model of care

Model of Care

C O U N T Y O F S A N T A B A R B A R A

F O R A L C O H O L , D R U G & M E N T A L H E A L T H S E R V I C E S

CO U N T Y O F SA N TA BA R B A R A AL C O H O L , DR U G & ME N TA L HE A LT H SE R V I C E S

300 N. San Antonio Rd • Santa Barbara, CA 93110 • (805) 681-5220 • www.countyofsb.org/admhs

March 2004

Dear Community,

Over the past several years, Alcohol, Drugand Mental Health Services has gatheredinput about the local system of care from stakeholders through many avenues,including: strategic planning processes, focusgroups, the Alcohol & Drug Program's TownHall Meetings, the Labor Management TaskForce's System of Care Project Team, theGrand Jury Repor t on Mental HealthServices, the Staff Hotline, the CBOCollaborative, the Mental Health Commission,the Advisory Board on Alcohol & DrugProblems, ongoing Department meetings,and feedback to the Executive Team.

We have consistently heard the concernthat too many parts of our system areoperating in isolation from each other --e.g., mental health and alcohol & drug programs, children's and adult services,county-provided and CBO-provided services,etc. The intention of this document is to articulate a model of care for Santa BarbaraCounty that unifies our service delivery system. As we provide treatment, support,and preventive services to people and fam-ilies who are at risk of, or living with, debilitating addictions and/or mental healthconditions, it is critical that we work together.Close teamwork enables us to provide more effective, respectful, culturally sensitiveand healing services to the community.

To begin addressing this need, ADMHS articulated its Core Values last year (seepage 3). This Model of Care document goesfurther to specify how those values should be actualized in the provision of services.

The next step is for each of the Alcohol,Drug & Mental Health Services Divisions todevelop a more specific model of caredescription, consistent with the overarchingprinciples presented here. ADMHS will alsoconduct team-building within each staff unitand then develop a Level of Care model thatwill set for th standardized criteria for consumer and community access to prevention and treatment services. We willalso work with our County and Community-Based partners on ways to incorporate thismodel of care in our collaborative services.

Sincerely,

Alcohol, Drug & Mental Health Executive Team

James L. Broderick, Ph.D.Director

Charles H. Nicholson, M.D. Medical Director

Heidi Anna Garcia, MFTAssistant Director - Programs

Al Rodriguez Manager - Alcohol/Drug Program

Carrie TopliffeAssistant Director - Administration

Laura Mancuso, M.A., C.R.C.Project Coordinator

The intention of this document is to articulate a model of care

for Santa Barbara County that unifies our service delivery system.

1

Criteria for “Adults and Older Adults Who Have a Serious Mental Disorder"

For the purposes of this part, "serious mental disorder" means a mental disorder which is severe in degreeand persistent in duration, which may cause behavioral functioning which interferes substantially with theprimary activities of daily living, and which may result in an inability to maintain stable adjustment andindependent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.Serious mental disorders include, but are not limited to, schizophrenia, as well as major affective disordersor other severely disabling mental disorders. This section shall not be construed to exclude persons with aserious mental disorder and a diagnosis of substance abuse, developmental disability, or other physical ormental disorder.

Members of this target population shall meet all of the following criteria:

(A) The person has a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a substance use disorder or developmental disorder or acquired traumatic brain injury pursuant to subdivision (a) of Section 4354 unless that person also has a serious mental disorder as defined in paragraph (2).

(B) (i) As a result of the mental disorder the person has substantial functional impairments or symptoms, or a psychiatric history demonstrating that without treatment there is an imminent riskof decompensation to having substantial impairments or symptoms.

(ii) For the purposes of this part, "functional impairment" means being substantially impaired as the result of a mental disorder in independent living, social relationships, vocational skills, or physical condition.

(C) As a result of a mental functional impairment and circumstances the person is likely to become so disabled as to require public assistance, services, or entitlements.

For the purpose of organizing outreach and treatment options, to the extent resources are available, this target population includes, but is not limited to, persons who are any of the following:

(A) Homeless persons who are mentally ill.

(B) Persons evaluated by appropriately licensed persons as requiring care in acute treatment facilitiesincluding state hospitals, acute inpatient facilities, institutes for mental disease, and crisis residential programs.

(C) Persons arrested or convicted of crimes.

(D) Persons who require acute treatment as a result of a first episode of mental illness with psychotic features.

16

S e r v i c e C r i t e r i a F o u r

Criteria for “Serious Emotional Disturbance”

The child meets one or more of the following criteria (A, B, or C):

A. As a result of a mental disturbance, the child has substantial impairment in at least two of the following areas:

❑ Self-care❑ School functioning❑ Family relationships❑ Community functioning

and has met one of the following two criteria:

❑ At risk of removal from home or has already been removed from the home, or❑ The mental disorder and impairments have been present for more than six months or are

likely to continue for more than one year without treatment

B. Displays one of the following:

❑ Psychotic features❑ Risk of suicide❑ Risk of violence

C. Meets special education eligibility requirements as emotionally disturbed under Chapter 26.5 ofthe California Code of Regulations.

15

S e r v i c e C r i t e r i a T h r e e

who we are . . . . . . . . .page 3-4• Alcohol, Drug & Mental Health Services Vision

• Mission

• Core Values

how we serve . . . . . . .page 5-9• Service Philosophy

• Model of Care

who we serve . . . . . . .page 10-12• Mandated Populations

service criteria . . . . . .page 13-16• Medical Necessity Criteria for Substance Abuse Medi-Cal

• Medical Necessity Criteria for the Mental Health Plan

• Criteria for “Serious Emotional Disturbance” from Welfare & Institutions Code

• Criteria for "Serious Mental Disorder" from Welfare & Institutions Code

2

Criteria for the Mental Health Plan (MHP)

(a) The following medical necessity criteria determine Medi-Cal reimbursement for specialty mental healthservices that are the responsibility of the MHP under this subchapter, except as specially provided.

(b) The beneficiary must meet criteria outlined in (1), (2), and (3) below to be eligible for services:(1) Be diagnosed by the MHP with one of the following diagnoses in the Diagnostic and

Statistical Manual, Fourth Edition, published by the American Psychiatric Association:(A) Pervasive Developmental Disorders, except Autistic Disorders(B) Disruptive Behavior and Attention Deficit Disorders(C) Feeding and Eating Disorders of Infancy and Early Childhood(D) Elimination Disorders(E) Other Disorders of Infancy, Childhood, or Adolescence(F) Schizophrenia and other Psychotic Disorders(G) Mood Disorders(H) Anxiety Disorders(I) Somatoform Disorders(J) Factitious Disorders(K) Dissociative Disorders(L) Paraphilias(M) Gender Identity Disorder(N) Eating Disorders(O) Impulse Control Disorders Not Elsewhere Classified(P) Adjustment Disorders(Q) Personality Disorders, excluding Antisocial Personality Disorder(R) Medication-Induced Movement Disorders related to other included diagnoses.

(2) Must have at least one of the following impairments as a result of the mental disorder(s) listed in subdivision (1) above:

(A) A significant impairment in an important area of life functioning.(B) A probability of significant deterioration in an important area of life functioning.(C) Except as provided in Section 1830.210, a probability a child will not progress

developmentally as individually appropriate. For the purpose of this section, a child is a person under the age of 21 years.

(3) Must meet each of the intervention criteria listed below:(A) The focus of the proposed intervention is to address the condition identified in (2) above.(B) The expectation is that the proposed intervention will:

1. Significantly diminish the impairment, or2. Prevent significant deterioration in an important area of life functioning, or3. Except as provided in Section 1830.210, allow the child to progress

developmentally as individually appropriate.(C) The condition would not be responsive to physical health care based treatment.

(c) When the requirements of this section are met, beneficiaries shall receive specialty mental health services for a diagnosis included in subsection (b)(1) even if a diagnosis that is not included in subsection (b)(1) is also present.

our core valuesOur decisions and service delivery reflect the following values:

• Quality Services for persons of all ages with addiction and/or mental illness

• Integrity in individual and organizational actions

• Dignity, Respect, and Compassion for all persons

• Active Involvement of clients and families in treatment, recovery, and policy development

• Diversity throughout our organization and Cultural Competency in service delivery

• A Model of Care that is clearly defined and promotes recovery

• Emphasis on Prevention and Treatment

• Integration among clinical/fiscal operations, ADP/MH, and services by ADMHS/Community-Based Organizations

• Parity across regions of the county

• Teamwork among ADMHS employees in an atmosphere that is fun, creative, and optimistic

• Collaboration with Community-Based Organizations,County partners, and other community agencies

• Continuous Learning and Improvement in service delivery and administration

314

S e r v i c e C r i t e r i a T w owho

we

are

Criteria for Substance Abuse Medi-Cal

All services must be provided by, or under the direction of, a physician and are subject to utilization controls.Reimbursement is for face-to-face individual and group counseling provided in an approved facility. There isno reimbursement for telephone contact or case management services.

Medical necessity is defined in Section 51303 as "reasonable and necessary to protect life, to preventsignificant illness or significant disability, or to alleviate severe pain." Substance abuse diagnoses are setforth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition,published by the American Psychiatric Association.

There are five types of services covered by Substance Abuse Medi-Cal:

1) Narcotic treatment program services utilizing methadone and/or levoalphacetylmethadol (LAAM) as narcotic replacement drugs for beneficiaries with a confirmed, documented history of opiate addiction who are at least 18 years of age, opiate free, and not pregnant -- Services include: intake,treatment planning, medical direction, body specimen screening, physician and nursing services related to substance abuse, medical psychotherapy, individual and/or group counseling, admission physical examinations and laboratory tests, medication services, and the provision of methadone and/or LAAM

2) Outpatient drug free treatment services -- Services include: admission physical examinations, intake, medical direction, medication services, body specimen screens, treatment and discharge planning, crisis intervention, collateral services, group counseling, and individual counseling

3) Day care habilitative services for pregnant and postpartum (up to 60 days) women and/or children under 21 who are eligible for EPSDT -- Services include: intake, admission physical examinations, medical direction, treatment planning, individual and group counseling, body specimen screens, medication services, collateral services, and crisis intervention

4) Perinatal (pregnant or postpartum, up to 60 days) residential substance abuse services -- Services include: intake, admission physical examinations and laboratory tests, medical direction, treatment planning, individual and group counseling services, parenting education, body specimen screens, medication services, collateral services, and crisis intervention services

5) Naltrexone treatment services for beneficiaries with a confirmed, documented history of opiate addiction who are at least 18 years of age, opiate free, and not pregnant -- Services include: intake,admission physical examinations, treatment planning, provision of medication services, medical direction, physician and nursing services related to substance abuse, body specimen screens, individual and group counseling, collateral services, and crisis intervention services

NOTE: This is an overview of Drug Medi-Cal criteria only. Please see Title 22 for additional eligibility criteria.

13

S e r v i c e C r i t e r i a O n eOverviewAlcohol, Drug & Mental Health Services (ADMHS) is a department of the County ofSanta Barbara. We are the public authority at the County level for alcohol & otherdrug services and mental health services. As a public agency, we are responsiblefor assisting many of the County's most vulnerable residents, especially those whoare uninsured or underinsured.

We provide leadership, coordination, and oversight of prevention, early intervention, treatment, and recovery support services to over 15,000 children, youth, adults, older adults, and families each year.

Our work is overseen by the Advisory Board on Alcohol & Drug Problems, and theMental Health Commission, both appointed by the elected Board of Supervisors.ADMHS strives for full integration of alcohol, drug, and mental health services at alllevels. Approximately 90% of our budget comes from state and federal sources.Services are provided by County employees, Community-Based Organizations, andcontracted private practitioners (Network Providers). This document describes ourvision, mission, values, service philosophy, model of care, and priority populations.

MissionThe mission of Alcohol, Drug & Mental Health Services (ADMHS) is to promote theprevention of and recovery from addiction and mental illness among individuals,families and communities by providing effective leadership and delivering state-of-the-art, culturally competent services.

VisionWe envision a world in which people affected by alcohol, drug, and mental health problems are valued by their communities andempowered to strive for their dreams.

4

service

criteria

EPSDT enables us to be reimbursed for the diag-nosis and treatment of Medi-Cal eligible childrenand youth under the age of 21 who have a mental disorder. EPSDT stands for “Early andPeriodic Screening, Diagnosis, and Treatment.”Medical necessity is defined more broadly underEPSDT; it includes services to help those underage 21 maintain their level of functioning,regardless of whether their condition is expectedto improve.

ADMHS serves children and youth with seriousemotional disturbance and adults/older adultswith serious mental disorders who are uninsured and/or indigent. Welfare & InstitutionsCode 5600.3 specifies that the following “priority target populations” would be served “tothe extent resources are available”:

(a) Children or adolescents with SED (see Service Criteria Three)

(b) Adults and older adults with a serious mental disorder (see Service Criteria Four)

(c) Adults or older adults who require or are at risk of requiring acute inpatient care, residential treatment, or outpatient crisis services because of psychosis or the likelihood of suicide or violence

(d) Persons needing treatment due to a natural disaster or emergency.

ADMHS also serves people with SED or SMI whohave insurance or other financial resources ifthey are unable to obtain treatment for their men-tal health conditions elsewhere.

ADMHS serves people who have co-occurring disorders if they meet the above criteria. For those with concurrent serious mental illnessand serious alcohol or drug problems, a determination will be made about where the per-son is best served.

ADMHS serves people in crisis due to a mentaldisorder by providing emergency assessments inthe community, and voluntary or involuntary inpatient care.

ADMHS serves people who are involved withother service systems (education, social services,Regional Center, criminal justice, etc.) if theymeet the above criteria.

Advancing the rehabilitation and recovery of individuals, families, and communities with alcohol, drug, and mental health problems is achallenging endeavor. Everyone involved in oursystem of care needs to be creative, act withintegrity, and work collaboratively. We should alladvocate for improvements in the policies andfunding sources that shape our services at thelocal, state, and national level. At the same time,we need to work diligently to make the best possible use of all resources available to us now.It is our hope that defining our model of caremore clearly will enable us to be more united inthis mission.

service philosophy

Everything we do is oriented toward supportingand promoting recovery for our clients andproblem solving for our communities.

It is our role to help clients identifywhat brings purpose, meaning, andquality into their lives, and to identifypersonal goals for living, learning,working, and social relationships. All aspects of treatment are in serviceof these self-determined goals.

Clients should always be able to describe whythey are engaging in treatment, includingdetox, inpatient treatment, medication,psychotherapy, group therapy, peer support,and skill-building. We are also invested inbuilding upon the assets available withincommunities that support individual success,and using these assets to address environ-mental conditions that exacerbate individual,family and neighborhood alcohol and otherdrug related problems.

As clients recover, their identity as a servicerecipient becomes less central, and theybecome more engaged in community life as a volunteer, employee, neighbor, artist,author, student, parent, sibling, son/daughter,friend, advocate, member of a faith community, etc.

We embrace a “system of care” philosophy.Our service system is strengthened by par tnerships with community-based organizations, other county and state departments, network providers, and schoolsand colleges. Many of our clients are servedby multiple agencies/departments and wewant services to be well-coordinated andaccessible to clients and families.

We believe that teams are the best way toprovide high quality services to persons andcommunities impacted by unsafe alcoholuse, addiction and/or mental illness. Theteam’s primary purpose is to help those weserve to reach their personal goals. Teamsare strengthened by the inclusion and collo-cation of staff from multiple disciplinesincluding administrative and support staff,each of whom brings needed expertise:licensed and non-licensed staff, consumers,family members, community based organizations, network providers, and representatives of other service systems.

512

how

we

serve

• MediCal beneficiaries, children with SED, adults, and older adults with SMI who also have co-occurring disorders

• MediCal beneficiaries, children with SED. adults, and older adults with SMI who are also involved with other service systems.

These priority populations are illustrated in the following diagram:

ADMHS is the Mental Health Plan Provider for allMediCal beneficiaries in Santa Barbara County –including children, adults, and older adults -- whomeet the criteria for medical necessity as definedin California Code of Regulations, Title 9, Chapter11, Sections 1830.205 and 1830.210:

(a) Have an included DSM-IV diagnosis and

(b) as the result of the mental disorder, have a significant impairment in an important area of life functioning or a probability of significant deterioration in an important area of life functioning and

(c) are expected to benefit from the proposed intervention (those under 21 qualify if it is probable that the intervention will enable the child/youth to progress developmentally as individually appropriate) and

(d) the condition would not be responsive to treatment by a physical health care practitioner.

Mental health services to MediCal beneficiariesare provided by ADMHS-operated clinics, contracted Network Providers, and community-based organizations.

We must always be attuned to the profoundimportance of cultural attributes in individual,family, and community life. We strive to bring

flexibility creativitypersistence

to all aspects of our work. Teams are operatedin a way that encourages all voices to be heardwhile also maintaining a clear focus on thedesired outcome.

Alcohol, Drug & Mental Health Services(ADMHS) has a unique role as the leader ofthe system of care – a special responsibilityas the public authority for mental health &alcohol/drug services and funding.

Community-based organizations are keymembers of the system of care. They are inti-mately involved with and knowledgeable aboutthe communities they serve. They leverageadditional resources to serve clients and the community as a whole. Bringing cost-effectiveness and flexibility to our system ofcare, we rely on them to provide a significantpor tion of direct services. ADMHS andCommunity-Based Organizations engage inreciprocal consultation in order to benefit fromeach other’s areas of expertise.

Natural and community supports provide anenduring resource throughout the lives ofADMHS consumers. We recognize the interdependence of all members of the communities we serve. We work closely withconsumers, family members, youth groups,faith-based groups, schools and colleges,adult education programs, volunteer serviceprograms, and other organizations to supportour clients, just as they suppor t other community members. We provide training anddevelopment for these agencies, institutions,and groups so that they sustain clients in thecommunity as their recovery progresses andtheir need for professional services diminishes.

Clients, family members, and community-based organizations have a stake in administration and policy development. We actively seek the benefit of their wisdomthrough active involvement in decisions aboutour system of care.

6 11

Individuals and teams need a “whatever it takes” attitude to meetthe complex needs of our clients.

MediCal eligible

Quadrant 1 Medi-CalSMI/SED clientsw/ or w/o co-occuring substance use conditions

(priority population)

Quadrant 2 Medi-Cal Non-SMI/SEDclients w/ or w/o co-occuring substance use conditions


Non-MediCaleligible

Quadrant 3 Non-Medi-CalSMI/SED clients w/ or w/o co-occuring substance use conditions


Quadrant 4Non-Medi-CalNon-SMI/SEDclientswithout substance use conditions

(non-priority population)

SMI or SED

Not SMI or SED

who

we

serve

model of careOur model of care is “BiopsychosocialRehabilitation and Recovery” with a team-based approach to service delivery.

While this model is applied differently withinthe various ADMHS Divisions and otherorganizations, we all share a commitment toteamwork. The word "team" here refers toindividuals and agencies who collaborativelyplan and deliver services to clients.

The biological, psychological, and socialaspects of rehabilitation services are eachdescribed below:

• Biological In serving clients with addictions, the team focuses on thebiological impacts of substance use and abstinence in the individual. This awareness helps the client to manage biochemical changes and facilitates referrals, where appropriate, for medicaldetox, medication therapy for cravings, and possibly medication to treat mental health issues as clients gain sobriety.

In serving individuals with serious mental illness, the whole team focuses on the neuro-biological impacts of the condition and the role of psychiatric medications in helping the client to stabilize his or her acute symptoms, achieve long-term stability, and access the full range of services. The team works to anticipate and prevent crises, and stays in close contact with clients and family members during inpatient and outpatient treatment. Clients often have concurrent physical health problems that need medical attention.

• Psychological Team members provide support for coping with and recovering from long-term alcohol, drug, and mental health problems. By addressing psychological issues, the team helps clients to avoid relapse,hospitalization, or incarceration. Many clients have experienced domestic violence or other forms of trauma and need sensitive, proficient support in their recovery. The team aids clients to identify personally meaningful goals andto fully engage in their own treatment.

7

mandated populations

Alcohol & Drug ProgramADP serves a wide range of county residentsand communities experiencing problemsrelated to alcohol and other drug misuse,abuse or dependence.

Services may be offered to:• neighborhoods impacted by uncontrolled

drinking or drug use;

• families concerned about a loved one’s use of alcohol or other drugs; or

• an individual who has developed a serious problem with alcohol or other drug use.

We are obligated to serve the following special populations:

Prevention Services• Youth at risk for alcohol or other

drug problems

• Communities concerned with alcohol or other drug problems

Treatment Services• Intravenous drug users

• Intravenous drug users who are pregnant

• Intravenous drug users with children

• Addicted women with children

• Youth, families and other individuals withalcohol or other drug problems, whether voluntarily choosing or mandated to receive services

• County residents who are MediCal beneficiaries (see Attachment One)

Mental Health Services ADMHS is mandated to provide mental healthservices to a number of priority populations:

• All MediCal beneficiaries with mental health needs

• Children with serious emotional disturbance (SED) to the extent resources are available

• Adults and Older Adults with serious mental illness (SMI) to the extent resources are available

10

how

we

serve

98

• Social Social interventions by the team are aimed at reintegrating the client into community life. Team members meet with clients in their natural environments as much as possible. This increases the team’s awareness of environmental issues and provides more accurate information about needed interventions. The team helps clients to develop improved relationships with family members, friends, and the community.

Clients are linked with community resources such as vocational supports, housing, education, benefits, faith-based organizations, recreation centers, and volunteer roles. Community interventions designed to address environmental factors that contribute to individual, family and neighborhood problems with alcohol and other drugs, or the escalation of mental health conditions, are valued tools.

Teams that are community based and that build upon the mutual interests of institutions, local agencies and residents create opportunities for reducing harm and promoting safer environments for all.

The overall goal of services is to promote theclient’s recovery and to engage communitiesin addressing local conditions that impedesuccessful recovery.

A successful team:

• provides a message of hope and encouragement to clients and their families

• assists them to develop skills

• links them to other community resources

• helps them todevelop individual empowerment plans to pursue a path of recovery even when public services are completed

how

we

serve

We recognize that relapses are a naturaloccurrence on the path to recovery, and theteam helps clients to learn from and preventthem. Peer supports – such as peer counseling and 12-step programs – providevital contact with others who are further alongin their recovery and to the community as awhole. Services are aimed at helping clientsto find their niche in the community and toengage fully in community life.

Educating the community about alcohol, drug,and mental health issues and recovery is animportant part of implementing our model ofcare. Assessing community factors thatimpede individual, family and neighborhoodresolution of alcohol, other drug and mentalhealth problems require thoughtful use oforganizing strategies that lead to formation ofcommunity teams.

• Medical professionals – physicians, nurses, and physician extenders – lead the team’s treatment of the biological aspects of clients’ conditions.

• Licensed mental health practitioners identify and address clients’ therapeutic issues through psychological assessment and individual & group psychotherapy.

• People knowledgeable about addiction issues help clients understand the impact of substance use in their lives and support them in making needed, lasting changes.

• Rehabilitation Specialists bring to the team a unique expertise in helping clients to set meaningful goals and to utilize community resources and natural supports.

• Care Coordinators help clients to link with services, build needed skills and engage with their own natural and informal support systems.

• Peer counselors lend their unique credibility and experiences to the team’s efforts to promote recovery.

• Clients, Family Members, Family Mentors, Family Advocates, Patient Representatives, Medical Records Technicians, Receptionists and Office Assistants are all valued members of the team. The function of Administration -including Fiscal, Human Resources, Contracts Administration, Information Technology, and Facilities - is to facilitate the smooth and effective provision of direct services to clients by the teams.

• Prevention specialists lend their knowledge of environmental factors that are used toassist communities in addressing unsafe alcohol and other drug practices.

Clients benefit from the myriad talents of multi-disciplinary teams. In addition to serving as a collaborative team member, each discipline provides leadership in their area of expertise.

model of careOur model of care is “BiopsychosocialRehabilitation and Recovery” with a team-based approach to service delivery.

While this model is applied differently withinthe various ADMHS Divisions and otherorganizations, we all share a commitment toteamwork. The word "team" here refers toindividuals and agencies who collaborativelyplan and deliver services to clients.

The biological, psychological, and socialaspects of rehabilitation services are eachdescribed below:

• Biological In serving clients with addictions, the team focuses on thebiological impacts of substance use and abstinence in the individual. This awareness helps the client to manage biochemical changes and facilitates referrals, where appropriate, for medicaldetox, medication therapy for cravings, and possibly medication to treat mental health issues as clients gain sobriety.

In serving individuals with serious mental illness, the whole team focuses on the neuro-biological impacts of the condition and the role of psychiatric medications in helping the client to stabilize his or her acute symptoms, achieve long-term stability, and access the full range of services. The team works to anticipate and prevent crises, and stays in close contact with clients and family members during inpatient and outpatient treatment. Clients often have concurrent physical health problems that need medical attention.

• Psychological Team members provide support for coping with and recovering from long-term alcohol, drug, and mental health problems. By addressing psychological issues, the team helps clients to avoid relapse,hospitalization, or incarceration. Many clients have experienced domestic violence or other forms of trauma and need sensitive, proficient support in their recovery. The team aids clients to identify personally meaningful goals andto fully engage in their own treatment.

7

mandated populations

Alcohol & Drug ProgramADP serves a wide range of county residentsand communities experiencing problemsrelated to alcohol and other drug misuse,abuse or dependence.

Services may be offered to:• neighborhoods impacted by uncontrolled

drinking or drug use;

• families concerned about a loved one’s use of alcohol or other drugs; or

• an individual who has developed a serious problem with alcohol or other drug use.

We are obligated to serve the following special populations:

Prevention Services• Youth at risk for alcohol or other

drug problems

• Communities concerned with alcohol or other drug problems

Treatment Services• Intravenous drug users

• Intravenous drug users who are pregnant

• Intravenous drug users with children

• Addicted women with children

• Youth, families and other individuals withalcohol or other drug problems, whether voluntarily choosing or mandated to receive services

• County residents who are MediCal beneficiaries (see Attachment One)

Mental Health Services ADMHS is mandated to provide mental healthservices to a number of priority populations:

• All MediCal beneficiaries with mental health needs

• Children with serious emotional disturbance (SED) to the extent resources are available

• Adults and Older Adults with serious mental illness (SMI) to the extent resources are available

10

how

we

serve

• MediCal beneficiaries, children with SED, adults, and older adults with SMI who also have co-occurring disorders

• MediCal beneficiaries, children with SED. adults, and older adults with SMI who are also involved with other service systems.

These priority populations are illustrated in the following diagram:

ADMHS is the Mental Health Plan Provider for allMediCal beneficiaries in Santa Barbara County –including children, adults, and older adults -- whomeet the criteria for medical necessity as definedin California Code of Regulations, Title 9, Chapter11, Sections 1830.205 and 1830.210:

(a) Have an included DSM-IV diagnosis and

(b) as the result of the mental disorder, have a significant impairment in an important area of life functioning or a probability of significant deterioration in an important area of life functioning and

(c) are expected to benefit from the proposed intervention (those under 21 qualify if it is probable that the intervention will enable the child/youth to progress developmentally as individually appropriate) and

(d) the condition would not be responsive to treatment by a physical health care practitioner.

Mental health services to MediCal beneficiariesare provided by ADMHS-operated clinics, contracted Network Providers, and community-based organizations.

We must always be attuned to the profoundimportance of cultural attributes in individual,family, and community life. We strive to bring

flexibility creativitypersistence

to all aspects of our work. Teams are operatedin a way that encourages all voices to be heardwhile also maintaining a clear focus on thedesired outcome.

Alcohol, Drug & Mental Health Services(ADMHS) has a unique role as the leader ofthe system of care – a special responsibilityas the public authority for mental health &alcohol/drug services and funding.

Community-based organizations are keymembers of the system of care. They are inti-mately involved with and knowledgeable aboutthe communities they serve. They leverageadditional resources to serve clients and the community as a whole. Bringing cost-effectiveness and flexibility to our system ofcare, we rely on them to provide a significantpor tion of direct services. ADMHS andCommunity-Based Organizations engage inreciprocal consultation in order to benefit fromeach other’s areas of expertise.

Natural and community supports provide anenduring resource throughout the lives ofADMHS consumers. We recognize the interdependence of all members of the communities we serve. We work closely withconsumers, family members, youth groups,faith-based groups, schools and colleges,adult education programs, volunteer serviceprograms, and other organizations to supportour clients, just as they suppor t other community members. We provide training anddevelopment for these agencies, institutions,and groups so that they sustain clients in thecommunity as their recovery progresses andtheir need for professional services diminishes.

Clients, family members, and community-based organizations have a stake in administration and policy development. We actively seek the benefit of their wisdomthrough active involvement in decisions aboutour system of care.

6 11

Individuals and teams need a “whatever it takes” attitude to meetthe complex needs of our clients.

MediCal eligible

Quadrant 1 Medi-CalSMI/SED clientsw/ or w/o co-occuring substance use conditions


Quadrant 2 Medi-Cal Non-SMI/SEDclients w/ or w/o co-occuring substance use conditions


Non-MediCaleligible

Quadrant 3 Non-Medi-CalSMI/SED clients w/ or w/o co-occuring substance use conditions


Quadrant 4Non-Medi-CalNon-SMI/SEDclientswithout substance use conditions

(non-priority population)

SMI or SED

Not SMI or SED

who

we

serve

EPSDT enables us to be reimbursed for the diag-nosis and treatment of Medi-Cal eligible childrenand youth under the age of 21 who have a mental disorder. EPSDT stands for “Early andPeriodic Screening, Diagnosis, and Treatment.”Medical necessity is defined more broadly underEPSDT; it includes services to help those underage 21 maintain their level of functioning,regardless of whether their condition is expectedto improve.

ADMHS serves children and youth with seriousemotional disturbance and adults/older adultswith serious mental disorders who are uninsured and/or indigent. Welfare & InstitutionsCode 5600.3 specifies that the following “priority target populations” would be served “tothe extent resources are available”:

(a) Children or adolescents with SED (see Service Criteria Three)

(b) Adults and older adults with a serious mental disorder (see Service Criteria Four)

(c) Adults or older adults who require or are at risk of requiring acute inpatient care, residential treatment, or outpatient crisis services because of psychosis or the likelihood of suicide or violence

(d) Persons needing treatment due to a natural disaster or emergency.

ADMHS also serves people with SED or SMI whohave insurance or other financial resources ifthey are unable to obtain treatment for their men-tal health conditions elsewhere.

ADMHS serves people who have co-occurring disorders if they meet the above criteria. For those with concurrent serious mental illnessand serious alcohol or drug problems, a determination will be made about where the per-son is best served.

ADMHS serves people in crisis due to a mentaldisorder by providing emergency assessments inthe community, and voluntary or involuntary inpatient care.

ADMHS serves people who are involved withother service systems (education, social services,Regional Center, criminal justice, etc.) if theymeet the above criteria.

Advancing the rehabilitation and recovery of individuals, families, and communities with alcohol, drug, and mental health problems is achallenging endeavor. Everyone involved in oursystem of care needs to be creative, act withintegrity, and work collaboratively. We should alladvocate for improvements in the policies andfunding sources that shape our services at thelocal, state, and national level. At the same time,we need to work diligently to make the best possible use of all resources available to us now.It is our hope that defining our model of caremore clearly will enable us to be more united inthis mission.

service philosophy

Everything we do is oriented toward supportingand promoting recovery for our clients andproblem solving for our communities.

It is our role to help clients identifywhat brings purpose, meaning, andquality into their lives, and to identifypersonal goals for living, learning,working, and social relationships. All aspects of treatment are in serviceof these self-determined goals.

Clients should always be able to describe whythey are engaging in treatment, includingdetox, inpatient treatment, medication,psychotherapy, group therapy, peer support,and skill-building. We are also invested inbuilding upon the assets available withincommunities that support individual success,and using these assets to address environ-mental conditions that exacerbate individual,family and neighborhood alcohol and otherdrug related problems.

As clients recover, their identity as a servicerecipient becomes less central, and theybecome more engaged in community life as a volunteer, employee, neighbor, artist,author, student, parent, sibling, son/daughter,friend, advocate, member of a faith community, etc.

We embrace a “system of care” philosophy.Our service system is strengthened by par tnerships with community-based organizations, other county and state departments, network providers, and schoolsand colleges. Many of our clients are servedby multiple agencies/departments and wewant services to be well-coordinated andaccessible to clients and families.

We believe that teams are the best way toprovide high quality services to persons andcommunities impacted by unsafe alcoholuse, addiction and/or mental illness. Theteam’s primary purpose is to help those weserve to reach their personal goals. Teamsare strengthened by the inclusion and collo-cation of staff from multiple disciplinesincluding administrative and support staff,each of whom brings needed expertise:licensed and non-licensed staff, consumers,family members, community based organizations, network providers, and representatives of other service systems.

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how

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Criteria for Substance Abuse Medi-Cal

All services must be provided by, or under the direction of, a physician and are subject to utilization controls.Reimbursement is for face-to-face individual and group counseling provided in an approved facility. There isno reimbursement for telephone contact or case management services.

Medical necessity is defined in Section 51303 as "reasonable and necessary to protect life, to preventsignificant illness or significant disability, or to alleviate severe pain." Substance abuse diagnoses are setforth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition,published by the American Psychiatric Association.

There are five types of services covered by Substance Abuse Medi-Cal:

1) Narcotic treatment program services utilizing methadone and/or levoalphacetylmethadol (LAAM) as narcotic replacement drugs for beneficiaries with a confirmed, documented history of opiate addiction who are at least 18 years of age, opiate free, and not pregnant -- Services include: intake,treatment planning, medical direction, body specimen screening, physician and nursing services related to substance abuse, medical psychotherapy, individual and/or group counseling, admission physical examinations and laboratory tests, medication services, and the provision of methadone and/or LAAM

2) Outpatient drug free treatment services -- Services include: admission physical examinations, intake, medical direction, medication services, body specimen screens, treatment and discharge planning, crisis intervention, collateral services, group counseling, and individual counseling

3) Day care habilitative services for pregnant and postpartum (up to 60 days) women and/or children under 21 who are eligible for EPSDT -- Services include: intake, admission physical examinations, medical direction, treatment planning, individual and group counseling, body specimen screens, medication services, collateral services, and crisis intervention

4) Perinatal (pregnant or postpartum, up to 60 days) residential substance abuse services -- Services include: intake, admission physical examinations and laboratory tests, medical direction, treatment planning, individual and group counseling services, parenting education, body specimen screens, medication services, collateral services, and crisis intervention services

5) Naltrexone treatment services for beneficiaries with a confirmed, documented history of opiate addiction who are at least 18 years of age, opiate free, and not pregnant -- Services include: intake,admission physical examinations, treatment planning, provision of medication services, medical direction, physician and nursing services related to substance abuse, body specimen screens, individual and group counseling, collateral services, and crisis intervention services

NOTE: This is an overview of Drug Medi-Cal criteria only. Please see Title 22 for additional eligibility criteria.

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S e r v i c e C r i t e r i a O n eOverviewAlcohol, Drug & Mental Health Services (ADMHS) is a department of the County ofSanta Barbara. We are the public authority at the County level for alcohol & otherdrug services and mental health services. As a public agency, we are responsiblefor assisting many of the County's most vulnerable residents, especially those whoare uninsured or underinsured.

We provide leadership, coordination, and oversight of prevention, early intervention, treatment, and recovery support services to over 15,000 children, youth, adults, older adults, and families each year.

Our work is overseen by the Advisory Board on Alcohol & Drug Problems, and theMental Health Commission, both appointed by the elected Board of Supervisors.ADMHS strives for full integration of alcohol, drug, and mental health services at alllevels. Approximately 90% of our budget comes from state and federal sources.Services are provided by County employees, Community-Based Organizations, andcontracted private practitioners (Network Providers). This document describes ourvision, mission, values, service philosophy, model of care, and priority populations.

MissionThe mission of Alcohol, Drug & Mental Health Services (ADMHS) is to promote theprevention of and recovery from addiction and mental illness among individuals,families and communities by providing effective leadership and delivering state-of-the-art, culturally competent services.

VisionWe envision a world in which people affected by alcohol, drug, and mental health problems are valued by their communities andempowered to strive for their dreams.

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service

criteria

Criteria for the Mental Health Plan (MHP)

(a) The following medical necessity criteria determine Medi-Cal reimbursement for specialty mental healthservices that are the responsibility of the MHP under this subchapter, except as specially provided.

(b) The beneficiary must meet criteria outlined in (1), (2), and (3) below to be eligible for services:(1) Be diagnosed by the MHP with one of the following diagnoses in the Diagnostic and

Statistical Manual, Fourth Edition, published by the American Psychiatric Association:(A) Pervasive Developmental Disorders, except Autistic Disorders(B) Disruptive Behavior and Attention Deficit Disorders(C) Feeding and Eating Disorders of Infancy and Early Childhood(D) Elimination Disorders(E) Other Disorders of Infancy, Childhood, or Adolescence(F) Schizophrenia and other Psychotic Disorders(G) Mood Disorders(H) Anxiety Disorders(I) Somatoform Disorders(J) Factitious Disorders(K) Dissociative Disorders(L) Paraphilias(M) Gender Identity Disorder(N) Eating Disorders(O) Impulse Control Disorders Not Elsewhere Classified(P) Adjustment Disorders(Q) Personality Disorders, excluding Antisocial Personality Disorder(R) Medication-Induced Movement Disorders related to other included diagnoses.

(2) Must have at least one of the following impairments as a result of the mental disorder(s) listed in subdivision (1) above:

(A) A significant impairment in an important area of life functioning.(B) A probability of significant deterioration in an important area of life functioning.(C) Except as provided in Section 1830.210, a probability a child will not progress

developmentally as individually appropriate. For the purpose of this section, a child is a person under the age of 21 years.

(3) Must meet each of the intervention criteria listed below:(A) The focus of the proposed intervention is to address the condition identified in (2) above.(B) The expectation is that the proposed intervention will:

1. Significantly diminish the impairment, or2. Prevent significant deterioration in an important area of life functioning, or3. Except as provided in Section 1830.210, allow the child to progress

developmentally as individually appropriate.(C) The condition would not be responsive to physical health care based treatment.

(c) When the requirements of this section are met, beneficiaries shall receive specialty mental health services for a diagnosis included in subsection (b)(1) even if a diagnosis that is not included in subsection (b)(1) is also present.

our core valuesOur decisions and service delivery reflect the following values:

• Quality Services for persons of all ages with addiction and/or mental illness

• Integrity in individual and organizational actions

• Dignity, Respect, and Compassion for all persons

• Active Involvement of clients and families in treatment, recovery, and policy development

• Diversity throughout our organization and Cultural Competency in service delivery

• A Model of Care that is clearly defined and promotes recovery

• Emphasis on Prevention and Treatment

• Integration among clinical/fiscal operations, ADP/MH, and services by ADMHS/Community-Based Organizations

• Parity across regions of the county

• Teamwork among ADMHS employees in an atmosphere that is fun, creative, and optimistic

• Collaboration with Community-Based Organizations,County partners, and other community agencies

• Continuous Learning and Improvement in service delivery and administration

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S e r v i c e C r i t e r i a T w owho

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Criteria for “Serious Emotional Disturbance”

The child meets one or more of the following criteria (A, B, or C):

A. As a result of a mental disturbance, the child has substantial impairment in at least two of the following areas:

❑ Self-care❑ School functioning❑ Family relationships❑ Community functioning

and has met one of the following two criteria:

❑ At risk of removal from home or has already been removed from the home, or❑ The mental disorder and impairments have been present for more than six months or are

likely to continue for more than one year without treatment

B. Displays one of the following:

❑ Psychotic features❑ Risk of suicide❑ Risk of violence

C. Meets special education eligibility requirements as emotionally disturbed under Chapter 26.5 ofthe California Code of Regulations.

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S e r v i c e C r i t e r i a T h r e e

who we are . . . . . . . . .page 3-4• Alcohol, Drug & Mental Health Services Vision

• Mission

• Core Values

how we serve . . . . . . .page 5-9• Service Philosophy

• Model of Care

who we serve . . . . . . .page 10-12• Mandated Populations

service criteria . . . . . .page 13-16• Medical Necessity Criteria for Substance Abuse Medi-Cal

• Medical Necessity Criteria for the Mental Health Plan

• Criteria for “Serious Emotional Disturbance” from Welfare & Institutions Code

• Criteria for "Serious Mental Disorder" from Welfare & Institutions Code

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March 2004

Dear Community,

Over the past several years, Alcohol, Drugand Mental Health Services has gatheredinput about the local system of care from stakeholders through many avenues,including: strategic planning processes, focusgroups, the Alcohol & Drug Program's TownHall Meetings, the Labor Management TaskForce's System of Care Project Team, theGrand Jury Repor t on Mental HealthServices, the Staff Hotline, the CBOCollaborative, the Mental Health Commission,the Advisory Board on Alcohol & DrugProblems, ongoing Department meetings,and feedback to the Executive Team.

We have consistently heard the concernthat too many parts of our system areoperating in isolation from each other --e.g., mental health and alcohol & drug programs, children's and adult services,county-provided and CBO-provided services,etc. The intention of this document is to articulate a model of care for Santa BarbaraCounty that unifies our service delivery system. As we provide treatment, support,and preventive services to people and fam-ilies who are at risk of, or living with, debilitating addictions and/or mental healthconditions, it is critical that we work together.Close teamwork enables us to provide more effective, respectful, culturally sensitiveand healing services to the community.

To begin addressing this need, ADMHS articulated its Core Values last year (seepage 3). This Model of Care document goesfurther to specify how those values should be actualized in the provision of services.

The next step is for each of the Alcohol,Drug & Mental Health Services Divisions todevelop a more specific model of caredescription, consistent with the overarchingprinciples presented here. ADMHS will alsoconduct team-building within each staff unitand then develop a Level of Care model thatwill set for th standardized criteria for consumer and community access to prevention and treatment services. We willalso work with our County and Community-Based partners on ways to incorporate thismodel of care in our collaborative services.

Sincerely,

Alcohol, Drug & Mental Health Executive Team

James L. Broderick, Ph.D.Director

Charles H. Nicholson, M.D. Medical Director

Heidi Anna Garcia, MFTAssistant Director - Programs

Al Rodriguez Manager - Alcohol/Drug Program

Carrie TopliffeAssistant Director - Administration

Laura Mancuso, M.A., C.R.C.Project Coordinator

The intention of this document is to articulate a model of care

for Santa Barbara County that unifies our service delivery system.

1

Criteria for “Adults and Older Adults Who Have a Serious Mental Disorder"

For the purposes of this part, "serious mental disorder" means a mental disorder which is severe in degreeand persistent in duration, which may cause behavioral functioning which interferes substantially with theprimary activities of daily living, and which may result in an inability to maintain stable adjustment andindependent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.Serious mental disorders include, but are not limited to, schizophrenia, as well as major affective disordersor other severely disabling mental disorders. This section shall not be construed to exclude persons with aserious mental disorder and a diagnosis of substance abuse, developmental disability, or other physical ormental disorder.

Members of this target population shall meet all of the following criteria:

(A) The person has a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a substance use disorder or developmental disorder or acquired traumatic brain injury pursuant to subdivision (a) of Section 4354 unless that person also has a serious mental disorder as defined in paragraph (2).

(B) (i) As a result of the mental disorder the person has substantial functional impairments or symptoms, or a psychiatric history demonstrating that without treatment there is an imminent riskof decompensation to having substantial impairments or symptoms.

(ii) For the purposes of this part, "functional impairment" means being substantially impaired as the result of a mental disorder in independent living, social relationships, vocational skills, or physical condition.

(C) As a result of a mental functional impairment and circumstances the person is likely to become so disabled as to require public assistance, services, or entitlements.

For the purpose of organizing outreach and treatment options, to the extent resources are available, this target population includes, but is not limited to, persons who are any of the following:

(A) Homeless persons who are mentally ill.

(B) Persons evaluated by appropriately licensed persons as requiring care in acute treatment facilitiesincluding state hospitals, acute inpatient facilities, institutes for mental disease, and crisis residential programs.

(C) Persons arrested or convicted of crimes.

(D) Persons who require acute treatment as a result of a first episode of mental illness with psychotic features.

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S e r v i c e C r i t e r i a F o u r

Santa Barbara County Alcohol Drug and Mental Health Services Staff

Santa Barbara County Mental Health Commission

Santa Barbara County Advisory Board on Alcohol and Drug Problems

Aegis Medical Systems, Inc.

American Medical ResponseMental Health Assessment Team

Area Agency on Aging

Carpinteria Policy Panel

Casa Pacifica Children’s Crisis Care and Treatment Center

Casa Serena

Central Coast CommissionSenior Citizens Area Agency on Aging

Central Coast Headway

Charles Golodner Counseling Group

Child Abuse Listening And Mediation

City of Santa Barbara

Community Action Commission of Santa Barbara County

Community Recovery Network

Council on Alcohol and Drug Abuse

Domestic Violence Solutions

Family Life Counseling Services

Family Service Agency of Santa Barbara

Future Leaders of America

Good Samaritan

Guadalupe Police Dept.

Mental Health Association in Santa Barbara County

Mental Health Systems, Inc.

Santa Barbara Neighborhood Clinics

Noah’s Anchorage

Pacific Pride Foundation

Phoenix of Santa Barbara

Salvation Army

Sanctuary Psychiatric Center of Santa Barbara

Santa Barbara County Department of Social Services

Santa Barbara County Probation Department

Santa Barbara County Public Health

Santa Barbara County Schools

Santa Maria Valley Youth Family Services

Santa Maria - Gay and Lesbian Resource Center

Santa Ynez Valley People Helping People

Sharon Elam Counseling Service

Sheriffs Department Jail Inmate Treatment Services

Telecare Corporation

The Right Detour, Inc.

Thomas Frutchey

Transitions Mental Health Association

U. C. Berkeley Institute for Social Change

U. C. Irvine Pathology Services

UCSB – Isla Vista Alcohol and Drug Council

Work Training Program, Inc

Zona Seca

A C K N O W L E D G M E N T S

Our partner Departments, Boards, Commissions and contracted Community Based Providers who provided

input during the Model of Care development include, but are not limited to, the following agencies:

Model of Care

C O U N T Y O F S A N T A B A R B A R A

F O R A L C O H O L , D R U G & M E N T A L H E A L T H S E R V I C E S

CO U N T Y O F SA N TA BA R B A R A AL C O H O L , DR U G & ME N TA L HE A LT H SE R V I C E S

300 N. San Antonio Rd • Santa Barbara, CA 93110 • (805) 681-5220 • www.countyofsb.org/admhs

model of care

Documents