Madera County Innovation Plan by wuyunyi

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									                      MADERA COUNTY
                 BEHAVIORAL HEALTH SERVICES
                                   Administration
                                                                           P.O. BOX 1288
JANICE MELTON, LCSW                                              MADERA, CA 93639-1288
DIRECTOR OF BEHAVIORAL HEALTH SERVICES                              PHONE (559) 675-7926
 eMENTAL HEALTH DIRECTOR                                              FAX (559) 675-4999
 eALCOHOL/DRUG PROGRAM ADMINISTRATOR   CONFIDENTIAL CLIENT INFORMATION FAX (559) 661·2818




     MADERA COUNTY BEHAVIORAL HEALTH
                SERVICES

         PROPOSED INNOVATIONS PROJECTS

                              APRIL      16,2010




                                          1
                              MADERA COUNTY

                         INNOVATION FY 2010 / 2011
                            TABEL OF CONTENTS




Program Summary                                                    3
Exhibit A County Certification                                     4

Exhibit B 	 Community Program Planning                             6

Exhibit C 	 Innovation Work Plan Narrative
            INN #1 New Model for Access Into Services              13
            INN # 2 Linkage to Physical Health by Pharmacist
            & Reverse Integration from Mental Health to Physical   48

Exhibit D 	 Innovation Work Plan Description
            INN #1 New Model for Access Into Services              62
            INN # 2 Linkage to Physical Health by Pharmacist
            & Reverse Integration from Mental Health to Physical   67

Exhibit E 	 Annual Update MHSA Summary Funding Request             71

Exhibit E5 	 INN Budget Summary                                    72

Exhibit F   INN Budget Narrative                                   74
Exhibit F   New Program/Project Budget Detail/Narrative
            INN #1 New Model for Access Into Services              79
            INN # 2 Linkage to Physical Health by Pharmacist
            & Reverse Integration from Mental Health to Physical   81
            INN Administration & Operation Saving                  83

Addendums 	                                                        85




                                       2
      Madera County Request for Fiscal Year 2010 – 2011 MHSA Innovation Funding
                                       Summary

Madera County is requesting MHSA Innovation (INN) funding for new INN work plans. The INN
work plan #1 is a collaboration with the emergency room staff, mental health staff and
peer/family members who will engage clients (and families) in crisis. The focus of the mental
health and emergency room staff will be for assessment of health problems, medication
management, and crisis services. Once the need for health and/or crisis services has been
resolved, the mental health staff will link the peer/family members to clients for follow-up
services in hopes they will be able to assist and engage the clients in recovery activities such as
outpatient treatment or community support groups.

The INN work plan #2 calls for a contract pharmacist and contract psychiatrist who will be
available for consulting with emergency room staff and primary care providers to provide linkage
of mental health and physical health. This model of using a pharmacist and psychiatrist to
consult with health practitioners was developed based on mental health staff reports that health
practitioners in general do not respond to their letters or phone calls but do tend to respond to
contacts by pharmacists or psychiatrists.

Innovation Plan (INN):
Madera County is requesting $854,297 for the new Innovation workplans, which includes
$387,697 from FY 10/11 planning estimates, $233,300 from FY 09/10 planning estimates, and
$233,300 from FY 08/09 planning estimated for the 10/11 INN Plan update.

  Type                 Program #              Funds Requested # of Clients
#1 INN Increase Access    #1 INN Increase Access        $661,022        250
to Services             into the System from Crisis
                          Service & Peer Support
#2     INN     Promote #2 INN Linkage to Physical        $19,200         50
Interagency                 Health and Reverse
Collaboration             Integration from Mental
                         Health to Physical Health
INN                            Administration           $105,053        N/A

INN                            Operating Reserve               $69,022            N/A




                                                 3
    EXHIBIT A 


County Certification




         4
                                       EXHIBIT A



                              INNOVATION WORK PLAN

                               COUNTY CERTIFICATION


 County Name:      Madera County

      County Mental Health Director                              Project Lead

 Name: Janice Melton                                Name: Debbie DiNoto

 Telephone Number: (559) 675-7850               Telephone Number: (559) 675-7850

 E-mail: jmelton@kingsview.org                      E-mail: ddinoto@kingsview.org

 Mailing Address:                                   Mailing Address:
 PO Box 1288                                        PO Box 1288
 Madera, California 93639                           Madera, California 93639




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.




                                  X~S~4/13/10
                                tor/Designee)           Date
                                                                     Director
                                                                     Title




                                                5
        EXHIBIT B 


Community Program Planning




            6
                                    EXHIBIT B

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


County Name:         Madera
Work Plan Name:      INN—1A and 1B New Model for Access Into Services and
                     INN—2 Linkage to Physical Health by Pharmacist & Reverse
                          Integration from Mental Health to Physical Health

Instructions: Utilizing the following format please provide a brief description of
the Community Planning and Local Review Processes that were conducted as
part of the 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)

During the MHSA stakeholder process for the PEI/WET, Housing, Cap/Tech and
Innovations planning, Madera County Behavioral Health Services (MCBHS) did
extensive outreach to the community regarding the Innovations component. This
process involved mostly focus groups, individual contacts, questionnaires,
community meetings, etc. At that time, clients, family members, stakeholders
and the public stated their priorities for planning purposes. During this process, it
was discovered that large group stakeholder meetings were not effective in
obtaining input. There are no behavioral health Community Based Organizations
(CBO's) in Madera County. Madera County BHS found that small focus groups
and questionnaires were more effective in obtaining public response. For the
Innovations planning, MCBHS did extensive interviews and small focus groups
where clients, family members, the public. Stakeholders stated they felt more
comfortable in expressing their ideas and concerns. MCBHS went to these
groups/organizations (rather than them coming to us) in order to obtain their
input.

Although there was extensive outreach during the prior year’s Innovations
planning process, MCBHS again went to key stakeholders, staff, and providers
and met with clients/family members. Focus groups were held at the places
where those groups normally met. Other locations were handicapped
accessible. Interpreters, including for the deaf and heard of hearing were also
available as necessary.

MCBHS explained the purpose of the MHSA Innovations component. Input was
sought regarding priorities and if the priorities had changed from the previous
year. MCBHS asked if they wanted to add any additional information to the
planning process.



                                          7
MCBHS also placed questionnaires in English and in Spanish regarding the
Innovations planning process on its website. Newspaper articles were sent to
the local papers regarding the Innovations planning process, how to contact staff
for input and the link to the website for responding to questionnaires.

During the focus groups and presentations to the public, a PowerPoint
presentation was conducted which listed the purpose of the MHSA, the
Innovations Project, the issues from the Community System and Supports
planning, the PEI/WET, Cap/Tech and Housing planning processes. The
PowerPoint specifically stated that the Innovations project had a focus on
learning and developing new mental health approaches and practices. This was
further emphasized by staff who was presenting. Input was sought from each of
the focus groups and stakeholder entities on the directions for the INN projects.

The feedback from these entities was incorporated in the three proposed INN
projects. Even though during the planning process it was explained that the INN
project was to be new and have a focus on learning, there often were comments
from stakeholders, clients and family members that they would like to have the
state funding cuts restored for more core services including housing and jobs.

An INN Survey was posted on the Madera County Behavioral Health Website.
Seventy-eight people responded. The surveys that were collected from the
website or by hand show the following results:

Demographics
Male                                                    33.3%
Female                                                  66.7%
Other                                                    0

Client                                                  12.8%
Family Member                                            2.6%
Work for Madera County Behavioral Health                29.5%
Work for another agency within the County of Madera     23.1%
Interested community member                             17.9%
Health care provider                                      7.7%
Member of the faith based community                      14.1%
School personnel                                          1.3%
Other                                                     5.6%

Age
Under 18 years                                                0
18--25 years                                               2.6%
26-59 years                                               87.0%
60+ years                                                 10.4%




                                        8
Ethnicity 

Latino                                                   42.3% 

African American                                          2.6% 

Caucasian/White                                          46.2% 

Asian/Pacific Islander                                    5.1% 

American Indian/Native American                           3.8% 

Other                                                     3.8% 


Issues 


Almost 99 percent (98.7%) found the issues that were raised in the CSS planning 

process still to be relevant. They were; 

   •	 Homelessness,
   •	 Isolation,
   •	 Criminal Justice/Juvenile Justice Involvement/Incarceration,
   •	 Inability to obtain employment,
   •	 Out-of-home placements/institutionalization,
   •	 Involuntary treatment/hospitalization and
   •	 Transportation

Additionally, 92.1 percent found the issues that were raised during the 2008 PEI,
Housing, WET, Cap/Tech and INN community planning process still relevant.
Those included the following;
   •	 Obtaining basic information about mental illness,
   •	 How to respond to those experiencing mental health issues in a supportive
       manner,
   •	 Reduce stigma against mental illness,
   •	 Reduce isolation,
   •	 Provide early intervention/prevention of mental illness or from the illness
       progressing,

Ninety four percent of the people who filled out the questionnaires stated they
would like Madera County to develop an INN plan to address the following;
   •	 How to respond to those experiencing mental health issues in a supportive
       manner,
   •	 Provide early intervention,
   •	 Prevention of mental illness or from the illness progressing.

The following summarized comments were received regarding the direction for
mental health services through the Innovations Projects.
   •	 Crisis teams to include family and peer support members
   •	 More nursing and coordination of physical health types of services
   •	 Crisis prevention teams
   •	 Better discharge planning from the hospital
   •	 Need housing for women with children



                                        9
   •	 Provide on-site childcare services
   •	 Educate family members about mental illness and the community about
      mental illness
   •	 Need more peer reps, peer advocates, peer “bridgers”, peer counselors,
      peer case managers and peer self-help facilitators to help clients into and
      maintain in the system.

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

This process involved focus groups with the following entities. Madera County
had found through the other planning processes for MHSA, there is a better
response if we go to the individuals/groups/agencies rather than have large,
stakeholder meetings.
   •	 Madera Unified School District, Special Education Coordinator and

       Assistant Superintendent 

   •	 Migrant Farm Workers (presentation done in Spanish to the Latino 

       population)

   •	 MCBHS Adult Outpatient staff (included Caucasian, Latino, African 

       American, Native American and LGBTQ) 

   •	 Center for Independent Living Program Coordinator
   •	 MHSA Children and TAY Youth Full Service Partnership Team (included
       Latino's)
   •	 MHSA Adult Full Service Partnership Team (included Latino's)
   •	 Shunnamite House (permanent supportive housing for homeless women)
       (underserved populations of Latino and African American clients)
   •	 Hope House (MCBHS Client Wellness and Recovery Center--Madera
       (included Latino and African American and LGBTQ clients/family
       members)
   •	 Mountain Community Wellness Center (MCBHS Client Wellness and
       Recovery Center--Oakhurst) (included clients/family members)
   •	 Madera County Department of Social Services (including Latino's)
   •	 Madera County Probation Department (included Latino's and African
       American's)
   •	 Madera County Department of Corrections (jail) (included Latino's)
   •	 Fresno/Madera Area on Aging (FMAAA)
   •	 Picayune Rancheria of the Chukchansi Indians (included Native 

       Americans) 

   •	 Madera County Behavioral Health Management/Administration (included
       Latino's)
   •	 Madera Community Hospital Administration and Emergency Room staff
   •	 Madera Community Hospital Rural Health Clinic (RHC)
   •	 Madera County Department of Public Health Services (included Latino's
       and Asian's)
   •	 Chowchilla Police Department



                                        10
   •	 Madera City Police Department
   •	 Madera County Sheriff's Office (included Latino's)
   •	 Interagency Children and Youth Services Council of Madera County. This
      organization includes representatives from;
          •	 Superior Court,
          •	 Madera County Superintendent of Schools,
          •	 Madera County Action Agency,
          •	 Behavioral Health Services,
          •	 Madera County Board of Supervisors,
          •	 Child Abuse Prevention Council,
          •	 District Attorney's Office,
          •	 Juvenile Justice,
          •	 Probation Office,
          •	 Public Health,
          •	 Social Services,
          •	 Sheriff/Coroner's Office,
          •	 Housing Authority of the City of Madera,
          •	 Community Liaison,
          •	 Darin Camarena Health Center,
          •	 First 5 of Madera County,
          •	 Madera County Local Child Care and Development Planning
             Council and
          •	 Madera Unified School District (includes Latino's, Asians and
             African Americans).

There were questionnaires posted on the MCBHS website and newspapers
articles published requesting input in the Madera newspaper, the local Spanish
newspaper as well as the Oakhurst (mountain communities) newspaper.

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

The 30-day stakeholder review was from March 4, 2010 to April 6, 2010. The
date of the public hearing was April 7, 2010. There were no substantive
comments received during the posting nor at the public hearing.




                                       11
         EXHIBIT C 


Innovation Work Plan Narrative




              12
                               EXHIBIT C #1 INN 1A & 1B 


                             Innovation Work Plan Narrative


                                                                      Date: 3-3-10
County: Madera

Work Plan Number: INN—1A and1B

Work Plan Name: New Model for Access Into Services

Purpose of Proposed Innovation Project (check all that apply)
   INCREASE ACCESS TO UNDERSERVED GROUPS
   INCREASE THE QUALITY OF SERVICES, INCLUDING BETTER OUTCOMES
   PROMOTE INTERAGENCY COLLABORATION
   INCREASE ACCESS TO SERVICES

Madera County has divided its INN—01 Plan into Parts A and B. The reason for this is to
better describe the learning experience we wish to embark upon, for ease of reading,
understanding, maximize staffing, resources, etc.

Currently, Madera County Behavioral Health provides crisis intervention services at
Madera Community Hospital ER and has for several years. Staff works as part of a team
approach with the ER staff. MCBHS is currently working with Madera Community
Hospital and the ER Director regarding the incorporation of the peer/family member staff
at the ER as part of the crisis worker/medical team for a client who is in crisis.

Crisis/assessment staff is currently available 24/7 on an on-call/call-back status. The
crisis/assessment staff has traditionally been housed as part of the Madera Counseling
Center during normal business hours. This clinic is located a few miles from the ER.

The proposed INN—01 A and B plan will house these crisis/assessment staff and the
newly proposed peer/family member staff at the Madera Community Hospital’s Rural
Health Clinic (RHC) located across the parking lot from the ER on the Madera Community
Hospital grounds. Crisis/assessment staff (already known and familiar to the ER staff)
along with the peer/family member staff will walk across the parking lot to see clients in
crisis at the ER. There, the crisis/assessment staff and the new Peer/Family member
staff will provide services to clients/families in the ER. While a client is being seen for a
crisis evaluation, the peer/family member staff will engage the client’s family. They will
greet them and talk about what crisis services are, what happens with their family
members during this time, etc. They will also talk about what follow-up services are
available for their family member and for themselves. They will show that recovery is
possible and provide hope to the family.

After the client is assessed, the client/family member staff will be able to provide
supportive services to the client while they are in the ER and explain what services are
available (INN—1B). They will be able to demonstrate to the client there is hope for
recovery. The client/family member staff will be trained in available resources so if there



                                            13
                                 EXHIBIT C #1 INN 1A & 1B 


                              Innovation Work Plan Narrative

is a need for housing, employment, food, etc.; they will be able to refer the client and their
family as necessary. The ultimate goals of these projects are to learn whether or not
peer/family member support will increase access into the mental health system (INN—
01A and improve the quality of care through a new model of peer support and clinical
team services (INN—01B).

When the crisis and the peer/family member staff are not busy at the ER, they will be able
to provide the supportive and clinical services through the new model being proposed in
INN—01B. If the person in crisis is not hospitalized, they will be able to go over and
immediately join supportive clinical and peer services and groups going on at the Rural
Health Clinic across the parking lot from the ER. These services and groups (part of
INN—01B) will be available on a walk-in basis from 8 am to 8 pm Monday through Friday.
These services and groups will emphasize recovery principles and ways to deal with
situations in one’s lives so clients will learn how to handle the various crisis situations that
may arise. The goal of this Project is to learn whether we can create a model of
peer/family member support and clinical services to increase the quality of services
including retention rates.

Madera County is a small, rural county. In the INN—01A plan, statistics will be presented
that show the number of new admits to the Madera Community Hospital Emergency
Room (ER) for crisis visits. Within a 90 day period of time, there were 173 visits of new
clients for crisis services. This time period didn’t account for existing clients who may
have frequented the ER for crisis visits. The 173 visits within the 90 day period of time
averaged to 1.9 visits per day. In order to maximize resources, staffing, etc., the
proposed clinical crisis/assessment staff and peer/family member support staff that will be
providing the services in INN—01A and B, will be the same staff. When they are not
performing the engagement functions within INN—01A, within their prescribed workday,
they will be providing the supportive services described in INN—01B.

These proposed supportive services in INN—01B will include an assessment for initial
services into the mental health system. Clients who need full service partnership (FSP)
services or intensive long term services (at least one year), will be referred to the main
mental health clinic in Madera or other outlying clinics throughout the county (e.g., the
Oakhurst mountain region or Chowchilla) as appropriate. Those clients who could benefit
or wish to benefit from shorter-term outpatient services provided in tandem with
peer/family member support services, will be referred to the clinical and peer services
provided in the Innovations Project INN—01B.

Since this Project is located with the Rural Health Clinic, this project will be able to work
with the primary care physicians in obtaining mental health services for their patients.
These new INN Projects (INN—01A and B) will be a new and innovative way to provide
timely access to our “front door” for services. MCBHS looks forward to a close working
relationship with the primary care physicians. In addition to INN Projects 01A and B, for
those clients currently receiving mental health services who are stabilized and can be
referred to a medical home (reverse integration) or for those clients who need physical



                                              14
                                EXHIBIT C #1 INN 1A & 1B 


                             Innovation Work Plan Narrative

health services, they will be referred for those services at the Rural Health Clinic
proposed in the INN—02 Project.




                                             15
                               EXHIBIT C #1 INN 1A & 1B 


                             Innovation Work Plan Narrative


                                                                     Date: 3-3-10
County: Madera

Work Plan Number: INN-01A

Work Plan Name: New Model for Access Into Services

Purpose of Proposed Innovation Project (check all that apply)
   INCREASE ACCESS TO UNDERSERVED GROUPS
   INCREASE THE QUALITY OF SERVICES, INCLUDING BETTER OUTCOMES
   PROMOTE INTERAGENCY COLLABORATION
   INCREASE ACCESS TO SERVICES

Briefly explain the reason for selecting the above purpose(s).

Increase Access into the System from Crisis Services

Madera County residents and people who worked in Madera County stated they would
like to see an Innovation Project trying to increase access into the mental health for those
individuals who received crisis services. They wanted to learn if the engagement of peer
support and family support in crisis services would increase service access for follow-up
mental health services. Currently, in Madera County only 22% of those individuals
accessing crisis services follow through with on-going outpatient services. The numbers
are even fewer (4%) for those who are hospitalized.

During the planning process, our Latino and other clients were questioned as to what
would make a difference in their experience in entering and engaging services. They
stated that having peer support during this time was extremely important to help reduce
their fears and anxieties. Just talking to another client/family member as to what to
expect during the crisis visit and future services would help to engage them into follow-up
services. They stated this would help to change the entire treatment experience from one
where they felt like they had “failed”, to one of hope for recovery.

This Project is important. Experiencing a crisis is an unnecessary disruption to one’s life
and their family’s lives. MCBHS wants to improve the overall mental wellbeing of its
community through increased access to on-going services. In response to the planning
process, MCBHS is proposing an Innovation Project which will focus on learning the
following;

Will the provision of engagement and outreach services by Peer/Family Member Support
staff for people that go to the Emergency Room (ER) for crisis services, (including those
who were hospitalized) result in those same people to be engaged to come in for on-
going mental health and peer supportive services? Would access increase for youth and



                                            16
                                EXHIBIT C #1 INN 1A & 1B 


                             Innovation Work Plan Narrative

transition age youth (TAY), if a TAY provided that outreach and engagement? It was due
to the stakeholders, clients and family member’s input during the planning process, this
Innovations Project was chosen. This Project’s essential purpose is to increase access to
services.



Project Description
Describe the Innovation, the issue it addresses and the expected outcome, i.e., how the
Innovation project may create positive change. Include a statement of how the Innovation
project supports and is consistent with the General Standards identified in the MHSA and
Title 9, CCR, section 3320. (Suggested length – one page)
Description of the Innovation Project

This Project will employ an integrated team of transition age youth (TAY) and adult/family
support specialists to engage clients (and families) at initiation of mental health crisis
services at the Hospital’s Emergency Department. Through the client/family support
specialists providing engagement services, clients/family members will see that people
can and do recover from mental health challenges. They enter the system with a strong
recovery message—an expectation that recovery is not only possible but highly probable.

This team will provide engagement services at the ER or after the client is released from
being hospitalized. The model for providing these engagement services will be
developed with input from clients, family members, stakeholders and staff. Client/family
member staff, stakeholder and crisis/assessment staff input will be sought as well as
seeking input via surveying the clients/family members who received services. It will be
through this input that the identification and development of strategies that promote
continued client engagement and motivation to move forward with successive recovery
goals will be developed and refined.

In addition to the model being refined through input, the team will be trained in;

   •	 Motivational interviewing techniques,

   •	 Recovery principles,

   •	 Use of Wellness Recovery Action Plan (WRAP)

   •	 Use of storytelling, setting an example for clients/family members

   •	 Client culture and beliefs

   •	 Cultural competency issues including cultural beliefs, traditions, religious and/or
      spiritual affiliation and level of acculturation




                                             17
                                 EXHIBIT C #1 INN 1A & 1B 


                              Innovation Work Plan Narrative

   •	 Mental Health First Aid—Mental Health First Aid is an evidenced-based program
      that teaches how to identify signs and symptoms of mental illness, how to
      intervene until professional health can arrive, risk factors for suicidality, active
      listening skills, etc. This program has been shown to improve the mental health
      status of clients who become “mental health first aiders” in addition to reducing the
      stigma of mental illness in the general public.

Since there are not enough dollars in the Innovations allocation, we will be unable to
provide the peer/family member support 24/7. In reviewing the data regarding crisis visits
by people who are not currently receiving services through MCBHS, the number of crisis
visits averages 1.9 visits per day. MCBHS also analyzed data to see which times of day
had the greatest number of crisis visits at the ER. Those times were determined to be
between 8 am and 8 pm, primarily Monday through Friday. Therefore, these are the
hours that the client/family member staff will be providing the supportive services. Clinical
crisis/assessment staff will be on-call/call-back status between the hours of 8 PM on
Friday to 8 AM Monday and holidays.

On certain weekends, there is also peer/family member staff providing supportive
services through the wellness and recovery center located within the city of Madera. This
wellness and recovery center is called Hope House. Clients and family members are
welcome to participate in those weekend services if they choose. If a client/family shows
up in the ER during the hours that the peer/family support is unavailable, the peer staff
will follow-up with the client/family as soon as possible on their next work day.

Engagement by client/family member support staff will be an important element of this
Project. Madera County BHS’s focus of their crisis services will no longer just be on
medication management, assessment for lethality and grave disability (typical clinical
crisis services). This Project will involve engagement of clients and family members by
peer/family member support staff at the ER or after someone is released from an
inpatient unit. This engagement will welcome clients and family members. It will
emphasize recovery and resiliency. It will focus on clients taking an active role and the
development of their own personal wellness and recovery plan.

The peer/family members of this team will welcome clients and families to behavioral
health services and emphasize the hope for recovery and the ability of the client to take
an active role in fulfilling their recovery goals. All clients referred to outpatient services
will be contacted by the clients/family members of this team and asked if they would like a
phone call or visit to their home or place of residence prior to their assessment at the
clinic site (see INN—01—B). This will identify those clients who were not able to be seen
if the peer/family member staff are unavailable. Given the statistics above regarding the
number of crisis visits, time of visits, etc., we do not anticipate this will happen frequently.
Since the family member/peer staffs are part of the crisis/treatment team, they will have
signed confidentiality statements and there will be no issues with confidentiality or HIPAA.

Madera County Behavioral Health Services will learn whether peer and family
engagement results in improved utilization of mental health services for clients that have


                                              18
                                EXHIBIT C #1 INN 1A & 1B 


                              Innovation Work Plan Narrative

their initial engagement at the emergency room. MCBHS will also learn whether or not
having a TAY peer support specialist will make a positive difference in access for the
youth and the TAY population.

Issue

Research shows that people don’t come to Mental Health treatment services because of;

   •	 Stigma

   •	 Language and cultural barriers

   •	 Physical barriers

   •	 Financial barriers

   •	 Lack of recognition of mental health symptoms

   •	 Lack of support for primary care physician in recognizing and treating mental
      health issues

Adults, children and older adults with serious mental illness (SMI) or serious emotional
disorder (SED) can lead lives characterized by recurrent significant crisis. It is not
inevitable that people with mental health issues will have crisis. The crisis often represent
the combined impact of factors including; lack of available services and supports, stigma,
poverty, unstable housing, co-occurring disorders, trauma, victimization, etc.
Homelessness, contact with law enforcement and other adverse events can cause crisis
and can contribute to the impact of mental and emotional disturbances.

Often, because the general public won’t come in for treatment services, they will seek
treatment at the hospital emergency room when a situation becomes a crisis. The
traditional focus of crisis services has been to assess for lethality, provide medication,
followed by an outpatient referral for services or to hospitalize if they are a danger to self,
others or gravely disabled. This approach has not been particularly effective for Madera
County. For some who won’t seek ongoing treatment, the ER becomes the only mental
health services they receive.




Madera County Statistics

Madera County Behavioral Health Services examined 90 consecutive days of data (FY
2009—2010) of those individuals who showed up at the Madera County Hospital
Emergency Room for mental health crisis services. This data did not include those



                                              19
                               EXHIBIT C #1 INN 1A & 1B 


                             Innovation Work Plan Narrative

clients who may have already been receiving services through Madera County Behavioral
Health Services. The examination of the data showed the following;

   •	 There were 173 individual visits for mental health crisis services to the Emergency
      Room at Madera Community Hospital during a 90 day period of time. (Again,
      these statistics did not include individuals currently receiving Madera County BHS
      services.)

   •	 The statistics showed that 169 were unique individuals and two were individuals
      who had already received crisis services within that 90 day period of time.

There were 46 people hospitalized (27%) out of those 169 unique individuals who came
in for crisis services. Only 11 out of the 46 (4%) came in for follow-up mental health
services after being hospitalized. For those remaining 123 individuals who sought crisis
services but were not hospitalized, less than 22% came in for follow-up
treatment/services.

   •	 In examining the age groups of those individuals that received crisis services at the
      ER, 20% were youth between the ages of 0—17.

   •	 There were also two individuals who had reoccurring episodes at the emergency
      room. Those two individuals were between the ages of 0—17.

The age groups broke down as follows;

            Age                  Number of Individuals         Age Group Percentages

           0—15                             25                            15%

          16—17                             9                             5%

          18—24                             32                            19%

Total Youth/Transition Age
       Youth (TAY)
                                            66                            39%
   (0—24 years of age)

          25—59                             91                            54%

            60+                             12                            7%




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As stated earlier, none of the 173 visits examined were currently open to Madera County
Behavioral Health Services. However, 19 of those individuals (11%) did have a prior
history of services with MCBHS, either receiving mental health or substance abuse
services or both.

The data was also analyzed as to what days and times of the day people came to the ER.
The vast majority of people came between the hours of 8 am to 8 pm, Monday through
Friday. Therefore, based on the data, the peer staff will be available along with the
crisis/assessment staff during that time period. Crisis/assessment staff will be on-call and
available for callbacks between 8 pm Friday to 8 am Monday. Peer/family member staff
will contact those seen in the ER during this time period on the next business day.

People won’t seek mental health services through the clinic but will go to the local
hospital emergency room when they experience a mental health crisis. Even though they
are referred for follow-up services, in Madera County less than 22% will actually seek
them. Even fewer (4%) sought follow-up mental health services after being hospitalized.

Expected Outcome (positive change)

Madera County BHS expects to find a new model for increasing access to services for
individuals whose first point of contact is receiving crisis services in the ER or were
hospitalized. Outreach by peer/family member staff (including TAY) at the emergency
room, after being released from the emergency room or an inpatient facility will increase
access to and utilization of mental health treatment services and in particular the youth
and transition age youth populations (increase access).

General Standards Identified

This Innovation Project supports and is consistent with the general principles of the
MHSA in the following ways;

1. Community Collaboration—this Project was developed with community participation.
   It supports collaboration with clients who currently are or have been in the system.
   Their input was appreciated and implemented in the design of this Project. The
   community, including providers, representatives from underserved and unserved
   populations and other organizations will continue to be involved through the
   dissemination of its findings and continued input. They will review the findings;
   provide input on Project design, goals, measurement tools, impact of the model, etc.,
   for its continuance and change.

   Since this is a learning Project, MCBHS will continue to ask the community as to how
   they would like to remain involved and collaborate with MCBHS on this Project.
   Those ideas and inputs will be sought through stakeholder meetings, questionnaires,
   etc., and implemented.




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2. Cultural Competence—this Project will pay attention to the needs of culturally diverse
   populations. They will provide input as to what is necessary to attract and retain
   individuals from different ethnic backgrounds to appropriate outpatient and peer
   support services. The peer and clinical staff will be trained to understand and
   effectively address the needs and values of the particular racial/ethnic, cultural and/or
   linguistic population or community. Their own personal experiences (should they
   choose to share) will also be incorporated in the training. This training will include the
   clinical and clerical support staff for this Project. MCBHS will seek to hire
   bilingual/bicultural peer/family member staff.

   The Project will be evaluated with special attention given to diverse populations and
   will work to address their needs. A goal of this Project is to determine which
   strategies are effective or ineffective for different age, ethnic and cultural groups.
   Other programs throughout the mental health system will be informed as to this
   Project’s effectiveness in hopes it can be replicated.

   Client/Family Member Driven Mental Health System—this Project includes the
   ongoing involvement and engagement of peer/family member support staff to clients
   seeking services. People who will receive the peer/family member support for service
   engagement will have the role in identifying their needs, preferences, strengths. They
   will have a shared decision-making role in determining which follow-up services and
   supports are the most effective and helpful. Since this is a learning Project, MCBHS
   will ask clients/family members as to how they would like to remain involved and
   collaborate with MCBHS on this Project.

   The families of children and youth will have a primary decision-making role in the care
   chosen for their own children. This includes the identification of needs, preferences
   and strengths. There will be a shared decision-making role in determining which
   services and supports that would be most effective and helpful for their children.

   This Project includes the ongoing involvement of clients and family members in roles
   such as, but not limited to, development and evaluation. Project development and
   implementation is driven by client need. Based upon feedback, certain strategies may
   be added or removed from the Project and/or applied in other programs. Clients and
   family members will be involved in all stages of programming, including need
   assessment, resource development, implementation and evaluation.

3. Wellness, Recovery and Resilience Focus—The Peer/Family Support staff will
   demonstrate and focus on the possibilities of recovery and resiliency. They will
   complement what is being provided by the clinical team. This Project will increase
   resilience and will promote wellness and recovery for people with severe mental
   illness by providing a continuum of care. This continuum ranges from specialty mental
   health services to recovery oriented services, medication and chronic disease
   management which will emphasize overall health and wellness.




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4. Integrated Service Experiences for Clients and their Families—this Project
   encourages and provides for access to a full range of services provided by multiple
   agencies, programs, etc., for clients. Clients will have access to multiple levels of care
   for their mental and physical health needs, e.g., access to mental health and physical
   health care. Referrals will be made for clients who need physical health services to
   primary care physicians. Clients at the ER will also have any physical health needs
   assessed, treated or referred for additional medical services. In addition Peer/Family
   member staff will have training on available resources for housing, employment and
   other needs that the clients in the ER may present.

   This Project will integrate peer/family member support services as an adjunct to the
   clinical services for people seeking emergency or crisis services at the ER. The
   client/family member team and outreach/engagement services will have equal
   importance as the clinical services MCBHS has to offer people in the community.
   Clients and families will be able to get their needs met in one location. They will also
   be able to get any information needed about the mental health system and services as
   well as other services, e.g., housing, employment, food, etc., in one location.


Contribution to Learning
Describe how the Innovation project is expected to contribute to learning, including
whether it introduces new mental health practices/approaches, changes existing ones, or
introduces new applications or practices/approaches that have been successful in non-
mental health contexts. (Suggested length – one page)

The Madera County BHS Innovations Project would provide a new approach to dealing
with mental health crisis services in the ER. Crisis services would be combined with
peer/family support services. There will be a TAY peer advocate to work with TAY and
youth. Outreach and engagement by peer and family member staff would happen at the
ER and, if necessary, afterwards (including after hospitalization) to provide outreach and
engagement services. MCBHS is unaware where there is any program currently doing
this. A literature and program search yielded nothing. Several randomized control trials
have demonstrated the impact of services provided by peer employees on positive client
outcomes. The evidence in support of their effectiveness however, has primarily
emerged from descriptive studies. In examining the data on peer services in the mental
health system, the meta-study Emerging Research Base of Peer-Run Support Programs
examined 34 different meta-studies on peer-run support programs. The majority of the
studies focused on the role support groups and vocational peer support programs. None
of the studies mentioned in the 32 references had this proposed type of project of having
peer/family member staff including TAY peer staff be a partner to clinical
crisis/assessment staff in a hospital ER, to engage clients to increase access and
retention in treatment services. A search of the National Mental Health Consumer’s Self-
Help Clearinghouse website (US Dept. of Health and Human Services), again failed to
find a program that had a model with its primary focus being to increase access and



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retention of unserved and underserved populations in an ER setting.

It is unknown to Madera County Behavioral Health if there are other service providers
who are providing this service in the ER. An extensive internet and literature search did
not find a similar program. This Project is, however, similar to a recently approved
Innovations Project from San Diego County. It is hoped that we will be able to collaborate
as to our models and findings with San Diego County.

This Project’s proposal of peer/clinical staff at an ER will be new and different. MCBHS
wants to focus the learning portion of this Project on will this increase access into
outpatient services. Does this proposed Project made a difference?

Madera County BHS Learning/Practice Change Goal

   1. Hypothesis—MCBHS will have peer/family member (including TAY) staff at the
      emergency room engaging clients/family members and will provide follow-up
      engagement if necessary, after the client leaves the ER (including after
      hospitalization). Will this engagement lead to an increased access and utilization
      of mental health services? Is there a difference between the engagement at the
      ER and/or for those who are discharged from the ER and followed by peer/family
      member services after they have returned home?

          a.	 Goal/Outcome—Clients seen in the ER or who are hospitalized will access
              and utilize services at higher rates.

          b. Goal/Outcome—Peer/Family member engagement services will be more
             successful with certain age, gender, cultural groups, etc., than the current
             referral process for ongoing services.

          c.	 Goal/Outcome—Youth and TAY seen at the ER or who were hospitalized
              will access services at higher rates due to outreach and engagement by a
              TAY peer provider.

          d. Goal/Outcome—TAY engagement services will be more successful in
             getting youth and TAY into services than the current referral process.

          e.	 Goal/Outcome—Youth/TAY and adults will access services equally whether
              engaged at the ER or on the next business day by peer/family member
              staff.

   2. Hypothesis—can voluntary, recovery-oriented, peer driven services be successful
      in a general hospital emergency room?

          a.	 Goal/Outcome—by providing peer/family services, there will be better
              recovery outcomes and access to treatment.

          b. Goal/Outcome—by providing TAY peer services, there will be better


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              recovery outcomes and access to treatment by the youth and TAY
              population.

          c.	 Goal/Outcome—by providing peer/family services, there will be a change in
              the attitude of the ER staff towards recovery and mental health services. In
              particular there will be a change in the attitude towards youth and TAY
              recovery and mental health services.


Timeline
Outline the timeframe within which the Innovation project will operate, including
communicating results and lessons learned. Explain how the proposed timeframe will
allow sufficient time for learning and will provide the opportunity to assess the feasibility of
replication. (Suggested length – one page)

Implementation/Completion Dates: ____07/10—06—13 _
                                     MM/YY – MM/YY

The overall time frame for which the Project will operate will be three years. During this
time frame MCBHS will be able to conclude if outreach and engagement by peer and
family member support staff does/doesn’t engage people into services who experienced
crisis/hospitalization. Information on the implementation and Project data will be
disseminated quarterly to clients/family members through the Department’s Quality
Management Committee. There are stakeholders (including clients and family members)
who sit as regular members of this committee.
MCBHS would examine what does and doesn’t work in this new model of engagement
into the system. What elements would be necessary to create a model for other counties
to use? The development of the measurement tools would include stakeholders, peer
and clinical staff as well as clients and family members. Data would then be gathered
regarding this Project.

Data would be collected quarterly. The County would set up the Project measurement
based upon input from the stakeholders, clients, etc. Stakeholders, including clients and
providers would be involved in the design of this Project’s assessment and surveyed as
part of the evaluation process. This data would be submitted to the Department’s Quality
Management Committee which includes clients, providers and family members.

As data and feedback was obtained, the Project would be refined and retested. The
Project would be reviewed on an annual basis with a final comprehensive assessment
after June 2013. The proposed timeline for this Project is three years. That allows time
for;

   •	 The Project development,




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    •   Development of measurement instruments and data,

    •   The ability to see what works and doesn’t work

    •   Modification as necessary,

    •   Testing/retesting, etc.

Data would be presented at the Mental Health Board Meeting as well as at the MHSA
stakeholders meeting. Data would also be presented to the ER and hospital staff as well
as any groups who wish to receive that information. There has been a request to present
the data to the Madera Unified School District personnel (special education coordinator
and psychologist along with other designated staff). This would be done. Data would
also be presented at the wellness and recovery centers located in Madera and Oakhurst
to clients and family members. Data would also be written in articles annually about the
Project in the local English and Spanish newspapers and posted on the Department’s
website. During the review and assessment, comments and perspectives of the various
stakeholders would be sought and recorded.

6/10--Approval of Innovation Plan by the Oversight and Accountability Commission.

7/10--10/10
During this period of time, training for peer staff would be purchased on crisis intervention
services and how to provide peer engagement and support to individuals and families,
Mental Health First Aid, etc. Training would also be developed and/or purchased on
cultural competency issues in working with families and individuals.

Peer/clinical staff’s input as well as client/family member and stakeholder’s input would be
sought on the model of services to be developed. Initial model would be developed along
with outcome measures for testing.

Contracts for payment for the adult and/or family member and Transition Age Youth Peer
Support individuals would go to the Board of Supervisors, interviews held, individuals
chosen and trained on the provision of peer support services, engagement and cultural
competency issues. Training would also be provided for the ER staff and other hospital
staff. Peer staff (if they chose) would be included as part of the client/family member
culture training.

MOU’s and other administrative documents would be developed and implemented.
Space issues would be addressed and resolved prior to the beginning of the Project.

Training of staff on data collection and management would begin. The formulation of
questionnaires and other forms of data management would start. There would also be
additional training in team building, recovery principles, how to engage clients/families,
cultural competency issues, etc. This training will be provided to all Project staff.



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Training of staff at this early stage of model development will be a start of the team 

building process for this Project.      


11/10--12/10 

Staff at the Madera Community Hospital RHC and the Emergency Room staff would be 

introduced to the crisis/peer staff and educated regarding the services provided. 


1/11--3/11 

Data would be collected regarding outcomes (see Project Measurement section for 

specifics). Input would also be gathered from stakeholders, families, clients, etc. 

Changes will be made to the Project as appropriate based on data and input. The Model 

would be further defined along with new data elements and means to collect the data. 

Additional training needs addressed (based upon data and staff requests). 



4/11--6/11 

Peer staff would continue to provide engagement and supportive services. Data would 

be collected regarding outcomes (see Project Measurement section for specifics). Input 

would also be gathered from stakeholders, families, clients, etc. Changes will be made to 

the Project as appropriate based on data and input. The Model would be further defined 

along with new data elements and means to collect the data. Additional training needs 

would be addressed as necessary based upon the data and staff requests. 


7/11--6/12 

Data would be examined on a quarterly basis regarding satisfaction with services and 

readmission to the ER. Input would also be gathered from stakeholders, families, clients,

etc. Changes will be made to the Project as appropriate based on data and input. 

Additional training needs would be identified and provided. Stakeholders would be 

informed of results. The Model would be further defined along with new data elements 

and means to collect the data. 


7/12--6/13 

Data would be examined on a quarterly basis. Input would also be gathered from 

stakeholders, families, clients, etc. Changes will be made to the Project as appropriate 

based on data and input. Additional training needs would be identified and provided. At 

the end of the third year, MCBHS would be able to determine if this approach works or 

doesn’t. Stakeholders would be informed of results. MCBHS would determine if other 

counties could replicate approach for their crisis services and have this be an effective 

alternative. The Model would be further defined along with new data elements and 

means to collect the data. 



Project Measurement




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Describe how the project will be reviewed and assessed and how the County will include
the perspectives of stakeholders in the review and assessment.

Review and Assessment
Data would be gathered regarding the crisis intervention services for those individuals
who chose to participate. Data would be collected quarterly.
Stakeholders, including clients and staff will be surveyed as part of the Project evaluation
development process. Additionally, since this Project includes family and TAY
engagement, there is an expectation of continual feedback from the families and TAY’s
served. Peer/clinical staff’s input as well as client/family member and stakeholder’s input
would be sought on the model of services to be developed. Initial model would be
developed along with outcome measures for testing. In addition, client/family member
and stakeholder input would be sought on the development of the instruments used to
measure the outcomes. Data would be gathered quarterly regarding receiving initial peer
outreach and engagement services.
There would be specific updates provided to our stakeholders and an opportunity to
provide input at the Project, client (especially TAY’s), family member, staff and community
levels. Final reports may be distributed to providers for posting.
Specific data to be gathered and evaluated includes, but is not limited to, the following:
   1. Does Peer Support and Family Member staffs engaging clients after receiving
      crisis services at the ER or after being hospitalized, increase access to services?
          a.	 Increase in the number of people who entered services through the ER who
              received on-going outpatient services
          b. Increase in number of people who report it was because they were engaged
             by peer/family member staff, they participated in on-going mental health
             services (survey)
                  i.	 Clients/family members report that the outreach by peer/family
                      member staff was why they came in for services (surveys and key
                      informant interviews)
          c.	 Rate of persons served reporting that they received the services they
              needed (survey)
          d. Clients/family members reported that they stayed in services because of the
             client/family member involvement (survey/informant interviews)
          e.	 Data examined will also include;
                  i.	 Demographics (including language, age, cultural issues, etc.)
   2. Does TAY Peer Support staff engaging youth and TAY’s after receiving crisis
      services at the ER or after being hospitalized, increase access to services?




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        a.	 Increase in number of youth and TAY’s who report it was because they
            were engaged by a TAY Peer Support staff member that they participated in
            on-going mental health services (survey)
        b. Rate of TAY served reporting that they received the services they needed
           (survey)
        c.	 Data examined will also include;
                i.	 Demographics (including language, age, cultural issues, etc.)
  3. Successful linkage and/or enrollment in mental health services for clients who
     receive the peer outreach and engagement services (survey)
        a.	 Are there any differences in response from adults, TAY, etc., in accepting
            services, e.g., how many go to services, remain engaged in services, etc.?
        b. Are there any differences in those clients who received outreach services in
           the ER as opposed to receiving outreach services after they were
           discharged from the ER?

  4. Recovery-oriented, peer driven services will be successful in changing the attitude
     of ER staff toward mentally ill clients (survey and informant interviews)

        a.	 The provision of peer/family services will change the attitude of the ER staff
            towards recovery and mental health services. In particular there will be a
            change in the attitude towards youth and TAY recovery and mental health
            services.

                i.	 Rate at which ER staff report they are more sensitive to cultural
                    (including client culture), ethnic/linguist backgrounds of clients in the
                    ER (survey and key informant interviews)

               ii.	 Rate at which ER staff report being more sensitive to stigma about
                    persons with mental health issues (survey and key informant
                    interviews)

               iii.	 Rate at which ER staff report they have an increase in knowledge
                     about mental health issues (survey and key informant interviews)

               iv.	 Rate at which ER staff know how to provide an action plan on how to
                    help a person in a mental health crisis due to their Mental Health
                    First Aid training (survey and key informant interviews)

  5. Other outcomes as indicated by peer staff and stakeholders during the review
     process.


Leveraging Resources (If Applicable)


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Provide a list of resources to be leveraged, if applicable.
In development.




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                                                                     Date: 3-2-10
County: Madera

Work Plan Number: INN-01B

Work Plan Name: New Model for Access Into Services

Purpose of Proposed Innovation Project (check all that apply)
   INCREASE ACCESS TO UNDERSERVED GROUPS
   INCREASE THE QUALITY OF SERVICES, INCLUDING BETTER OUTCOMES
   PROMOTE INTERAGENCY COLLABORATION
   INCREASE ACCESS TO SERVICES

Briefly explain the reason for selecting the above purpose(s).

Increase The Quality of Services, Including Better Outcomes

Madera County Behavioral Health Services (MCBHS) traditionally has had low
penetration and retention rates for unserved and underserved populations. During the
Innovations planning process, clients, family members, stakeholders and the community
stated an Innovations Project focusing on this issue would be appropriate. They wanted
to assist MCBHS in this learning endeavor.

Madera County’s Innovation Project wants to learn if having clients, family members and
community advocates (Promotores) as equal partners in the development of a model of
services in a new and different way, would make a difference in increasing the
penetration and retention rates. During the planning process, clients and family members
were asked (and in particular Latino clients and family members) what would help to
engage them and retain them for receiving services. They stated that having a
client/family member talk to them before being seen by a clinician as to what was going to
happen today, what types of services were available, community resources, etc., would
help reduce anxiety, help to feel that they had an advocate and that the client/family
member could relate to what they were experiencing, etc. They stated this would help to
engage and retain them in services. They wanted to develop a new model for the
provision of peer and clinical services. They didn’t just want the peer services available
at the wellness and recovery center. They wanted to see if a new way or model to
integrate peer/family services and clinical services together would provide a better overall
initial experience (improved quality) for themselves and others entering the system.
Would there be better outcomes regarding penetration, engagement and retention in the
system?

MCBHS and its clients, family members, stakeholders, etc., will look at a new way to
engage and retain clients and their families. Issues addressed would include examining
the initial assessment process and treatment services. Would providing those services in



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a new and different way make a difference in future penetration and retention rates for
mental health services? Would learning how to address this problem with an equal
partnership between peer and family member staff and advocates with clinical
assessment/treatment services staff achieve these results? Would this be true for
unserved and underserved populations? Due to the low rates of service for these
populations and feedback during the planning process from our clients, family members,
stakeholders, community, etc., MCBHS selected “Increasing the Quality of Services,
Including Better Outcomes” a the essential purpose for this project.


Project Description
Describe the Innovation, the issue it addresses and the expected outcome, i.e., how the
Innovation project may create positive change. Include a statement of how the Innovation
project supports and is consistent with the General Standards identified in the MHSA and
Title 9, CCR, section 3320. (Suggested length – one page)

Description of the Innovation Project

This Project’s approach will be new and different adaptation of a peer/family member
support project. Could a new and different partnership between peer/family staff,
community advocates (Promotores) and treatment staff improve quality outcomes by
increasing penetration and retention rates for unserved and underserved populations?
This Project would learn how to increase engagement and retention rates through this
partnership. MCBHS wants to focus the learning portion of this Project on how a different
model of peer and clinical team/services can create that positive change.

Since this is a new model, this Innovation Project staff (both professional and client/family
member staff) will be the ones to design and implement it. They will also modify it as
necessary (based upon data collection as part of this learning project). Modifications to
the model will be done through input from the clients/family member staff, stakeholders
such as the Promotores and other community members and by examining the results
from the various surveys and outcomes described in the learning portion of this project.
Client/family member staff, stakeholder and crisis/assessment staff’s input will be sought
as well as input via survey and interviews with the clients/family members who received
services. It will be through this input that the identification and development of strategies
that promote continued client engagement and motivation to move forward with recovery
goals will be developed and refined.
In addition to the model being refined through input, the team will be trained in;

   •   Motivational interviewing techniques,

   •   Recovery principles,

   •   Use of Wellness Recovery Action Plan (WRAP)


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   •	 Use of storytelling, setting an example for clients/family members

   •	 Client culture and beliefs

   •	 Cultural competency issues including cultural beliefs, traditions, religious and/or
      spiritual affiliation and level of acculturation

   •	 Mental Health First Aid—which in an evidenced-based program designed to teach
      signs and symptoms of mental illness, risk factors for suicide, how to intervene
      until professional help can arrive, etc.

   •	 Team building principles

Training will be provided to this project staff so that everyone, clients/family members and
clinical staff start out on an “equal footing.” The peer/family member staff will have the
same basic concepts for this project as the clinical staff. Going through the training
together will be a time where team building can occur. This time period of team training
and development will allow staff to have their concepts, ideas and expectations aligned
with each other. The importance of team building will be to create a synergistic team who
are in alignment with the ideas, principles, values and structure of this Project.

In Madera County, Promotores (community advocates) were developed as part of the
Madera County Behavioral Health’s Prevention, Early Intervention Plan (PEI) through the
Mental Health Services Act (MHSA). These Promotores are located throughout Madera
County. They may be working with someone in the community that they believe needs
an assessment for on-going services. In the event that this happens, the family
member/peer staff and clinical staff would work together with the Promotores to engage
the client into services and provide continuing support for on-going services. (For
additional information on Promotores, please see Madera County’s approved PEI plan.)

Since this is a new model of services, the Innovations Project will examine if certain peer
support services work to improve the quality of services through the development of a
new model of peer/clinical staff services which leads to better engagement, penetration
and retention of clients. Does individual clinical and peer staff services or a combination
of clinical and peer staff services together (either individually with clients/family members
or in a group setting) help to improve the overall quality of services? These are issues
that will be explored as the model is developed and revised. Roles and responsibilities of
the peer/clinical staff may change. Issues regarding differences in backgrounds,
orientation and authority will be examined and solutions sought. Since the purpose of this
Innovations Project is to learn, new forms of service delivery may be developed based
upon the input received. As these are developed, they will be examined as part of the
learning process of this Innovations Project.

MCBHS wants to locate this Project which would include peer/family member staff and
clinical staff at a newly proposed clinic site co-located with the Madera rural health clinic
(RHC). The peer and clinical staff will work together to meet the needs of clients/family


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members in an integrated mental health and physical health setting. The rural health
clinic is located on the grounds of the local hospital where crisis services are provided.
The offices would be decorated in culturally appropriate ways to have the office look
appropriate and familiar to ethic populations.

Training will be available for all RHC staff (including clerical and support staff) to increase
their cultural competency and reduce stigma when working with patients who may have
mental health issues. Clients and family members will take an active role as presenters
and in the design of the training. As will be stated in INN—02, clients did not want to
disclose to primary care that they were receiving mental health services because of
stigma. Research bears this out (see INN—02). The proposed training (Mental Health
First Aid) is an evidenced-based training that reduces stigma and teaches people how to
respond to someone who is experiencing mental health issues. This training will be not
only for the primary care clinical staff but for clerical staff as well. It is the clerical/support
staffs who have the first contact with a client/patient. It is important these staff be
included to help to reduce stigma and provide a supportive environment for anyone who
may have mental health issues who receives physical health services.

This project will employ a team of clients/family members, including a transition age youth
(TAY). This team will be linguistically and culturally competent. Recovery principles
would be emphasized. The ultimate goal is to increase quality. A secondary goal would
be to increase access, utilization and retention of mental health resources/services. The
end result of this Project would be a new model of services which works for increasing
access and retention of unserved and underserved populations in a small, rural, county
mental health program. The results would be shared with other counties.

Issue Project Addresses

Madera County Behavioral Health Services (MCBHS) has historically had problems
regarding access (penetration) and retention of unserved and underserved populations,
e.g., Latinos, older adults, etc., in services. The presented data will illustrate this point.
The penetration rate data below displays a comparison of totals vs. estimates of the
prevalence of serious mental illness/serious emotional disturbance in Madera and
California. The results were based on estimates of need for Mental Health Services
developed by Charles Holzer from the University of Texas. These estimates represent
"targets" and are compared across gender, race/ethnicity, and age to service data
obtained through the State Department of Mental Health’s Client and Service Information
(CSI) data. It is important to remember that they are based on census data combined
with estimates that were calculated by applying prediction weights. Due to the way
census data is updated, the data in the tables should be viewed as "best available."

Retention rate data refers to service rates analyzed by race/ethnicity, gender and age.
The charts for retention illustrate the total number of CSI clients served by the number of
services. The state figures only reflect both Medi-Cal and non-Medi-Cal clients and
services provided in the County Mental Health program. The County figures represent


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                                  Innovation Work Plan Narrative

  Medi-Cal data of clients who attend the behavioral health services at county-operated and
  county-contracted clinics. It does not reflect data of other Medi-Cal mental health
  providers which may be available to residents of the county.

  Penetration Rates for Medi-Cal Beneficiaries (State ITWS data) 1

                                                   Penetration Rates %
      Demographics
                                    Madera County                         California
      Calendar Year            2006     2007      2008             2006    2007           2008
      Total:                     4.85      4.80     5.35             6.28      6.19       6.19
      Age:
      0—5                          0.65       0.83        0.88       1.23        1.31          1.40
      6—17                         6.14       5.95        6.96       7.69        7.71          7.81
      18—59                        6.60       6.69        7.19       8.93        8.70          8.56
      60+                          3.28       2.86        3.08       3.32        3.34          3.40
      Gender:
      Males                        4.87       4.77        5.55       5.77        6.88          6.90
      Females                      4.83       4.84        5.18       6.95        5.67          5.65
      Race/Ethnicity:
      White/Caucasian             11.04       9.82      11.17       12.29       11.84      11.72
      Latino/Hispanic              2.67       2.88       3.26        3.24        3.29       3.41
      African American             9.40       9.50      10.53       10.20        9.94      10.10
      Asian/Pac Islander           2.99       3.36       4.73        4.77        4.45       4.39
      Native American              5.23       8.11      10.10       11.21       10.86      10.69
      Other                        7.31       9.27       8.28        7.98        9.56       8.96

  Penetration Rates Compared to Medi-Cal Beneficiaries (from State ITWS data)


Demographics                   Madera Medi-Cal Eligibles vs. Beneficiaries Served %
                      Calendar Year 2006     Calendar Year 2007            Calendar Year 2008
                     Medi-Cal        Medi-Cal      Medi-Cal        Medi-Cal       Medi-Cal          Medi-Cal
                    Beneficiary     Beneficiary   Beneficiary     Beneficiary    Beneficiary       Beneficiary
                     Eligible         Served       Eligible         Served        Eligible           Served




  1
   Penetration Rate Comparison from State Department of Mental Health Information Technology Web
  Services (ITWS) and External Quality Review Organization (EQRO) data




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Race/Ethnicity:

White/Caucasian          21.42         11.04        21.42         9.82        20.93        11.17
Latino/Hispanic          70.63          2.67        70.63         2.88        71.11         3.26
African American          3.04          9.40         3.04         9.50         3.07        10.53
Asian/Pac Islander        1.33          2.99         1.33         3.36         1.34         4.73
Native American           0.71          5.23         0.71         8.11         0.72        10.10
Other                     2.87          7.31         2.87         9.27         2.83         8.28

     Retention Rates for All Medi-Cal Clients (from State ITWS data)

   Number Services
     Approved per
   Beneficiary Served                Madera Overall                       State Overall
                                           %                                   %
Calendar Year             2006         2007         2008          2006        2007        2008
1 service                 12.63         9.86        9.16          8.53        8.76        9.04
2 services                7.51          9.05        7.23          6.22        6.42        6.51
3 services                6.53          6.39        5.34          5.29        5.28        5.46
4 services                5.06          5.04        4.87          4.95        4.92        5.03
5—15 services             32.99        30.77        31.60         32.14      32.56        32.14
> 15 services             35.27        38.89        41.80         42.87       42.05       41.83

   Number Services
     Approved per
   Beneficiary Served              Madera Foster Care                   State Foster Care
                                           %                                    %
Calendar Year             2006         2007           2008        2006        2007        2008
1 service                 8.50          4.88          4.23        6.02         6.61       6.32
2 services                2.61          2.44          3.52        4.45         4.86       5.18
3 services                3.27          1.63          4.23        4.66         4.66       4.22
4 services                3.27          3.25          2.82        3.76         4.20       4.03
5—15 services             28.10        21.95         22.54        24.66       25.19       24.80
> 15 services             54.25        65.85         62.68        56.45       54.48       55.46


   Number Services
     Approved per
   Beneficiary Served         Madera Transition Age Youth           State Transition Age Youth
                                          %                                      %
Calendar Year              2006        2007          2008         2006        2007        2008
1 service                  15.56       10.42         11.14        10.01       10.10        9.04
2 services                  8.25       7.44          4.12          6.85        6.88        6.51
3 services                  9.21       4.76          6.54          5.38        5.45        5.46



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4 services                    6.98         5.65           5.57           4.61       4.61          5.03
5—15 services                26.98         30.36          29.30         28.57       28.96        32.14
> 15 services                33.02         41.37          43.34         44.57       43.99        41.83

     This Project is important to MCBHS. Providing appropriate care and supports to people
     and families experiencing mental illness so they recover is our primary purpose. This
     Project’s goal would be to develop a new model of how peers and family members in an
     integrated treatment team can increase access and retention of unserved and
     underserved populations. This Project’s approach will be a new and different adaptation
     of a peer/family member support project. MCBHS wants to focus the learning portion of
     this Project on elements needed to develop a new model, determine if it works, make
     refinements as necessary and share the model with other counties. The expected
     outcome of this project is how it can create positive change to improve the quality of
     services and increase the retention of the unserved and underserved populations
     receiving mental health services in a small, rural county mental health clinic.

     General Standards Identified

     This Innovation Project supports and is consistent with the general principles of the
     MHSA in the following ways;

     1. Community Collaboration—this project was developed with community participation.
        It supports collaboration with clients who currently are or have been in the system.
        Their input was appreciated and implemented in the design of this project. The
        community, including primary care providers, representatives from underserved and
        unserved populations and other organizations will continue to be involved through the
        dissemination of its findings and continued input. They will review the findings;
        provide input on project design, goals, measurement tools, impact of the model, etc.,
        for its continuance and change.

        Since this is a learning Project, MCBHS will continue to ask the community as to how
        they would like to remain involved and collaborate with MCBHS on this Project.
        Those ideas and inputs will be sought through stakeholder meetings, questionnaires,
        etc., and implemented.

     2. Cultural Competence—this project will pay attention to the needs of culturally diverse
        populations. They will provide input as to what is necessary to attract and retain
        individuals from different ethnic backgrounds to appropriate services. The peer and
        clinical staff will be trained to understand and effectively address the needs and
        values of the particular racial/ethnic, cultural and/or linguistic population or community.
        Their own personal experiences (should they choose to share) will also be
        incorporated in the training. This training will include the clinical and clerical support
        staff for this Project. MCBHS will seek to hire bilingual/bicultural peer/family member
        staff.




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   Rural health clinic staff (including professional and support staff) will be trained in
   Mental Health First Aid. This evidenced-based program demonstrates it reduces
   stigma and increases knowledge about mental health issues and how to intervene
   until appropriate help can arrive. Madera County has clients and staff trained as
   presenters of this program. This is the same training that will be provided to the Rural
   Health Clinic staff in INN—02 (see INN—02). This training helps to recognize mental
   illness, teach people a thoughtful and appropriate way to respond to someone who
   has mental health issues and helps to reduce stigma. Many clients have stated that
   they don’t like to tell anyone in physical health that they have a mental illness due to
   stigma and they way they are treated. Research bears this out. Clients with mental
   illness do have to contend with stigma issues. Since this project will be co-located
   with physical health at the Rural Health Clinic, Madera County wants to try to reduce
   the stigma as much as possible while educating the staff on appropriate ways to
   respond to signs and symptoms of mental illness.

   The project will be evaluated with special attention given to diverse populations and
   will work to address their needs. A goal of this program is to determine which
   strategies are effective or ineffective for different age, ethnic and cultural groups. This
   and other programs throughout the mental health system will be informed as to this
   Project’s effectiveness in hopes it can be replicated.

3. Client/Family Member Driven Mental Health System—this project includes the
   ongoing involvement and engagement of peer/family member support staff to clients
   seeking services. People who will receive the peer/family member support for service
   engagement will have the role in identifying their needs, preferences, strengths. They
   will have a shared decision-making role in determining which follow-up services and
   supports are the most effective and helpful.

   The families of children and youth will have a primary decision-making role in the care
   chosen for their own children. This includes the identification of needs, preferences
   and strengths. There will be a shared decision-making role in determining which
   services and supports that would be most effective and helpful for their children.

   This project includes the ongoing involvement of clients and family members in roles
   such as, but not limited to, development and evaluation. Program development and
   implementation is driven by client need. Based upon feedback, certain strategies may
   be added or removed from the Project and/or applied in other programs. Clients and
   family members will be involved in all stages of programming, including need
   assessment, resource development, implementation and evaluation.

   Since this is a learning Project, MCBHS will ask clients/family members as to how
   they would like to remain involved and collaborate with MCBHS on this Project.

4. Wellness, Recovery and Resilience Focus—The Peer/Family Support staff will
   demonstrate and focus on the possibilities of recovery and resiliency. They will
   complement what is being provided by the clinical team. This project will increase



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   resilience and will promote wellness and recovery for people with severe mental
   illness by providing a continuum of care. This continuum ranges from specialty mental
   health services to recovery oriented services, medication and chronic disease
   management which will emphasize overall health and wellness.

5. Integrated Service Experiences for Clients and their Families—this project encourages
   and provides for access to a full range of services provided by multiple agencies,
   programs, etc., for clients. Clients will have access to multiple levels of care for their
   mental and physical health needs, e.g., access to mental health and physical health
   care. Referrals will be made for clients who need physical health services by staff and
   staff from the RHC will make referrals for mental health services of their primary care
   patients to the Project.

   Since the Peer/Family member staff will be trained in available resources in the
   community, they will be able to give information and make referrals for housing, food,
   clothing, employment, etc., as necessary to clients/families.



Contribution to Learning
Describe how the Innovation project is expected to contribute to learning, including
whether it introduces new mental health practices/approaches, changes existing ones, or
introduces new applications or practices/approaches that have been successful in non-
mental health contexts. (Suggested length – one page)

Several randomized control trials have demonstrated the impact of services provided by
peer employees on positive client outcomes. The evidence in support of their
effectiveness however, has primarily emerged from descriptive studies. In examining the
data on peer services in the mental health system, the meta-study Emerging Research
Base of Peer-Run Support Programs examined 34 different meta-studies on peer-run
support programs. The majority of the studies focused on the role support groups and
vocational peer support programs. None of the studies mentioned in the 32 references
had this proposed type of project of developing a model in partnership with clinical staff to
engage clients to increase access and retention in treatment services. A search of the
National Mental Health Consumer’s Self-Help Clearinghouse website (US Dept. of Health
and Human Services), again failed to find a program that had a model with its primary
focus being to increase access and retention of unserved and underserved populations in
a small, rural county-operated mental health system.

This Project’s model of peer/clinical staff partnership will be new and different. MCBHS
wants to focus the learning portion of this Project on how a new model of
clinical/peer/family member partnership can increase access and retention for the
unserved and underserved population of small rural county mental health service system.
Through this project we will learn what elements are necessary for this. What does and



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                             Innovation Work Plan Narrative

doesn’t make a difference? What impacts does this have on clients in receiving quality
services, retention, access, etc? What impacts will this have on staff in the provision of
services, working relationships, etc? Will this new model improve penetration and
retention by adapting/modifying a peer service model for unserved and underserved
populations? Through increasing penetration and retention rates for unserved and
underserved populations, can this new model change the quality of mental health
services?

When this Project has been completed, this information will be available to other county
mental health systems as to how to develop new model of peer support and clinical
services to increase access and retention of the unserved and underserved populations.

Madera County BHS Learning/Practice Change Goal

As part of this Project, MCBHS would examine the following;
   •	 What elements are necessary to create a new and successful model of a
      peer/family member partnership in a small, rural county public mental health
      system?
           o	 Which supportive services work better to engage and retain clients?
           o	 Does a combination of clinical and peer staff providing services together
               either individually or in a group setting help to engage and retain clients in
               treatment?
           o	 Does initial engagement by peer/family member staffs help to retain clients
               in service?
           o	 Does on-going engagement by peer/family member staff help to retain
               clients in service?
           o	 Do clients/family members provide improved quality of services through this
               new model of client/family member and clinical staff combination for service
               provision?
   •	 As a result, would there be an improvement in the quality of services including
      better outcomes?
           o	 Would this new model of peer and clinical staff result in an increase the
               access to services for clients and families, especially the unserved and
               underserved populations of a small, rural county?
           o	 Will penetration rates increase as a result of this new model?
           o	 Do any factors of this new model decreases recidivism rates in crisis
               services?
           o	 What factors of this model help to engage clients?
           o	 Was the model effective in providing services to this population?
           o	 Were services appropriate to meet the client’s needs?
           o	 Was staff responsive to the needs of the clients/family members?
           o	 Were services responsive and accessible?
           o	 Were clients/family members able to increase their knowledge of recovery
               principles and utilize that knowledge?




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                              Innovation Work Plan Narrative

          o	 Was there an increase in involvement and decision making by the client in a
             recovery-focused manner?
          o	 What factors help to retain clients, especially the unserved and underserved
             population in treatment?
          o	 Do these factors help to increase the retention rates for services?
          o	 Does this model decrease stigma about mental health services for a small,
             rural county behavioral health department?


Timeline
Outline the timeframe within which the Innovation project will operate, including
communicating results and lessons learned. Explain how the proposed timeframe will
allow sufficient time for learning and will provide the opportunity to assess the feasibility of
replication. (Suggested length – one page)

Implementation/Completion Dates: ____7/10—6/13___
                                     MM/YY – MM/YY

MCBHS would examine what does and doesn’t work in this new model of partnership
between peer and clinical staff. What elements would be necessary to create a model for
other counties to use? The development of the measurement tools would include
stakeholders, peer and clinical staff as well as clients and family members. Data would
then be gathered regarding this project.

Data would be collected quarterly. The County would set up the project measurement
based upon input from the stakeholders, clients, etc. Stakeholders, including clients and
providers would be involved in the design of this project’s assessment and surveyed as
part of the evaluation process. This data would be submitted to the Department’s Quality
Management Committee which includes clients, providers and family members.

As data and feedback was obtained, the project would be refined and retested. The
project would be reviewed on an annual basis with a final comprehensive assessment
after June 2013. The proposed timeline for this project is three years. That allows time
for;

   •	 The new model development,

    •	 Development of measurement instruments and data,

    •	 The ability to see what in the model works and doesn’t work

    •	 Modification of the model as necessary,

    •	 Testing/retesting the model, etc.




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Data would be presented at the Mental Health Board Meeting as well as at the MHSA
stakeholders meeting. Data would also be presented any primary care practice groups
who wish to receive that information. Data would also be presented at the wellness and
recovery centers located in Madera and Oakhurst to clients and family members. Data
would also be written in articles annually about the project in the local English and
Spanish newspapers and posted on the Department’s website. During the review and
assessment, comments and perspectives of the various stakeholders would be sought
and recorded.

At the end of the Project, MCBHS would have enough data to determine if this approach
works and if it can be replicated by other counties. That information would be
disseminated.

Timeframe

6/10--Approval of Innovation Plan by the Oversight and Accountability Commission

7/10--10/10
During this period of time training for peer staff would be purchased on how to provide
peer engagement and support to individuals and families. Training would also be
developed and/or purchased on cultural competency issues in working with families and
individuals. Training would also be purchased for clinical staff on recovery principles,
working with peer staff as equal members of a team, short-term crisis resolution services
and other clinical training as appropriate. The team (both clinical and peer/family
member staff) will be trained in the following. One of the purposes of this training will be
to have client/family member staff be on an equal footing with clinical staff. The spent
together in training will also be a time used for team building purposes. Team building is
important for the success of this new model of an equal partnership.

Training will include but is not limited to;
   •	 Motivational interviewing techniques,

   •	 Recovery principles,

   •	 Use of Wellness Recovery Action Plan (WRAP)

   •	 Use of storytelling, setting an example for clients/family members

   •	 Client culture and beliefs

   •	 Cultural competency issues including cultural beliefs, traditions, religious and/or
      spiritual affiliation and level of acculturation.

   •	 Mental Health First Aid




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                             Innovation Work Plan Narrative

   •   Team building principles

During this time the clinical, administrative and peer/family member staff would also be 

trained on quality management/improvement issues and how to develop and measure 

outcomes. Outcome development and what data to collect, measure, etc., would be 

initaited. 


Contract for payment for the adult and/or family member and Transition Age Youth Peer 

Support individuals would go to the Board of Supervisors, interviews held, individuals 

chosen and trained on the provision of peer support services, engagement and cultural

competency issues. Clinical staff would continue to be trained in the above mentioned 

issues. 


Any MOU’s/contracts with the primary care facilities, etc., would be developed and taken 

to the Board of Supervisors for approval. 


10/10—12/10 

Model of services will be developed by crisis and peer staff, stakeholders, etc. Model will 

continue to be refined as the Project continues based upon input from clients, family 

members, staff, stakeholders, data, etc. 


11/10--12/10 

Staff at the RHC would be introduced to the crisis/peer staff and assessment staff. RHC 

staff would be educated regarding the services provided and in Mental Health First Aid. 

Data formulation and management would continue. 


1/11--3/11 

Data would be collected regarding outcomes and analyzed. Program model changes 

made as appropriate to meet overall goals based upon data and input. Project staff 

training (based upon data and input from Project staff) would be done as appropriate for 

new model.


4/11--6/11 

Model would continue to be examined to see if it improved quality services including 

overall access and retention of services, especially for unserved and underserved 

populations. Data would be collected regarding outcomes and analyzed. Results would 

be reported to local stakeholders as appropriate. Program model changes made as 

appropriate to meet overall goals based upon data and input. Project staff would receive 

training as appropriate (based upon data and input from Project staff) for provision of new 

model of services. 


7/11--6/12 

Data would be examined on a quarterly basis regarding satisfaction with services, access 

and retention rates. Changes to model as appropriate depending on results of data. 





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                               EXHIBIT C #1 INN 1A & 1B 


                            Innovation Work Plan Narrative

Model further tested. Additional training needs (based upon data and input from Project
staff) would be identified and provided. Stakeholders would be informed of results.

7/13—10/13
Results regarding the elements necessary for the success of the project would be
disseminated.


Project Measurement
Describe how the project will be reviewed and assessed and how the County will include
the perspectives of stakeholders in the review and assessment.

Review and Assessment
Stakeholders, including clients and staff will be surveyed as part of the project evaluation
development process. Additionally, since this project includes family engagement, there
is an expectation of continual feedback from the families served. Data would be gathered
regarding receiving peer and clinical outreach, engagement and supportive services.
Data would be collected quarterly.
Clients/family members and stakeholders input would be solicited for the development of
outcome measures and measurement tools. That input would be incorporated into the
Project’s measurement system.
Data that was collected would be utilized to determine what elements are necessary for
peer/clinical partnerships. Peer and clinical staff, stakeholders, clients, etc., would be
asked information as to what does and doesn’t work in this model of services. What
could be done to improve the model? Would they recommend this service to family,
neighbors, etc.? Would they come back again if necessary? Representatives from
unserved and underserved populations in the community would be asked as to how this
Project was or wasn’t working for their community. Were the populations served happy
with the service? Would they come back again?
Data collected would include but not be limited to:
   •	 Client, family and staff satisfaction and assessment of peer/clinical services
   •	 Retention of new clients at one month, three months, six month intervals
   •	 Level of change in recovery culture and effectiveness of peer engagement 

      approaches 

   •	 Other outcomes as indicated by clients, family members and stakeholders during
      the review process
The data measurement would include but not be limited to the following. Since this is a
learning project regarding a new model of services, the peer/family member staff and
clinical staff as well as stakeholders, clients, family members, etc., would discuss what



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needs to be measured, the types of data to be collected and how it will be collected. After
reviewing the data, changes in the model would be made with input from the team,
stakeholders, etc. Some of the data collected (and possible methods used) would include
the following;
What elements are necessary to create a new and successful model of a peer/family
member partnership in a small, rural county public mental health system?
   •	 Which supportive services work better to engage and retain clients? Was this
      model effective?
          o	 Data on access and retention, client/family member surveys, etc., focus
             groups
   •	 Does a combination of clinical and peer staff providing services together either
      individually or in a group setting help to engage and retain clients in treatment?
      Were the services appropriate to meet the clients needs?
          o	 Data on access and retention, client/family member surveys, etc., focus
             groups
   •	 Does initial engagement by peer/family member staffs help to retain clients in
      sevice?
          o	 Data on retention for clients/family members who have participated in this
             process. Method of data collection could include surveys questioning if the
             initial outreach was effective in keeping them in services, etc.
   •	 Does on-going engagement by peer/family member staff help to retain clients in
      service?
          o	 Data on retention for clients/family members who have participated in this
             process. Method of data collection could include surveys questioning if the
             continuing outreach, engagement and supportive services were effective in
             keeping them in services, etc.
   •	 Do clients/family members provide improved quality of services through this new
      model of client/family member and clinical staff combination for service provision?
          o	 Method of data collection could include surveys, focus groups, complaints,
             enrollment data, etc. Data could include asking if recipients of this learning
             project were pleased with the services. Would they recommend the
             services to friends/family, etc. Did they find the services useful? Was the
             program responsive to their needs? Were they able to function better
             because of the services? Were services convenient, timely, etc.? Were the
             persons served able to participate meaningfully in treatment decisions?
             Was the information received useful to make informed choices in their
             treatment? What was the rate at which persons serviced reported they were
             treated with politeness, respect and dignity by staff? The rate at which
             persons served reported they were treated with sensitivity to their gender,




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             age, sexual orientation, culture, religious, ethnic and linguistic
             backgrounds?
   •	 Does this new model of peer and clinical staff result in an increase in the access to
      services for clients and families, especially the unserved and underserved
      populations of a small, rural county?
          o	 Method of data collection could include surveys, informant interviews,
             complaints, encounter data, enrollment data, billing records, etc. Data could
             include the rate of persons served reporting that they received services they
             need. The rates of utilization of services as compared to the identified
             needs of the community. Persons served perceived and experienced
             services as convenient. Increase in enrollment data for ongoing services for
             clients who were first seen at the ER or were hospitalized.
   •	 Were clients/family members able to increase their knowledge of recovery 

      principles and utilize that knowledge? 

          o	 Method of data collection could include surveys, key informant interviews,
             recidivism data from the ER. Data could include counting the increase in
             WRAP and Crisis plan development, possible use of the Recovery Self-
             Assessment (RSA) to assess the degree to which recovery-oriented
             practices are implemented by the Project. The RSA measures recovery
             oriented practices are implemented by the program. Possible use of the
             Recovery Markers Questionnaire (RMQ) which measures a client’s recovery
             needs and the impact of available supports. Possible use of the Illness
             Management and Recovery Scale (IMR) which gauges a client’s
             perspective on illness management and progress toward recovery goals,
             etc.
Data would be examined as to what this Project did to improve penetration and retention
rates. Rates would be examined as to what they were prior to the Project and what they
were during and after Project implementation. Ultimately, this data on retention and
penetration as well as client satisfaction regarding the model, level of change in recovery
culture, etc., would all be used to determine if quality was improved for unserved and
underserved clients in the system. As part of this data review, clients, family members,
stakeholders, etc., would review the findings and their comments would be solicited.
Changes to the project would include their input.
The data would also be presented at the quarterly Quality Management Committee
(QMC) meetings. These meetings in addition to MCBHS staff have clients, family
members, private providers, etc., as a part of this committee. This committee’s input
would also be sought, recorded and included in the project.
During the annual write-up about the project that would be posted in the English and
Spanish newspapers in Madera County. There would be a phone number and a
hyperlink connection to MCBHS for the public’s input for the review and assessment so
their input can be included.




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This data collection and review is core to the learning goal of this Project. This data
would be included in the final report on this Project and available to other counties for
their information/use.


Leveraging Resources (If Applicable)
Provide a list of resources to be leveraged, if applicable.

To be determined.




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                                                                     Date: 2-25-10
County: Madera

Work Plan Number: INN-02

Work Plan Name: Linkage to Physical Health by Pharmacist and Reverse Integration
from Mental Health to Physical Health

Purpose of Proposed Innovation Project (check all that apply)
   INCREASE ACCESS TO UNDERSERVED GROUPS
   INCREASE THE QUALITY OF SERVICES, INCLUDING BETTER OUTCOMES
   PROMOTE INTERAGENCY COLLABORATION
   INCREASE ACCESS TO SERVICES

Briefly explain the reason for selecting the above purpose(s).

Promote Interagency Collaboration
During the Innovations Planning Process, MCBHS clients complained about the lack of
coordination between mental health and physical health. Clients stated they were
concerned about indicating on their physical health records that they have a mental
illness because of stigma. Our client’s fear is founded. Historically, people with serious
mental illnesses have been treated as if mental illness were the only defining health factor
in their lives, e.g., "he/she's the schizophrenic..." Primary Care often is not trained in
mental health issues. Research shows that one half to two thirds of diagnosable mental
illnesses often goes unrecognized in a primary care setting.
Conversely, mental health providers often tend to overlook signs of physical disorders
with clients dismissing such concerns as psychosomatic or the result of their mental
illness. In one study, nearly half of women’s health issues were overlooked by
psychiatrists. When examining such data there appears to be a strong need for improved
coordination of care between mental health and physical health care providers.

BHSA staff has complained that primary care won’t respond to phone calls, letters, etc.
Primary care providers state that mental health won’t answer any questions when they
ask, so they have stopped trying. Physical health states they can’t get anyone into
mental health services, so they have stopped trying.

When this situation was discussed with Madera County Behavioral Health Service’s
(MCBHS’s) contracted pharmacist (stakeholder), she indicated that she had no trouble
with communication between herself and primary care. She usually can get a physician
right away on the telephone for consultation and/or other services. MCBHS contracts
with a pharmacist to provide overview of the medications the psychiatrists prescribe. As
part of this oversight process, she informs physicians, etc., about concerns if a
medication has side effects that might affect a person’s health, e.g., diabetes, heart



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disease, weight, etc. The pharmacist also looks for other complicating factors. For
example, the pharmacist may say, “This client is Latino and at risk for diabetes. When
was the last time they were tested?”

During the Innovations planning process, clients and family members stated they would
like to have a learning Project that would address the need for greater interagency
collaboration between physical health services and mental health. They stated they
wanted MCBHS and primary care to collaborate and work more closely together to
address their multiple mental and physical health needs. When the idea of having the
pharmacist available to provide this experience was explained to clients and family
members, they stated they would like to see if the pharmacist could provide this linkage
instead of a case manager and see if better results were achieved.

Research will show the most common model of integration between mental health and
primary care was done through psychiatrists, clinical psychologists, mental health
therapists, clinical nurses with behavioral health training and experience, or social
workers. Many models incorporated a “care manager” acting as the communication link.
MCBHS had already tried several of these types of linkages with little to no success.
Since the purpose of the Innovations Project is learning, the pharmacist was chosen as
there was no research found that had a pharmacist in this type of role. These are the
reasons, along with the interest in this project from clients, family members and
stakeholders, as to why this Project was chosen.


Project Description
Describe the Innovation, the issue it addresses and the expected outcome, i.e., how the
Innovation project may create positive change. Include a statement of how the Innovation
project supports and is consistent with the General Standards identified in the MHSA and
Title 9, CCR, section 3320. (Suggested length – one page)
Describe the Innovation
This project involves an innovative collaboration between the MCBHS’ contracted
pharmacist and local primary care providers. The pharmacist will work with the primary
care physicians and MCBHS staff by linking and coordinating the MCBHS client’s mental
health and physical health care. Clients who need physical health services would be
referred by staff (including peer/family member staff) and coordinated with physical health
care as necessary by the pharmacist. The pharmacist will call the primary care provider
and make the referral as well as an appointment for services. The pharmacist would then
work with clinical staff to transition any records that need to be obtained by the primary
care physician regarding medications, etc. All HIPAA and confidentiality regulations
would be respected. HIPAA does allow for the coordination of treatment between
physical health and mental health providers.
This Project would also include the pharmacist transitioning those MCBHS clients who
are stable and receiving only medication services from a mental health home to a medical
home (reverse integration). Those stable, “meds only” clients may have presenting


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physical health issues but are not receiving coordinated (or any) physical health care.
This project proposes to transition these clients to a medical home. We will learn if this
transition will relieve the problem of inadequate access for clients with more acute mental
health needs due to an overburdened system.
MCBHS will establish a formal relationship between the Rural Health Clinic (RHC) on the
grounds of Madera Community Hospital. This clinic is where the proposed staff in INN—
01A and B hoped to be housed. The pharmacist will make referrals to physical health of
those clients with stable SMI and who can be transitioned to a medical home. The
pharmacist will work with BHS clinical and peer staff as well as clients and family
members in this transition process.
The pharmacist will also be able to accept cross-referrals of primary care patients in need
of specialized mental health services. They will be referred to the clinical and peer staff
described in the INN—1B Project. As necessary, there will be access to formal and
informal psychiatric consultation for the RHC staff from MCBHS’s psychiatrists. This can
be arranged by the pharmacist. Also if the primary care physician needs consultation
regarding substance abuse services, a drug and alcohol counselor will also be available
for consultation.
Supervision of the pharmacist and the pharmacist’s contract will be done by the Division
Manager over this project. This Division Manager will have access to the MCBHS
Director regarding this Project, the pharmacist and their contract.
MCBHS will provide training to the primary care staff (including medical and support staff)
on mental illnesses, stigma, etc. This will increase their knowledge about mental health
issues and how to respond in a positive manner to our clients. Most training only occurs
with the medical staff. MCBHS proposes to also train not only the medical staff but the
support staff in Mental Health First Aid. Support staffs are usually the first people one
encounters at a medical office. MCBHS would want to learn if this makes a positive
difference on how our clients are treated and help to reduce stigma.
Mental Health First Aid is an evidenced-based program that builds mental health literacy,
helping the public identify, understand and respond to signs of mental illness. It gives key
skills to assist people with mental illness. Participants are introduced to risk factors and
warning signs for mental health or substance use problems. They learn about evidenced-
supported treatment and self-help strategies.
Issue Project Addresses
Statistics have shown that people with serious mental illnesses die, on average 25 years
earlier than the general population. Often, there is little contact between
psychiatric/mental health care and physical health care. The lack of inter-provider
coordination and communication is seen as a barrier to the quality of health care. This
was addressed in the President's New Freedom Commission Report. Further, the State
Department of Mental Health's contract with the county states, "That the MHP shall work
to ensure that services are coordinated with physical health care and other agencies used
by its beneficiaries. The MHP shall exchange information in an effective and timely
manner…"



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Numerous studies over the past 30 years have found high rates of physical health-related
problems and death among individuals with serious mental health issues. According to
the Bazelon Center for Mental Health Law, studies have shown that nearly half of people
with serious mental health issues had at least one chronic illness severe enough to limit
daily functioning. Adults with mental health issues were almost twice as likely to have
multiple medical disorders as adults without a mental illness. Those that have co-
occurring mental health and substance abuse disorders were the most likely to have
medical problems.
Madera County Statistics
During an intake, clinicians ask clients if they have a primary care physician (PCP). If a
client doesn't, they will make a referral for medical services. In reviewing charts, it has
been noted that even though the client states they have a PCP, there is still little
coordination between psychiatrists and the client’s medical physician. As stated prior,
clinical staff states they have little success in linking clients with primary care. This is
evident by the following statistics.
In examining 100 random mental health records of open MCBHS clients, the following
statistics were discovered. Sixty-two percent of the clients had a documented Axis III
diagnosis. An Axis III diagnosis indicates general medical conditions, e.g., diabetes,
heart disease, etc., as told by the client to the clinician. Only 40% of these 100 clients
had a primary care physician. There were only 22% of those 100 clients who had
releases of information between MCBHS and the primary care physician. Only 3% of
those 100 clients had any medical records in the chart indicating coordination of care with
the primary care physician.
There appears to be a need for more collaboration between MCBHS and primary care.
For these reasons our Innovation planning stakeholders indicated to us that promoting
interagency collaboration in this area should be the essential purpose of this Innovations
Project. Clients and family members wanted to learn if a pharmacist providing this
function would produce better results.
Outcome to Create Positive Change
This project will provide the following components which will assist us in learning if a
pharmacist can provide linkage between primary care and behavioral health. This project
will also assist in learning if a pharmacist can transition stable SMI from the mental health
system to a medical home for on-going medication monitoring and attention to physical
health needs. The overall outcome would be to create positive change in determining a
new way to increase collaboration and mental and physical wellness.
The Project is aligned with the MHSA General Standards in the following ways;
This Innovation Project supports and is consistent with the general principles of the
MHSA in the following ways;

1. Community Collaboration—the community was involved in the planning and
   development process of this project. Their input was appreciated and implemented in
   the design of this project. This project supports interagency collaboration between a



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   number of different service providers from the mental and physical health field. The
   community will continue to be involved through the dissemination of the findings of this
   project and any suggestions, etc. for its continuance and change.

   Since this is a learning Project, MCBHS will ask the community as to how they would
   like to remain involved and collaborate with MCBHS on this Project. Those ideas and
   inputs will be sought through stakeholder meetings, questionnaires, etc., and
   implemented.

2. Cultural Competency—MCBHS staff and peer support staff will work with the primary
   care physicians and their staff in providing an understanding of client/family member
   culture as well as other cultural competency issues. As stated earlier, clients are
   afraid to tell their primary care physician they have mental health issues due to
   stigma. Providing cultural competency training including client culture to primary care
   staff will help to reduce that stigma.

   Again, this approach of using a pharmacist was chosen at the request of clients and
   family members. They know that they, themselves have had little success in obtaining
   primary care services as well as the difficulty of behavioral health staff in obtaining
   such services. Since the pharmacist’s calls are always responded to quickly by
   primary care, the clients and family members wanted to try this approach to see if they
   could learn if it works as a future model of services.

   The local Rural Health Clinic personnel located on the grounds of the Community
   Hospital in Madera has requested training on Mental Health First Aid for its staff. This
   evidenced-based program helps to reduce stigma and increases knowledge about
   mental health issues and how to intervene until appropriate help arrives. Madera
   County has clients and staff trained as presenters in this program. This training will
   help to have PCP staff more at ease when encountering a mental health client.
   Clients state they are sometimes treated as if their mental illness is the only thing that
   defines them. Their physical health concerns are dismissed as being psychosomatic.
   The Mental Health First Aid training will help to reduce the stigma that exists within the
   physical health arena; help physical health staff to understand mental illness, and how
   to react to someone who may have mental health issues in a supportive and helpful
   manner.

   In addition to this training, the PCP staff, including the support/clerical staff will receive
   training in client culture, etc. Clients/family members that wish to present on
   client/family member culture will be encouraged to do so. This will further the
   competency of the PCP staff on client/family member culture to help reduce stigma
   and put them more at ease when working with our clients.

   The project will be evaluated with special attention given to diverse populations and
   will work to address their needs. Madera County has a large Latino population. This
   population is prone to diabetes, heart disease, etc. Many won’t seek physical health
   services until they are in a crisis situation. Being able to link these special populations



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   earlier for preventative services will help. Clients will be referred to primary care
   providers who speak the client’s language and may be from the same cultural
   backgrounds. This will help to reduce disparities among racial/ethnic, linguistic and
   the cultural populations of Madera County.

   The pharmacist is very culturally aware to the ethnic populations in Madera County.
   She has worked with Latino and other ethnic populations for many years. She knows
   the culturally sensitive providers of primary care within Madera County and has an
   established working relationship with them. As stated earlier, she is aware of the
   various physical health conditions of certain ethnic populations, is sensitive to these
   issues and requests special testing for conditions such as diabetes, high blood
   pressure, etc., which may occur with more frequency in these populations.

   A goal of this program is to determine which strategies are effective or ineffective for
   different age, ethnic and cultural groups and to inform this and other programs
   throughout the mental health system as to their effectiveness in hopes they can be
   replicated.

3. Client/Family Driven Mental Health System—this project includes the ongoing
   involvement clients and family members in roles such as, but not limited to,
   development and evaluation. Program development and implementation may
   depending on client/family member feedback, have certain strategies added or
   removed from the program and/or applied in other programs.

   Clients and family members will be involved in all stages of programming, including
   needs assessment, resource development, implementation and evaluation. Since this
   is a learning Project, MCBHS will ask clients/family members as to how they would
   like to remain involved and collaborate with MCBHS on this Project. As data is
   collected on this project, and services may need to be modified, clients and family
   members will be asked again for input on their involvement and collaboration with
   MCBHS on this project.

   Wellness, Recovery and Resilience Focus—this project increases resilience and
   promotes wellness and recovery for people with severe mental illness by providing a
   continuum of care. This continuum ranges from specialty mental health and recovery
   services to medication and chronic disease management which will emphasize overall
   heath and wellness. Having worked with Behavioral Health, the pharmacist

   understands the recovery model and knows that clients can and do recover.

   Overall health and wellness is important for our clients so they may life more fulfilling
   lives. Research shows that a person with mental illness will die on an average 25
   years earlier than someone without a mental illness. Many of our clients do not have
   general health care. By providing this health care coordination, they will be able to
   live longer and have more opportunities for fulfilling lives.




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   Our clients and family members wanted the pharmacist to fulfill this role regarding
   linkage since they have been unable to obtain adequate health care for themselves or
   through their mental health professional, e.g., care manager, therapist, etc. Especially
   since the cutbacks in State funding have eliminated many positions within MCBHS,
   there are fewer staff to provide/coordinate this type of service. Clients and family
   members were encouraged by the pharmacist providing this linkage for them in their
   hopes to have adequate health care resources.

   Again, clients have had little success in obtaining or coordinating physical health care
   for themselves. The pharmacist has had no trouble in referring clients for on-going
   medical services. Primary care staff will take and return her phone calls. This has not
   been the case for our behavioral health staff. This is why clients and family members
   wanted to learn if a pharmacist would make a difference in the coordination of these
   services.

   The pharmacist has worked with mentally ill clients and their families. She is familiar
   with recovery and wellness for this population and believes that clients can and do
   recover. Through the linkage of behavioral health and primary care, she will assist in
   the recovery of individuals with mental health issues though innovative services that
   empower clients and families to achieve their goals. She will ensure accesses to
   medically necessary services through engaging individuals with mental illness who
   may not be able to seek these services are their own.

4. Integrated Service Experiences for Clients and their Families—this project encourages
   and provides for access to a full range of services provided by multiple agencies,
   programs, etc., for clients. Clients will have access to multiple levels of care for their
   mental and physical health needs, e.g., access to mental health and physical health
   care. Referrals will be made for clients who need physical health services by staff and
   staff from the RHC will make referrals for mental health services of their primary care
   patients to the Project.

   The pharmacist linking clients to medical services will provide a holistic approach to
   medical and mental health services. Medications can be coordinated. As clients need
   specialty health services, those referrals can be made. MCBHS staff (including
   peer/family support) and the contracted pharmacist will now be taking into account all
   of somebody's physical, mental, and social conditions in their treatment.
   The pharmacist will be able to Identify and monitor persistent health needs and
   support intervention in a coordinated and minimally disruptive manner. She can refer
   for screening strategies for proactively identifying and locating persons with persistent
   physical health conditions; and promote the well-being of the population served
   through preventive health interventions.

   If clients need other services, primary care staff and the pharmacist can work with the
   MCBHS staff (including clinical and peer support staff) to provide housing, food,
   clothing, etc.



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Contribution to Learning
Describe how the Innovation project is expected to contribute to learning, including
whether it introduces new mental health practices/approaches, changes existing ones, or
introduces new applications or practices/approaches that have been successful in non-
mental health contexts. (Suggested length – one page)

In reviewing the meta-analysis of Integration of Mental Health/Substance Abuse and
Primary Care by the US Dept. of Health and Human Services, October 2008, (948
references/studies) the most common model of integration between mental health and
primary care was done through either psychiatrists, clinical psychologists, mental health
therapists, clinical nurses with behavioral health training and experience, or social
workers. Many models incorporated a “care manager” acting as the communication link.

A pharmacist was mentioned as one of the providers involved in four of the 948
references/studies; however, those four references/studies didn’t focus on integrated care
between a mental health agency, e.g., county mental health clinic and physical health or
the population served didn’t have a mental health condition. The pharmacist did not play
the role in linking clients from behavioral health to physical health services. The
pharmacist only provided medication education and information. MCBHS is unaware of
a model that provides the linking/transitioning by a pharmacist of stable SMI clients from a
small, rural, county mental health provider to a physical health care home. This project
proposes to enhance the role a pharmacist plays in the overall health and recovery of
SMI clients through increased collaboration and communication.

In the meta-study by the US Dept. of Health and Human Services, the 948 references
included the 16 studies mentioned in “Evaluating the Impact of Pharmacists in Mental
Health: Discussion,” published in Medscape Today in 2003. The author of this article
examined the 16 studies and found most of them to be poorly done and nonreplicable.
Out of the 16 studies they referenced, only four were conducted in outpatient psychiatric
clinics. Most of those four studies were about providing "case management services"
which the author described as “drug monitoring and education.” Drug monitoring and
education is not the linkage/transitioning of client’s to physical health services which is
being proposed in this Innovations Project.

The Finley et al, 2002 study from the “Evaluating the Impact of Pharmacists in Mental
Health, Discussion”, stated that the pharmacist was the "case manager." That study was
conducted in a primary care Health Maintenance Organization (HMO) setting not in a
small, rural, county mental health setting, such as Madera County Behavioral Health
Services. Again, the “case management” services were providing drug monitoring and
education to the private HMO physical health patients. Drug education and monitoring is
not the linkage to physical health that is being proposed by this Project.




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The second Finley study mentioned in the article, (2003) was the same. It had the
pharmacist in a private HMO primary care setting not a small, rural, county mental health
setting. The pharmacist only provided drug monitoring and education to the private,
primary care HMO population. Both of those studies (2002, 2003) didn't have the
pharmacist as a case manager performing the linkage in referring mental health clients in
a small, county mental health service to primary care which is what is being proposed in
this Innovations Project.

MCBHS’ innovation project will use a pharmacist as the primary person in linking clients
with mental health conditions to physical health. This is new and a change from the
existing way mental health has tried to coordinate physical and mental health
care/services in the past. This will allow our clients to have integrated care and a medical
home.
Madera County wants to learn the following; will having a pharmacist coordinating
physical and mental health care increase interagency collaboration?
Will MCBHS be able to;
   •	 Promote interagency collaboration between community health centers and mental
      health in providing coordinated physical and mental health care?
          o	 Will there will be;
                 ƒ	 An increase the number of clients able to get physical health care
                    after the linkage by the pharmacist?
                 ƒ	 An increase in clients who indicate that they felt more understood by
                    primary care staff?
                 ƒ	 An increase in clients who indicated their primary care staff was more
                    informed about their mental health issues?
                 ƒ	 An increase in the number of clients indicate they were more
                    satisfied with the services they received from their primary care staff
                    after being linked by the pharmacist?
          o	 Would primary care staff indicate they learned more about mental health
             issues and medications and are more comfortable with serving the SMI
             population?
   •	 Transition stable SMI clients in the mental health system to a primary care medical
      home for medication monitoring, chronic disease management education and
      counseling and attention to physical health care needs?
          o	 Will MCBHS serve more unserved and underserved SMI due to stable SMI
             clients being transitioned to a medical home?
To properly measure the intended learning goals, outcome measures will be developed
that focus on the impact of clients receiving coordinated medical and mental health
services along with the transition to a medical home. Several measurement instruments
would be developed including pre and post surveys for clients and key primary care



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providers. Clients and family members would be involved in the development of the
surveys and any other measurement tools.


Timeline
Outline the timeframe within which the Innovation project will operate, including
communicating results and lessons learned. Explain how the proposed timeframe will
allow sufficient time for learning and will provide the opportunity to assess the feasibility of
replication. (Suggested length – one page)

Implementation/Completion Dates: ____7/10—6/13___
                                     MM/YY – MM/YY

This Project would be designed to operate over a three year period. This will give
multiple opportunities for assessment and evaluation during this time period. It will allow
for sufficient time for learning and adaptation to occur in a way to improve the outcomes
of the program. An ongoing assessment process and time after the completion of the
Project will allow for the final evaluation to be comprehensive. That evaluation would
include input from stakeholders, clients, family members, etc.

Data would be gathered quarterly regarding the coordination of physical and mental
health care. The project would be reviewed on an annual basis with a final
comprehensive assessment after June 2013. This gives time for;

   •	 The pharmacist, clients/family members, other stakeholders and staff to develop
      this new model,

   •	 The pharmacist, clients/family members, other stakeholders and staff to develop
      measurement instruments and data,

   •	 The pharmacist, client/family members, other stakeholders, staff and management
      the ability to see what is and isn’t working in this project,

   •	 Modifications as necessary. The pharmacist, clients/family members, other
      stakeholders and staff will develop any modifications as necessary to the Project
      and to data collection instruments,

   •	 The pharmacist will be testing and retesting the model, etc.

   •	 The pharmacist and staff will collect data to determine if this approach works,

   •	 Determination if this approach can be replicated by other counties.

Stakeholders, including clients, family members, providers and the pharmacist would be
involved in the design of this project’s assessment and surveyed as part of the evaluation



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process. This data would be submitted to the Department’s Quality Management
Committee which includes clients, providers and family members. In addition there will
be specific outcome measures related to client and staff satisfaction and other health
outcomes in both the primary care and mental health settings.

Data would be presented at the Mental Health Board Meetings, MHSA stakeholder
meetings, to any primary care practice groups who wish to receive that information, etc.
Data would also be presented at the wellness and recovery centers located in Madera
and Oakhurst to clients and family members. The Project would also be written in articles
in the local English and Spanish newspapers and posted on the Department’s website.
During the review and assessment process, comments and perspectives of the various
stakeholders would be sought and recorded.

6/10—Approval by the Oversight and Accountability Commission of this Innovation Plan
7/10—12/10
Model of services will be developed by crisis and peer staff, stakeholders, etc. Model will
continue to be refined as the Project continues based upon input from clients, family
members, staff, stakeholders, data, etc.
Contracts will be developed for the consulting pharmacist. Any forms necessary for
monitoring/evaluation will be developed and implemented. The pharmacist, clients/family
members and stakeholders input would be solicited for the development of outcome
measures and measurement tools. That input would be incorporated into the Project’s
measurement system.
Data and linkages would initiate. Data would be examined on a quarterly basis regarding;
   •	 Increased interagency collaboration regarding mental health clients getting 

      physical health needs met 

   •	 Increase interagency collaboration regarding physical health clients being able to
      access mental health services
   •	 MCBHS being able to serve more unserved and underserved SMI due to stable
      SMI clients being transitioned to a medical home

Training on various issues, e.g., Mental Health First Aid, cultural competency, client
culture, primary care and behavioral health terminology, etc., would commence. As
necessary and based upon data collected in this Project, additional training needs would
be documented and provided.

1/11—6/11 Data and linkages would continue. Data would be examined on a quarterly
basis. Changes would be made to program as appropriate based on data and input by
clients/family members, stakeholders, staff and the pharmacist. Additional training needs
would be identified and provided. Stakeholders would be informed of results.

7/11—6/12 Data and linkages would continue. Data would be collected quarterly.
Changes will be made to program as appropriate based on data and input by



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clients/family members, stakeholders, staff and the pharmacist.. Additional training needs
would be identified and provided. Stakeholders would be informed of results.

7/12—6/13 Data would be examined on a quarterly basis. Data would be examined
regarding MCBHS being able to serve more unserved and underserved SMI due to stable
SMI clients being transitioned to a medical home, the interagency collaboration and
client’s satisfaction with the Project. Changes will be made to program as appropriate
based on data and input by clients/family members, stakeholders, staff and the
pharmacist..

Additional training needs would be identified and provided. Stakeholders would be
informed of results. MCBHS would have enough data to determine if this approach works
and if it can be replicated by other counties. That information would be disseminated.


Project Measurement
Describe how the project will be reviewed and assessed and how the County will include
the perspectives of stakeholders in the review and assessment.

Review and Assessment

Stakeholders, including the pharmacist, clients and providers would be involved in the
design of this project’s assessment and surveyed as part of the evaluation process. The
design for the assessment of data would be submitted to the MCBHS’ Department’s
Quality Management Committee which includes clients, providers and family members.
There will be specific outcome measures developed related to client and staff satisfaction
and other health outcomes in both the primary care and mental health settings.
In addition to the demographic data about the clients receiving services in this project,
MCBHS would review and assess (but is not limited to) the following;
   •	 Has there been improved communication and collaboration between mental health
      and primary care? (survey)
   •	 Is there improved interagency collaboration? (survey)
   •	 Has this improved communication and collaboration resulted in improved 

      outcomes for clients served by the medical home model of services? (data) 

   •	 Has the collaboration;
          o	 Improved mental health outcomes due to integrated treatment and disease
             management support? (data and survey)
          o	 Increased the number of physical health clients referred for mental health
             services? (data)




                                            59
                                     EXHIBIT C #2 INN

                             Innovation Work Plan Narrative

          o	 Increased staff satisfaction with both the primary care staff and mental
             health staff who are part of this Project? (survey)
          o	 Increased the number of mental health clients referred and able to obtain
             physical health services after linkage by the pharmacist? (data)
          o	 Increased the number of clients who indicated that they felt more
             understood by primary care staff? (survey)
                  ƒ	 Increased the number of clients who indicated their primary care staff
                     was more informed about their mental health issues? (survey)
                  ƒ	 Increased the number of clients who indicated they were more
                     satisfied with the services they received from their primary care staff
                     after being linked by the pharmacist? (survey)
   •	 Would primary care staff indicate they learned more about mental health issues
      and medications and are more comfortable with serving the SMI population?
      (survey)
          o	 Transitioned stable SMI clients in the mental health system to a primary
             care medical home for medication monitoring, chronic disease management
             education and counseling and attention to physical health care needs?
             (data)
          o	 Will MCBHS serve more unserved and underserved SMI due to stable SMI
             clients being transitioned to a medical home? (data)
   •	 Other outcomes as indicated by the pharmacist, stakeholders, clients, families,
      etc., during the review process.


Leveraging Resources (If Applicable)
Provide a list of resources to be leveraged, if applicable.

In development.




                                             60
          EXHIBIT D 


Innovation Work Plan Description




               61
                          EXHIBIT D #1 INN 1A & 1B 


                      Innovation Work Plan Description
                        (For Posting on DMH Website)


County Name: Madera                                  Annual Number of Clients to Be
                                                     Served (If Applicable)
Work Plan Name INN—1A and 1B
New Model for Access to Services                     _250__ Total


Population to be Served (if applicable):
Clients/family members at Madera Community Hospital Emergency room who
themselves or family members received crisis mental health services (INN—01A) and
for the residents of Madera County wishing to access mental health services within the
Madera city limit (INN—01B).


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


 Madera County has divided its INN—01 Plan into Parts A and B. The reason
 for this is to better describe the learning experience we wish to embark upon,
 for ease of reading, understanding, maximize staffing, resources, etc.




                                       62
                           EXHIBIT D #1 INN 1A & 1B 


                       Innovation Work Plan Description
                         (For Posting on DMH Website)

The proposed INN—01 A and B plan will house the crisis/assessment staff and the
newly proposed peer/family member staff at the Madera Community Hospital’s Rural
Health Clinic (RHC) located across the parking lot from the ER on the Madera
Community Hospital grounds. Crisis/assessment staff along with the peer/family
member staff will provide services to clients/families in the ER. While a client is being
seen for a crisis evaluation, the peer/family member staff will engage the client’s family.
They will greet them and talk about what crisis services are, what happens with their
family members during this time, etc. They will also talk about what follow-up services
are available for their family member and for themselves. They will show that recovery
is possible and through example, provide hope to the family.

After the client is assessed, the client/family member staff will be able to provide
supportive services to the client while he/she is in the ER and explain what outpatient
and peer support services are available (INN—1B). They will be able to demonstrate
to the client there is hope for recovery. The client/family member staff will be trained in
available resources so if there is a need for housing, employment, food, etc.; they will
be able to refer the client and their family as necessary for services/resources. The
ultimate goals of these projects are to learn whether or not peer/family member support
will increase access into the mental health system (INN—01A) and improve the quality
of care through a new model of peer support and clinical team services (INN—01B).

When the crisis and the peer/family member staff are not busy at the ER, they will be
able to provide the supportive and clinical services through the new model being
proposed in INN—01B. If the person in crisis is not hospitalized, they will be able to go
over and immediately join supportive clinical and peer services and groups going on at
the Rural Health Clinic across the parking lot from the ER. These services and groups
(part of INN—01B) will be available on a walk-in basis from 8 am to 8 pm Monday
through Friday. They will emphasize recovery principles and ways to deal with
situations in one’s lives so clients will learn how to handle the various crisis situations
that may arise. The goal of this Project is to learn whether we can create a new model
of peer/family member support and clinical services to increase the quality of services
including retention rates.

Madera County is a small county. In the INN—01A plan, statistics show within a 90
day period of time, there were 173 visits of new clients for crisis services. This time
period didn’t account for existing clients who may have frequented the ER for crisis
visits. The 173 visits within the 90 day period of time averaged to 1.9 visits per day. In
order to maximize resources, staffing, etc., the proposed clinical crisis/assessment
staff and peer/family member support staff that will be providing the services in INN—
01A and B, will be the same staff. When they are not performing the engagement
functions within INN—01A, within their prescribed workday, they will be providing the
supportive services described in INN—01B.

These proposed supportive services in INN—01B will include an assessment for initial



                                         63
                           EXHIBIT D #1 INN 1A & 1B 


                       Innovation Work Plan Description
                         (For Posting on DMH Website)

services into the mental health system. Clients who need full service partnership
(FSP) services or intensive long term services (at least one year), will be referred to
the main mental health clinic in Madera or other outlying clinics throughout the county
(e.g., the Oakhurst mountain region or Chowchilla) as appropriate. Those clients who
could benefit or wish to benefit from shorter-term outpatient services provided in
tandem with peer/family member support services, will be referred to the clinical and
peer services provided in the Innovations Project INN—01B.

Since the INN-01B Project is located with the Rural Health Clinic, this project will be
able to work with the primary care physicians in obtaining mental health services for
their patients. These new INN Projects (INN—01A and B) will be a new and
innovative way to provide timely access to our “front door” for services. MCBHS looks
forward to a close working relationship with the primary care physicians. In addition to
INN Projects 01A and B, for those clients currently receiving mental health services
who are stabilized and can be referred to a medical home (reverse integration) or for
those clients who need physical health services, will be referred for those services at
the Rural Health Clinic proposed in the INN—02 Project.

Madera County BHS Learning/Practice Change Goal

Madera County BHS Learning/Practice Change Goal—INN—01A

   1. Hypothesis—MCBHS will have peer/family member (including TAY) staff at the
      emergency room engaging clients/family members and provide follow-up
      engagement if necessary, after the client leaves the ER (including after
      hospitalization). Will this engagement lead to an increased access and
      utilization of mental health services? Is there a difference between the
      engagement at the ER and/or for those who are discharged from the ER and
      followed by peer/family member services after they have returned home?

          a.	 Goal/Outcome—Clients seen in the ER or who are hospitalized will
              access and utilize services at higher rates.

          b. Goal/Outcome—Peer/Family member engagement services will be more
             successful with certain age, gender, cultural groups, etc., than the current
             referral process for ongoing services.

          c.	 Goal/Outcome—Youth and TAY seen at the ER or who were hospitalized
              will access services at higher rates due to outreach and engagement by
              a TAY peer provider.

          d. Goal/Outcome—TAY engagement services will be more successful in
             getting youth and TAY into services than the current referral process.

          e.	 Goal/Outcome—Youth/TAY and adults will access services equally



                                        64
                           EXHIBIT D #1 INN 1A & 1B 


                       Innovation Work Plan Description
                         (For Posting on DMH Website)

              whether engaged at the ER or on the next business day by peer/family
              member staff.

   2. Hypothesis—can voluntary, recovery-oriented, peer driven services be 

      successful in a general hospital emergency room? 


          a.	 Goal/Outcome—by providing peer/family services, there will be better
              recovery outcomes and access to treatment.

          b. Goal/Outcome—by providing TAY peer services, there will be better
             recovery outcomes and access to treatment by the youth and TAY
             population.

          c.	 Goal/Outcome—by providing peer/family services, there will be a change
              in the attitude of the ER staff towards recovery and mental health
              services. In particular there will be a change in the attitude towards youth
              and TAY recovery and mental health services.

Madera County BHS Learning/Practice Change Goal—INN—01B

As part of this Project, MCBHS would examine the following;
   •	 What elements are necessary to create a new and successful model of a
      peer/family member partnership in a small, rural county public mental health
      system?
           o	 Which supportive services work better to engage and retain clients?
           o	 Does a combination of clinical and peer staff providing services together
               either individually or in a group setting help to engage and retain clients
               in treatment?
           o	 Does initial engagement by peer/family member staffs help to retain
               clients in service?
           o	 Does on-going engagement by peer/family member staff help to retain
               clients in service?
           o	 Do clients/family members receive an improved quality of service through
               this new model of client/family member and clinical staff combination for
               service provision?
   •	 As a result, would there be an improvement in the quality of services including
      better outcomes?
           o	 Would this new model of peer and clinical staff result in an increase the
               access to services for clients and families, especially the unserved and
               underserved populations of a small, rural county?
           o	 Will penetration rates increase as a result of this new model?
           o	 Do any factors of this new model decreases recidivism rates in crisis
               services?
           o	 What factors of this model help to engage clients?
           o	 Was the model effective in providing services to this population?


                                         65
                 EXHIBIT D #1 INN 1A & 1B

             Innovation Work Plan Description
               (For Posting on DMH Website)

o	   Were services appropriate to meet the client’s needs?
o	   Was staff responsive to the needs of the clients/family members?
o	   Were services responsive and accessible?
o	   Were clients/family members able to increase their knowledge of
     recovery principles and utilize that knowledge?
o	   Was there an increase in involvement and decision making by the client
     in a recovery-focused manner?
o	   What factors help to retain clients, especially the unserved and
     underserved population in treatment?
o	   Do these factors help to increase the retention rates for services?
o	   Does this model decrease stigma about mental health services for a
     small, rural county behavioral health department?




                              66
                                   EXHIBIT D #2 INN 


                          Innovation Work Plan Description
                            (For Posting on DMH Website)


County Name: Madera                                    Annual Number of Clients to Be
                                                       Served (If Applicable)
Work Plan Name INN—02 Linkage to Physical
Health by Pharmacist and Reverse Integration from _50__ Total
Mental Health to Physical Health


Population to be Served (if applicable):
Madera County Behavioral Health Services (MCBHS) clients who are seriously and
persistently mentally ill or have a serious emotional disturbance.


Project Description (suggested length – one-half page): Provide a concise overall
description of the proposed Innovation.
During the Innovations Planning Process, MCBHS clients complained about the lack of
coordination between mental health and physical health. Clients stated they were
concerned about indicating on their physical health records that they have a mental
illness because of stigma. Our client’s fear is founded. Historically, people with
serious mental illnesses have been treated as if mental illness were the only defining
health factor in their lives, e.g., "he/she's the schizophrenic..." Primary Care often is
not trained in mental health issues. Research shows that one half to two thirds of
diagnosable mental illnesses often goes unrecognized in a primary care setting.
Conversely, mental health providers often tend to overlook signs of physical disorders
with clients dismissing such concerns as psychosomatic or the result of their mental
illness. In one study, nearly half of women’s health issues were overlooked by
psychiatrists. When examining such data there appears to be a strong need for
improved coordination of care between mental health and physical health care
providers.

BHSA staff has complained that primary care won’t respond to phone calls, letters, etc.
Primary care providers state that mental health won’t answer any questions when they
ask, so they have stopped trying. Physical health states they can’t get anyone into
mental health services, so they have stopped trying.

When this situation was discussed with Madera County Behavioral Health Service’s
(MCBHS’s) contracted pharmacist (stakeholder), she indicated that she had no trouble
with communication between herself and primary care. She usually can get a
physician right away on the telephone for consultation and/or other services.

During the Innovations planning process, clients and family members stated they
would like to have a learning Project that would address the need for greater
interagency collaboration between physical health services and mental health. They



                                        67
                                     EXHIBIT D #2 INN 


                           Innovation Work Plan Description
                             (For Posting on DMH Website)

stated they wanted MCBHS and primary care to collaborate and work more closely
together to address their multiple mental and physical health needs. When the idea of
having the pharmacist available to provide this experience was explained to clients and
family members, they stated they would like to see if the pharmacist could provide this
linkage instead of a case manager and see if better results were achieved. Since the
purpose of the Innovations Project is learning, the pharmacist was chosen as there
was no research found that had a pharmacist in this type of role.
This project involves an innovative collaboration between the MCBHS’ contracted
pharmacist and local primary care providers. The pharmacist will work with the primary
care physicians and MCBHS staff by linking and coordinating the MCBHS client’s
mental health and physical health care. Clients who need physical health services
would be referred by staff (including peer/family member staff) and coordinated with
physical health care as necessary by the pharmacist. The pharmacist will call the
primary care provider and make the referral as well as an appointment for services.
The pharmacist would then work with clinical staff to transition any records that need to
be obtained by the primary care physician regarding medications, etc. All HIPAA and
confidentiality regulations would be respected. HIPAA does allow for the coordination
of treatment between physical health and mental health providers.
This Project would also include the pharmacist transitioning those MCBHS clients who
are stable and receiving only medication services from a mental health home to a
medical home (reverse integration). Those stable, “meds only” clients may have
presenting physical health issues but are not receiving coordinated (or any) physical
health care. This project proposes to transition these clients to a medical home. We
will learn if this transition will relieve the problem of inadequate access for clients with
more acute mental health needs due to an overburdened system.
Madera County wants to learn the following; will having a pharmacist coordinating
physical and mental health care increase interagency collaboration?
Will MCBHS be able to;
   •	 Promote interagency collaboration between community health centers and
      mental health in providing coordinated physical and mental health care?
          o	 Will there will be;
                  ƒ   An increase the number of clients able to get physical health care
                      after the linkage by the pharmacist?
                  ƒ   An increase in clients who indicate that they felt more understood
                      by primary care staff?
                  ƒ   An increase in clients who indicated their primary care staff was
                      more informed about their mental health issues?
                  ƒ   An increase in the number of clients indicate they were more
                      satisfied with the services they received from their primary care




                                          68
                                  EXHIBIT D #2 INN

                         Innovation Work Plan Description
                           (For Posting on DMH Website)

                    staff after being linked by the pharmacist?
         o	 Would primary care staff indicate they learned more about mental health
            issues and medications and are more comfortable with serving the SMI
            population?
   •	 Transition stable SMI clients in the mental health system to a primary care
      medical home for medication monitoring, chronic disease management
      education and counseling and attention to physical health care needs?
         o	 Will MCBHS serve more unserved and underserved SMI due to stable
            SMI clients being transitioned to a medical home?
To properly measure the intended learning goals, outcome measures will be developed
that focus on the impact of clients receiving coordinated medical and mental health
services along with the transition to a medical home. Several measurement
instruments would be developed including pre and post surveys for clients and key
primary care providers. Clients and family members would be involved in the
development of the surveys and any other measurement tools.




                                        69
            EXHIBIT E 


Annual Update MHSA Summary Funding 

              Request 


               and 

            EXHIBIT E5 


        INN Budget Summary




                 70
      2010/11 ANNUAL UPDATE                                                                                                                            EXHIBIT E
                                                            MHSA SUMMARY FUNDING REQUEST


County: Madera                                                                                                                               Date:           3/4/2010

                                                                                                        MHSA Funding
                                                                                                                                                     Local Prudent
                                                               CSS               WET              CFTN               PEI               INN
                                                                                                                                                       Reserve
A. FY 2010/11 Planning Estimates

     1. Published Planning Estimate                            $3,515,500                                              $850,400         $522,300

     2. Transfers

     3. Adjusted Planning Estimates                            $3,515,500
B. FY 2010/11 Funding Request

     1. Requested Funding in FY 2010/11                        $3,515,500                                            $1,385,635         $854,297

     2. Requested Funding for CPP

     3. Net Available Unexpended Funds

         a. Unexpended FY 06/07 Funds

         b. Unexpended FY 2007/08 Fundsa/

         c. Unexpended FY 2008/09 Funds                        $2,205,810

         d. Adjustment for FY 2009/2010                        $2,205,810

         e. Total Net Available Unexpended Funds                        $0                $0               $0                $0                 $0

     4. Total FY 2010/11 Funding Request                       $3,515,500                 $0               $0        $1,385,635         $854,297
C.   Funds Requested for FY 2010/11
     1. Previously Approved Programs/Projects
         a. Unapproved FY 06/07 Planning Estimates                                        $0
                                                    a/
         b. Unapproved FY 07/08 Planning Estimates                                        $0

         c. Unapproved FY 08/09 Planning Estimates                                                                     $900,300         $233,300

         d. Unapproved FY 09/10 Planning Estimates                                                                      $93,100         $233,300

         e. Unapproved FY10/11 Planning Estimates              $3,515,500                                              $392,235         $387,697

         Sub-total                                             $3,515,500                 $0                         $1,385,635         $854,297

         f. Local Prudent Reserve

     2. New Programs/Projects

         a. Unapproved FY 06/07 Planning Estimates

         b. Unapproved FY 07/08 Planning Estimatesa/

         c. Unapproved FY 08/09 Planning Estimates

         d. Unapproved FY 09/10 Planning Estimates

         e. Unapproved FY10/11 Planning Estimates

         Sub-total                                                      $0                $0               $0                $0                 $0

         f. Local Prudent Reserve

     3. FY 2010/11 Total Allocation b/                         $3,515,500                 $0               $0        $1,385,635         $854,297
a/Only applies to CSS augmentation planning estimates released pursuant to DMH Info. Notice 07-21, as the FY 07/08 Planning Estimate for CSS is scheduled for 

reversion on June 30, 2010.

b/ Must equal line B.4. for each component.

NOTE

         WET Funds -DMH previously approved on May 22, 2009 $316,100 from FY 2006/07 Planning Estimates and $435,700 from FY 2007/08 Planning
         Estimates and prior to this date DMH previously approved WET funds of $55,800. FY09/10 $309,525 , FY10/11 $219,539, FY11/12 $222,736 for a total of
     1   $751,800.
     2   Madera County is anticipating utilizing all the unspent FY 08/09 CSS funds during the FY 09/10




                                                                                   71
FY 2010/11                                                                                                                                                                EXHIBIT E5
                                                                                 INN BUDGET SUMMARY

  County: Madera                                                                                                                                                 Date:      3/4/2010

                             INN Programs                                                                            Estimated MHSA Funds by Age Group (if applicable)
                                                                             FY 10/11 Requested
                                                                                                           Children and      Transition Age
        No.                             Name                                   MHSA Funding                                                       Adult            Older Adult
                                                                                                              Youth              Youth
                   Previously Approved Programs
  1.                                                                                             $0
  2.                                                                                             $0
  3.                                                                                             $0
  4.                                                                                             $0
  5.                                                                                             $0
  6.                                                                                             $0
  7.                                                                                             $0
  8.                                                                                             $0
  9.                                                                                             $0
 10.                                                                                             $0
 11.                                                                                             $0
 12.                                                                                             $0
 13.                                                                                             $0
 14.                                                                                             $0
 15.                                                                                             $0
 16. Subtotal: Programs                                                                          $0                     $0                     $0                    $0           $0 Percentage
 17. Plus up to 15% County Administration                                                                                                                                               #DIV/0!
 18. Plus up to 10% Operating Reserve                                                                                                                                                   #DIV/0!
     Subtotal: Previously Approved Programs/County Admin./Operating
 19. Reserve                                                                                     $0
                             New Programs

   1.     1 New Model for Access Into Services                                             $661,022               $224,747              $158,645               $158,645      $118,985
            Linkage to Physical Health By Pharmacist & Reverse Integration
   2.     2 from Mental Health to Physical Health                                           $19,200                                       $5,760                 $9,600        $3,840
            Development of Model of Integrated Peer Support & Clinical
            Service in a Small, Rural County Mental Health System to
  3.      3 Increase Access and Retention                                                        $0                     $0                     $0                    $0           $0
  4.                                                                                             $0
  5.                                                                                             $0
  6. Subtotal: Programs                                                                    $680,222               $224,747              $164,405               $168,245      $122,825 Percentage
  7. Plus up to 15% County Administration                                                  $105,053                                                                                            15%
  8. Plus up to 10% Operating Reserve                                                       $69,022                                                                                           8.8%
  9. Subtotal: New Programs/County Admin./Operating Reserve                                $854,297
 10. Total MHSA Funds Requested for INN                                                    $854,297

Note: Previously Approved Programs that propose changes to essential purpose, learning goal, and/or funding as described in the Information Notice are considered New.
                                                                                           $854,297




                                                                                                      72
     EXHIBIT F 


New Innovation Budget 


      Narrative 


         and 


Project Budget Detail





          73
                        Request Fiscal Year 2010 - 2011 INN Funding 

                                     Budget Narrative 


In this plan request, Madera County is requesting INN funding for the Fiscal Year (FY) 2010-
2011 in two workplans and for costs associated with administration and the operating reserve :

   1.	 New Model for Access Into Services
   2.	 Linkage to Physical Health by Pharmacist & Reverse Integration from Mental Health to
       Physical
   *	 Administration and Operating Reserve

INN Request MHSA Workplans:

Madera County is requesting INN funding for two (2) new Workplans. The amount of funding
requested is $854,297 for this MHSA INN 2010-11 Plan update. This amount is comprised of
the allocation from FY 2010-2011 of $387,697, FY 2009-2010 of $233,300, and from FY 2008-
2009 of $233,300. Madera County is completing an initial plan request for INN. This plan is
assuming the Planning Estimates for fiscal year 2011/12 and fiscal year 2012/13 will remain at
the Planning Estimate level of fiscal year 2010/11 of $522,300.

The following budget outline summarizes the two Madera County MHSA INN Workplans:

INN Work Plan #1 New Model for Access Into Services:

Description: This work plan will implement the INN plan by collaborating with stakeholders, the
Emergency Room, and other community groups, and it will assist in increasing access and
reducing the number of crisis visits. This work plan staff will work with our local hospital staff.
The work plan will engage clients who are in a crisis mode and attempt to develop a relationship
so the initial services will be on the hospital campus and not in a mental health clinic (reduce
stigma). This work plan will also link peer support and family support with the community and
attempt to engage the person or the person’s family members in crisis and to offer tools that will
allow the person to cope in times of crisis rather than a return visit to the Emergency Room.

The direct clinical service staff will evaluate and assess the clients. The peer/family members
will provide support and outreach services to clients and their family members. The 0.20 FTE
Behavioral Health Division Manager, and 1.00 FTE Supervising Mental Health Clinician will be
available to the service staff and peer/family members for clinical supervision and guidance.
The 2.00 FTE Program Assistants will be available to provide support for the direct service staff
and peer/family members staff. The Program Assistants will be responsible for receptionist
duties, medical records, recording data into the Anasazi medical records system, and
scheduling clients for individual and, group services.

The Proposed Staffing: 0.20 FTE Behavioral Health Division Manage, 1.00 FTE Supervising
Mental Health Clinician, 1.50 FTE Mental Health Clinicians, 2.00 Mental Health Crisis
Worker/License Nursing Staff, 0.10 FTE Certified Alcohol & Drug Counselors, and 2.00 Program



                                                74
Madera County
INN MHSA Budget Narrative 2010-11

Page 2 


Assistant,. Salaries are based on current Madera County salaries approved by the Board of
Supervisors. TOTAL FTE 6.80

Program Salary Cost:

Division Manager    FY 2010-11: $ 17,140          FY 2011-12: $ 17,569       FY 2012-13 $ 17,997
Supervisor MH Clinician
                    FY 2010-11: $ 37,838          FY 2011-12: $ 38,783       FY 2012-13 $ 39,729
MH Clinicians       FY 2010-11: $ 88,167          FY 2011-12: $ 90,370       FY 2012-13 $ 90,699
MH Crisis Workers   FY 2010-11: $123,332          FY 2011-12: $126,416       FY 2012-13 $129,498
Certified Counselor FY 2010-11: $ 4,618           FY 2011-12: $ 4,733        FY 2012-13 $ 4,849
Program Assistant   FY 2010-11: $ 34,924          FY 2011-12: $ 35,796       FY 2012-13 $ 36,669
Budgeted Amount FY 2010-11: $306,019              FY 2011-12: $313,667       FY 2012-13 $319,441

Employee Benefits: Benefits for the 6.80 FTE are based on the current Madera County
benefits package that includes the following: FICA 0.0608, Medicare 0.0142, PERS 0.1622, and
health insurance coverage of $585.29 per month based on full time equivalency.

Budgeted Amount FY 2010-11: $82,624               FY 2011-12: $ 84,689       FY 2012-13 $ 86,248


The total personnel expenditures will be:

Budgeted Amount FY 2010-11: $388,643 FY 2011-12: $398,356                    FY 2012-13 $405,689

Operating Expenditures: This includes professional services of translation and interpreter
services. For staff travel and transportation, the staff will use a County van or will be reimbursed at
50 cents per mile if they use their own vehicle. This work plan will have the cost for the building
rent (lease), utilities, and repairs/maintenance. General Office includes the estimated costs for
office supplies, phone and cell phones, educational materials, program flyers, and bulletins.

Budgeted Amount FY 2010-11: $99,618               FY 2011-12: $79,045        FY 2012-13 $79,045

Budget includes 2 full time and 5 part-time peer/family members who will work 15-20 hours per
week. Based on past history, these work hours will not impact peer/family member Social
Security (SS), Supplemental Security Income (SSI), or other benefits the peer/family member is
receiving. Since there are not enough dollars in the Innovations allocation, we will be unable to
provide the peer/family member support staff services on a 24/7 basis. The plan is to schedule
the peer/family member support staff during the peak hours between 8:00 a.m. and 8:00 p.m.
Madera County averages approximately 2.4 crises per day. If a client/family shows up in the ER
during the hours that the peer/family support is unavailable, they will assigned to follow-up with
the client/family as soon as possible on their next work day. The budget includes 2 full time and
5 part-time peer/family members who will work around 15-20 hours (each) per week.

Budgeted Amount FY 2010-11: $137,761              FY 2011-12: $139,478       FY 2012-13 $143,577


2

                                                  75
Madera County
INN MHSA Budget Narrative 2010-11

Page 3 



The work plan includes one-time expenditures for a phone system, software programs, and office,
reception, and group room furniture of chairs desks and book cases.

Budgeted Amount FY 2010-11: $35,000           FY 2011-12: $ 0          FY 2012-13 $ 0

Total Operating Expenditures and costs for Peer/Family Members will be:

Budgeted Amount FY 2010-11: $272,379 FY 2011-12: $218,523              FY 2012-13 $222,622

The Total Revenues:

Budgeted EPSDT          FY 2010-11: $0        FY 2011-12: $ 6,430      FY 2012-13 $ 13,148
Budgeted FFP            FY 2010-11: $0        FY 2011-12: $42,869      FY 2012-13 $ 87,656
Total Budgeted          FY 2010-11: $0        FY 2011-12: $49,299      FY 2012-13 $100,804

The work plan net cost is:

Budgeted Amount FY 2010-11: $661,022 FY 2011-12: $567,580              FY 2012-13 $527,507



INN Work Plan #2 Linkages to Physical Health by Pharmacist and Reverse Integration
from Mental Health to Physical Health

Description: This work plan will consist of a contracted Pharmacist one day a month and a
contracted Psychiatrist working 2 hours a month to be available for consultation services with
Emergency Room staff and Primary Care Providers. Consultation will generally be related to
Psychotropic Medication.

This project involves an innovative collaboration between the BHS’ contracted pharmacist, BHS’
contracted psychiatrist and local primary care providers. The pharmacist will work with the
primary care physicians and BHS staff by linking and coordinating the BHS client’s mental
health and physical health care. Clients who need physical health services would be referred
and coordinated with physical health care as necessary by the pharmacist. The contract
psychiatrist will be available for case consultation with the primary care providers.

The Total Operating Expenditures will be:

Budgeted Amount FY 2010-11: $19,200           FY 2011-12: $ 19,200     FY 2012-13 $19,200


Total Revenues of:


3

                                              76
Madera County
INN MHSA Budget Narrative 2010-11

Page 4 


Budgeted Amount FY 2010-11: $ 0                FY 2011-12: $ 0           FY 2012-13 $ 0 



The net cost for the work plan is: 


Budgeted Amount FY 2010-11: $19,200            FY 2011-12: $ 19,200      FY 2012-13 $19,200 




Table:


The table below reflects a summary of the total planning request for FY 2010-11 and
includes funding type, number of clients to be served, and costs.

 Type                 Work Plan #              Funds Requested       # of Clients
# 1 INN             Model for Access Into         $661,022               250
                          Services

#2 INN           Linkage to Physical Health         $19,200               50
                 by Pharmacist & Reverse
                   Integration from Mental
                      Health to Physical

*Please note that we are only asking for $387,697 of the INN allocation for MHSA INN 09/10
planning estimates, and FY 08/09 of $233,300 and FY 09/10 of $233,300 for a total of $854,297.
We are not requesting funds for Fiscal Year 2011/12 and 2012/13 since these Planning
Estimates’ aren’t available at this time.

*Administration:

Madera County is requesting INN funding to sustain the costs associated with the concerted
amount of administration support required for ensuring ongoing community planning,
implementation and monitoring of our MHSA work plans and activities. The Administration staff
cost is based on an estimate of staff time related to the Innovation work plans. The
Administration staff is composed of a portion of the Director, Assistant Director, and Compliance
Officer. Some of the Fiscal staff responsibilities include payment of outside vendors, contract
development, contract monitoring, human resources reporting, budgets and cost reports. Some
of the Local Information Technology staff responsibilities include client account receivables,
assisting clinical staff with the electronic medical records functions and reposting of the
necessary data to the appropriate state department. Salaries are based on current Madera
County salaries approved by the Board of Supervisors. Benefits for the 7.80 FTE are based on
the current Madera County benefits package that includes the following: FICA 0.0608, Medicare
0.0142, PERS 0.1622, and health insurance coverage of $585.29 per month based on full time
equivalency. The operating costs for this work plan will have the cost for the building rent



4

                                               77
Madera County
INN MHSA Budget Narrative 2010-11
Page 5

(lease), utilities, A87 costs and repairs/maintenance. General Office includes the estimated
costs for office supplies, phone and cell phones

Administration Cost of:

Personnel       FY 2010-11: $ 63,173         FY 2011-12: $ 64,753    FY 2012-13 $ 66,332
Operating Expense
                FY 2010-11: $ 41,880         FY 2011-12: $ 30,659    FY 2012-13 $ 30,795
Budgeted Amount FY 2010-11: $105,053          FY 2011-12: $95,412    FY 2012-13 $ 97,127


Operating Reserved Cost of:

Budgeted Amount FY 2010-11: $69,022          FY 2011-12: $ 0         FY 2012-13 $ 0

The net cost for the work plan is:

Budgeted Amount FY 2010-11: $174,075 FY 2011-12: $ 95,412            FY 2012-13 $97,127




5
                                             78
2010/11 ANNUAL UPDATE                               NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                    EXHIBIT F




County:           Madera                          FY 2010 / 2011                                                                           Date:         3/4/2010

                                    #1 INN New Model for Access Into Access Into 

Program/Project Name and #:                         Services 




                                                                                                                               Community Mental
                                                                                     County Mental Health Other Governmental
                                                                                                                                Health Contract       Total
                                                                                         Department            Agencies
                                                                                                                                  Providers
A. EXPENDITURES
Community Services and Supports
    1. Client, Family Member and Caregiver Support Expenditures
          a. Individual-based Housing                                                                                                                          $0
          b. Other Supports                                                                                                                                    $0
    2. General System Development Housing                                                                                                                      $0
    3. Personnel Expenditures                                                                                                                                  $0
    4. Operating Expenditures                                                                                                                                  $0
    5. Estimated Expenditures when service provider is not known                                                                                               $0
    6. Non-recurring expenditures                                                                                                                              $0
    7. Other Expenditures*                                                                                                                                     $0
    8. Total Proposed Expenditures                                                                    $0                  $0                 $0                $0


Workforce Education and Training
    1. Personnel Expenditures                                                                                                                                  $0
    2. Operating Expenditures                                                                                                                                  $0
    3. Training Expenditures                                                                                                                                   $0
    4. Training Consultant Contracts                                                                                                                           $0
    5. Residency Expenditures                                                                                                                                  $0
    6. Internship Expenditures                                                                                                                                 $0
    7. Mental Health Career Pathway Expenditures                                                                                                               $0
    8. Stipend Funds                                                                                                                                           $0
    9. Scholarship Funds                                                                                                                                       $0
    10. Loan Repayment Funds                                                                                                                                   $0
    11. Non-recurring Expenditures                                                                                                                             $0
    12. Other Expenditures*                                                                                                                                    $0
    13. Total Proposed Expenditures                                                                   $0                  $0                 $0                $0


Capital Facilities
    1. Pre-Development Costs                                                                                                                                   $0
    2. Building/Land Acquisition                                                                                                                               $0
    3. Renovation                                                                                                                                              $0
    4. Construction                                                                                                                                            $0
    5. Repair/Replacement Reserve                                                                                                                              $0
    6. Other Expenditures*                                                                                                                                     $0
    7. Total Proposed Expenditures                                                                    $0                  $0                 $0                $0


Technological Needs
    1. Personnel                                                                                                                                               $0
    2. Hardware                                                                                                                                                $0
    3. Software                                                                                                                                                $0
    4. Contract Services                                                                                                                                       $0
    5. Other Expenditures*                                                                                                                                     $0
    6. Total Proposed Expenditures                                                                    $0                  $0                 $0                $0


Prevention and Early Intervention (PEI)
    1. Personnel                                                                                                                                               $0
    2. Operating Expenditures                                                                                                                                  $0
    3. Non-recurring Expenditures                                                                                                                              $0
    4. Subcontracts/Professional Services                                                                                                                      $0
    5. Other                                                                                                                                                   $0
    6. Total Proposed Expenditures                                                                    $0                  $0                 $0                $0


                                                                                79
2010/11 ANNUAL UPDATE                               NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                    EXHIBIT F




County:         Madera                            FY 2010 / 2011                                                                           Date:         3/4/2010

                                    #1 INN New Model for Access Into Access Into 

Program/Project Name and #:                         Services 




                                                                                                                               Community Mental
                                                                                     County Mental Health Other Governmental
                                                                                                                                Health Contract       Total
                                                                                         Department            Agencies
                                                                                                                                  Providers


Innovation (INN)
    1. Personnel                                                                               $388,643                                                 $388,643
    2. Operating Expenditures                                                                  $237,379                                                 $237,379
    3. Non-recurring Expenditures                                                               $35,000                                                  $35,000
    4. Training Consultant Contracts                                                                                                                          $0
    5. Work Plan Management                                                                                                                                   $0
    6. Other                                                                                                                                                  $0
    7. Total Proposed Expenditures                                                             $661,022                   $0                 $0         $661,022

B. REVENUES
    1. New Revenues
         a. Medi-Cal (FFP only)                                                                                                                                $0
         b. State General Funds                                                                                                                                $0
         c. Other Revenue                                                                                                                                      $0
    2. Total Revenues                                                                                 $0                  $0                 $0                $0

C. TOTAL FUNDING REQUESTED                                                                     $661,022                   $0                 $0         $661,022


             *Enter the justification for items that are requested under the "Other Expenditures" category.
             Justification:

             Please include your budget narrative on a separate page.

                 Prepared by:                    Janet A. Mesiah

           Telephone Number:                      559/ 675- 7926




                                                                                80
2010/11 ANNUAL UPDATE                                NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                      EXHIBIT F




County:           Madera                            FY 2010 / 2011                                                                            Date:         3/4/2010
                                               g        y            y
                                   Reverse Integration from Mental Health to Physical
Program/Project Name and #:                              Health



                                                                                                                                  Community Mental
                                                                                        County Mental Health Other Governmental
                                                                                                                                   Health Contract       Total
                                                                                            Department            Agencies
                                                                                                                                     Providers
A. EXPENDITURES
Community Services and Supports
    1. Client, Family Member and Caregiver Support Expenditures
          a. Individual-based Housing                                                                                                                             $0
          b. Other Supports                                                                                                                                       $0
    2. General System Development Housing                                                                                                                         $0
    3. Personnel Expenditures                                                                                                                                     $0
    4. Operating Expenditures                                                                                                                                     $0
    5. Estimated Expenditures when service provider is not known                                                                                                  $0
    6. Non-recurring expenditures                                                                                                                                 $0
    7. Other Expenditures*                                                                                                                                        $0
    8. Total Proposed Expenditures                                                                       $0                  $0                 $0                $0


Workforce Education and Training
    1. Personnel Expenditures                                                                                                                                     $0
    2. Operating Expenditures                                                                                                                                     $0
    3. Training Expenditures                                                                                                                                      $0
    4. Training Consultant Contracts                                                                                                                              $0
    5. Residency Expenditures                                                                                                                                     $0
    6. Internship Expenditures                                                                                                                                    $0
    7. Mental Health Career Pathway Expenditures                                                                                                                  $0
    8. Stipend Funds                                                                                                                                              $0
    9. Scholarship Funds                                                                                                                                          $0
    10. Loan Repayment Funds                                                                                                                                      $0
    11. Non-recurring Expenditures                                                                                                                                $0
    12. Other Expenditures*                                                                                                                                       $0
    13. Total Proposed Expenditures                                                                      $0                  $0                 $0                $0


Capital Facilities
    1. Pre-Development Costs                                                                                                                                      $0
    2. Building/Land Acquisition                                                                                                                                  $0
    3. Renovation                                                                                                                                                 $0
    4. Construction                                                                                                                                               $0
    5. Repair/Replacement Reserve                                                                                                                                 $0
    6. Other Expenditures*                                                                                                                                        $0
    7. Total Proposed Expenditures                                                                       $0                  $0                 $0                $0


Technological Needs
    1. Personnel                                                                                                                                                  $0
    2. Hardware                                                                                                                                                   $0
    3. Software                                                                                                                                                   $0
    4. Contract Services                                                                                                                                          $0
    5. Other Expenditures*                                                                                                                                        $0
    6. Total Proposed Expenditures                                                                       $0                  $0                 $0                $0


Prevention and Early Intervention (PEI)
    1. Personnel                                                                                                                                                  $0
    2. Operating Expenditures                                                                                                                                     $0
    3. Non-recurring Expenditures                                                                                                                                 $0
    4. Subcontracts/Professional Services                                                                                                                         $0
    5. Other                                                                                                                                                      $0
    6. Total Proposed Expenditures                                                                       $0                  $0                 $0                $0


                                                                                 81
2010/11 ANNUAL UPDATE                               NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                      EXHIBIT F




County:         Madera                             FY 2010 / 2011                                                                            Date:         3/4/2010
                                              g        y            y
                                  Reverse Integration from Mental Health to Physical
Program/Project Name and #:                             Health



                                                                                                                                 Community Mental
                                                                                       County Mental Health Other Governmental
                                                                                                                                  Health Contract       Total
                                                                                           Department            Agencies
                                                                                                                                    Providers


Innovation (INN)
    1. Personnel                                                                                                                                                $0
    2. Operating Expenditures                                                                     $19,200                                                  $19,200
    3. Non-recurring Expenditures                                                                                                                                $0
    4. Training Consultant Contracts                                                                                                                            $0
    5. Work Plan Management                                                                                                                                     $0
    6. Other                                                                                                                                                    $0
    7. Total Proposed Expenditures                                                                $19,200                   $0                 $0          $19,200

B. REVENUES
    1. New Revenues
         a. Medi-Cal (FFP only)                                                                                                                                  $0
         b. State General Funds                                                                                                                                  $0
         c. Other Revenue                                                                                                                                        $0
    2. Total Revenues                                                                                   $0                  $0                 $0                $0

C. TOTAL FUNDING REQUESTED                                                                        $19,200                   $0                 $0          $19,200


             *Enter the justification for items that are requested under the "Other Expenditures" category.
             Justification:

             Please include your budget narrative on a separate page.

                 Prepared by:                     Janet A. Mesiah

           Telephone Number:                      559/ 675- 7926




                                                                                82
2010/11 ANNUAL UPDATE                                NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                     EXHIBIT F




County:           Madera                            FY 2010 / 2011                                                                           Date:         3/4/2010


Program/Project Name and #:             INN Administration and Operation Saving



                                                                                                                                 Community Mental
                                                                                       County Mental Health Other Governmental
                                                                                                                                  Health Contract       Total
                                                                                           Department            Agencies
                                                                                                                                    Providers
A. EXPENDITURES
Community Services and Supports
    1. Client, Family Member and Caregiver Support Expenditures
          a. Individual-based Housing                                                                                                                            $0
          b. Other Supports                                                                                                                                      $0
    2. General System Development Housing                                                                                                                        $0
    3. Personnel Expenditures                                                                                                                                    $0
    4. Operating Expenditures                                                                                                                                    $0
    5. Estimated Expenditures when service provider is not known                                                                                                 $0
    6. Non-recurring expenditures                                                                                                                                $0
    7. Other Expenditures*                                                                                                                                       $0
    8. Total Proposed Expenditures                                                                      $0                  $0                 $0                $0


Workforce Education and Training
    1. Personnel Expenditures                                                                                                                                    $0
    2. Operating Expenditures                                                                                                                                    $0
    3. Training Expenditures                                                                                                                                     $0
    4. Training Consultant Contracts                                                                                                                             $0
    5. Residency Expenditures                                                                                                                                    $0
    6. Internship Expenditures                                                                                                                                   $0
    7. Mental Health Career Pathway Expenditures                                                                                                                 $0
    8. Stipend Funds                                                                                                                                             $0
    9. Scholarship Funds                                                                                                                                         $0
    10. Loan Repayment Funds                                                                                                                                     $0
    11. Non-recurring Expenditures                                                                                                                               $0
    12. Other Expenditures*                                                                                                                                      $0
    13. Total Proposed Expenditures                                                                     $0                  $0                 $0                $0


Capital Facilities
    1. Pre-Development Costs                                                                                                                                     $0
    2. Building/Land Acquisition                                                                                                                                 $0
    3. Renovation                                                                                                                                                $0
    4. Construction                                                                                                                                              $0
    5. Repair/Replacement Reserve                                                                                                                                $0
    6. Other Expenditures*                                                                                                                                       $0
    7. Total Proposed Expenditures                                                                      $0                  $0                 $0                $0


Technological Needs
    1. Personnel                                                                                                                                                 $0
    2. Hardware                                                                                                                                                  $0
    3. Software                                                                                                                                                  $0
    4. Contract Services                                                                                                                                         $0
    5. Other Expenditures*                                                                                                                                       $0
    6. Total Proposed Expenditures                                                                      $0                  $0                 $0                $0


Prevention and Early Intervention (PEI)
    1. Personnel                                                                                                                                                 $0
    2. Operating Expenditures                                                                                                                                    $0
    3. Non-recurring Expenditures                                                                                                                                $0
    4. Subcontracts/Professional Services                                                                                                                        $0
    5. Other                                                                                                                                                     $0
    6. Total Proposed Expenditures                                                                      $0                  $0                 $0                $0


                                                                                  83
2010/11 ANNUAL UPDATE                               NEW PROGRAM/PROJECT BUDGET DETAIL/NARRATIVE                                                     EXHIBIT F




County:         Madera                             FY 2010 / 2011                                                                           Date:         3/4/2010


Program/Project Name and #:            INN Administration and Operation Saving



                                                                                                                                Community Mental
                                                                                      County Mental Health Other Governmental
                                                                                                                                 Health Contract       Total
                                                                                          Department            Agencies
                                                                                                                                   Providers


Innovation (INN)
    1. Personnel                                                                                 $63,173                                                  $63,173
    2. Operating Expenditures                                                                    $41,880                                                  $41,880
    3. Non-recurring Expenditures                                                                $69,022                                                  $69,022
    4. Training Consultant Contracts                                                                                                                           $0
    5. Work Plan Management                                                                                                                                    $0
    6. Other                                                                                                                                                   $0
    7. Total Proposed Expenditures                                                              $174,075                   $0                 $0         $174,075

B. REVENUES
    1. New Revenues
         a. Medi-Cal (FFP only)                                                                                                                                 $0
         b. State General Funds                                                                                                                                 $0
         c. Other Revenue                                                                                                                                       $0
    2. Total Revenues                                                                                  $0                  $0                 $0                $0

C. TOTAL FUNDING REQUESTED                                                                      $174,075                   $0                 $0         $174,075


             *Enter the justification for items that are requested under the "Other Expenditures" category.
             Justification:

             Please include your budget narrative on a separate page.

                 Prepared by:                    Janet A. Mesiah

           Telephone Number:                      559/ 675- 7926




                                                                                 84
ADDENDUMS 





    85
                        MADERA COUNTY
                   BEHAVIORAL HEALTH SERVICES
                                       Administration
                                                                                 P.O. BOX 1288
 JANICE MELTON, LCSW                                                   MADERA, CA 93639-1288
 DIRECTOR OF BEHAVIORAL HEALTH SERVICES                                   PHONE (559) 675-7926
   .MENTAL HEALTH DIRECTOR                                                  FAX (559) 675-4999
   .ALCOHOUDRUG PROGRAM ADMINISTRATOR        CONFIDENTIAL CLIENT INFORMATION FAX (559) 661-2818




                       Anuncio de Revision Publica de 30 dias

                                     Marzo 4 - Abril 6,2010

                                 Aviso de Audiencia Publica

                                   Abril 7, 2010 a las 11 :30 AM

                 200 West 4th Street, Sala de Conferencias en el segundo piso
                                      Madera, CA 93637

          Decreto de los Servicios de Salud Mental (MHSA, por sus siglas en ingles)
                          Proyecto de Innovacion y Plan de Gastos

EI Departamento de Servicios de Salud Conductual del Condado de Madera esta anunciando
un periodo de revision y comentario publico para el Proyecto de Innovacion. La propuesta de
  este proyecto tambiem esta disponible en linea en www.madera-county.com. Una copia se
puede pedir en la oficina de administracion del departamento, 117 North R Street, en la cuidad
     de Madera 0 tambiem puede lIamar al telefono (559) 675-7850 para pedir una copia.

    EI Departamento de Servicios de Salud Conductual pide aportaciones y recomendaciones
durante el periodo de revision publica que comenzara el dia 4 de marzo y terminara el dia 6 de
 abril. Comentarios substantivos seran resumidos e incorporados en el documento, segun sea
el case. EI departamento pide comentarios, sugerencias y preguntas antes de las 5 PM el dia 7
   de abril del 2010. Favor de mandar comentarios, sugerencias y preguntas a este domicilio:

                                     Debbie C. DiNoto, LMFT
                             Madera County Behavioral Health Services
                                          PO Box 1288
                                       Madera, CA 93639
                                     ddinoto@kingsview.org

 Una audiencia publica sobre este proyecto se lIevara a cabo en el Consejo de Salud Mental el
                        dia 7 de abril, 2010, a las 11 :00 de la manana.




                                                 86
                        MADERA COUNTY
                   BEHAVIORAL HEALTH SERVICES
                                       Administration
                                                                                  P.O. BOX 1288
 JANICE MELTON, LCSW                                                    MADERA, CA 93639-1288
 DIRECTOR OF BEHAVIORAL HEALTH SERVICES                                    PHONE (559) 675-7926
   -MENTAL HEALTH DIRECTOR                                                   FAX (559) 675-4999
   -ALCOHOL/DRUG PROGRAM ADMINISTRATOR        CONFIDENTIAL CLIENT INFORMATION FAX (559) 661-2818



                   NOTICE OF 30-DAY PUBLIC REVIEW PERIOD

                                      March 4-April 6, 2010

                               NOTICE OF PUBLIC HEARING

                                     April 7, 2010 at 11 :30 AM

                     200 West 4th Street, Second Floor Conference Room
                                  Madera, California 93637

                                MENTAL HEALTH SERVICES ACT (MHSA)
                             INNOVATIONS PROJECT AND EXPENDITURE PLAN

 The Madera County Behavioral Health Services (BHS) Department is posting its Innovations
  Projects for public review and comment. The Project proposal can be viewed on the BHS
 website at WVNJ. madera-countv.com. A copy of the Project proposal can be obtained at BHS
    Administration, 117 North R Street, Madera or by contacting BHS at (559) 675-7850.

BHS is seeking public and stakeholder input and feedback regarding the proposal during the 30­
 day period beginning March 4, 2010 and ending April 7, 2010. Substantive responses will be
summarized and incorporated into the document as applicable. BHS invites and welcomes any
            comments, suggestions or questions prior to 5:00 PM, April 7, 2010, to:

                                     Debbie C. DiNoto, LMFT
                             Madera County Behavioral Health Services
                                          PO Box 1288
                                       Madera, CA 93639
                                         (559) 675-7850
                                     ddinoto@kingsview.org

   A Public Hearing on the Project Proposal will be held at the Madera County Mental Health
                    Board meeting to be held on April 7, 2010 at 11 :30 AM.




                                                  87
Departamento de Salud Mental del Condado de Madera





 ELGRUPO
    DE
 ENFOQUE ,
SERE ,I
   AQUI


                         88
                    MENTAL HEALTH SERVICES ACT
                  STAKEHOLDER STEERING COMMITTEE
                  CONSUMER AND FAMILY MEMBER




   Topics for these meetings include ideas and thoughts on
                     innovative services.




Meeting will be held on Wednesday, January 13,2010 from 3:00-4:00p.m.
                                 at
                            Hope House
                            117 North R Street
                            Madera, CA 93637
                              (559) 664-9021


                 For more information please contact:
                            Debbie DiNoto
                            (559) 675-7850

      Consumers and Family Members ...we need your help!
We will be discussing the community mental health needs and what services
                     will be used to meet those needs.




                                   89
***Anuncio Publico***

EI Departamento de Servicios de Salud Conductual del Condado de Madera pide el
apoyo de la comunidad

El Departamento de Servicios de Salud Conductual del Condado de Madera pide el
apoyo de la comunidad para el proyecto de Innovaci6n. Los fondos para este proyecto
vienen del Decreto de los Servicios de Salud Mental (MHSA, por sus siglas en ingIes),
tambien conocida coma la Proposici6n 63, que fue aprobada por los votantes de
California en Noviembre de 2004. La proposici6n ofrece una oportunidad (mica para
destinar fondos a la ampliaci6n de los recursos de prevenci6n y tratamiento de salud
mental dirigido a nifios, j6venes en etapa de transici6n, adultos, personas mayores y sus
familias. Los fondos provienen de un impuesto del 1% sobre las personas con ingresos
mayores de un mill6n de d61ares anuales.

El Departamento acogera con agrado el apoyo del publico y de compafiias que tengan
experiencia, interes 0 competencia en el tema. El Departamento llevara a cabo
actividades para la planificaci6n y apoyo del publico para las siguientes ideas para el
proyecto de Innovaci6n:

   1. Como responder a las personas que estan sufriendo de una enfermedad mental
   2. Como prevenir la enfermedad mental mediante una prevenci6n suficientemente
      precoz como para que la condici6n no acabe por incapacitar a la persona.

El Departamento pide el apoyo de la comunidad y se les pide que participen en una
encuesta. La encuesta esta disponible en linea en la pagina Web http://www.madera­
county.com/behavioralhealth/services.html.

Para preguntas 0 mas informaci6n, por favor p6ngase en contacto con Salvador Cervantes
(559) 675-7850.




                                            90
Madera County Behavioral Health Seeks Your Input

Madera County Behavioral Health Services is currently seeking input for its Innovation
Project. The funding for this project comes from the Mental Health Services Act
(MHSA), also known as Proposition 63, which was passed by California voters in 2004.
MHSA provides increased funding, personnel and other resources to support county
mental health programs and monitor progress toward statewide goals for children,
transition age youth, adults, older adults, and families. The funds come from a one­
percent tax on individuals who earn more than one million dollars annually.

There are several components of the MHSA. Madera County Behavioral Health Services
is currently seeking input from the community for its Innovation Project. MHSA states
that the Innovation Project must include one or more of the following purposes:
    • Increase access to underserved populations (e.g., Latinos, Older Adults, Youth,
        etc.)
    • Increase the quality of services, including better outcomes
    • Promote interagency collaboration (e.g., with health care clinics, social services,
        etc.)
    • Increase access to services
MHSA also requires that Innovation Projects contribute to learning rather than provide
services as a primary focus. It is important that Projects do the following:
    • Introduce new mental health practices/approaches, including prevention and early
        intervention that have not been done before in Madera County.
    • Make a change to an existing mental health practice/approach, including
        adaptation for a new setting or community, or
    • Introduce a new application to the mental health system of a promising
        community-driven practice/approach or a practice/approach that has been
        successful in non-mental health context or setting.

Madera County Behavioral Health Services is developing an Innovation Project plan to
address the needs identified in its 2005 and 2008 planning process. This plan will include
ways to respond to those experiencing mental health issues in a supportive manner, how
to provide early mental health intervention, and how to prevent mental illness from
progressing.

Madera County Behavioral Health Services would like to hear your thoughts about its
hmovation Project plan. We invite you to participate in completing an on-line survey,
which you may access at http://www.madera-county.comlbehavioralhealth/services.html.
If you do not have internet access or would like more information, please call Salvador
Cervantes at (559) 675-7850.




                                             91
Madera County Behavioral Health Seeks Your Input

Madera County Behavioral Health Services is currently seeking input for its Innovation
Project. The funding for this project comes from the Mental Health Services Act
(MHSA), also known as Proposition 63, which was passed by California voters in 2004.
MHSA provides increased funding, personnel and other resources to support county
mental health programs and monitor progress toward statewide goals for children,
transition age youth, adults, older adults, and families. The funds come from a one­
percent tax on individuals who earn more than one million dollars annually.

There are several components of the MHSA. Madera County Behavioral Health Services
is currently seeking input from the community for its Innovation Project in response to
the needs identified in its 2005 and 2008 planning process. This plan will include ways
to respond to those experiencing mental health issues in a supportive manner, how to
provide early mental health intervention, and how to prevent mental illness from
progressmg.

Madera County Behavioral Health Services would like to hear your thoughts about its
Innovation Project plan. We invite you to participate in completing an on-line survey,
which you may access at http://www.madera-county.com/behavioralhealth/services.htm\.
If you do not have internet access or would like more information, please call Salvador
Cervantes at (559) 675-7850.




                                           92
The Mental Health Services Act states that the Innovation Projects must include one or
more of the following purposes:

   a. Increase access to underserved             b. Increase the quality of services
      populations, e.g., Latinos, Older             including better outcomes
      Adults, Youth, etc.
   c. Promote interagency                        d. Increase access to services
      collaboration, e.g., with health
      care clinics, social services, etc.

   The Mental Health Services Act also states that the Innovation Projects as one that
   contributes to learning rather than a primary focus on providing a service. It is
   important that the Project does the following;
         • Introduces new mental health practices/approaches including prevention and
             early intervention that have not been done before in Madera County.
         • Makes a change to an existing mental health practice/approach including
             adaptation for a new setting or community, or
         • Introduces a new application to the mental health system of a promising
             community-driven practice/approach or a practice/approach that has been
             successful in non-mental health contexts or settings.

   In addition to the requirement to contribute to learning, the Project must be aligned with
   the General Standards identified in the Mental Health Services Act when applicable.
   These General Standards are:
       • Community Collaboration-Initiates, supports and expands collaboration and
          linkages, especially connections with systems, organizations, healers and
          practitioners not traditionally defined as part of mental health care
       • Cultural Competence-Demonstrates cultural competency and capacity to
          reduce disparities in access to mental health services and to improve outcomes
       • Client Driven Mental Health System-Includes the ongoing involvement of clients
          (and participants in prevention programs) in roles such as, but not limited to,
          implementation, staffing, evaluation and dissemination
       • Family Driven Mental Health System-Includes the ongoing involvement of
          family members in roles such as, but not limited to, implementation, staffing,
          evaluation and dissemination
       • Wellness, Recovery and Resilience Focus-Increases resilience and/or
          promotes recovery and wellness
       • Integrated Service Experience-Encourages and provides for access to a full
          range of services provided by multiple agencies, programs and funding sources
          for clients and family members




                                            93
   •  Integrated Service Experience-Encourages and provides for access to a full range
      of services provided by multiple agencies, programs and funding sources for clients
      and family members
The major mental health issues for the County of Madera were identified through the
Mental Health Services Act (MHSA) planning process in 2005 as the following;
      • Homelessness
      • Isolation
      • Criminal Justice/Juvenile Justice involvement/incarceration
      • Inability to obtain employment
      • Out of home placements/Institutionalization
      • Inability to obtain employment
      • Involuntary Treatment/Hospitalization
      • Transportation

During the 2008 Prevention/Early Intervention, Housing and Workforce, Education and
Training and Innovation community planning process, there were additional needs
identified. Those needs included the following;
   • Obtaining basic education about mental illness
   • How to respond to those experiencing mental health issues in a supportive manner
   • Reduce stigma against mental illness
   • Reduce isolation
   • Provide early intervention
   • Prevention of mental illness or from the illness progressing
   • An entry point to obtain employment within the mental health system
   • Utilizing existing persons in the community as a resource for those individuals
        reluctant to seek services in a traditional setting

In response to the MHSA Planning process, Madera County Behavioral Health Services is
developing a plan to address the following above items;
    • How to respond to those experiencing mental health issues in a supportive manner
    • Provide early intervention
    • Prevention of mental illness or from the illness progressing

Please let us know if the issues described are still relevant and if you agree or disagree
with the direction Madera County Behavioral Health Services is planning for its Innovation
Project. You can complete a questionnaire at
You are also welcome to call Salvador Cervantes at (559) 675-7850 with your comments
and questions.




                                        94
                                                                    What is the Mental Health SeNices
                                                                                  Act?


                                                                    • Legislation (proposition 63) that was
    Mental Health Services Act                                        passed by the voters
                                                                      - Taxes millionaires at 1 % for mental health
                   Proposition 63                                       services and programs
         Passed by California voters in
                    2004




        Components of MHSA                                                   Innovation Projects
                                                                    • Must include one or more of the following
• Legislation had several components that                             purposes:
  have been implemented incrementally                                 -Increase access to underserved populations,
                                                                        e.g., Latinos, Older Adults, Youth, etc.
  - CSS-Community Services and Supports
                                                                      -Increase the quality of services including
  - PEl-Prevention/Early Intervention Services                          better outcomes
  - Housing                                                           - Promote interagency collaboration, e.g., with
  - WET-Workforce, Education and Training                               health care clinics, social services, etc.
  - CaplTech-Capital Facilities and Technology                        - Increase access to services
  - Innovations                                                      The MHSA states that the Innovation Projects
                                                                     must
                                                                      - Contribute to teaming rather than a primary
                                                                        focus on prOViding a service.




    What Innovations Must Do
• Important that the Project does the following
   - Introduces new practices/approaches
      • That have not been done before in Madera County
  - Makes a change to an existing mental health
    practice/approach
      • Including adaptation for a new setting or community.
        or
  - Introduces a new application to the mental health
    system of a promising community-driven
    practice/approach or
  - A practice/approach that has been successful in
    non-mental health contexts or settings




                                                                                                                        1


                                                               95
                                                                     IWhat is the Mental Health Services Act?
 I    Mental Health Services Act
                                                                      • Legislation (proposition 63) that was passed
                                                                        by the voters
                                                                        o Taxes millionaires at 1% for mental health
                                                                          services and programs
             Proposition 63
             Passed by California voters in 2004




IComponents ofMHSA                                                   I Innovation Projects
                                                                      • Must include one or more of the following
 • Legislation had several components that                              purposes:
   have been implemented incrementally                                  o Increase access to underserved populations, e.g.,
                                                                          Latinos, Older Adults, Youth, etc.
     o CSS-Community Services and Supports
                                                                        o Increase the quality of services including better
     o PEl-Prevention/Early Intervention Services                         outcomes
     o Housing                                                          o Promote interagency collaboration, e.g., with
     o WET-Workforce, Education and Training                              health care clinics, social services, etc.
     o CapfTech-Capital Facilities and Technology                       o Increase access to services
                                                                      • The MHSA states that the Innovation Projects must
     o Innovations
                                                                        o Contribute to learning rather than a primary focus on
                                                                          providing a service.




IWhat Innovations Must Do                                            I General Standards of MHSA
• Important that the Project does the following                       • Project must be aligned with the General
  o Introduces new practices/approaches                                 Standafds (when applicable);
    • Thai have not been done before in Madera County
                                                                        o Community Collaboration
  o Makes a change to an existing mental health
                                                                        o Cultural Competence
    practice/approach
    • Including adaptation for a new setting or community, or           o Client Driven Mental Health System
  o Introduces a new application to the mental health                   o Family Driven Mental Health
    system of a promising communily-driven                              o Wellness, Recovery and Resilience Focus
    practice/approach or
                                                                        o Integrated Service Experience
  o A practice/approach that has been successful in non­
    mental health contexts or sellings




                                                                                                                                  1


                                                                96
I CSS Planning Process in 2005                                I PEl/WET/Housing/Cap Tech and
                                                               Innovations Planning 2008
 • The major mental health issues for the                             Needs identified in 2005 remained the same
   County of Madera identified were                                   Additional needs identified
     o Homelessness                                                     Obtain eduCation about mental illness
                                                                        How to respond to those experiencing mental health
     o Isolation                                                        issues
     o Criminal Justice/Juvenile Justice                                Reduce stigma
                                                                        Reduce isolation
       involvement/incarceration
                                                                o       Provide eany intervention
     o Inability to obtain emptoyment                           o       Prevention of mental illness or from the illness
                                                                        progressing
     o Out of home placementsllnstitutionalization                      Obtain employment within the mental health system
     o Involuntary Treatment/Hospitalization                            Utilize persons in the community as a resource for those
                                                                        individuals reluctant to seek services in a traditional
     Q Transportation                                                   setting




IFocus of Madera's Innovation Project                         I Research        for Innovations Project-Ol

 •       How to respond to those experiencing                  • On average small rural hospitals have 99
         mental health issues in a supportive                    emergency room (ER) visits per week
         manner                                                 Q     9.4% were mental health related
 •       Provide early intervention                                   • 30% involve mental health as a primary diagnosis
                                                                      • 70% mental health problem is secondary to the reason
 •       Prevention of mental illness or from the                       for the ER visit-Muskie School of Public Service 2005
         illness progressing




I Research For Innovations Project-OOI                        IResearch for Innovations Project--OOI
 • Four-fold increase in patients treated for                  • Looked at people who came into ER who
   mental health/substance abuse in FQHC's                       were not currently open to MCBHS
   between 1998-2003                                            Q     Looked at 3 month period of lime
 • FQHC's had 1.4 million visits for depression                 Q     173 tolal cases
   in 2004                                                      Q     62 brought in by law enforcement on a 5150
     Q   Third most common presentation after diabetes           Cl   66 had a positive tox screen
         and hypertension-DMMA: The Care Continuum              Q     Most people brought in between 8 AM-5 PM (71)
         Alliance-2008                                          Q     Second most popular time is between 5 PM-10
                                                                      PM (34)




                                                                                                                                   2


                                                         97
IResearch for Innovations Project---OOI                              I Research for Innovations Project-DOl
 • Madera Statistics continued                                        • Madera Statistics continued
  a Most common presenting problems are;                                a Age statistics
    • Depression (88)                                                        • 0-15        25    15%
    • An<iety (55)                                                           • 16-17        9    5%
    • Anger (16)                                                             • 18-24       32    19%
  a For those experiencing catastrophic life events,                         • 25-59        91   54%
    the most common presenting problems were;                                • 60+          12    7%
    • Disruptions in personal relationships and/or support              CJTotal number of children and youth-20%
      systems (42)                                                      a Total number of childrenlyoulhfTAY-24%
    • Disruption in living arrangements (14)                            a Two ofthe children and youth were at ER more
  a 46 people out of 173 hospitalized at a psychiatric                    than one lime during this time period (tolal169
    facility                                                              individuals for 173 visits)




IFocus of Madera BHS INN Project 001                                 IResearch for INN Project 002
 • Innovations Project 001-Provide Expanded
                                                                      • People with mental illnesses die, on average,
   Crisis Intervention Services
                                                                        25 years earlier than the general population
  a Provide crisis assessments and crisis
    management services for those entering Madera                     • Behavioral health conditions are not
    Community Hospital Emergency Room                                   uncommon among Medicaid beneficiaries,
  a Provide pro-active crisis management services                       and are often complicated by co-morbid
    • Short term visits to teach coping skills through crisis           physical conditions.
      management plans
    • Follows SAMHSA best practice guidelines for mental
      health crisis services 2009.
    • Peer Support Is available




IResearch for INN Project 002                                        IResearch for INN Project 002
• Blending Behavioral Health into Primary
                                                                      • Emphasis on prevention and self-help
  Care-American College of Mental Heath
                                                                        approaches
  Administration 2007
  a Brief four or fewer 15 minute visits in tandem with
                                                                      • Management of psychosocial aspects of
    the PCP                                                             chronic and acute diseases
    • Decrease in medical utilization                                 • Application of behavioral principles to
      o 28% for Medicaid patients                                       address lifestyle and health risk issues
      lJ20% decrease   for commercial insurance
      Cl27% decrease   in psychiatry visits                           • Not long-term therapy but short-term
      a 34% decrease   in psychotherapy sessions                        prevention strategies
      Q 48% decrease   in crisis visits




                                                                                                                            3


                                                                98
I Proposal for INN Project 002                                        I Proposal for INN Project 002
                                                                       • Innovations Project 2-Pharmacist Linkage
 • Innovations Project a02-Pharmacist Linkage                            " New opportunities:
   " MCBHS staff have difficulty gelling primary care                      • Coordinating medical visits/consu~ation between
     to respond to requests for coordination of care                         MCBHS and primary care for patients with chronic
                                                                             medical conditions like diabetes, heart disease, etc.
   " MCBHS will have phannacist link with primary
                                                                           • MCBHS will provide short-term intervention/prevention
     care for dients who are on psychiatric
                                                                             mental health services for people with chronic medical
     medications and may have chronic physical health                        conditions that are seen in primary care
     conditions,                                                           • Psychiatrist is available to primary care for consultation
                                                                             on medications and psychiatric conditions




IConcerns Regarding Integration                                       IConcerns Regarding Integration
                                                                       • Stigma
 • Difficulties in sharing information about                             c MCBHS is willing to provide training for all staff (including
                                                                           clerical and support staff) on MH issues/concerns
   patients
                                                                         c MH staff will be available to answer questions/concerns
   " HIPAA allows for sharing of infonnation to provide                    and talk with patients
     coordinated treatment                                               c PSYChiatric staff/consultation will be available for RHC
 • "Turf issues"-there are different practice                              staff/physicians

   cultures                                                            • Reimbursement Issues
                                                                         o MH will provide consultation and will be able to bill for
  " MCBHS is willing to provide training for all slaff
                                                                           assessments/services if patient is referred
    (including clerical and support staff) on MH
    issues/concerns                                                    • Space issues?




IResearch for INN Project 003                                         I Innovations Project-003

• MCBHS has low service penetration rate and                          • MCBHS would provide peer staff to welcome
  retention rate for Latinos                                            BHS clients to services to see if that would
• There may be limited follow-up with treatment                         help retention
  recommendations                                                     • Peer support and short-term services
  c Research shows that this may also be true with physical             available
    health for this population
                                                                         e Services culturally appropriate for population
• Research shows that by providing culturally                            e Focus on wellness aspect for clients
  sensitive stafflbilingual-,bicultural staff has helped
  c Need to be able to listen to story
                                                                      • If assessments for services were done not at
  c Can't always be done in physical health due to need to see
                                                                        the mental health clinic,
    people                                                               e would people access services?




                                                                                                                                           4


                                                                 99
I Innovations Project--003
 • Would like to have assessment clinical staff
   and peer staff co-located with proposed
   Innovations Project-001 staff
  o See if people will come in for treatment
  a See if different location will reduce stigma for
    services
  a See if coordination with RHC will allow for
    assistance with PCP's for consultation services
    and better outcomes for diseases that have a MH
    component
  a See if peer support helps wtth retention and
    follow-through of services




                                                             5


                                                       100
                      -        .      ~--   - -   .   -­   -   - -   -­   ~-   -   ~------   -­   ---­   --~-




1. Encuesta de Innovacion del Departamento de Salud Mental del
Condado de Made...

  1. Yo soy
  o   Hombre

  o   Mujer

  o   Otro(a)



  2. Yo soy
  o   Un c1iente de el departamento de salud mental

  o   Un familiar de un cliente de ef Departamento de Safud Mental

  D   Otro

  o   Yo trabajo para el Departamento de Safud Mental

  o   Yo trabajo para otro departamento del Condado de Madera

  D   Un miembro de fa comunidad interesado

  o   Un proveedor de servicios de salud

  o   Un miembro de una organizaci6n religiosa

  o   Un empleado de las escuelas



  3. Mi edad es
  o   Menos de 18 alios

  o   18 a 25 alios

  o   25 a 59 alios

  o   60 alios de edad    0   mayor



  4. Mi etnicidad es
  o   Latino

  o   Otro(a)




                                                               101
5. Los resultados que encontramos durante el proceso de planificacion de
MHSA que se lIevaron a cabo en el 2005 fueron los siguientes:
• Personas sin hogar
• Aislamiento
• Encarcelamiento
• Dificultad buscando empleo
• Colocacion afuera del hogar 0 en una institucion
• Tratamientos y 10 hospitalizaciones involuntarias
• Transportacion

lUsted piensa que estos resultados todavia tienen relevancia?
OSi
o   No


6. Durante el proceso de planificacion para los componentes de Prevencion
e Intervencion Precoz, Viviendas, Educacion y Formacion de la Mano de
Obra y de Innovacion, encontramos las siguientes necesidades:
• Obtener una educacion basica sobre la salud mental
• Como responder cuando una persona esta sufriendo de una enfermedad
mental
• Como reducir el estigma contra las personas que sufren de una
enfermedad mental
• Como reducir el aislamiento
• Como proveer servicios de intervencion
• Como prevenir que las enfermedades de la mente se progresen
• Como obtener trabajo dentro de el sistema de salud mental
• Como utilizar personas de confianza como un recurso para aquellas
personas que no querran buscar ayuda en una clinica de salud mental

lUsted piensa que estos resultados todavia tienen relevancia?
OSi
ONO




                                   102
7. Con respeto a la pregunta anterior, el Departamento de Salud Mental
esta desarrollando un plan para responder a las necesidades anteriores.
Este plan incluye como:
• responder a las personas que estan sufriendo de una enfermedad mental
• proveer intervencion precoz
• prevenir que las enfermedades de la mente se progresen

lUsted esta de acuerdo que estos planes de innovaci6n responderian a las
necesidades listadas en la pregunta anterior?
OSi
o   No


8. lSi no esta de acuerdo, usted piensa que el departamento de salud
mental deberia enfocarse en otras areas que serian mas importantes? Si es
asi, por favor explique sus sugerencias.

I                          ~




                                   103
Innovation

 1. I am a


                                                                       Response    Response
                                                                        Percent     Count

                                                                           33.3%          25


                                                                           66.7%          50

                                 Other                                      0.0%             o

                                                               answered question          75

                                                                skipped question             3



2. I am a


                                                                       Response    Rel>ponse
                                                                        Percent     Count

                                Client   1.·;···,·1                        12.8%            10


                      Family Member      IJ                                 2.6%             2

             Work for Madera County
                                                                           29.5%         23
       Behavioral Health Services

     Work for another agency within
                                                                           23.1%          18
             Madera County of Madera


     Interested community member                                           17.9%          14 .


                  Health care provider                                      7.7%             6

            Member of the faith based
                                                                           14.1%            11
                           community


                     School personnel                                       1.3%


                Other (please specify)                                      5.1%             4

                                                               answered question         78

                                                                skipped question             o




                                                      1 of 4


                                                         104
·3. My age is

                                                                                 Response    Response
                                                                                  Percent     Count

                       Under 18 years                                                 0.0%            o
                          18-25 years    Q                                            2.6%            2

                                                                                     87.0%          67

                            60+ years    1,,,,,,,,.,,,,,.,,1                         10.4%            8

                                                                        answered qllestion          77

                                                                         skipped question



 4. What is your ethnicity?


                                                                                 Response    Resp.anse
                                                                                  Percent     Count

                                Latino                                               42.3%          33


                     African American                                                 2.6%            2


                    Caucasian/White                                                 46.2%           36

                Asian/Pacific Islander                                                5.1%            4


   American Indian/Native American                                                    3.8%            3

                Other (please specify)                                                3.8%            3

                                                                        answered question           18

                                                                         skipped question             0




                                                               2 of 4


                                                                 105
 5. The major mental health issoesfbr the Qounty of Madera were Identified through the Mental Health Services Act
 (MHSA) pJaht1ingprocess In 20'05 as the following; • Homelessness - Isolation· Criminal Justice/Juvenih~ Jusfi<;e
 involvement/incarceration - Inability to obtain employment - Out of home placements/Institutionalization ­
 Involuntary Treatment/Hospitalization· Transportation Do you find these issues to remain relevant?

                                                                                              Response     Response
                                                                                               Percent        Count

                                Yes                                                               98.7%              7$

                                No    0                                                            1.3%

                                                                                    answered question                 76

                                                                                      skipped question                 2



  6. DUr'lngtlie20.08Prevention/Early Intervention, Housing and Workforce, Education an(f Training and Innovation
  ci:lmmunityplanning process, there were additional needs identified. Those needs includ.ed the following;­
  Qb'tal01ngbllsic.edticiifion .about mental illness· How to respond to those experiencing mental health issues in a
. SJ:!PfJortivemanner- RedUce stif:jma against mental illness· Reduce isolation· Provide early Intervention •
  PrEiverifloilofrt\ental inness or from the illness progressing· An entry point to obtain employment within the
       •   _   _   ".   r   _                         •




  mental health system - Utilizing existing persons in the community as a resource for those individuals reluctant to
  seek services in a traditional setting Do you see these issues as still being relevant?


                                                                                              Re.s,ponse   Response
                                                                                               Percent        Count

                                Yes                                                               92.1%               70

                                No    \".·,,1                                                      7.9%                6




                                                                                      skiPPed question                 2




                                                          3 of 4


                                                            106
 7. in re$ponse to the MHSA Planning process stated in Question #6, Madera County Behavioral Health Services is
. developing   a pian to address the following above items; a. How to respond to those e~periencing mental health
 issues in a supportive manner b. Provide early intervention c. Prevention of mental illness or from the illness
'progressingDo you agree or disagree with an Innovations Project which will be developed to address the issues
 stated above?


                                                                                              Response     Response
                                                                                               Percent      Count

                                                                                                  94.7%             72

                           Disagree   CJ                                                           5.3%               4

                                                                                    answered q.uestion              76

                                                                                      skipped question                2



 8. ·If you disagree, do you think there are areas Madera County Behavioral Health should focus on that would be
-r:t1oreimportant? If so, please describe those areas below.


                                                                                                           Response
                                                                                                            Ct:lunt

                                                                                                                      19

                                                                                    fjnswered question              19

                                                                                      skipped question              59




                                                        4 of 4

                                                           107
                                     Department of Behavioral Health Services
                         Community Stakeholder Focus Groups/Key Informant Interviews 2010


  Date focus
                                                                                  Staff Person
    group            Attendee #   Group
                                                                                  Conducting Focus
  conducted
                                                                                  Group
     1/21/10             2        Madera Unified Special Education Coordinator    Debbie DiNoto

 No response to                                                                   Debbie DiNoto
emails, letters or                North Fork Tribal TANF
  phone calls
 No response to                                                                   Salvatore Cervantes,
                                  Nora and Associates (Latina Business Women's
emails, letters or                                                                Marizela Torkildsen
                                  Association)
  phone calls
                                                                                  Marizela Torkildsen
     1/12/10             8        Migrant Farm Workers
                                  Adult Outpatient FSP Services, MHSA Services,   Larry Penner
     1/15/10             50       LPS services, Courts, Intensive Services, AOD
                                  services
     1/15/10             1        City of Madera Police Department                Debbie DiNoto
                                  Center for Independent Living Program           Larry Penner
     1/15/10             1
                                  Coordinator
                                  MHSA Children and Youth Full Service            Larry Penner
     1/15/10             10       Partnership Team (therapists, case workers,
                                  supervisor)
     1/15/10             1        Chowchilla Police Department                    Shawn Daly

                                  Ready, Set, Go Program (At Risk TAY) and        Larry Penner
     1/15/10             3                                                        Marizela Torkildsen
                                  Workforce Development Office (WIB) (All ages)
                         4        Department of Social Services                   Debbie DiNoto
     1/25/10



                                                                                                         1


                                                           108
     1/15/10         7    Shunamite House (shelter for homeless women)       Marizela Torkildsen

                          Mountain Wellness and Recovery Center,             Morrissa Holzman
     1/15/10         20
                          Oakhurst (clients and family members)
     1/20/10         1    Housing Authority of the City of Madera            Debbie DiNoto

     1/20/10         1    Madera County Probation                            Shawn Daly

                                                                             Debbie DiNoto
     1/20/10         3    Madera County Department of Corrections
                                                                             Larry Penner
     1/27/10         1    Madera County Sheriff's Office                     Larry Penner

Requested written                                                            Larry Penner
 material and link   1    Fresno Madera Area Agency on Aging
to questionnaires
 No response to                                                              Marizela Torkildsen
                          Centro Binacional Para EI Desarollo Indigena
  emails, phone
                          Oaxaqueno
 calls nor letters
Requested written                                                            Larry Penner
 material and link   1    First 5 of Madera County
to questionnaires
Requested written                                                            Larry Penner
 material and link   1    Lesbian, Gay, Bisexual, Transgender, Questioning
to questionnaires
                                                                             Debbie DiNoto
     1/19/10         3    Picayune Rancheria of the Chukchansi Indians
                                                                             Larry Penner
                          Community Action Partnership of Madera County      Marizela Torkildsen
     1/19/10         3
Requested written                                                            Shawn Daly
 material and link   1    Head Pastor and Believers Church
to questionnaires
Requested written                                                            Larry Penner
 material and link   1    Madera County Healthy Families Taskforce
to questionnaires


                                                                                                   2


                                                     109
                                 Family Members of Transition Age Youth being         Marizela Torkildsen
     1/21/10            6        served in the system (included Spanish speaking
                                 Familv Members)
 1/8/10,1/12/10                  Madera County Behavioral Health Services             Debbie DiNoto
                        6
     2/12/10                     Management
1/25/10,2/22/10         6        Madera Community Hospital                            Debbie DiNoto

                                                                                      Larry Penner
     1/13/10            10       Adult/Older Adult Consumer Focus Group
                                                                                      Debbie DiNoto
                                 Madera County Public Health Services                 Marizela Torkildsen
     1/13/10            3
                                 (Administration and Direct Services)
                                 Madera County Behavioral Health Services Mental      Debbie DiNoto
  2/3/10, 3/3/10        11
                                 Health Board
Requested written                                                                     Debbie DiNoto
                                 State Center Community College District - North
 material and link      1
                                 Centers (Administration and Counseling Services)
to questionnaires
Requested written                                                                     Debbie DiNoto
 material and link      1        Chowchilla School District
to questionnaires
                                 Madera School District Administration, Sheriffs      Debbie DiNoto
                                 Office, Probation, Public Health, Department of
                                 Social Services, Madera Police Dept., Madera
  Interagency                    Superior Court, First Five, Public Member at
 Youth Services         30       Large, Madera County District Attorney's Office,
    Council                      Madera County's Public Defender's Office, Madera
                                 Community Hospital, Children's Hospital of Central
                                 California Inc., Juvenile Justice, Department of
                                 Corrections, etc.
                     Total 198




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