulting in additional resources for services to be provided within the county. The department will budget to provide housing subsidies out of the savings recognized from the reduced level of care to independent housing; subsidies have been estimated at $250 per client, per month.

Year One: Case Managers $ 195,000 MHSA Coordinator 9,279 Clinical Program Mgr 18,679 Housing Subsidies 17,500 Travel 39,000 Transportation Subsidies 3,100 Administration 42,384 Total Annual Estimate $ 324,942

Year Two: Case Managers $ 195,000 MHSA Coordinator 9,279 Clinical Program Mgr 18,679 Housing Subsidies 35,600 Travel 39,000 Transportation Subsidies 6,600 Administration 45,624 Total Annual Estimate $ 349,782

Year Three Case Managers $ 195,000 MHSA Coordinator 9,279 Clinical Program Mgr 18,679 Housing Subsidies 53,500 Travel 39,000 Transportation Subsidies 10,300 Administration 48,864 Total Annual Estimate $ 374,622

4. If applicable, provide a list of resources to be leveraged.

Tuolumne County Behavioral Health Department will provide an estimated cash match of $135,000 each year for three years to support the Innovation Project, with funds from the placement reduction and Medi-Cal match. Additionally, by the end of the first year of case management services, a feasibility study will be generated to estimate the amount of Medi-Cal revenue that could be generated if Medi-Cal is billed for appropriate case management services, and this will be included as leveraged

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resources to continue supporting this project in years two and three, and beyond. We anticipate between 20 to 30% of the three case managers’ time will be Medi-Cal billable. If successful, funds saved from the ongoing residential placement costs will be made available to continue the ongoing Task Force and service component of this project once the three year project comes to an end.

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EXHIBIT D

Innovation Work Plan Description(For Posting on DMH Website)

County Name

Tuolumne County

Work Plan Name

Annual Number of Clients to Be Served (If Applicable) 60 Total

Building a Life at Home Innovation Project

Population to Be Served (if applicable):

Our target population to be served will be severe mentally ill peers who have experienced at least one hospitalization and/or psychiatric emergency visit and/or a placement in residential facilities in and out of the county.

Project Description (suggested length - one-half page): Provide a concise overall description of the proposed Innovation.

The Building a Life at Home Project proposes to change cultural attitudes and beliefs through an innovative collaboration between our existing Behavioral Health Department, consumers and families, representatives of Spanish-speaking and Native American residents, and key and diverse stakeholders representing organizations and systems (Public Guardian, Adult Protective Services, Law Enforcement, Probation and Ombudsman programs) who all play a part in the decision to conserve severely mentally ill residents in long term residential in and out-of-county facilities or who would refer community members for more restrictive services. Our Innovation Plan meets the definition of Innovation as the project introduces our local mental health system to a community defined approach of collaboration that has been successful in a non-mental health context. We hope to ultimately create positive change with a process that is inclusive and representative of unserved and underserved individuals. We propose to form a Task Force that meets regularly to address community- issues related to the mentally ill (addressing fears, concerns, and hopes) and alternatives to restrictive higher level placements.This type of collaboration has never existed before in our county specific to behavioral health issues for the conserved population, as the prevailing community attitudes have been that mentally ill issues are the sole responsibility of Tuolumne County Behavioral Health Department and its’ professionals. The “Building a Life at Home” Task Force will oversee the development, implementation, and assessment of best practice case management and peer recovery and resiliency strategies that target mentally ill consumers currently living at home but requiring a higher level of care, and mentally ill peers residing in residential facilities in and out of

county that need to return home to live safe and independent lives. While the clinical practices we propose to pilot are not philosophically new, the composition, structure, diverse attitudes and beliefs, and role of the newly formed community collaborative with regard to oversight and assessment to these practices is innovative to our community, and crucial to our goal to change community attitudes, and create cohesion and engagement over time.

EXHIBIT E

Mental Health Services Act

Innovation Funding Request

County: Tuolumne Date: 24-Mar-10

Innovation Work Plans FY 09/10 Required

MHSA

Estimated Funds by Age Group

(if applicable)

No. Name Funding Children, Youth,

Transition Age Youth Adult Older Adult

1 Building a Life at Home 435100 8702 13053 348080 65265

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26 Subtotal: Work Plans $435,100 $8,702 $13,053 $348,080 $65,265

27 Plus County Administration

28 Plus Optional 10% Operating Reserve

29 Total MHSA Funds Required for Innovation $435,100

EXHIBIT F

Innovation Projected Revenues and Expenditures

County: Tuolumne Fiscal Year: 2009/10

Work Plan #:

Work Plan Name: Building a Life at H

New Work Plan

Expansion Months of Operation: 07/10-06/13

MM/YY - MM/YY

County Mental Health Department

Other Governmental

Agencies

Community Mental Health

Contract Providers Total

A. Expenditures

1. Personnel Expenditures

4. Training Consultant Contracts

5. Work Plan Management

6. Total Proposed Work Plan Expenditures

2. Operating Expenditures

3. Non-recurring expenditures

802,746

246,600

$1,049,346 $0 $0

$802,746

$246,600

$0

$0

$0

#########

b. FFP

c. (insert source of revenue)

B. Revenues

1. Existing Revenues

3. Total New Revenue

2. Additional Revenues

a. Realignment 200,000

414,246

$614,246 $0 $0

$0

$200,000

$414,246

$0 $614,246

4. Total Revenues $614,246 $0 $0 $614,246

C. Total Funding Requirements $435,100 $0 $0 $435,100

Prepared by: Tracie M. Riggs Date: 3/24/2010


______________________________________________________

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

Tuolumne County Behavioral Health Mental Health Services Act

INNOVATION COMPONENT PLAN

30 Day Public Comment Form March 29, 2010 to April 30, 2010

PERSONAL INFORMATION (optional)

Name: ________________________________

Agency/Organization: ________________________________

Phone Number: ____________ Email address______________

Mailing address:

MY ROLE IN THE MENTAL HEALTH COMMUNITY

__ Client/Consumer __ Family Member __ Education __ Social Services __ Service Provider __ Law Enforcement/ Criminal Justice __ Probation __ Other (specify) _________________

WHAT DO YOU SEE AS THE STRENGTHS OF THE PLAN? IF YOU HAVE CONCERNS ABOUT THE PLAN, PLEASE EXPLAIN.

Tuolumne County Administration Center (Mailing Address:) 2 South Green Street Sonora, CA 95370 Phone: 209/533-6245 Fax: 209/588-9563

Documents

Beatrice W. Readel, LCSW Director Development …archive.mhsoac.ca.gov/Counties/Innovation/docs/InnovationPlans/INN...May 29, 2010 · The Innovation plan was made available for public