Comment BHCS Response

Luvenia Jones on Housing: There are people who enter Many individuals served in the Alameda County Behavioral Health Care the system at age 18, and still don’t have stable housing System struggle to find and obtain permanent housing that is the least at age 50; how about housing for those on fixed income? restrictive and most integrated setting that is appropriate for meeting their How do Non-FSP enrollees get housing assistance? How needs. Our MHSA housing investments focus on expanding and do the MHSA Plan funds help them? improving a range of affordable housing options with associated services for those impacted by serious mental illness. Individuals living in licensed board and cares pay a significant amount of their monthly Social Security checks toward residence at the facility leaving them with minimal spending money. The cost of care in a licensed home contributes to this diminished spending money. Ultimately, the high cost of housing in our County coupled with Social Security disability benefits not keeping pace with true regional living costs contribute to real limits on personal spending money for many BHCS clients. Our employment supportive services are intended to help people move toward increasing their income and meaningful activity over time. The BHCS Housing Services Office invests in a range of housing-related supports available to non-FSP clients including emergency and transitional housing, short-term housing financial assistance, housing education and counseling, housing-focused case management services, and housing search assistance and information. MHSA funding is helping to leverage additional housing- related resources through Alameda County’s Whole Person Care program known as Alameda County Care Connect. These new programs and resources will become available beginning in July of 2017.

Diane Wylder on School-Based services: Is there a PEI 1B/C School-Based Mental Health Consultation in Elementary and part of the plan that focuses efforts on training at schools, Middle Schools offers consultation, training and technical assistance to going through teachers to reach and educate parents? teachers, school staff and parents around mental health topics including Any concentrated efforts to better inform/train parents increasing mental health supports in schools, positive behavioral through the schools? coaching, restorative justice and positive school climate activities. PEI 12 Suicide Prevention and Trauma Informed Care also offers training around mental health topics and suicide prevention to entire school communities (youth, teachers, staff, and families)

Joe Rose on Community Planning: For the next year- MHSA funded FSP programs currently have outcome data on would like to see measurable results of what programs hospitalization. For the next Three Year Plan, one of the goals is to what receive MHSA funding are most cost-effective, in improve the MHSA website and include FSP outcomes regarding helping reduce hospitalizations and re-hospitalizations. hospitalizations among other outcomes. BHCS will conduct analysis Data should be tracked so that the funds designated to based on outcomes to inform decisions about provider contract renewals. less “successful” programs can added to most cost- effective programs in the future.

ACBHCS FY16-17 PLAN UPDATE PUBLIC COMMENT ATTACHMENTS, P. 1

Margot Dashiell on services to African-Americans: The African American Steering Committee for Health & Wellness was Figures pertaining to the African American consumer formed to provide recommendations to BHCS on culturally-competent suggest a crisis. Figures for African American entering the treatment and prevention strategies that serve African American most restrictive services (5150 commitments) and consumers and their families residing in Alameda County. The Committee assignment to the Santa Rita jail Mental Health Unit hover is currently reviewing designs for a Health and Wellness Center for this just short of 50%, even though African Americans are only population. BHCS is awaiting their final recommendations in order to 12% of Alameda County. A report presented to the BOS proceed with next steps. on 4/24/17 entitled "Ending Homelessness in Alameda County" from the Social Services Agency, states that 56% To date three programs specifically designed to serve the African of the homeless in the County are African American. (43% American community have been approved and are in the final contract of the homeless population are living with serious mental stages. These programs include: the development of four housing units; illness.) In the past decade there has not be nor is there support group services for African American family members, and now an adequate a strategy to target this population with prevention and early intervention services focusing on the transition age services. Ethnic service centers aimed at Native youth (TAY) population ages 18 to 24. Americans, Latino and Asian consumers have been able to launch a series of programs to meet needs in their respective communities. The fact that there is nothing comparable for African Americans is a major deficit in the array BHCS programs. Without a center with adequate resources and experienced professionals with a mission to recruit, engage and meet the needs of this community, it does not seem realistic to expect that the statistical picture will improve.

Margot Dashiell on FSP 5 - FACT: The text states that FACT partners who express interest in education tied to (short/long-term) the program has been able to move completely to the IPS vocational goals receive help exploring programs that might be a good fit model of supported employment. This is an encouraging based on their interests, including specialized training, apprenticeships development as people living with serious mental illness and other skilled trades, adult basic education, GED, community colleges, or substance abuse disorder often find a road to recovery and universities. Staff will link partners to programs based on their through supported experience in the labor market. What is preference and provide individualized support to help them successfully not clear is the role of the personal services coordinator enroll, stay in school, and complete the program. who, it is mentioned, now handles educational services. What are the educational services? It would be important to know what educational and informational resources are actually being employed to assist FACT partners in seeking employment training to assist them in job mobility. In the East Bay there are vocational and academic and basic skills programs centered at the community colleges, which can provide opportunities for individuals seeking to rebuild their life and develop skills to assist them in advancing in the job market. There are also programs like Cypress Mandela which have track records in placing people in union apprenticeships. Does educational services indicate linkages of this sort, or does it mean something else? And have job training programs utilized linkages with institutions specializing in training for skilled trades?

ACBHCS FY16-17 PLAN UPDATE PUBLIC COMMENT ATTACHMENTS, P. 2

MENTAL HEALTH SERVICES ACT ALAMEDA COUNTY

FY 2016-2017 PLAN UPDATE

PROVIDER REPORTS

Bonita House, HOST Adult Full-Service Partnership Program Outcomes, June P. 1 2007-December 2015 East Bay Community Recovery Project, Forensic Assertive Community Treatment, P. 12 Bi-Annual Monitoring Report, Jan 1- June 30, 2016 East Bay Community Recovery Project, Transitional Assertive Community P. 29 Treatment, Annual Monitoring Report, July 1, 2015 - June 30, 2016

East Bay Community Recovery Project, PREP Alameda County, August 2016 P. 72

Geriatric Assessment & Response Team (GART), FY 2015-16 P. 90

Alameda County Underserved Ethnic Language Population Programs, PEI P. 92 Community Survey and Focus Group Results FY 2015-16 Crisis Support Service of Alameda County, Text Line Program, Year End Report P. 119 FY 2015-16 Crisis Support Service of Alameda County, Community Education Program, Year P. 152 End Report FY 2015-16 Crisis Support Service of Alameda County, Clinical Program, 2015-16 Annual P. 172 Report Crisis Support Service of Alameda County, Crisis Line Program, Year End Report, P. 204 FY 2015-16 Vocational Program - Alameda County (Individual Placement Services), ACVP P. 226 Outcomes, January 2016 – February 2017

Bonita House, Inc.

HOST

ADULT FULL-SERVICE PARTNERSHIP PROGRAM OUTCOMES June 2007 - December 2015 Based on a Total of 146 Partners

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 1 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Psychiatric Hospitalization

50

P 40 75.6% Decrease in a the Number of Partners with 30 r Psychiatric Hospitalizations t 20 from the 12 Months Prior to n Enrollment in HOST e 10 Compared to the Most Recent r 0 12 Months of Enrollment as s 12 Months First 12 Most Recent of 12/31/15 Prior to Months of 12 Months Enrollment Enrollment Post Enrollment

A 160 d 140 90.1% Decrease in m 120 the Number of New i 100 Psychiatric Hospitalizations s 80 from the 12 Months Prior to s 60 Enrollment in HOST i 40 Compared to the Most Recent o 20 12 Months of Enrollment as n 0 of 12/31/15 s 12 Months First 12 Months Most Recent 12 Prior to of Enrollment Months Post Enrollment Enrollment

2,000

1,500 93.5% Decrease in the Number of Days Partner's D 1,000 Were in a Psychiatric a Hospital from the 12 Months y 500 Prior to Enrollment in HOST s Compared to the Most Recent 0 12 Months of Enrollment as 12 Months First 12 Most Recent of 12/31/15 Prior to Months of 12 Months Enrollment Enrollment Post Enrollment ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 2 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Incarcerations

25

P 20 52.2% Decrease in a 15 the Number of Partners r Incarcerated from the 12 t 10 Months Prior to Enrollment in n 5 HOST Compared to the Most e Recent 12 Months of r 0 s 12 Months First 12 Most Recent Enrollment as of 12/31/15 Prior to Months of 12 Months Enrollment Enrollment Post Enrollment

I n c 50 45 a 40 64.6% Decrease in r 35 the Number of New c 30 25 Incarcerations from the 12 e 20 Months Prior to Enrollment in r 15 HOST Compared to the Most a 10 5 Recent 12 Months of t 0 Enrollment as of 12/31/15 i 12 Months First 12 Most Recent o Prior to Months of 12 Months Enrollment Enrollment Post n Enrollment s

1200 82.4%(including outlier*- 1000 solid bars) 14.0% (without outlier- 800 striped bars) D 600 Increase in a 400 the Number of Incarceration y Days from the 12 Months s 200 Prior to Enrollment in HOST 0 Compared to the Most Recent 12 Months First 12 Most Recent Prior to Months of 12 Months 12 Months of Enrollment as Enrollment Enrollment Post of 12/31/15 Enrollment

* One Partner (outlier) accounted for more than 1/3 of the Incarceration days (345) in the First 12 Months of Enrollment, and almost 1/2 of the Incarcerations days (365) in the Most Recent 12 Months. ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 3 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Homelessness

120

P 100 85.1% Decrease in the Number of Partners Who a 80 r Experienced Homelessness t 60 from the 12 Months Prior to n 40 Enrollment in HOST e Compared to the Most Recent 20 r 12 Months of Enrollment as s 0 of 12/31/15 12 Months Prior First 12 Months Most Recent 12 to Enrollment of Enrollment Months Post Enrollment

H o 400 m 350 93.5% Decrease in e 300 the Number of New Episodes l 250 of Homelessness Among e 200 Partners from the 12 Months s 150 Prior to Enrollment in HOST s 100 Compared to the Most Recent n 50 12 Months of Enrollment as e 0 of 12/31/15 s 12 Months Prior First 12 Months Most Recent 12 s to Enrollment of Enrollment Months Post Enrollment

30,000 25,000 91.8% Decrease in 20,000 the Number of Days of D Homelessness Among 15,000 a Partners from the 12 Months y 10,000 Prior to Enrollment in HOST s 5,000 Compared to the Most Recent 0 12 Months of Enrollment as 12 Months First 12 Most Recent of 12/31/15 Prior to Months of 12 Months Enrollment Enrollment Post Enrollment

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 4 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Employment

80 70 P 60 88.9% Increase in a 50 the Number of Partners r Employed from the 12 t 40 Months Prior to Enrollment in n 30 HOST Compared to the Most e 20 Recent 12 Months of r 10 s Enrollment as of 12/31/15 0 12 Months Prior First 12 Months Most Recent 12 to Enrollment of Enrollment Months Post Enrollment

20,000 18,000 16,000 289.3% Increase in 14,000 the Number of Days of D 12,000 Employment Among Partners a 10,000 from the 12 Months Prior to y 8,000 Enrollment in HOST 6,000 s 4,000 Compared to the Most Recent 2,000 12 Months of Enrollment as 0 of 12/31/15 12 Months Prior First 12 Months Most Recent 12 to Enrollment of Enrollment Months Post Enrollment

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 5 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Education

50 45 P 40 190.9% Increase in a 35 the Number of Partners in r 30 School or Taking Classes in t 25 the 12 Months Prior to n 20 Enrollment in HOST 15 e 10 Compared to the Most Recent r 5 12 Months of Enrollment as s 0 of 12/31/15 12 Months Prior First 12 Months Most Recent 12 to Enrollment of Enrollment Months Post Enrollment

16,000 14,000 432.3% Increase in 12,000 the Number of Days Partners D 10,000 Were in School or Taking a 8,000 Classes in the 12 Months y 6,000 Prior to Enrollment in HOST s 4,000 Compared to the Most Recent 2,000 12 Months of Enrollment as 0 of 12/31/15 12 Months First 12 Months Most Recent 12 Prior to of Enrollment Months Post Enrollment Enrollment

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 6 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Psychiatric Hospitalization Partners with Psychiatric Hospitalizations: 12 Months Prior to Enrollment 41 First 12 Months of Enrollment 26 Most Recent 12 Months Post Enrollment 10 Decrease in Partners with Psychiatric Hospitalizations: 75.6%

New Psychiatric Hospital Admissions: 12 Months Prior to Enrollment 141 First 12 Months of Enrollment 38 Most Recent 12 Months Post Enrollment 14 Decrease in New Psychiatric Hospital Admissions: 90.1%

Psychiatric Hospital Days: 12 Months Prior to Enrollment 1,563 First 12 Months of Enrollment 1,673 Most Recent 12 Months Post Enrollment 101 Decrease in Psychiatric Hospital Days: 93.5%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 7 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Incarceration Incarcerated Partners: 12 Months Prior to Enrollment 23 First 12 Months of Enrollment 19 Most Recent 12 Months Post Enrollment 11 Decrease in Incarcerated Partners 52.2%

New Incarcerations: 12 Months Prior to Enrollment 48 First 12 Months of Enrollment 25 Most Recent 12 Months Post Enrollment 17 Decrease in New Incarcerations 64.6%

Without Days Incarcerated*: Outlier* 12 Months Prior to Enrollment 472 435 First 12 Months of Enrollment 1071 726 Most Recent 12 Months Post Enrollment 861 496 Change in Days Incarcerated 82.4% 14.0% *One partner (outlier) accounted for more than 1/3 of the incarceration days (345) in the First 12 Months of Enrollment, and almost 1/2 of the incarceration days (365) in the Most Recent 12 Months

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 8 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Homelessness Homeless Partners: 12 Months Prior to Enrollment 114 First 12 Months of Enrollment 42 Most Recent 12 Months Post Enrollment 17 Decrease in Homeless Partners 85.1%

New Episodes of Homelessness: 12 Months Prior to Enrollment 356 First 12 Months of Enrollment 23 Most Recent 12 Months Post Enrollment 23 Decrease in Episodes of Homelessness 93.5%

Days of Homelessness 12 Months Prior to Enrollment 29,511 First 12 Months of Enrollment 3,074 Most Recent 12 Months Post Enrollment 2,428 Decrease in Days of Homelessness: 91.8%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 9 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Employment Employed Partners: 12 Months Prior to Enrollment 27 First 12 Months of Enrollment 75 Most Recent 12 Months Post Enrollment 51 Increase in Employed Partners: 88.9%

Days Employed 12 Months Prior to Enrollment 4,205 First 12 Months of Enrollment 18,901 Most Recent 12 Months Post Enrollment 16,372 Increase in Days Employed 289.3%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 10 Bonita House, Inc. HOST Program Outcomes 2007 - 2015 Based on a Total of 146 Partners

Education Partners in School or Taking Classes: 12 Months Prior to Enrollment 11 First 12 Months of Enrollment 49 Most Recent 12 Months Post Enrollment 32 Increase in Partners in School or Taking Classes 190.9%

Days in School or Taking Classes: 12 Months Prior to Enrollment 2,030 First 12 Months of Enrollment 14,429 Most Recent 12 Months Post Enrollment 10,806 Increase in Days in School or Taking Classes 432.3%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 11

Forensic Assertive Community Treatment

Bi-Annual Monitoring Report January I – June 30, 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 12 Forensic Assertive Community Treatment Program Report Prepared by: John Knowles, MSW and the FACT Team

FACT is a full service partnership (FSP) program of the East Bay Community Recovery Project that is a contract with Behavioral Healthcare Services to provide services to and maintain an active caseload of 76-79 adult participants (age 18-59). FACT has been providing housing and wraparound supportive services to individuals identified by the county as persons who continue to cycle in and out of psychiatric emergency and inpatient services and Santa Rita jail. The program provides an intensive level of services to the individuals enrolled in the program, partners, to encourage and support their wellness and recovery efforts with the goal of significantly reducing or eliminating the need for psychiatric emergency and inpatient services and incarceration.

I. Program Deliverables

Reporting Period - 01/01/16 to 6/30/16 (3rd and 4th Quarter of Fiscal Year 15/16)

Process and Outcome Measures TOTAL 1. Number of unduplicated partners in the program during this period.  => Adult FSPs Only: Number of these partners who graduated to a less  intensive level of mental health service. 2. Number of partners who entered the program during this period. ➒ =>Number of these partners who entered the program  without benefits (e.g. SSI, Medi-Cal). 3. Number of partners who completed their first six months in the FSP during this period.  => Number of these partners who completed application for or got their benefits reinstated within six months of enrollment.  4. Number of partners who completed their first 12 months in the FSP during this period.  => Number of the partners who were linked  to primary care within 12 months of program enrollment. => Number of these partners whose income through public benefits or wages  increased within 12 months of enrollment.

The FACT Program averaged 70 partners per month, enrolled 9 new partners, transitioned/graduated three partners and discharged two partners during this reporting period January to June 30, 2016. Two FACT partners who completed the program were able to successfully transition to less intensive outpatient BHCS services, 1 was enrolled with a level 1 mental health service team and the other was transitioned to Pathways to Wellness and a private therapist. The FACT Team discharged two partners who were not utilizing the resources of the FSP program.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 13 There were seven partners that completed their first 6 months of the program and two who completed their first year with FACT. Of those partners, five entered the program with benefits and one who was able to increase their overall wages through the application and award of public benefits. The FACT team members work with the partners and the Homeless Action Center (HAC) to initiate a partner’s first time application(s) for benefits or submit the necessary paperwork to reinstate benefits at the time of enrollment.

II. NARRATIVE Reporting Period - 01/1/16 to 6/30/16 (3rd and 4th Quarter of Fiscal Year 15/16)

1. OUTREACH and ENGAGEMENT Program enrollment of partner’s is achieved through the team’s provision of intensive and ongoing outreach and engagement services that begin with our responding to referrals from providers in the community, jail, and institutions.

Total Enrollment Total

FACT REFERRALS : Jan 2016 to June 2016

Enrollment Date or Date of reason for not Outreach

Referral PSP Referred By being enrolled Date (s) s Total Referrals

1 1/14/16 75243961* CJMH 2/18/16 1

2 2/10/16 75160728 CJMH 6/2/16 5/12/16, 5/27/16 3 2/11/16 40811201* CJMH 3/25/16 2/11/16, 3/23/16 2 4 2/15/16 75254502 prison referral 5/31/16 3 5 3/12/16 75033964* BHC/transfer 3/16/16 4 6 3/16/16 75063848 EOCS 6/30/16 4/8/15 5

7 3/16/16 42599101 EOCS MIA

8 3/31/16 75002921 Crisis Response 4/1/16 3/30/16 6

9 4/29/16 75051158* CJMH MIA 5/26/16 6/2/2016 10 4/29/16 26572801* CJMH 5/12/16, 5/27/16 7 11 5/4/16 75055017 EACSC outreach 4/12, 7/29 12 5/5/16 75104500 EACSC 6/8/2016 5/27/16 8 13 5/9/16 75107571 EACSC outreach 4/12, 7/29 14 5/10/16 75139145* CJMH 6/9/16 9

15 5/11/16 75122184 EACSC MIA 16 6/10/16 21074001 CJMH outreach 6/23/16, 7/1/16 17 6/26/16 75180800 BHC/transfer outreach 18 7/1/16 75216983 BHC/Transfer outreach 19 7/11/16 58688301* CJMH outreach 7/22, 7/25,7/29

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 14 20 7/11/16 75055017* CJMH outreach 7/22, 7/25,7/29 21 7/11/16 75117087* CJMH (Paul W) Sept Release FACT CENSUS as of 6/30/2016 -- *CJMH Referral specific to the 9 ----75 addl FACT slots F/u Needed

FACT program enrollment contract goal is 66-69 partners with a dedicated additional 10 slots reserved for the transition of BHC TrACT partners needing the FACT Full Service Partnership level of ongoing support and care. Our outreach and engagement efforts are for the purposes of continuity of care for enrolled partners and enrollment of “potential eligible” individuals. The county screens individuals to ensure that they meet enrollment criteria. These individuals comprise the FACT Program “potential eligible” list. Many of these “potential eligible” individuals have received a long history of services from a variety and extensive number of providers in the ACBHCS network.

In engaging individuals, we begin the therapeutic relationship development and collaborating processes by introducing ourselves followed by our informing the individual(s) of the services offered by the program to support their wellness and recovery efforts. We assess the individual to confirm their diagnostic eligibility—severe and persistent mental health condition(s), and a review of their charges to ensure they are appropriate for the program with consideration for staffing levels, program acuity level, and staff and partner safety. We are most careful when it comes to to enrolling potential eligible individuals charged with a felony crime that included the use of a deadly weapon. Rarely would we enroll an individual with a charge of this type.

The safety of the team and other partners is always a consideration when evaluating an individual for enrollment. We advocate for medication support services should an incarcerated or institutionalized individual believe it in their best interest for managing symptoms of their mental health condition(s). We encourage utilizing this support as it has been our experience that taking medications not only increases an individual’s opportunity for a successful transition from jail to the community but is also a key to successfully living independently in the community and staying out of jail.

Nine partners enrolled into the program during this reporting period because of this outreach and engagement process. This process is ongoing and our efforts increase as partners begin to graduate and or discharge from the program and slots open for enrollment of new partners become available.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 15 2. Peer Specialist

Hiring and Retention Efforts The peer support staff support both the FACT and TrACT program staff and partners. In the 3rd and 4th quarters of FY 15/16, the programs have continued to retain two peer staff. One peer’s primary role on the team is “program receptionist” and it is the receptionist’s responsibility to create a welcoming atmosphere as the first contact for all callers and visitors (partners and guest) to the program office. This peer’s work is vital to the daily coordination and provision of services to the program’s partners as the peer team member creates a daily partner needs list that the team uses each morning when planning and coordinating daily services for the partners. This peer employee continues to support the program administrative needs by coordinating and distributing daily county reports to the appropriate program administrative team members. The peer specialist hired in the 2nd quarter of FY 15/16 has proven to be a strong employee who brings a lot of experience and enthusiasm to the team and partners. The peer’s work with the BHC TrACT team has been a necessary part of the services provided by the team. We have had numerous peer specialist interviews this reporting period from which we hired one peer specialist for the FACT peer position. This individual was hired in the 4th quarter of the fiscal year and brings a great deal of experience to the position and the team

3. Program Successes

FACT Expansion Grant FACT has been successful in implementing the funding for the expansion grant that went into effect January 1, 2016. Currently all 9 slots have been filled by referrals to the FACT program.

On November 6, 2015 the FACT and CJMH director met to discuss the criteria for the FACT expansion slots. Below is a list of the agreed upon criteria for the additional 6- 9 slots in FACT.

Criteria for FACT: expansion grant slots

1. Diagnosis of a serious mental illness (thought disorder or mood disorder)

2. 2 or more incarcerations within 12 months of each other, with the most recent within the last 30 days.

3. A minimum of one admission to J. George in the prior 12 months or 3 or more visits to PES within the last 12 months.

 or has been treated in a State hospital within the last 12 months.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 16

4. If they have had a prior treatment/case management or are currently open to a program:

 but they were unsuccessful in engaging with them for at least 1 year while in the community

 and the treatment program recommends a higher level of care.

5. No known local family or natural supports.

6. Presence of substance use disorder.

7. Preference given to 1370 population, including both felony and misdemeanor cases.

8. Eligible for County services.

9. Needs approval of CJMH Director, or designee.

10. CJMH Director or designee reserves the option to assign someone to FACT that may not meet all of the criteria but appears to be in need of the level of care to deter further involvement with the Criminal Justice system.

FACT had to create a referral form for the expansion slots- it is placed below.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 17 The new staffing pattern post the expansion is as follows: FACT TrACT  Psychiatrist - .395 FTE or 13.6 Psychiatrist - .105 FTE or 6.4 hours/week hours/week LVN - .438 FTE or 17.52 hours/week LVN - .162 FTE or 6.48 hours/ week  RN - .73 FTE or 29.2 hours/week RN - .27 FTE or 10.8 hours/week Employment/Education Specialist- Employment /Education Specialist 1 Exempt and 1 Non-Exempt @ 1 Exempt and 1 Non-Exempt @ .73 FTE or 29.2 hours/week .27 FTE or 10.8 hours/week Housing Specialists- Housing Specialists - 2 @ .73 FTE or 29.2 hours/week 2 @ .27 FTE or 10.8 hours/week Peer Housing Support Specialist Peer Specialist PSC (3) and PSC .27 or 11.8 hours per PSC (2) (one Licensed and Exempt) week Housing Coordinator - Exempt .73 FTE Housing Coordinator -Exempt .27 FTE (29.2 hours /week) (10.8 hours /week)  Program Coordinator – Exempt .73 FTE Program Coordinator – Exempt .73 FTE or or 29.2 hours/week (includes having a PSC 29.2 hours/week (includes having a PSC caseload) caseload) TrACT Program Supervisor FACT and TrACT Clinical Program Supervisor Program Manager

This chart shows that the additional funds were allocated to increase psychiatry and nursing hours. The funds allowed us to increase our employment to 2 full time positions and to add 2 PSC staff and 2 full time positions.

Reduction in Recidivism The program reduction of recidivism is a result of program services and resources available to its participants and the programs ability to support increased partner symptom stabilization and overall ability to function independently in the community. Program mental health and medication management services are instrumental in supporting a partner with symptom stabilization enabling partners to increase their ability to self- regulate and use their learned coping skills instead of regression to patterns of old behavior that resulted in their hospitalizations and or incarcerations.

The FACT outcome data has clearly illustrated the programs’ success in meeting the goal of reducing partner recidivism; both in the number of episodes and days spent in jail, psychiatric emergency and inpatient hospital settings. The benefits of reducing recidivism include…

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 18

. A partner receiving humane and respectful mental health and substance abuse community based services, . The enhancement of public safety through reducing partner offender’s risk to the community, . Cost-savings to public funded county healthcare and criminal justice (county court and jail services ) systems, and . An improvement in the quality of life of individuals suffering from mental health and substance abuse issues

Transition The program graduated/transitioned two partners from the program this reporting period ending June 30, 2016. One partner transitioned for services to West Oakland Mental Health for a lower level of care and the second partner was referred to Pathways to Wellness for Medication Management and a private counselor for therapy.

Program Treatment The program consists of a stress reduction, change, art and criminogenic group. Utilizing best practices the stress reduction group helps partners to identify stress from three basic sources: the environment, the body and one’s thoughts. They are taught how to manage internal and external stresses with coping skills. The Change group, continued to be offered weekly, has an evidenced based set of participant-centered resources that empowers criminal justice involved partners with substance related disorders encourages individuals to change their habits and thoughts that lead to risk taking behaviors. The Change Club to begin to change their thinking to change their behaviors. The expressive arts group teaches strategies that promote self-awareness and emotional regulation in order to improve functioning.

A newly offered group, Taking Charge, helps partners to identify their perceptions, beliefs and thoughts that lead to criminal behaviors and provides strategies to take charge of their internal cognitions in order to lower recidivism. This group is a component of Changing Offender Behavior: A complete Evidence-based System developed by The Change Company. The Change Company uses interactive journaling (employs evidence-based methods) to enhance the therapeutic relationship while bringing structure and consistency to the Change Club and the newly offered, 1-day a week, anger management group. In the course of gathering immediate and relevant information related to their problem areas, partners, with support from the staff facilitators, are able map out where they have been, where they are now, where they wish to go and how to get there. The interactive journals guide participants through self-exploration. Journals include text paired with core graphics that

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 19 engage the partners in the material. The Change Club facilitators use open-ended questions to emphasize each participant’s personal change journey.

The focus of the individual and group mental health, substance use and rehabilitation services continues to focus on the development or enhancement of daily living skills, emotional self-regulation, of identifying triggers and sobriety support needs, wellness and recovery tools, nutrition and healthy living.

Treatment services in the third and fourth quarter include the assessment and intervention-planning specific to a partner’s criminogenic needs and risk of re-offending. The initial risks will be assessed utilizing the programs recently updated mental health assessment. These needs and risks will further be assessed utilizing an implementing the Change Companies “Changing Offender Behavior” series, a cognitive-behavioral based program, beginning with “Starting Point: My Personal Assessment” journal where the group participants, supported by the facilitators, complete their own self-assessment. The assessment is comprised of the following life areas: current offenses and criminal history, alcohol and drugs, personality, friends, attitudes, values and beliefs, family relationships, education and employment experiences, anger and violence, and responsivity. The facilitators then score the assessment by assigning a level of risk for re-offending to each category of the assessment. Participants individualized interventions and tx planning can be developed based on the scoring of the assessment.

Residential / Outpatient Treatment In the third and fourth quarters of FY 15/16, 10 partners engaged in outpatient or residential treatment programs for co-occurring conditions. Fifty-six percent or 5 of the 9 partners enrolled during this period and the partners who completed their first 12 months (2/2) of the program were co-enrolled in treatment for substance use. The FACT team maintains ongoing contact with community residential and outpatient treatment providers to ensure optimal care and recovery services for our partners while in treatment. The team makes every attempt to participate in treatment and discharge planning to advocate for partners needs and support a quality transition back to the community at discharge or completion of an outpatient program. During this period, FACT partners have been enrolled in the East Bay Community Recovery Project and the Fairmont Outpatient Day Treatment programs. Additionally, partners received detox and residential treatment services at programs such as Cherry Hill, Cronin House, Wistar, Serenity House, Bonita House and Women on the Way.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 20 Community Events/Social Inclusion In quarters 3 and 4 of the FY 15/16, FACT hosted two community meetings on-site to convene the partner community to celebrate Valentine’s day and graduations. The community meetings continue to be an opportunity for partners to, 1) interact with program staff in a social and appropriate manner, 2) socialize with one another, 3) learn information about and sign up to participate in program services available (housing, groups, outings), and 4) learn about and sign up for peer events in the community.

Our community meetings have a consistent agenda that includes team member and partner introductions, brief overview of program services—including group, housing and employment—and ongoing discussions and celebrations for partner transitions and graduations. A primary benefit for partners from the community meetings is the opportunity for partners to develop and or enhance their social skills and strengthen individual social support networks.

The program participates in the CATS events and often gets tickets for baseball games, football games, theater, Alcatraz and the Monterey Aquarium. The team utilizes these events as an opportunity to decrease partner isolation and to strengthen individual social support networks.

Housing The FACT/TrACT increased its number of master leased units and successfully provided temporary shelter housing for 26 homeless men and women during this reporting period. These newly enrolled homeless individuals were in were in phase 1 of the program, the relationship development-stage. They were able to settle into the master leased housing units on the agency campus. These sober living units provide safe, clean, and a structured living environment that promotes recovery and encourages close contact between partners and staff. This is important as the staff begin to support the partners in getting their basic needs met and begin the comprehensive assessment, evaluation and treatment planning—goal development—process.

In some cases, individuals leaving residential programs who have yet to find housing occupy the master leased units. Partners will live there temporarily until their housing opportunity becomes available. Twelve of the twenty-two emergency shelter housed partners have been deemed eligible and eventually placed in S+C subsidized permanent supportive housing in the community. Partners housed have to maintain their housing 3 or more months in emergency housing. Partners housed in the community have been able to maintain their housing over a year without interruption or incident. This 6-month reporting period has seen new developments to enhance the programs housing services. The new housing coordinator was hired during this past quarter and has been busy in getting up to speed learning the expectations of our housing contracts and

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 21 agreements and the process for supporting the ongoing daily program housing needs. The Yardi housing database system has been been difficult to implement, however our goal is to finally implement it during this reporting period. We are still hoping that it will help us to increase the efficiency of the housing inventory, invoicing and accounts payable and receivable aspects of the the fiscal management of the housing program. It is still our expectation that the use of this database will bring a new level of accountability and efficiency to our housing services and program. Most importantly, this will free up a significant amount of time for the staff to focus on providing housing services to our partners.

Our program experienced two shelter + care audits this reporting period and we have yet to get any feedback on our performance in the audits.

Partner Housing Narrative When SLa came to be with the FACT program he had a few months clean and sober after almost a lifetime of ongoing alcohol use and abuse. He was attending day treatment at Highland hospital and living in a transitional housing program. Eventually, he came to stay at the FACT Emergency Shelter and expressed an interest in living independently. After spending many hours talking with SLa, it became clear that the most stable housing he had had in decades was his vehicle.

SLa’s marriage failed due to substance abuse, lost custody of his child, and eventually lost his relationship with his daughter altogether. SLa’s relationship with his siblings was strained, but his relationship with his mother was growing again. SLa became a leader in his shelter housing unit, often assisting others to attend NA/AA meetings. SLa was active with his program and often met with the housing specialist and his PSC. Eventually, SLa’s Shelter Plus Care application was completed and immediately approved.

SLa then took the lead on locating his own apartment, in which he currently still resides, one year later, without incident. SLa has fostered relationships with his landlord and his neighbors. SLa, though he has graduated his treatment program at Highland, continues to attend meetings daily and has created his own structured schedule to aid in his recovery. SLa often visits with the housing team and stops in to see the FACT staff and check in.

SLa reports he is now seeing his daughter regularly. He also reports that he talks to his brother daily and often sees his mother more than twice a week. SLa has always paid his rent on time, and takes pride in this. He budgeted and saved to purchase his own furnishings and often brings in pictures to show staff how his home is ‘growing into me.’ He is always smiling and reports that he feels healthy and strong which he thanks the FACT program for.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 22 Employment Research in the field of co-occurring disorders, shows that individuals participating in employment and/or educational activities are better able to manage and decrease the symptoms of the mental health condition, decrease their likelihood to self-medicate with substances, combat the boredom and isolation. In addition to that, being at a job or educational setting helps partners to socialize with peers as well as team members. These partners have also demonstrated a sense of purpose, as well as, achievement that helped them feel good about their accomplishments, increased his self-esteem and self- confidence, as well as, provide them with a paycheck.

The FACT program supports partners’ employment and education goals as part of the of the wraparound services offered; along with treatment, housing and social rehabilitation. Each partner’s needs are addressed and a treatment plan is put in place by the IPS employment specialist, with the support of the team. This is done in a collaborative fashion, with other community based programs who are working with the partner. FACT and TrACT Employment Services will need to work collaboratively with the Alameda County Vocational Program as well as the State Department of Vocational Rehabilitation Services. Together, the goal is to utilize appropriate resources for each individual partner in order to enable a rapid job search focus in line with the IPS approach of ensuring partners’ preferences and choices of employment.

This fiscal year we were awarded an expansion grant to increase the number of partners to be served by the FACT and TrACT programs. Therefore, we increased our capacity to provide employment services from 20 to 40 potential employment candidates, thus keeping in line with our commitment to begin providing fidelity based IPS Employment services. In other words we have added 1 full-time employment specialist position to the team. The employment specialists will have up to 40 slots for 2 IPS employment caseloads.

In other employment staffing news we lost our employment specialist of almost 4 years and struggled to find a replacement as the IPS employment specialist position description calls for a unique skillset that was not easy to find. In fact we were unable to hire anyone that had previous experience with the IPS Dartmouth model. We hired an individual for the first employment position in February and the second in May of the 3rd and 4th quarters of this FY.

This year a total of 21 partners expressed interest in competitive employment and the employment specialist ended this reporting period (6/30/2016) with a case load of 18. One of the staff is taking on that active caseload of 18 partners. Among that 18, five are actively engaged in weekly employer contact through independent job searches and staff referrals to employer partners. Two are currently enrolled in accredited college education. Others

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 23 are continuing to develop independent living skills to maintain weekly job searches alongside other goals.

Key highlights include one partner’s successful placement as a full-time laundry attendant at the Double Tree Hilton at the Berkeley Marina. This was the partner’s preferred industry, and the placement encouraged Alameda County Family Court to grant him weekend visitation rights with his kids. The employment specialist also worked closely with another partner on her naturalization process, and she successfully completed an in- person interview and submitted follow-up documentation related to that process. She is pursuing part-time work in Hayward near her housing, and Behavioral Health Court recently lifted the protective order so she can visit her father in Fremont.

As of the close of this fiscal year 2 other partners had completed interviews with employer partners: Every Dog Has Its Day Care, Inc. and Whole Foods Market, respectively. Both partners seem very excited and will hopefully receive job offers within the next two weeks.

Employer outreach has yielded 19 new employer contacts this reporting period.

Partners were helped with career interests, job skills, and educated on possible work challenges. They were supported with job categories that fit with their interests, resume preparation, and coaching for job interviews. In addition, they were encouraged to set realistic expectations, since many partners have not been in the work force for a while.

The biggest challenge for the FACT partners’ engagement in employment and educational related services has been medical and medication challenges, which were being addressed by the medical team, but required some time for stabilization and symptom management.

4. PROGRAM CHALLENGES

Program Staff: Hiring and Retention ACT teams are known for increased turnover in staff when compared to traditional case management teams. FACT and TrACT are fast paced intensive programs that can prove too difficult for some individuals to be successful. It does take a unique skillset and commitment to self-care to be successful in this type of program. The teams have experienced high turnover especially in the peer specialist positions.

In the past there have been issues of recruitment and retention of program team members, there have been several known barriers that may contribute to the challenge of recruiting and keeping competent and dedicated employees. These may include;

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 24 . lack of compensation that is commensurate with the duties and responsibilities of the positions, . the decreased availability of skilled and qualified professionals applying for open positions in the non-profit social services job market (especially for positions that, due to county contract expectations, require licensed or licensed eligible professionals) . this decreased availability of employment applicants increases the number of agencies in the county competing for the same small group of possible applicants . no COLA raises over the past two years from the county ( this was remedied beginning FY 16/17 ) . The high acuity and complex needs (chronic substance abuse) of the partner population. . The challenge of staff providing services and meeting documentation requirements has proven to be a mitigating factor to the ability of individuals to maintain longer-term employment.

The new FACT clinical supervisor and FACT/TrACT housing coordinator have been settling into their positions and the program has been on an upward movement towards meeting their goals for monthly service hours. The supervisor continues to support the oversight of and contributing to the program’s efforts to provide the level of service hours as stated in the FY 15/16 Exhibit A of our county contract. As we have completed the 3rd and fourth quarter and we have increased our service hours each month closing the FY with an all-time high of 1048 hours in a single month. We have hired a new psychiatrist for both FACT and TrACT and have hired 2 employment specialists to take on the implementation of the IPS model.

We were able to hire a housing coordinator and a peer housing specialist for both the TrACT/FACT programs during this reporting period and only have a single housing position left to fill. The personal service coordinator positions remained strong during this reporting period.

The program was awarded additional monies to expand the program—hire additional staff and serve more individuals increasing the contracted slots for TrACT to 29. It was determined that the following TrACT/FACT staffing increases take place:

 psychiatry was increased in TrACT to 5+ hours per week  one full time employment specialist  one licensed personal service coordinator - .5 fte or 20 hrs per week shared with FACT  one personal service coordinator - .25 fte or 10 hrs per week shared with FACT

FACT continues to make a concerted effort to find qualified candidates for the open position. In the meantime, a clinical consultant housing consultant has continued to support the program until the housing position is filled.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 25

Housing The biggest housing challenges were the housing market and an almost 0% vacancy rate and the significant number of partners with existing housing that for various reasons needed to be relocated. The housing market, especially for studios and 1 bedrooms became an issue during this reporting period for the first time in the history of our programs. The agency hired an independent housing consultant with the sole purpose of finding new property owners with units available that we could offer to our partners. The need for units has never been greater as the list of individuals ready to move into permanent subsidized housing continued to grow throughout the reporting period.

The unexpected relocation of partners (program graduates) became an immediate necessity when we had to terminate our relationship with one of our property owners. We reached a point where we could no longer trust that he had the best interest of his tenants-our former partners-in mind. After several phone calls, emails and meetings we decided it best for all parties involved that we terminate our relationship and relocate the partners in his units. Finding new housing and moving these individuals became our priority and so began the process of wait listing partners who were ready to move.

The number of partners housed utilizing our Shelter + Care permanent housing subsidies began to drop along with our partners utilizing units subsidized by HACA. All of this because we were dedicating our time and effort in relocating partners as opposed to housing new partners. As of the close of this reporting period, only a few partners still were in need of relocation and we were able to begin housing our partners who had not previously been housed. The only obstacle now is the lack of units available for rental in this poor rental market.

Partner Narrative This is the success story of David, a 59-year-old, African-American, Male, who has been diagnosed with schizophrenia and alcohol dependence. He was chronically homeless and preferred being on the street as opposed to living in any type of group living situation, detox or residential treatment. David to date has 90 episodes of treatment in Alameda County that includes, CJMH-Santa Rita, John George (EPS), Schuman Liles, FACT/TrACT programs, HAC and Tele-care Garfield (SNF) services, dating back to 1989.

Since 2009, David has been enrolled as member of the FACT program. Outreach and engagement with David was primarily while he was in custody or in psychiatric emergency services. During these interactions David consistently presented with disorganized thought patterns and auditory hallucinations. Countless efforts were made to transition David from the living on the streets to living in an apartment setting. David would engage with team members for brief periods of time limiting the opportunity for them to address his most basic and immediate needs. When David was encountered he would perceive that he had only been gone for a few days when in reality, David had disengaged from services and been on the run for weeks.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 26 Over time David’s comfort level with staff increased as the therapeutic alliance grew stronger and he learned he could count on the team for support. He agreed after many months in the program to move into our transitional housing. He had extreme difficulty in holding on to the key to his unit so we suggested he wear the door key around his neck. He eventually grew accustom to wearing it and did not lose his key again.

When staff located him in the community David would request for the program staff to “Take him home”. During this time David would not take meds with any kind of consistency and his mental health symptomatology continued and he continued responding to internal stimuli. He remained non-adherent to prescribed medication and was severely preoccupied with internal stimuli. David was often observed striking the sides of his head, in rapid forceful motions, rambling illogically and at times screaming in response to his auditory hallucinations.

In May of 2012, David was displaced, when the FACT/TrACT programs relocated and no- longer offered in-house living units on site. David was reassigned to transitional housing in the community. David became more symptomatic, his level of social function deteriorated and a need for a higher level of care became apparent. David’s symptomatic cycling, recidivism and mounting law violations of aggressive panhandling, petty theft and indecent exposure charges gave merit to taking his case to bed control. In spite of his ongoing and episodic trips to PES, In-patient and jail, David maintained a bond with the program and would insist that program staff aid in his early release from custody, give him a “Chicken Ticket” and to take him home to his apartment at the FACT program on San Pablo.

David remained engaged and continued to need support in all domains. David’s practical needs such as obtaining his Birth Certificate, DMV picture ID and Social Security Card required strategic team planning and rewarding David with his one of his favorite meal selections This proved to be a key motivator in keeping him engaged in the steps towards achieving any goal on his behalf, especially establishing his social security benefits. His benefits were turned off without being reinstated for over two years.

Achieving these benchmarks/goals (considering he was on the streets for years and did not have any of these basic benefits) opened gateways for David to gain access to needed community resources.

David’s last acute psychiatric episode of 3/7/2013 occurred when the staff went to pick him up from Santa Rita Jail as he was being released from custody. David’s manic behavior required that he be taken to emergency psychiatric services at John George Psychiatric Pavilion to be evaluated for a possible 5150. David’s psychological evaluation sanctioned an involuntary hold and placement on the unit of John George’s Inpatient Psychiatric Hospital. We were able to get David conserved, reinstate his medi-cal and have him transferred to the Garfield Neurobehavioral Center (Skilled Nursing Facility) where he received rehabilitation treatment from 4/23/2013 to 2/24/2104. The partner achieved sobriety, he began taking his meds as prescribed with support, regained his memory, cleaned up and presented as a new man upon his transition back to

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 27 the community. He reunited with his father during the end of his time at Garfield and has been visiting him regularly since that time.

Today, over 2 years later and through dedication of the FACT staff and David’s hard work, he is sober, stable on his meds, and living in the community. It has been over 3 years since he has been arrested or in need of a higher level of psychiatric care. His last episode in PES was 4/29/2013 and his last incarceration was 3/7/2013. David is a member of a Full Service Partnership that goes beyond standard outreach and practical treatment modalities, in order to encourage and support a better quality of life. “Whatever it takes approach” is not just a phrase but the foundation of integrated treatment that has David on a path to a successful recovery.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 28

TRANSITIONAL ASSERTIVE COMMUNITY TREATMENT

Annual Monitoring Report

July 01, 2015 – June 30, 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 29

TABLE of CONTENTS

I. Alameda County Behavioral Health Court (BHC)

Court Overview 3

II. Transitional Assertive Community Treatment (TrACT)

Program Overview 6

III. TrACT Program Descriptive Statistics

Newly Enrolled Partners FY 15/16 8

All Active Partners FY 15/16 9

IV. Reduction in Recidivism 8/1/2009-6/30/2016

Graphs for 8/1/2009-6/30/2016 15

V. TrACT Measures Compendium

A. Methods 19

B. Summary of Response- Paired Administration (2 interviews) 21

C. Summary of Response- Paired Administration (3 interviews) 25

VI. PROGRAM SUPPORT SERVICES 30

VII. PARTNER NARRATIVE 35

VIII. TrACT MASTER TRACKING LOG 38

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 30

I. Alameda County Behavioral Health Court

Court Overview

A 2006 study by the Bureau of Justice Statistics found that over half of all jail and prison inmates have mental health issues; an estimated 1.25 million suffered from mental illness, over four times the number in 1998. Research shows that people with mental illness are overrepresented in the criminal justice system by rates of two to four times the normal population. The severity of these illnesses vary, but advocates say that one factor remains steady: with proper treatment, many of these incarcerations could have been avoided. “Most people [with mental illness] by far are incarcerated because of very minor crimes that are preventable,” says Bob Bernstein, the Executive Director of the Bazelon Center for Mental Health Law. “People are homeless for reasons that should not occur, and they do not have basic treatment for reasons that should not occur and they get into trouble because of crimes of survival.”

To address this trend, many court systems have utilized the established “problem solving court” model to develop dedicated mental/behavioral health courts. These courts recognize that jails and prisons are poorly suited to rehabilitate these individuals (also referred to as inmates, defendants, offenders, referred individuals, participants, or partners; these terms are used interchangeably throughout this report) and meet their special needs. These courts specialize in dispositions to divert defendants to community care rather than further incarceration when the pending charges or criminal histories meet the mental health court criteria.

In August of 2009, after years of research, planning, community involvement and support, the Behavioral Health Court (BHC) began with the first participants appearing before the judge in Department 104 of the Wiley Manuel Courthouse. The BHC is a problem- solving court that operates under the criminal division of the California Superior Court, Alameda County. The mission of the BHC is to promote public safety and support the wellness and recovery of mentally ill offenders by diverting these individuals away from the criminal justice system and into community based rehabilitation and treatment services.

The BHC is a collaborative that brings county legal, criminal justice and behavioral health service providers together to form the BHC Panel. This panel, which presides over and facilitates the BHC, is comprised of representatives from the Criminal Justice Mental Health Team, the Public Defender’s office, the District attorney’s office, the Transitional Assertive Community Treatment Team (TrACT) team, the Probation department, and the Judge, representing the California Superior Court of the County of Alameda.

The primary criteria for acceptance to participate in this court-supervised program is for individuals who have been arrested in Alameda County and are either in custody or in the community, awaiting their court appearance. The arrested individuals/court defendants must have a diagnosis or mental

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 31 health condition that is severe in degree and persistent in duration. The condition also has to have been a determining factor in the commission of their crime.

The BHC is voluntary in nature, thus the defendant chooses to participate in the court program in lieu of having their case proceed in the regular court process. Upon completion of the BHC program, defendant’s charge or charges, as related to their particular offence, may be reduced from a felony to a misdemeanor or could potentially be dismissed from the participants’ criminal record.

Over the past few years the court panel has intentionally begun to increase the type and number of felony cases it will consider eligible for inclusion in the court program. This is important as the extensive research and statistics of mental/behavioral health courts across the country demonstrate the fact that participants with felony charges are highly motivated to participate and complete the court program because the court program is a better alternative to an extended time spent in custody for felony cases as compared to a misdemeanor case(s). The BHC statistics, illustrated in graph 1 below, are a comparison of the BHC’s participants percentage of misdemeanor and felony charges. This graph for this reporting period shows a slight increase in felony charges as compared to FY 14/15.

Type of Charges for Active Partners 7/1/2015 - 6/30/2016 (N=49)

MISDEMEANOR 29

FELONY 20 Type of Type Charge of

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32

Number of Partners

Graph 1: Type of charge for partners active between 7/1/15 and 6/30/16 (N=49). This graph shows that 59% of TrACT partners (N=29) were charged with misdemeanor charges, down 5% from FY 14/15 numbers. They faced shorter sentences than the 41% of partners with felony charges (N=20). Felony charges were up 5% compared to last year.

Probation violations in regular, non-problem solving courts require the judge hearing the case to issue a bench warrant for the arrest and detention of the defendant in the case. Some of the most common probation violations that qualify individuals for BHC include such offenses as failure to appear for a probation appointment, failure to appear for mandated court appointments, failure to appear for or complete a mandated treatment program or failure to comply with court restraining or stay away order(s).

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 32 Qualifying crimes and charges like probation violations, misdemeanor and felony wobbler offenses will all be considered for BHC. Subject to DA discretion, the following categories of crimes will be ineligible: Serious or violent felonies [PC 1192.7(c), 1192.8, 667.5(c)] Domestic Violence cases Crimes involving guns, whether used or not DUI offenses Sexual assaults

The BHC has established itself as a legitimate problem solving court. As the BHC’s positive reputation as an alternative to sentencing defendants to jail has grown over the years, it now include referrals from the Oakland, Hayward and Fremont courthouses of Alameda County. This is good news for the program because the first five years of the BHC, most referrals came internally through the BHC panel members and employees of Behavioral Health Care Services and work for the Court Advocacy Project (CAP). Their familiarity with and experience in the court setting helped to initially bring referrals into the fledgling program. They had easier access to potential participants and other referral sources in the court. Now, as the attorneys and judges of the Superior Court are more informed of the court’s eligibility and referral process, they have become active in referring clients/defendants to participate in the BHC. At present, the referral source for participants is primarily through the Alameda County’s public defender’s office. The BHC’s defense attorney has become responsible for coordinating colleagues’ referrals and presenting them to the BHC panel for review. The employees of CAP still play a vital role in the coordination of referrals for the court, however, they are no longer the sole source. In more rare instances, the judges representing the California Superior Court may request that certain cases be referred to the BHC.

A referred individual is initially provided with an overview of the BHC (including court expectations) by their defense attorney. The individual, after deciding they are interested in the court program, is referred to CAP clinicians for initial screening for mental health eligibility. This screening occurs either in jail or most often in court, when the referred individual/defendant/inmate is in “court holding” awaiting their court appearance.

Once an interested individual is deemed BHC eligible by the court assessor and attorneys, the TrACT services team member will meet with the potential participant for introductions and a brief overview of the TrACT program description/ including program benefits and expectations. This is followed by a brief psychosocial needs assessment and interview to inform the TrACT team of the individual’s immediate basic needs upon release from jail, including a housing or residential substance abuse treatment program. The interview determines whether the BHC eligible defendant is appropriate for services from the perspective of the TrACT program.

The Panel members then present their findings and recommendations to the probation representative and judge for final approval, which requires a unanimous vote by the panel to invite an individual to participate in the BHC. The individual is formally accepted into BHC during the next court session and will be asked by their defense attorney to sign the contract for participation in the BHC.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 33 II. Transitional Assertive Community Treatment (TrACT) Program Description TrACT is a 12-month transitional Assertive Community Treatment program that provides and coordinates predominantly community based rehabilitative, intensive mental health and co-occurring substance use treatment services. The need for co-occurring treatment services is evidenced by the severity of the participant’s mental health and often co-occurring substance use conditions as illustrated below in graphs 2 and 3.

TrACT Partner's Severe and Persistent Mental Health Conditions 7/1/2015 - 6/30/2016 (N=49)

SCHIZOPHRENIA 20

SCHIZOAFFECTIVE DISORDER 3

PSYCHOTIC DISORDER D/O NOS 9

MAJOR DEPRESSIVE DISORDER 5

BI-POLAR DISORDER 12 Mental Health Condition

0 5 10 15 20 25 Number of Partners

Graph 2: Primary Axis I Diagnoses/ Mental Health Conditions for TrACT Partners active between 7/1/2015 – 6/30/2016 (N=49). The majority of the participant’s primary diagnosis was either Schizophrenia (N=20) or Bi-Polar disorder (N=12). Together, these represent 65% of all active participants in the BHC TrACT program during this reporting period. Psychotic disorder (N=9) was the next most represented mental health condition/ diagnosis at 18%.

Mental health conditions that meet the criteria for participation in the BHC and TrACT include most Axis I DSM IV Diagnoses. The most common severe and persistent mental health conditions are Schizophrenia, Schizoaffective, Bipolar I, Major Depression with Psychotic Features and Post Traumatic Stress Disorder (PTSD). All of these mental health conditions have severe symptoms reported by the partners and observed by staff. These symptoms include but are not limited to the following: anxiety, depression, mania, paranoia, disorganized & delusional thinking and auditory & visual hallucinations. The experience of trauma is also associated with these mental health symptoms,_and causes debilitating distress.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 34 Substance Use Diagnoses for TrACT Partners Active During FY 15/16 (N=49)

POLYSUBSTANCE ABUSE/DEPENDENCE 23 DEFERRED / NO DIAGNOSIS 9 OPIOD ABUSE/DEPENDENCE 1 CANNABIS ABUSE/DEPENDENCE 3 METHAMPHETAMINE ABUSE/DEPENDENCE 5 ALCOHOL ABUSE/DEPENDENCE 8

0 5 10 15 20 25 Number of Partners

Graph 3: Substance abuse diagnosis for TrACT Partners active between 7/1/2015 – 6/30/2016 (N=49). The most common partner substance abuse diagnosis is Polysubstance Abuse/Dependence (N=23 or 47%) indicating that they had dependence or abuse issues with multiple substances that most often included a combination of alcohol, methamphetamine and cannabis. There were 18% (N=9/49) of partners that did not have a substance abuse diagnosis as compared to FY 14/15 where 13% (N=6/45) of the active partners did not have a substance abuse or dependence diagnosis.

Upon a participant’s enrollment, a TrACT team member assesses and develops an individual services and support plan (ISSP) with each partner to identify their hopes, dreams, and needs. This support plan enables the team to coordinate services and supports to assist the partner in achieving their goals. TrACT is a transitional (12 -months) assertive community treatment, multi-disciplinary team that consists of the following full and part-time team members providing services to the participants of the BHC: clinical and program supervisor, staff psychiatrist, nursing, personal service coordinator/case manager, peer specialist, housing specialist, employment and education specialist. The services provided include the following: case management, crisis prevention and intervention, general medical, mental health, substance abuse, medication support, peer support, and Wellness Recovery Action Planning (WRAP).

Primary program resources that become immediately available to BHC TrACT participants, through MHSA Prop 63 and Medi-Cal funding, include housing (independent living), continuing education, and competitive employment opportunities. These vital resources come with intensive support services and are provided in the context of the social rehabilitation model. This provides guidance for team members to teach and the partners to learn or re-learn the skills of living successfully in their community of choice. Partners receive housing and housing support, employment and employment support and/or education and education support services. In addition, activities of daily living include basic skills for self-care/personal hygiene, socialization, cooking, cleaning, shopping, housekeeping, and money management, that assist the individual in developing the skills to increase their independence and their belief and confidence in self. Ultimately, this program encourages a process of continued growth and opportunity.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 35 For example, as an individual reduces their mental health symptoms (through medication support services) and increases their living skills, they are in turn able to function better in the community.

Partners can take advantage of the services and resources of the TrACT program as they move from a more restrictive group living setting—board and cares, transitional housing, residential treatment—to the least restrictive setting of independent living and their own apartment.

It is within the context of these services and judicial supervision that partners are able to practice personal accountability, health, and wellness in all areas of their lives. It has been our experience over the years that active participation in a range of community-based services greatly assist individuals who struggle with the symptoms of their mental health conditions to achieve stability, wellness and recovery. This in turn helps to reduce and/or eliminate individuals’ use of psychiatric emergency, inpatient, and jail services.

TrACT provides weekly progress reports on enrolled participants to the BHC panel, informing them of each partner’s progress or challenges toward completing goals from their individual service plan. Based on input from the BHC panel, the partner may receive praise/rewards or consequences/sanctions from the court, based on their behavior and performance. Upon achieving the goals set in the service plan and meeting the conditions of their plea agreement, a BHC participant can graduate from the program with a reduction or dismissal of their charges.

III. TrACT Program Descriptive Statistics A. Newly Enrolled Partners FY 15/16 The following graph is based on the enrollment of 33 participants during the fiscal year ending June 30, 2016. This data is derived from ACBHCS PSP/INSYST reports during the aforementioned timeframe collected and compiled with analyses by the EBCRP TrACT team and research department.

NEW TRACT ENROLLMENTS BY MONTH 7/1/15-6/30/16 (N=33)

JUN - 16

MAY - 16

APR - 16

MAR - 16

FEB- 16

JAN - 16

DEC - 15

NOV - 15

OCT - 15

SEP - 15

AUG - 15

JUL - 15 0 1 2 3 4 5 Number of New Active Partners

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 36

Graph 4: Number of new TrACT Enrollments each month between 7/1/2015 and 6/30/2016. This graph shows that there were 33 new enrollments this reporting period. The number of new enrollments fluctuated during FY 15/16 with a range from 0 to 5. The largest number of partners enrolled in March and May 2016 (5) and the fewest new partners were enrolled in December 2015 (0), as well as July 2015 (1) . The average number of partners enrolled each month was 2.25. Note- enrollment of new partners/ participants in the BHC has to be a unanimous vote by all members of the BHC panel.

B. All Active Partners for FY 15/16 In serving 49 partners during this 12 month reporting period the TrACT team has demonstrated the continued capacity to increase the number of partners served in a 12 month period; up from 45 served in FY 14/15, 43 in FY 13/14 and 40 partners that were served in FY 12/13.

Partner Activity for FY 15/16 Partners Enrolled and Active as of July 1, 2015 16 Enrollments for FY 15/16 33 Total Active Partners FY 15/16 49

Partner Disposition Summary for the Reporting Period

Open and Active at the end of the reporting period 21

Successfully transferred to a lower level of care 8

Transferred to FACT 3

Did Not Complete including Partners enrolled and

d/c in the same year (9) 17

Total Dispositions FY 15/16 49

Active Partners by Month 7/1/15 to 6/30/16 (N=49)

Jun-16 May-16 Apr-16 Mar-16 Feb-16 Jan-16 Dec-15

MONTH Nov-15 Oct-15 Sep-15 Aug-15 Jul-15

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 NUMBER OF ACTIVE PARTNERS

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 37 Graph 5: Number of Active Partners Each Month between 7/1/2015 and 6/30/2016. The total number of partners served during FY 14/15 was 49. This includes the 16 partners continuing the program from the previous reporting period that were active as of July 1, 2015 and the 33 partners that were enrolled throughout FY 14/15. The number of active partners fluctuated during this reporting period with a range from 7 to 25. The average number of partners served each month was 17.6. Due to an influx of enrollments in March through June, TrACT ended this fiscal year with 49 active clients. This graph illustrates the fact that the TrACT census of 20 was met in the months of September and October of 2015, and May and June of 2016.

Status of Active Partners as of 6/30/2016 (N=49)

Graph 6: Status of active partners as of 6/30/2016 (N=49). This graph/chart shows the enrollment/discharge status of the 49 partners who were active at least 1 day during this reporting period of July 1,2015 to June 30, 2016. 43% of partners were open and actively enrolled in the program as of the year’s end. 22% of partners graduated from the court and the TrACT program and transitioned to the community (see graph 7 below for details of where these partners were transferred for services). 35% of partners “did not complete” the program and were discharged at some point in the reporting period.

Active Partner Transitions 7/1/2015 - 6/30/2016 (N=11)

27%

45% Transition to FACT Transition to Meds-Only Clinic Transition to Service Team 18%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 38 Graph 7: Active Partner transitions: These are the BHC TrACT Graduates who were active partner transitions for the reporting period of FY 15/16.

There were eight participants that completed BHC and graduated who were transitioned to a lower level of care. There were two graduation celebrations held in court over the course of this reporting period. The first was held on July 21, 2015 and the second was celebrated on June 16, 2016. Celebrating graduation in the court setting is quite a unique experience as family members, friends of the participants, community providers are all in attendance to show their support and appreciation for the partners’ hard work and success. There is food, drinks (non-alcoholic) and on occasion music. In the past there was a graduate who brought his turntable to court and played music for the socializing part of the graduation. There are not many people who can say that they have had this type of experience in a court of law.

The members of the BHC panel continue their efforts in creating a personalized graduation experience by saying a few words about each graduate, acknowledging each individual’s challenges and successes, and thanking them for their hard work in completing the program. The actual graduation consists of the presiding Judge, Prosecuting Attorney, and Defense Attorney all officially stating for the record and the graduation attendees, their name, their role in the court, each graduate’s name, and they announce that each individual successfully completed the Behavioral Health Court program.

They state, for the record, that the partner’s charges are either being dismissed or reduced from a felony to a misdemeanor from their criminal record. Furthermore, they announce that the individuals had completed the terms of their probation. The conclusion of the graduation was an opportunity to hear from the graduates as they are encouraged to talk about their experience with the BHC and offer any words of encouragement to the other court participants in attendance.

Age Range of Active Partners 7/1/2015 to 6/30/2016 (N=49)

55+ 2

45-54 5

35-44 10

Age Age Range 26-34 20

18-25 12

0 5 10 15 20 25 Number of Partners

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 39 Graph 8: Age range of partners active between 7/1/15 and 6/30/16 (N=49). The largest proportion of active partners (41%) fell into the 26-34 age range while a fifth (21%) fell into the 35-44 range. The latter is a shift compared to last year’s larger portion of clients in the 45-54 range. Worth noting is the 24% of youth (TAY) in the 18-25 category. Typically this age group is served by the TAY System of Care

GENDER OF ACTIVE PARTNERS 7/1/2015 TO 6/30/2016 (N=49)

Female 10 Gender

Male 39

0 5 10 15 20 25 30 35 40 45 Number of Partners

Graph 9: Gender of partners active between 7/1/15 and 6/30/16 (N=49). Consistent with last year, the TrACT program served a majority of male partners (80%, or N=39). This graph shows that female partners made up 20% ( N=10) of the total, which is also consistent with last year’s distribution (20%) of female clients.

Race/Ethnicity of Active Partners 7/1/2015 to 6/30/2016 (N=49)

14%

African American/Black

12% Caucasian/White

49 Asian/Pacific Islander Asian 2% Hispanic/Latino

22%

Graph 10: Race/Ethnicity of partners active between 7/1/15 and 6/30/16 (N=49). African Americans still make up the largest racial/ethnic group represented in the

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 40 program (49%), though this is a decrease from last year (64%). This graph shows an increase in the proportion of partners identifying as Hispanic/Latino (12%), compared to last year (2%). It also shows an increase in partners identifying as either Asian or Asian/Pacific Islander-- a total of 14% as compared to last year’s proportions (which included 4% of partners identifying as Asian/Pacific Islanders).

Housing for Active Partners 7/1/2015 - 6/30/2016 (N=49)

12 Independent Living 3 14 Transitional Housing 0 11 Living W/ Family 7 9 Treatment Facility 0 1 Jail 35 Homeless 2 RESIDENTIAL STATUS 4 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 NUMBER OF PARTNERS

Current/ DC Enrollment/ Admission

Graph 11: Housing at the time of entry and discharge, or as of 6/30/2016 (N=49). Partners’ housing was recorded at intake and compared to either their current place of housing or last known residence upon discharge/ graduation. While many partners entered the program while they were still in jail (N=35, or 71%), a significant portion of partners (N=26, or 53%) were living in either transitional housing or independent living situations upon exiting the TrACT program.

Income of TrACT Partners Active During FY15/16 at Intake, 6 Months, and 12 Months (N=49)

36 701+ 8 10 5 401-700 2 0 3 1-400 1 1 3 0 3

Income Range Income 38 2 n/a 35 0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 Number of Partners

At Exit or as of 6/30/16 6 months Entry

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 41 Graph 12: Income of TrACT Partners Active During FY 15/16 at program entry, 6 Months, and at exit or as of 6/30/16(N=49). The largest proportion (78%) of partners had $0 income at entry intake (N=38), while a combined total of 41 (84%) partners had an income of $400 or higher at 12 months. The n/a represents the 2 partners or 4% of partners that were discharged prior to 3 months in the program and the 35 partners or 71% that had were still enrolled in the program at the end of the reporting period yet had not reached 6 months of enrollment. The “0” in the income range represents the 6% (N= 3) of the partners that were either undocumented and ineligible for benefits and or undocumented and or had SSI benefits pending at 12 months.

In the graph above, $0 represents partners who either had no benefits—SSI income—upon intake/admission or partners who had their income benefits discontinued during their incarceration and needed to be reinstated. The $101-$400 range represents folks on General Assistance. $401 to $700 range represents partners who are receiving General Assistance, which includes a housing subsidy (average is $634). $701 + range represents partners )with SSI, SSDI, or both. The partners who were still not receiving full benefits at 12 months (13 or 27%) had open cases with HAC that have yet to be approved. The SSI application and hearing process have become quite complicated and time consuming. This trend has unfortunately only continued this year. New applications for benefits, on average, can take 6-12 months or longer, even with support and advocacy from the Homeless Action Center.

The program director has planned a meeting with Bay Area Legal Aide to begin working with them in addition to HAC. The number of partners without benefits is slowing rising and we need more resources to support the partners in overcoming their challenging disability cases and in a more timely manner.

Insurance Status on Enrollment and Program Discharge, 12 months or as of 6/30/2016. TrACT Partners Active During FY 15/16 (N=49)

40 No Insurance 3

1 Medicare/Medi-Cal 2 INSURANCE

8 Medi-Cal 44

0 5 10 15 20 25 30 35 40 45 50 NUMBER OF PARTNERS

Entry At Exit or as of 6/30/16

Graph 13: Insurance status on Enrollment and Program Discharge, 12 months, or as of 6/30/2016 for TrACT Partners active during FY 15/16( N=49). On enrollment 82% (N=40)

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 42 did not have medical insurance. However, the next assessment shows that 90% of partners (N=44) were enrolled in insurance (predominantly Medi-Cal). Of the 6% (or 3) partners with no insurance, two of these are on the path to American citizenship and benefits, while the third was discharged early from the program.

IV. Descriptive Statistics- TrACT Partner Reduction in Recidivism The expectation of the TrACT program and the BHC per the county contract exhibit A is to reduce partner use of and recidivism to psychiatric hospitalization and emergency services by 50% and partner involvement with and recidivism to the criminal justice system by 60%. Graph 14 on page 16 below clearly illustrates the programs 58% actual reduction in partner episodes of psychiatric hospitalization and graph 15 page 16 below illustrates a 17% reduction in days of partner days of hospitalization. Graph 16 on page 17 below demonstrates the 62% reduction in partner episodes of utilizing psychiatric emergency services. Graph 17 page 18 below indicates a 67% reduction in partner episodes of incarceration and graph 18 page 18 reveals an 83% reduction of partner days of incarceration.

The data for measuring outcomes is collected from the BHCS approved data collection and claiming system, Insyst. The data is based on a review of county- wide service utilization by the 50 partners who have graduated the program or were active in the program a minimum of 12 months during the time period of 8/1/2009 to 6/30/2016. There is considered to be a reduction in utilization of services when the total number of episodes and days of hospitalization, episodes of psychiatric emergency visits and episodes and days of incarceration from the partners’ 12 months post enrollment is less when comparing the same partners and the same categories—episodes and days of psychiatric hospitalization, emergency , and incarcerations to the 12 months prior to enrollment—being measured. The data is presented in a cumulative format that includes partners enrolled in the program beginning in August 2009 to the end of the current monitoring period of June 30, 2016. The time frame being measured, 12 months prior to and 12 months post enrollment, limits the number of TrACT participants data eligible (~7) for inclusion in the annual outcome measurement data. This FY 15/16, TrACT and BHC have completed year 7 of the court program. This creates the cumulative data set we analyze that now includes 50 (N) participants or an average of 7 participants annually that meet the criteria—individuals who have completed at least 12 months post enrollment—so that the comparison of both sets of data have the exact time frame (12 months) when looking at partners’ utilization of services 12 months prior to and 12 months post enrollment into the program. The criminal justice system data is solely sourced from the criminal justice mental health staffs recording of partner episodes and days of incarceration in Alameda County’s Santa Rita Jail using Clinicians Gateway (Insyst) database. We have yet to get access to the true data that is kept by the sheriff’s department at Santa Rita jail and therefore limited to the data we are able to capture.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 43 Hospitalization data includes partners hospitalized in John George, Villa Classic and Villa Short Stay Inpatient services and partners utilization of Sausal Creek, John George(PES) and Alta Bates (ER) are included in the data presented to comprise partner’s utilization of psychiatric emergency services.

Episodes of Hospitalization: TRACT PARTNERS ENROLLED 12 MONTHS AUGUST 1, 2009 - JUNE 30, 2016 (N=50)

First 12 Months in TrACT 22

12 months Prior 52

0 10 20 30 40 50 60 Number of Hospital Admissions

Graph 14: Number of Episodes of Hospitalizations for all TrACT partners (N=50) who completed or were enrolled at least 12 months in the program between 8/01/2009 and 6/30/16. Cumulatively, the number of partner hospital episodes dropped by 58% during the first 12 months in TrACT compared to the 12 months prior to enrollment.

Days Hospitalized: TrACT Partners enrolled 12 months August 1, 2009 - June 30, 2016 (N=50)

First 12 Months in TrACT 253

12 months Prior 303

220 230 240 250 260 270 280 290 300 310 Number of Days Hospitalized

Graph 15: Number of days hospitalized for all TrACT partners (N=50) between 8/1/2009 and 6/30/16 who completed or were enrolled at least 12 months in the program. Cumulatively, the number of days hospitalized has been reduced by 17% when comparing the data 12 months post vs. 12 months prior to enrollment.

The two hospitalization graphs have continued to indicate, over the 7 years the program has been in operation, the partners enrolled in TrACT for 12 months require fewer episodes and days of

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 44 hospitalization as compared to the 12 months prior to their enrollment into the BHC and TrACT. We have consistently and on an annual basis seen the hospital reduction in days to rank in the teens to twentieth percentile. The best explanation to describe this particular set of outcomes has to do with the provision of appropriate mental health services to partners enrolled in the program as opposed to jail incarcerations. The TrACT team and BHC panel member’s advocacy for partner treatment in the community in lieu of incarceration may explain the significant reduction of jail episodes and days of incarceration for partners in the program and can also be credited to the increase in or the smaller reduction of hospital days for TrACT participants when comparing 12 months prior to 12 months post enrollment. Interestingly enough is the fact that the episodes of hospitalization continue to decrease every year at a rate of 50 to 60 percent.

PES EPISODES: TRACT PARTNERS ENROLLED 12 MONTHS AUGUST 1, 2009 - JUNE 30, 2016 (N=50)

FIRST 12 MONTHS IN TRACT 40

12 MONTHS PRIOR 105

0 20 40 60 80 100 120 Number of PES Episodes

Graph 16: Number of Psychiatric Emergency Services (PES) episodes for all TrACT partners (N=50) enrolled between 8/1/2009 and 6/30/16 who completed or were enrolled at least 12 months in the program. The number of PES episodes dropped by 62% during the first 12 months in TrACT compared to the 12 months prior to enrollment.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 45 EPISODES OF INCARCERATIONS: TRACT PARTNERS ENROLLED 12 MONTHS AUGUST 1, 2009 - JUNE 30, 2016 (N=50)

FIRST 12 MONTHS IN TRACT 27

12 MONTHS PRIOR 81

0 10 20 30 40 50 60 70 80 90 Number of Incarcerations

Graph 17: Number of episodes of incarcerations for TrACT partners between 8/1/2009 and 6/30/2016 who completed or were enrolled at least 12 months in the program (N=50). The number of incarcerations dropped by 67% during the first 12 months in TrACT compared to the 12 months prior to enrollment.

DAYS INCARCERATED: TRACT PARTNERS ACTIVE 12 MONTHS AUGUST 2009 - JUNE 30, 2016 (N=50)

FIRST 12 MONTHS IN TRACT 376

12 MONTHS PRIOR 2238

0 500 1000 1500 2000 2500 Number of Days Incarcerated

Graph 18: Number of days of incarcerated for all TrACT partners (N=50) between 8/1/2009 and 6/30/16 who completed at least 12 months in the program. Cumulatively, the number of days incarcerated was reduced by 83% during the first 12 months in TrACT compared to the 12 months prior to enrollment.

The decrease in episodes of incarceration and number of days incarcerated is illustrated in graphs 17 and 18 above. While compelling, the finding is expected, since the TrACT program works with the BHC to divert clients into the program in lieu of incarceration. However, this should not diminish the substantial decrease in the number of days incarcerated (83%).

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 46

Overall it is clear that while participating in the BHC and receiving TrACT services, partners require fewer hospitalizations, PES, and incarceration services. Although they still require some amount of each of these services, it is clear that they are receiving more appropriate care. For example, with appropriate advocacy and interventions by the TrACT team, symptomatic partners are more likely to be hospitalized and treated than arrested and incarcerated.

V. TrACT Measures Compendium A. Methods

The TrACT Measures Compendium is a collection of existing instruments that were chosen to measure partner perceptions in several dimensions of their quality of life, functioning, and progress towards recovery. The Compendium consists of the following instruments:

1) Recovery Markers – a set of 27 questions focusing on various aspects of recovery in a Partner’s life. The questions are closed-ended and scaled with a 4-point Likert scale (Strongly agree, Agree, Disagree, or Strongly disagree)

2) Questions from the California Quality of Life Scale (CA-QOL) which measures how the Partner perceives his/her life is going in the areas of living situation, spending spare time, contact and relationships with family and friends, social activities, finances, victimization and safety, and health. Responses are scored with various Likert Scales (the majority of questions use 7-point scales). 3) Drug and alcohol problem markers – a set of seven Yes/No questions asking about potential markers for problematic drug and alcohol use.

4) Perceived Progress – adapted from the Mental Health Statistics Improvement Program (MHSIP) which asks Partners 12 questions to rate their agreement with statements about how much progress they are making in various areas of recovery and treatment. The responses are scored with a 6-point Likert Scale (Strongly agree, Agree, Neutral, Disagree, Strongly disagree, or Not applicable

The Measures Compendium is administered by members of the FACT/TrACT team or the EBCRP research assistant to the TrACT BHC participants three times. The 1st interview is done upon enrollment in the BHC and TrACT, and the 2nd is one year later. A final 3rd wave is administered one year after the completion of /transition from TrACT and the BHC. In the earlier days of the program this was usually 24 months from enrollment, however, with participants graduating BHC sooner this is not an absolute anymore. Last year, for instance, there was a client who graduated the program in just 5 months. His second survey was administered at six months, and he was given the third (and final) survey 12 months after that. That being said, TrACT makes every effort to stay in touch with partners and administer surveys in 12 month intervals to maintain consistency of information over time. One of the primary goals of the compendium is to measure a participant’s perceptions on their living in the

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 47 community and their ability to function independently of the TrACT FSP level of service intensity for the 12 months following the completion of BHC and the TrACT program.

The following miscellaneous information is in reference to this reporting periods collection and analysis of the measures compendium.

This report will focus on the results from the cumulative 44 Partners for whom we have outcomes from the initial administration (Time 1) to the one-year follow up (Time 2). A report will also be given on outcomes for those 23 Partners interviewed over three survey waves (Times 1, 2, and 3).

Administration Time 1 was collected within 30 days of baseline for 80 % of clients who entered the program during this reporting period. This is an improvement from last year’s rate of 70%, and reflects TrACT’s efforts to continuously streamline the interview collection process. A total of 25 new baseline interviews were successfully conducted during this period.

It is also important to mention that some of the partners included in the paired analyses completed baseline intakes in previous reporting periods. Some of these interviews were conducted as long as 18 to 20 months after the partners’ initial entrance into TrACT. Because of this, some of the scores may be inflated, as some partners have already received as much as 20 months of services from TrACT.

The protocols put into place for collecting these interviews have improved the process substantially. During this reporting period the overall average time between program intake and Admission Time 1 was 24.64 days (median = 13) and the time between Admission Time 1 and Admission Time 2 was 384 days (median = 367).

For interviews completed during this reporting period, Admission Time 1 interviews were administered much closer to program intake (quite a few at the same time). Overall, these interviews represent a truer baseline.

Admission Time 2 interviews continued to be administered much closer to 12 months, so the interval between the interviews continued to be more consistent.

For the post-discharge 3rd survey wave, a total of 5 new partners completed the third survey, which brings TrACT’s cumulative total to 23. Some partners returned incomplete surveys so not every question was answered by all 23 partners. Delays in completing the 3rd wave surveys continued to be a problem—one partner was interviewed two months after the 3rd wave deadline, while another was interviewed one month after. However, this is a marked improvement from last year, where some clients were interviewed four and five months after their deadline.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 48 Unfortunately, some partners who were due for surveys were not able to complete their 3rd interviews. The main reason for this was client non-responsiveness, despite staff’s repeated attempts to contact Partners and arrange interviews. Even with this year’s overall improvement, this points to the ongoing need to further streamline the communication process between clients and the evaluation team, so that referrals and interviews can be coordinated more easily. The goal is to keep working on this process in upcoming reporting periods.

Since sections of items differ on the number of scale responses, in the analysis of data we aggregated and averaged responses in a 4-point scale throughout (i.e. a seven-point scale was reduced to 4 points, retaining the original meaning of the Likert scale labels). Notes about the specific cutoff points are given below each graph.

B. Measures Compendium-Summary of Response Paired Administration -Partners with 2 completed interviews (N=44)

HOUSING The measure for housing outcomes was from questions on the CA-QOL related to living status and perceptions about safety in the home. Results for each Partner were summed and averaged_for_a_“housing”_index. Measures Compendium Average Scores Housing- 2 Interviews (N=44)

Administration Time 2 2.77

Administration Time 1 2.72

2.68 2.69 2.70 2.71 2.72 2.73 2.74 2.75 2.76 2.77 2.78

Graph 19: Average Scores for the Housing Section of the Measures Compendium from Administration Time 1 and Time 2 paired interviews (N=44). Average Score has been calculated so that 1 – 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 2 = 0.05 . % of respondents with higher scores at Time 2 than at Time 1 (improvement) = 65%

A large majority of partners (65%) reported improvement in the Housing measures indicating that they are more satisfied with their living arrangements after 1 year in the program. There was an average increase of 0.05 in the scores overall. This reflects the strength of TrACT housing assistance; most partners are much more satisfied with their housing at 1 year in the program than when they are when

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 49 first admitted. Because of the efficient nature of the TrACT housing support, most partners have already received housing support from TrACT prior to completing the measures compendium at Time 1. For this reason, the slight increase we see at Time 2 indicates that partners’ changing housing needs are continuing to be addressed after their initial housing placement.

Perceived Progress results were averaged from the 12-question Perceived Progress Scale. Measures Compendium Average Scores Perceived Progress- 2 Interviews (N=44)

Administration Time 2 2.77

Administration Time 1 2.58

2.45 2.50 2.55 2.60 2.65 2.70 2.75 2.80

Graph 20: Average Scores for the Perceived Progress Section of the Measures Compendium from Administration Time 1 and Time 2 paired interviews (N=44). Average Score has been calculated so that 1 – 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 2 = 0.19

. % of respondents with higher scores at Time 2 than at Time 1 (improvement) = 76%

The increase in scores from Time 1 to Time 2 show that a majority (76%) of partners answered more positively to questions like “I deal more effectively with daily problems,” “I am able to control my life, “and “My symptoms are not bothering me”. This indicates that partners reported an increased ability to function and manage their symptom at Time 2. Increased functioning and self-sufficiency are essential in order for partners to move to a lower level of care and live independently, two of the major goals of TrACT.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 50 Drugs and Alcohol Questions taken from the Dayna Drug and Alcohol Screening Measures Compendium Average Scores Drugs and Alcohol - 2 Interviews (N=44)

Administration Time 2 3.33

Administration Time 1 2.80

2.50 2.60 2.70 2.80 2.90 3.00 3.10 3.20 3.30 3.40

Graph 21: Average Scores for the Drugs and Alcohol Section of the Measures Compendium from Administration Time 1 and Time 2 paired interviews (N=44). Average Score has been calculated so that 1 – 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 2 = 0.53

. % of respondents with higher scores at Time 2 than at Time 1 (improvement) = 78%

As this graph indicates, over three quarters (78%) of TrACT clients report a reduction in their alcohol or substance abuse. Relative to the other sections covered in the Measures Compendium, the 0.53 improvement between Times 1 and 2 is a significant change. The improved scores indicate that partners reported fewer instances of legal troubles, health issues, and times when “drinking and/or drug use caused problems with relationships, school, or work.” It indicates that partners spent less “time thinking about trying to get alcohol and/or other drugs” and similar substance abuse related issues. As such, this graph indicates that for those struggling with substance abuse issues, the TrACT program can help partners get on the road to recovery.

Quality of Life Selected items from the CA-QOL Measures Compendium Average Scores Quality of Life - 2 Interviews (N=44)

Administration Time 2 2.94

Administration Time 1 2.76

2.65 2.70 2.75 2.80 2.85 2.90 2.95 3.00

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 51 Graph 22: Average Scores for the Quality of Life Section of the Measures Compendium from Administration Time 1 and Time 2 paired interviews (N=44). Average Score has been calculated so that 1 – 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 2 = 0.18

. % of respondents with higher scores at Time 2 than at Time 1 (improvement) = 62%

Recovery This section reports on the results from the 23-question Recovery Markers Scale. Measures Compendium Average Scores Recovery - 2 Interviews (N=44)

Administration Time 2 1.98

Administration Time 1 2.08

1.92 1.94 1.96 1.98 2.00 2.02 2.04 2.06 2.08 2.10

Graph 23: Average Scores for the Recovery Section of the Measures Compendium from Administration Time 1 and Time 2 paired interviews (N=44). Average Score has been calculated so that 1 – 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 2 = -0.10

. % of respondents with higher scores at Time 2 than at Time 1 (improvement) = 48%

A little less than half of partners (48%) reported improvement in areas like “My psychiatric symptoms are under control”, “I have more good days than bad”, “I believe I can make positive changes in my life”, etc. These areas indicate positive changes in partners’ abilities to manage their illness and become more independent. These are both major goals of the TrACT program and the fact that the majority of partners showed improvement highlights the effectiveness of the program. That there is a decrease in the average scores (-0.10) indicates that a few partners had symptom relapses during the reporting period, and scored much lower at Time 2. This is not unexpected, given the significant stresses many partners are handling. However, the lowered numbers bring down the average for the group as a whole.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 52 C. Measures Compendium-Summary of Response

Paired Administration -Partners with 3 completed interviews (N=23)

Measures Compendium Average Scores - 3 Interviews (N=23) 4

3.5

3

2.5

Average ScoresAverage 2

1.5

1 Administration Time 1 Administration Time 2 Administration Time 3

Recovery Quality of Life Drug and Alcohol Perceived Progress Housing

Graph 24 Measures Compendium Average Scores from Administration Time 1, Administration Time 2, and Administration Time 3. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses.

Administration Time 3 was collected for 5 partners during this reporting period. Combined with the 18 from previous periods we were able to analyze data from all administration points for 23 partners. Administration Time 1 and Time 2 are ostensibly collected during the 12 months that the partner is receiving TrACT services. Administration Time 3 represents the partner’s status after approximately 12 months without TrACT services. These responses are intended to represent the lasting impact of the services each partner received while in TrACT.

Administration Time 3, while not always collected exactly 24 months after the partner’s enrollment, is still collected after the partner is no longer receiving TrACT series. As such, this interview can be a good indicator of the lasting impact of the program. We can expect these data to continue become more robust in the future as more interviews are collected.

It is difficult to look at the combined data from all sections on one graph, so they have been broken out by section below. For the most part, the majority of partners reported increased average scores for every section between Time 1 and Time 2, and then a smaller decrease in average scores from Time 2 and Time 3. This indicates that partners showed the most improvement in each area while they were receiving services from TrACT and these improvements did not always have the most lasting effect for every partner.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 53 The majority of partners showed improvement between Time 1 and Time 3 in each section, indicating that most partners experienced some lasting results from the TrACT program.

Measures Compendium Average Scores - 3 Interviews (N=23) 2.08 2.07 2.07

2.06

2.05 2.04 2.04

2.03 2.03 Average ScoreAverage

2.02

2.01

2 Administration Time 1 Administration Time 2 Administration Time 3

Recovery

Graph 25: Measure Compendium Average Scores- 3 Interviews (N=23). Average Scores for the Recovery portion of the Measures Compendium from Administration Time 1, Administration Time 2, and Administration Time 3 interviews. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses. . Difference between average scores at Time 1 and Time 3 = 0.04 . % of respondents with higher scores at Time 3 than at Time 1 (lasting improvement) = 50%

The increase between Time 1 and Time 2 is likely due to the support from TrACT service team especially in the psychiatry and medication management areas. Responses to “My psychiatric symptoms are under control”, “I have reasons to get out of bed in the morning”, “I am growing as a person”, etc. are, not surprisingly, much more positive when a partner is meeting with a psychiatrist periodically and regularly taking their medication.

Partners are often already prescribed medication upon admission to TrACT, but are re-assessed by the TrACT service team regularly to determine the effectiveness of their current regime. Some partners have their medications adjusted to increase effectiveness while minimizing the side effects. The team also takes into account any co-occurring conditions the partner may have to tailor the medications and mental health treatment for each partners’ individual needs. While the changes may be slight, the increase in scores between Time 2 and Time 3 is likely related to both increased medication compliance and partners continuing with their substance abuse recovery. Partners who relapse and use drugs or alcohol again after leaving TrACT are likely to also experience a recurrence of mental health symptoms as well. Partners who abstain from drugs and alcohol and take their medication as directed are more likely to experience continued success in their overall recovery. The TrACT program endeavors to aid partners in finding mastery on both these counts.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 54 Quality of Life Measures Compendium Average Scores - 3 Interviews (N=23) 2.95 2.92 2.925

2.9 2.87 2.875

2.85

2.825 2.81 Average ScoreAverage 2.8

2.775

2.75 Administration Time 1 Administration Time 2 Administration Time 3

Quality of Life

Graph 26: Average Scores for the Quality of Life portion of the Measures Compendium from Administration Time 1, Administration Time 2, and Administration Time 3 interviews. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses.

. Difference between average scores at Time 1 and Time 3 = 0.06

. % of respondents with higher scores at Time 3 than at Time 1 (lasting improvement) = 50%

The Quality of Life section asks general subjective questions like, “How do you feel about your life in general?” “How do you feel about the way things are in general between you and your family?” and “How do you feel about the amount of fun you have?” Though not trivial areas to examine, these questions are fairly ambiguous and are very easily swayed by the partner’s mood or attitude during the interview. If a partner is stressed or worried, they may report lower scores, and if a partner is relaxed and comfortable they may report higher scores.

This being said, we predict that the increase between Time 1 and Time 2 and the decrease between Time 2 and Time 3 may be related to the management of partner funds through sub-payee services. When partners are working with their service coordinators to develop and implement personal budgets and are spending their funds on required necessities, they may not need as much financial support from their families, which could improve their perception of those relationships.

Additionally when partners know they have budgeted appropriately to cover their bills and basic needs, they may feel more at ease. This is especially likely toward the end of the month, which can be a very stressful time for people reliant on a fixed income to last through the whole month.

In addition to the financial support that partners receive in TrACT, housing may play a role in the positive increase observed. The overall housing goals of TrACT are to move partners into more independent living conditions. A partner who is living with family members and relying on them for

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 55 support may be experiencing significant stress related to their family relationships and dynamics. They may report more negatively than a partner who is living independently and supporting his or herself.

Although the increase between Time 1 and Time 3 is relatively small, half of partners (50%) showed lasting improvements in their Quality of Life even after leaving TrACT. This is consistent with FY14-15 numbers. Be it a result of the lessons learned through sub-payee services, or a combination of other factors like more independent housing, it is clear that partners felt better about their lives even after they stopped receiving services from TrACT than they did before entering the program.

Drugs and Alcohol Measures Compendium Average Scores - 3 Interviews (N=23) 3.5 3.42 3.4 3.3

3.2 3.10 3.1 3 2.95

Average ScoreAverage 2.9 2.8 2.7 Administration Time 1 Administration Time 2 Administration Time 3

Drug and Alcohol

Graph 27: Average Scores for the Drug and Alcohol Progress portion of the Measures Compendium from Administration Time 1, Administration Time 2, and Administration Time 3 interviews. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses

. Difference between average scores at Time 1 and Time 3 = 0.15

. % of respondents with higher scores at Time 3 than at Time 1 (lasting improvement) = 74%

This domain had a slight increase in average scores at Time 1 and Time 3 (.15) which is up .05 from last year’s report. The percentage of respondents with higher scores at Time 1 and Time 3 increased 3% from last year.

Substance abuse is a challenging area to have continued success in, because the temptation to use is very intense for some partners. This stress becomes even more powerful once they leave the supportive environment of TrACT and are living independently in the community. The TrACT staff psychiatrist specializes in treating substance abuse and addiction. While in TrACT, the psychiatry services partners receive are centered around treatment of co-occurring disorders; both mental health and substance abuse. This kind of treatment is rare and not easy to find in psychiatry services outside of the TrACT program. This added support likely contributes to the significant improvement (an increase of .47) we observed between Time 1 and Time 2. Even though there was a dip in partners’

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 56 scores when they exit the concentrated support of the TrACT program, we can see that the average score at Time 3 was still .15 higher than at Time 1. A significant percentage of partners (74%) reported higher scores at Time 3 than Time 1.

It is becoming clearer, as a larger number of partners complete interviews at Time 3, that the co- occurring disorder support and opportunity for residential treatment that TrACT partners receive leads to a majority of partners successfully maintaining their recovery. TrACT’s integrated approach continues to have a very powerful positive effect on most clients. They show lasting improvements in their ability to manage their addictions after leaving TrACT.

Perceived Progress Measures Compendium Average Scores - 3 Interviews (N=23)

2.8 2.76 2.75

2.7 2.67

2.65

2.6

2.55 2.50

Average ScoreAverage 2.5

2.45

2.4

2.35 Administration Time 1 Administration Time 2 Administration Time 3

Perceived Progress

Graph 28: Average Scores for the Perceived Progress portion of the Measures Compendium from Administration Time 1, Administration Time 2, and Administration Time 3 interviews. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses

. Difference between average scores at Time 1 and Time 3 = 0.17 . % of respondents with higher scores at Time 3 than at Time 1 (lasting improvement) = 60%

Although the slight decrease from Time 2 to Time 3 was expected as partners may not have as consistent access to medication support and psychiatry services as they did while in TrACT, the average scores at Time 3 indicate that over half of partners (60%) are reporting lasting improvements in their perception of their own progress. On average partners continued to answer more positively to questions like “I am able to take care of my needs,” “I do things that are meaningful to me,” “I am able to handle things when they go wrong,” and “My symptoms are not bothering me” at Time 3 than they did at Time 1. This indicates that partners are making consistent progress in their functioning and self- sufficiency. These skills are essential in order for them to sustain their independence and manage their mental health conditions.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 57 HOUSING

Measures Compendium Average Scores - 3 Interviews (N=23) 2.88 2.87 2.86 2.84 2.82 2.80 2.8 2.78 2.76 2.75

Average ScoreAverage 2.74 2.72 2.7 2.68 Administration Time 1 Administration Time 2 Administration Time 3

Housing

Graph 29: Average Scores for the Housing portion of the Measures Compendium from Administration Time 1, Administration Time 2, and Administration Time 3 interviews. Average Score has been calculated so that 1 - 2.5 are negative responses and 2.5 – 4 are positive responses

. Difference between the average scores at Time 1 and Time 3 = -0.05

. % of respondents with higher scores at Time 3 than at Time 1 (lasting improvement) = 59%

Although a number of partners (14) reported improvement in the Housing measures at Time 3, there was an average decrease of - 0.05 between Time 1 and Time 3. Even with this decrease, partners responses were still positive overall at all three points. While in TrACT, (Time 2) partners responded more positively about their housing than 12 months after they stopped receiving services (Time 3). TrACT partners’ housing subsidy continues to be paid after they leave TrACT and is for the most part more stable and independent than before they entered the program, which probably accounts for the overall positive average score at Time 3 (2.75) and that 59% of partners reported increased scores between Time 1 and Time 3.

VI. PROGRAM SERVICES Legal Partners are initially attracted to the idea of participating in Behavioral Health Court (BHC) because in most cases they will be released from custody within 2 weeks of signing the court papers. Clearing their criminal records or reducing their charge or charges from a felony to a misdemeanor increases the likelihood of an individual being eligible for certain types of employment, subsidized housing and educational grant and loan opportunities. All “deals” regarding the status of charges post completion

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 58 of the program are made at the discretion of the attorneys with input from the judge and are determined on a case by case basis.

One of the most desirable benefits for partners enrolled in TrACT and BHC is the fact that it reduces the amount of time partners are spending in jail since the focus is diversion. As opposed to time in jail, partners are instead reintegrating into the community; learning and developing the much needed social rehabilitation skills required to function independently. TrACT partners facing felony charges are given the opportunity to successfully complete the program and have the courts consider reducing their charges. Every partner’s case is scrutinized on an individual basis with the end goals being diversion from the jails and providing more opportunities and access to mental health and co-occurring substance misuse treatment and stabilization in the community.

Healthcare Many partners who are enrolled in TrACT have had lengthy histories of incarcerations and many haven’t seen a primary care physician for years. Along with having severe mental health conditions, partners also suffer from common and chronic medical problems such as diabetes, hepatitis, hypertension, HIV and asthma. Physical health problems are further complicated as a result of years of chronic substance abuse. Some partners are also in dire need of dental and vision care. This past year, the nursing team supported a partner to obtain a pair of eyeglasses through resources in the community for a low cost. Sometimes the partners who are enrolled have no Medi-Cal benefits, which makes access to health care resources challenging. The TrACT staff are consistently looking out for free clinics and services offered and being creative in finding ways to support such partners.

All TrACT partners meet with the staff psychiatrist within the first week of enrollment for a thorough mental health assessment and medication evaluation. The TrACT nursing team meets with partners during their first few weeks in the program to administer a comprehensive health questionnaire (health issues from the partner perspective) and then proceed to do a nursing general physical review of a partners systems-their overall health presentation. The nursing staff will also attempt to obtain all relevant medical information from their own assessment, the health questionnaire and collateral information from previous providers in the community and hospital records. This is so partners can be linked to primary care physicians and medical appointments can be made as needed. The nursing team continues to track and support partners during this initial phase to ensure their basic medical needs are being met. Partners who suffer from chronic medical conditions such as diabetes and asthma are continually provided psycho-education about their health needs and symptoms and how to use medical devices such as the blood glucose meter and inhalers in safe and healthy ways.

TrACT medical staff also provide partners with psycho-education around medication management with the goal of eventually moving partners toward managing their own medications independently. Along with monitoring the medications, partners are encouraged to understand: the purpose of their medications, the dosage, how to recognize their symptoms, how to manage side effects, how to read labels and packages, and how to self-administer medications on a daily basis.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 59 Housing Partners who were homeless at the time of their incarceration are at an even higher risk of becoming homeless post incarceration. TrACT staff have supported partners with criminal records to obtain housing through heavy advocacy and having positive relationships with our landlords. TrACT staff have been able to successfully obtain housing for these partners in the community (see Graph 11 , page 15). A majority of partners need housing and are referred to and supported by housing staff to be placed initially in appropriate emergency and transitional housing in the community. Some partners have also been referred to residential treatment programs (ranging from 1 to 6 months) in order to support them with their abstinence and recovery from substance abuse and also stabilize their mental health symptoms. Type of placement is based on need and considered on a case by case basis as TrACT believes in supporting partners based on their needs while also taking into consideration their level of functioning in the community so partners can continue to move toward independence at their own pace and feel empowered at the same time.

Of the eight partners who graduated from TrACT this past year, four of the eight were housed independently in Oakland utilizing the Shelter + Care permanent subsidy, two chose to live with family upon graduation and one was unable to meet the eligibility criteria, specifically chronically homeless, and ended up couch surfing by choice. The other graduate left the state for the east coast to live with his brother. Some of the currently enrolled TrACT partners continued to live with family members in the community. Staff provided collateral support to family members along with social rehabilitation support since family members can find it challenging to live with partners’ mental health symptoms on a day to day basis. Staff also provided psycho-education to family members about mental illness, substance abuse, and medications as needed.

TrACT staff provide extensive social rehabilitation services in the community to support partners in maintaining their housing independently for the long term. Some of the social rehabilitation services with regard to housing include: money management skills so partners can learn and take responsibility for their portion of the rent and bills, cooking cleaning and laundry skills, skills to develop a healthy structure during the day, and general skills to improve Activities of Daily Living (ADL’s).

The inability for individuals who have graduated from the program to maintain their independent living once transitioning to a lower level of care has become an unfortunate reality. This is a trend that has been happening over the past 12-18 months in TrACT. We believe this is happening in the other FSP programs in the county as well and this is impacting TrACT significantly more because TrACT has graduated more individuals than all of the other original FSPs combined (TrACT has graduated 48 individuals since inception). The significant decrease in the amount and intensity of support services available to the partner after transitioning to a lower level of care along with the high rate of alcohol and drug relapse has contributed to a number of graduates losing their housing. This is a challenge to the TrACT team as the human and financial resources involved in trying to support these individual’s back into recovery and into new placements can be costly. Devoting staff time to supporting these individuals has taken away from the ability to provide maximum services to partners that are enrolled in the program. Also, the amount of staff time spent in working with these individuals that are not

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 60 enrolled in the program is not billable and therefore challenges our ability to meet individual staff productivity and our annual contracted service hours.

We have recognized the need for more support from the programs that we are transitioning our partners and have put more emphasis on the housing aspect when planning a transition and a warm hand-off to a lower level of care provider. However, this issue is bigger than 1 or 2 programs as an effort to improve partners maintaining in housing for the long term would require systemic support. This effort has begun as we have met with many county staff; housing director, service team director and the Crisis Response Program’s supervisor regarding graduation /transitions, the need for a longer period for a warm hand-off of the partner to the lower level of care provider.

Public Benefits / Entitlements All TrACT partners who needed support with reinstating their benefits at the time of enrollment were supported by staff with this process. TrACT staff coordinated with Criminal Justice Mental Health (CJMH) in order to get the necessary “custody release” paperwork for partners whose SSI benefits and medical insurance have been temporarily been cut off as a result of their incarceration. TrACT staff also supported partners with obtaining identification, birth certificates, Social Security cards and other important documentation needed to get their medical benefits reinstated. TrACT also continued a working relationship with the advocates and attorneys at the Homeless Action Center (HAC) as they have been a tremendous resource, advocate and support for the partners throughout the application and approval process for the partners who have never had SSI benefits before.

This year we saw the continuation of the housing subsidy funds to the General Assistance (GA) benefits for participants who also had applied for SSI/SSDI. The benefit increased from the usual GA benefit of $364 to $634 which was of tremendous support for the partners who had to wait a long time for their benefits to be approved. The GA program continued to allow housing subsidy recipients of the $634 to choose to have the housing dollars sent directly to the recipients assuming that the housing funds were then paid to the landlord. We did a better job of collecting partner rent payments, especially GA housing dollars, this year. The program negotiated payment plans for partners who misspent their funds.

Employment / Vocational Services TrACT functions as a transitional program that supports partners’ employment and education goals as part of the of the wraparound services offered; along with treatment, housing and social rehabilitation. Each partner’s needs are addressed and a treatment plan is put in place by the IPS employment specialist, with the support of the team. This is done in a collaborative fashion, with other community based programs who are working with the partner. TrACT Employment Services will need to work collaboratively with the Alameda County Vocational Program as well as the State Department of Vocational Rehabilitation Services. Together, the goal is to utilize appropriate resources for each

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 61 individual partner in order to enable a rapid job search focus in line with the IPS approach of ensuring partners’ preferences and choices of employment.

This fiscal year we were awarded an expansion grant to increase the number of partners to be served by the FACT and TrACT programs. Therefore, we increased our capacity to provide employment services from 20 to 40 potential employment candidates, thus keeping in line with our commitment to begin providing fidelity based IPS Employment services. In other words we have added 1 full-time employment specialist position to the team. The employment specialists will have up to 40 slots for 2 IPS employment caseloads.

In other employment staffing news we lost our employment specialist of almost 4 years and struggled to find a replacement as the IPS employment specialist position description calls for a unique skillset that was not easy to find. In fact we were unable to hire anyone that had previous experience with the IPS Dartmouth model. We hired an individual for the first employment position in February and the second in May of the 3rd and 4th quarters of this FY.

This year a total of 21 partners expressed interest in competitive employment and the employment specialist ended this reporting period (6/30/2016) with a case load of 18. One of the staff is taking on that active caseload of 18 partners. Among that 18, five are actively engaged in weekly employer contact through independent job searches and staff referrals to employer partners. Two are currently enrolled in accredited college education. Others are continuing to develop independent living skills to maintain weekly job searches alongside other goals.

Key highlights include one partner’s successful placement as a full-time laundry attendant at the Double Tree Hilton at the Berkeley Marina. This was the partner’s preferred industry, and the placement encouraged Alameda County Family Court to grant him weekend visitation rights with his kids. The employment specialist also worked closely with another partner on her naturalization process, and she successfully completed an in-person interview and submitted follow-up documentation related to that process. She is pursuing part-time work in Hayward near her housing, and Behavioral Health Court recently lifted the protective order so she can visit her father in Fremont.

As of the close of this fiscal year 2 other partners had completed interviews with employer partners: Every Dog Has Its Day Care, Inc. and Whole Foods Market, respectively. Both partners seem very excited and will hopefully receive job offers within the next two weeks.

Employer outreach has yielded 19 new employer contacts this reporting period.

Partners were helped with career interests, job skills, and educated on possible work challenges. They were supported with job categories that fit with their interests, resume preparation, and coaching for job interviews. In addition, they were encouraged to set realistic expectations, since many partners have not been in the work force for a while.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 62

The biggest challenge for the TrACT partners’ engagement in employment and educational related services has been putting in regular hours to engage in these services. Most of the TrACT partners were in a substance abuse program, which makes it difficult to get them to participate in employment and/or educational related services, concurrently. In addition, many of them also had medication challenges, which were being addressed by the medical team, but required some time for stabilization and symptom management.

Family, Community, Culture, and Social Support The TRACT partner population is ethnically diverse and includes individuals who identify as African American, Asian, Asian Pacific Islanders, Hispanic, White, and Multi-racial. The program is staffed by a culturally and ethnically diverse team. The TRACT program recognizes the importance of social inclusion and preservation of communities. TRACT staff have supported partners requests to help them connect to community groups and social activities with individuals from the same or similar cultural community or practices. TRACT also connects clients with community organizations like Pool of Consumer Champions (POCC), Best Now and PEERS in an effort to help partners improve social connections, take on leadership roles and become more involved with their communities.

Staff have worked and supported partners and their families who are immigrants as well as those struggling with acculturation and assimilation challenges. Staff have also supported partners and their families by linking them with appropriate treatment, self-help and illness education groups in the community.

Although the goal of TRACT is to move partners into more independent living situations, several TRACT partners have chosen to continue living with their family members after successfully graduating from the program. Staff work with these families by providing housing and social rehabilitation support and connecting them with appropriate resources in the community so they understand how to address the continuing needs of the partner. Partners are encouraged to continue or re-establish healthy family and social supports like friends, peers, church, co-workers , etc. TRACT helps partners enlist social connections to support them in their ongoing efforts to normalize their recovery experience and strengthen their wellness efforts to live independently in the community.

VII. Partner Narrative

Introduction to TrACT Pat Brown, is a 30-year-old African American female who was referred to the TrACT program and Behavioral Health Court (BHC) by Criminal Justice Mental Health (CJMH) in April 2015. Her first contact with Alameda County Behavioral Health Care Services (ACBHCS) began in late 2010 and since then she has had multiple emergency psychiatric hospitalizations at John George including an inpatient stay (in 2015), contacts with mobile crisis, Sausal Creek Outpatient services for medications, and was a part of the Telecare Changes program. In 2015, partner was arrested for assault charges against her mother,

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 63 stemming from her mental illness, and was referred from the CJMH team to BHC and then the TrACT program.

Records obtained from CJMH indicate that Pat has had varying Axis I diagnosis such as Adjustment Disorder, Drug Induced Disorders, Psychosis NOS, Mood Disorder NOS, and most recently Major Depressive Disorder, Recurrent, and Severe with Psychotic Features such as hearing negative voices, paranoid thoughts, and high anxiety. Pat has a history of using methamphetamines and alcohol to cope with her symptoms. Pat initially presented as ambivalent regarding participation in BHC and TrACT programs, but became more motivated as she learned of the benefits. The BHC panel team determined Pat to be a good fit for the TrACT program and she voluntarily enrolled in BHC on 4/6/15 and into the TrACT program on 5/14/15.

History of Homelessness Pat entered the program with a history of homelessness. As an adult she had been living in a van in the Bay Area with her boyfriend in between numerous hospitalizations for emergency psychiatric services. She then progressed to an apartment with her boyfriend, then ended up living with her mother, to support her while she (mother) suffered with cancer. While living with her mother, Pat felt she was ill prepared to offer support in that she was struggling with her own problems of drug/alcohol use to cope with symptoms of depression. Out of these problems, Pat assaulted her mother and was consequently arrested and incarcerated at Santa Rita jail, where she was identified as seriously mentally ill and referred from CJMH to the BHC and TrACT programs as described above.

Community Re-entry/Transitional support As a Transitional Assertive Community Treatment program, TrACT worked with BHC and Pat to plan for her transition out of Santa Rita back into the community. During this stage, TrACT supported Pat with public benefits. Due to her incarceration, her SSI support was discontinued. TrACT supported her in re-starting this benefit to help her toward her goals of independence. Initial assessments revealed the need for further mental health stabilization. The TrACT team coordinated a stay for Pat at Villa Fairmont Mental Health Rehabilitation Center for further symptom stabilization and engagement in recovery, with the goal of a rapid return to the community. The next step was to coordinate a dual- diagnosis residential treatment program due to the severity of drug/alcohol use and symptoms of depression that impaired her functioning in several life areas. The TrACT program successfully referred Pat to Cronin House where she stayed for a month and a half participating and successfully graduating from the treatment program.

Housing, Recovery, and Independence After graduating from Cronin House the TrACT team supported Pat ’s transition into the program’s temporary shelter housing. With a goal of obtaining her own apartment, Pat continued to work on symptom reduction and building independent living skills. The TrACT team supported Pat in scheduling psychiatric appointments with the program psychiatrist and nursing staff. Pat was supported in finding the best medication regimen with close daily monitoring. Pat received support and coaching from the

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 64 TrACT team to increase her motivation for improving her hygiene and housekeeping skills at the shelter housing. Over time she became the “House Mother” supporting other peers in the program shelter housing. Pat was referred to the Day Treatment program at EBCRP to further address drug/alcohol issues, independent living skills, coping strategies and problem solving skills. She attended every group five days a week. Through this programming and support from TrACT program staff, Pat learned new healthy coping skills and started utilizing them.

During her 12-month timeframe in the TrACT program, Pat only relapsed one time. She also learned budgeting and money management skills and is currently her own payee, learning to keep track of and pay her bills on time. As her self-confidence grew she started to take initiative to do things like call PG&E to pay her past debt. She was grateful to the team for their support and their believing in her. As she experienced achieving her treatment goals, her motivation for success continued to develop. For example, she reports becoming increasingly motivated to get her own apartment after completing Cronin House residential treatment. She expressed wanting to be in a better position to support her mother and for her mother to be proud of her. Over time she developed more confidence and self- esteem and started overcoming her social anxiety to emerge from her shell by and was able to reach out to family members such as her brother and sister and begin to repair the relationships. Her symptoms declined to the point where she reports the negative voices are almost non-existent. Since entering the TrACT program, Pat has not returned to PES, a psychiatric hospitalization or had any new charges or incarcerations.

As Pat continued to work with the program housing coordinator, she was supported toward her goal of independent living in her own apartment by applying for and utilizing the Shelter Plus Care subsidy for individuals with chronic mental illness and episodic history of homelessness. TrACT staff supported Pat in viewing various apartments in the Oakland area, until she found one she liked and signed the lease just as she was graduating from BHC. After moving into her new apartment, Pat re-connected with her nieces and nephews who now regularly visit her. Pat reports, “Life has finally started for me, I finally feel like an adult, my mom can finally be proud of me!”

Continuing Recovery As she approached her graduation from TrACT and BHC after 12 months, the TrACT program worked with Pat to develop a successful transition plan. Due to development of skills that enable Pat to live independently, the plan included connection to a lower level of care with West Oakland Community Support service team for supportive case-management services, psychiatric services, and recovery oriented supportive groups for ongoing support to build on her achievements. Pat has fully engaged with these services with the help of a warm handoff from her TrACT case-manager and housing coordinator. With a GED and some past Laney College experience, Pat hopes to build on her education in the near future. Pat enjoys her newly expanded support system of family, West Oakland Community Support team, peer relationships developed along her journey, and TrACT housing staff that continue to follow and support her with her housing plan.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 65 VIII. TrACT MASTER TRACKING LOG AUGUST 2009 to JUNE 2016 Measures Compendium1-Time Partner CLIENT FLOW Administered

1487

12 (Months) - 24 Months)

- AdmissionDate Partner No. Partner ( insyst #) Closed8 to FACT Transfer Date (if applicable) ServiceTeam TransferDate (if applicable) / Court Graduation Discharge Date Length in of Stay Months) BHC (In 1st (Admission) Code 1st* 2nd Code 2nd* 3rd Code 3rd*

75139235 8/24/09 4/19/11 n/a n/a 9/13/11 1/25/00 5/10/11 G 6/7/12 A 41938201 9/22/09 2/22/11 n/a 2/22/11 10/18/11 1/25/00 2/9/12 G 2/9/13 A 75024407 10/6/09 4/1/11 n/a 4/1/11 10/11/11 1/24/00 5/10/11 G 5/10/12 A 75115471 10/13/09 12/5/11 n/a 12/5/11 10/25/11 1/24/00 4/15/11 G 6/15/11 B 27517201 10/29/09 6/30/11 6/30/11 n/a 3/13/12 1/29/00 5/18/11 G 5/18/12 A 7/23/13 C 60983401 11/12/09 11/10/11 n/a 11/10/11 11/15/11 1/24/00 6/16/11 G 9/20/11 C 2/27/13 A 4003001 11/17/09 6/30/11 6/30/11 n/a 5/8/12 1/30/00 6/21/11 G 11/11/11 F 3/28/13 C 75141913 12/1/09 2/1/10 Did not complete 2/1/10 1/3/00 G 79449801 1/5/10 3/8/10 Did not complete 8/1/2410 >2 E 75050680 5/4/10 10/20/11 Did not complete >5 G 66036501 5/4/10 12/20/11 12/20/11 n/a 5/4/12 1/24/00 4/5/11 G 6/22/12 B 3/28/13 A 75043036 5/7/10 8/9/10 Did not complete 1/3/00 G 75154482 5/7/10 8/3/10 Did not complete <1 G 75066875 5/11/10 11/29/11 n/a 11/29/11 5/12/12 1/24/00 4/5/11 G 11/30/11 F 4/19/13 A 75044090 5/18/10 8/10/10 Did not complete 1/2/00 G 75137920 5/18/10 12/6/11 Did not complete 1/6/00 G 73942501 6/22/10 7/6/10 Did not complete <1 G G 75085552 7/13/10 10/18/11 n/a 10/18/11 7/13/12 1/24/00 9/30/11 D 10/29/11 F 3/19/13 A *Codes for Completion, Incompletion or delay of the Administration of Compendium A-Completed within 30 days B- Participants location is known and the participant is to acute to complete interview in first 30 days -symptomatology or location may negatively influence their responses to the compendium C- Participants location is unknown no interview was completed D- Partner prematurely discharged from BHC System / did not complete E- Early Completion from BHC F- Successful Graduation from TrACT and Compendium completed G- Partner enrolled prior to the implementation of the final version of the Measures Compendium (4/1/2011) H- Partner refused 1Measures Compendium developed for initial use 4/01/2011. Use of the online instrument initiated in February 2012 and discontinued December 2012 The grey shaded cells represent those partners that DID NOT COMPLETE the BHC and in most cases were not given the measure compendium blue shaded cells indicate partners still active in BHC yellow shaded cells indicate compendium due dates have not been reached pink shaded cells indicate that the partner successfully graduated BHC before the 3rd compendium could be administered peach shaded cells indicate that partner successfully graduated BHC and 3rd compendium is not due for ~ 1 year light blue shaded cells indicate that partner Transitioned from TrACT and Graduated the Behavioral Health Court light green shaded cells indicate that the partner was transitioned from TrACT and did not complete or graduate from BHC

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 66

Measures Compendium1-Time Partner CLIENT FLOW Administered

12 (Months) - 24 Months)

- scharge Date Date scharge AdmissionDate Partner No. Partner ( insyst #) Closed81487to FACT Transfer Date (if applicable) ServiceTeam TransferDate (if applicable) / Court Graduation Di Length in of Stay Months) BHC (In 1st (Admission) Code 1st* 2nd Code 2nd* 3rd Code 3rd* 75042104 8/3/10 2/1/11 Did not complete D 75107432 8/10/10 9/28/12 n/a 9/28/12 9/18/12 28 8/2/11 G 10/17/11 C 6/25/12 F 75015568 8/10/10 11/14/12 n/a 11/14/12A 8/14/12 29 10/5/11 B 6/7/12 F 4/25/13 19622001 8/24/10 2/1/11 Did not complete 6 D B 75114924 8/24/10 11/29/11 n/a 11/29/11 8/24/12 16 9/27/11 B D C 75121030 8/31/10 2/22/11 Did not complete 6 D B C E 75148248 9/28/10 12/31/12 Did not complete 26 9/13/11 C 11/29/11 D 16126501 10/17/10 6/30/12 n/a 6/30/12 6/30/12 20 6/12/12 F 24224801 11/2/10 8/1/12 Did not complete 23 11/4/11 G 6/26/12 D 75183123 12/21/10 1/31/11 Did not complete 2 D 75150941 1/25/11 Hc12/28/12cc n/a n/a 11/2/12 24 4/5/11 C 9/18/12 C 75183089 1/25/11 Hc9/11/12 n/a n/a 9/11/12 21 2/12/11 A 9/2/12 F Did not 75124249 2/22/11 2/22/11 2/22/11 2/22/11 Complete <7 D 75161161 4/5/11 11/30/12 Did not complete 14 4/5/11 A 75003486 5/6/11 F9/18/12 n/a 9/18/12 9/18/12 30 10/9/11 B 9/27/11 A 6/26/12 75188547 6/14/11 12/14/11 n/a 12/14/11 12/14/11 6 6/16/11 A E Did not 75067933 7/12/11 F7/12/11 7/12/11 7/12/11 Complete 28 9/20/11 C 9/18/12 A 1/11/13 7/12/11 Did not 51779701 11/29/11 7/12/11 Complete 11/29/11 4 D Did not 75079776 8/1/11 2/5/13 2/6/13 Complete 9/24/13 23 5/28/12 B 54064101 8/19/11 10/25/11 Did not complete 2 D 75108368 9/19/11 F 2/9/13 n/a 3/26/13 3/26/13 26 9/22/11 A 10/20/12 A 3/8/13 75059706 9/23/11 9/18/12 Did not complete <12 9/28/11 A 75103656 9/29/11 9/18/12 Did not complete 9 10/12/11 A 9/18/12 A 38339801 10/4/11 1/31/12 Did not complete 3 11/29/11 B 75109940 10/18/11 12/20/11 Did not complete 2 10/21/11 A 75031317 10/20/11 2/29/12 Did not complete 3 D Did not 75069477 1/10/12 F 4/2/13 4/3/13 Complete 4/3/13 22 6/14/12 B 9/18/12 A 3/8/13 75189794 1/26/12 F 7/2/13 n/a 7/2/13 7/2/13 22 2/23/12 A 3/30/13 A 3/19/14 75169517 2/7/12 7/1/12 n/a n/a 6/17/12 4 2/14/12 A 6/17/12 E E

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 67

Measures Compendium1-Time CLIENT FLOW Partner Administered

1st 12 (Months) th of in of th Stay 24 Months) - - Code 1st* applicable) Code 3rd* ( insyst #) Code 2nd* Partner No. Partner (Admission) (if applicable) ServiceTeam Discharge Date TransferDate (if 3rd BHC (In Months) BHC (In Leng AdmissionDate Closed81487to Court Graduation / Court Graduation 2nd FACT FACT Transfer Date

75055001 2/21/12 3/1/12 Did not complete <1 D 75063062 3/13/12 8/28/12 Did not complete >5 3/27/12 A

4/10/12 4/9/13 4/10/13 Did not 9/10/13 15 4/24/12 A 9/18/12 A D 75145095 Complete 10/22/1 75003618 4/10/12 7/2/13 n/a 7/2/13 7/2/13 15 6/7/12 B 9/18/12 A 3 A Did not 4/26/12 2/5/13 2/6/13 2/5/13 19 6/7/12 B 4/16/13 A 75180851 Complete 11835601 8/28/12 12/14/13 n/a 12/15/13 12/17/13 15 9/18/12 A 9/5/13 A 9/2/14 A Did not 75186669 9/18/12 9/18/12 9/18/12 9/18/12 Complete 14 9/18/12 A 10/15/13 A 10/16/1 75079503 9/18/12 9/30/13 n/a 9/30/13 9/30/13 14 9/18/12 A 10/17/13 A 4 A 11/26/1 75200546 10/23/12 12/12/13 n/a 12/13/13 7/8/14 13 11/16/12 A 10/30/13 A 4 A Did not 75143500 11/13/12 8/6/13 n/a Complete 8/15/13 8 11/29/12 A 11/25/1 75185474 11/13/12 1/14/14 1/15/14 n/a 7/8/14 15 11/20/12 A 11/26/13 A 4 A Did not 75012399 2/5/13 3/10/14 3/11/14 Complete 3/17/15 12 3/6/13 A 2/11/14 A 33481301 2/12/13 8/13/14 n/a 8/13/14 7/8/14 12 3/6/13 A 2/25/14 A 3/11/15 A 75067853 2/12/13 2/26/13 Did not complete <3 D 75046132 2/12/13 4/23/13 Did not complete <3 D 75109687 3/5/13 8/30/13 8/30/13 Did not Complete <6 D 75107571 3/5/13 3/26/13 Did not complete <3 D 75215414 4/2/13 8/15/14 n/a 8/15/14 7/8/14 16 5/29/13 B 6/17/14 A n/a B 75001080 4/30/13 4/29/14 4/30/14 n/a 7/8/14 11 5/7/13 A 5/13/14 A 6/11/15 A 75071964 5/8/13 8/15/14 8/15/14 n/a 2/23/15 17 5/16/13 A 6/20/14 A n/a B 75052459 5/21/13 7/2/13 Did not complete >2 5/29/13 A 75153395 5/30/13 8/6/13 Did not complete >3 5/30/13 A 75062814 6/14/13 7/8/14 n/a 7/8/14 7/8/14 13 6/19/13 A 7/8/14 A n/a B 75118876 6/18/13 9/24/13 Did not complete 9/24/13 <3 7/16/13 D 75120120 6/25/13 10/22/13 Did not complete 10/22/13 <3 Refused H

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 68 Partner CLIENT FLOW Measures Compendium1-Time Administered

1st 1st 3rd 3rd 2nd 2nd Date ( insyst #) Code 1st* Code Code 3rd* Code Admission Admission Code 2nd* Code Partner No. Partner (Admission) (24 months) (24 (12 Months) (12 (if applicable) Discharge DateDischarge vice Teamvice Transfer Closed Closed to 81487 Length of Stayin of Length Months) (In TrACT Date(if Date(if applicable) FACT Transfer Date Ser BH Court Graduation / BH Graduation Court Did not 75213218 7/24/13 8/22/14 8/23/14 complete 7/1/14 13 8/13/13 A 8/1/14 A 75163478 7/30/13 7/22/14 n/a 7/23/14 7/8/14 13 8/30/13 A 8/29/14 A 8/30/15 A

75044002 8/1/13 4/7/15 n/a n/a 2/23/15 21 8/21/13 A 9/5/14 A n/a C 75045807 8/14/13 3/1/15 n/a 4/3/15 2/23/15 20 8/21/13 A 9/2/14 A 10/27/15 A 75131862 9/20/13 9/4/15 n/a 10/26/15 7/21/15 22 9/23/13 A 10/23/14 A 10/22/15 A 75182065 10/22/13 4/15/14 Did not complete 4/15/14 7 11/5/13 A 45904001 11/21/13 1/29/14 Did not complete 1/29/14 <3 n/a H 75052402 12/5/13 1/31/14 Did not complete 1/31/14 <2 12/10/13 A 75219513 1/28/14 1/29/15 Did not complete 1/29/15 9 2/25/14 A 75220251 2/10/14 5/21/14 n/a n/a 5/20/14 4 3/3/14 A 3615501 2/13/14 6/30/15 n/a n/a 2/24/15 1 3/11/14 A H n/a C 75068746 2/14/14 7/30/14 n/a 4/29/14 7/29/14 5 3/11/14 A C n/a C 75039488 2/20/14 11/10/14 n/a n/a 11/10/14 9 3/18/14 A

75022614 4/22/14 12/29/15 n/a 9/18/14 7/21/15 15 5/20/14 A 5/5/15 A 6/5/16 A 75142656 4/22/14 9/19/14 Did not complete 9/19/14 5 5/7/14 A 5/12//15 45736601 5/9/14 6/30/15 n/a 6/30/15 5 4/16/14 A 5/5/15 A 6/20/16 A 75019460 5/9/14 2/17/16 n/a 8/28/15 9/18/15 16 5/18/14 A 6/1/15 A n/a C 75229237 6/3/14 2/23/15 n/a n/a 2/23/15 4 6/5/14 A 5/5/15 A n/a B 75141099 6/6/14 9/16/14 Did not complete 9/16/14 2 6/6/14 A 75036061 6/7/14 1/28/16 n/a 9/18/15 16 6/6/14 A 5/5/15 A n/a B 75037560 6/6/14 2/9/15 Did not Complete 4 6/6/14 A 75063111 6/16/14 4/4/16 n/a 4/4/16 3/24/15 9 6/27/14 A 7/9/15 A n/a B 75230111 6/17/14 3/9/15 n/a 10/12/14 2/23/15 4 6/30/14 A 7/17/15 A n/a B 75084168 6/27/14 8/12/14 Did not complete 8/12/14 2 7/15/14 A Did not 9894701 8/15/14 6/1/15 6/2/15 Complete 6/2/15 16 8/15/14 A less than 1 44789601 9/25/14 9/25/14 Did not complete 9/25/14 day n/a D

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 69

Partner CLIENT FLOW Measures Compendium1-Time Administered

ssion) 1st 1st 3rd 3rd 2nd 2nd Date ( insyst #) Code 1st* Code Code 3rd* Code Admission Admission Code 2nd* Code Partner No. Partner (Admi (24 months) (24 (12 Months) (12 (if applicable) Discharge DateDischarge Closed Closed to 81487 TrACT (In Months) Date(if Date(if applicable) of Length Stay in FACT Transfer Date Service Team Service Transfer BH Court Graduation / BH Graduation Court 75086047 5/14/15 5/2/16 n/a 5/2/16 5/2/16 13 5/26/15 A 5/13/16 A 75121856 5/14/15 7/24/15 n/a n/a Still open 8 n/a B 2 75095913 5/28/15 6/5/15 Did not complete 6/17/15 weeks 5/28/15 A 75233250 6/11/15 11/2/15 n/a 11/2/15 11/2/15 5 6/18/15 A 6/9/16 A 75165513 7/22/15 2/10/16 n/a n/a 2/10/16 8 2/20/15 A n/a C n/a C 75157268 8/28/15 12/10/15 Did not Complete 6 9/9/15 A 75246597 8/27/15 3/11/16 Did not Complete 7 10/20/15 B 75125819 8/10/15 1/25/16 Did not Complete 12/22/15 5 9/29/15 A never 75148248 opened n/a Did not complete BHC 7 n/a D never 75119028 opened n/a Did not complete BHC 6 n/a D 75166656 9/28/15 open Currently Open to BHC and Services 9 9/28/15 A 75015709 9/11/15 open Currently Open to BHC and Services 9 9/11/15 A 75084935 10/1/15 open Currently Open to BHC and Services 8 1/7/16 B 75235587 10/28/15 2/12/16 Did not complete 2/12/16 4 1/8/16 A 75216983 11/2/15 Open Currently Open to BHC and Services 7 11/2/15 A 75059410 11/20/15 12/16/15 Did not complete 12/16/15 4 N/A D 75092717 1/5/16 4/8/16 Currently Open to BHC and Services 4 1/5/16 A 75171301 1/21/16 Open Currently Open to BHC and Services 5 1/21/16 A 75136412 2/8/16 Open Currently Open to BHC and Services 4 2/26/16 A 75186488 2/24/16 Open Currently Open to BHC and Services 4 2/24/16 A 75033540 3/1/16 5/19/16 Did Not complete 5/19/16 3 n/a D 75211984 3/16/16 5/2/16 Did not complete 5/2/16 3 n/a D 75197234 3/18/16 Open Currently Open to BHC and Services 3 6/3/16 B 75080224 3/18/16 Open Currently Open to BHC and Services 3 3/18/16 A 75213793 3/22/16 6/8/16 Did not complete 6/8/16 3 n/a D 75222936 3/22/16 Open Currently Open to BHC and Services 3 n/a B 75215802 3/25/16 Open Currently Open to BHC and Services 3 5/12/16 B 75113955 4/20/16 Open Currently Open to BHC and Services 3 4/20/16 A

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 70 Partner CLIENT FLOW Measures Compendium1-Time Administered

n TrACT

1st 1st 3rd 3rd 2nd 2nd Date ( insyst #) (insyst Code 1st* Code Code 3rd* Code Admission Admission Code 2nd* Code PartnerNo. (In Months) (In (Admission) (24 months) (24 (12 Months) (12 (if applicable) (if DischargeDate Closed to to 81487 Closed Date(ifapplicable) FACT Transfer DateFACT ServiceTeamTransfer BH Court Graduation / BHCourt Length of Stayi of Length

75068600 4/26/16 5/26/16 Did not complete 5/26/16 1 5/9/16 A 75163478 4/29/16 Open Currently Open to BHC and Services 3 5/28/16 A 75095136 5/3/16 Open Currently Open to BHC and Services 2 5/10/16 A 75224409 5/5/16 Open Currently Open to BHC and Services 2 5/26/16 A 75201965 5/6/16 Open Currently Open to BHC and Services 2 6/10/16 A 75144187 5/6/16 6/7/16 Did not complete 6/7/16 2 n/a D 75180800 5/24/16 Open Currently Open to BHC and Services 2 6/23/16 A 75256567 5/31/16 Open Currently Open to BHC and Services 2 n/a B 75061989 6/1/16 open Currently Open to BHC and Services 1 7/10/16 B 75252657 6/24/16 open Currently Open to BHC and Services 1 6/30/16 A 75256405 6/24/16 open Currently Open to BHC and Services 1 7/1/16 A

*Codes for Completion, Incompletion or delay of the Administration of Compendium A-Completed within 30 days B- Participants location is known and the participant is to acute to complete interview in first 30 days -symptomatology or location may negatively influence their responses to the compendium C- Participants location is unknown no interview was completed D- Partner prematurely discharged from BHC System / did not complete E- Early Completion from BHC F- Successful Graduation from TrACT and Compendium completed G- Partner enrolled prior to the implementation of the final version of the Measures Compendium (4/1/2011) H- Partner refused 1Measures Compendium developed for initial use 4/01/2011. Use of the online instrument was initiated in February 2012 and discontinued December 2012 grey shaded cells represent those partners that DID NOT COMPLETE the BHC and in most cases were not given the measure compendium blue shaded cells indicate partners still active in BHC yellow shaded cells indicate compendium due dates have not been reached pink shaded cells indicate that the partner successfully graduated BHC before the 3rd compendium could be administered peach shaded cells indicate that partner successfully graduated BHC and 3rd compendium is not due at present light blue shaded cells indicate that partner Transitioned from TrACT and Graduated the Behavioral Health Court light green shaded cells indicate that the partner was transitioned from TrACT and did not complete/graduate from BHC

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 71

FISCAL YEAR 2015-2016 ANNUAL REPORT

East Bay Community Recovery Project (EBCRP) August, 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 72

Table of Contents

Enrollment and Characteristics of Clients Served 2 PREP Program Performance and Evaluation Results 5 Implementation Objectives A. Process Measures 5 ● Provide services/deliverables to 55-60 unduplicated clients at any time 5 ● Provide 8060 hours of direct service 5 ● Contractor shall deliver up to 3 Wellness Recovery Action Planning (WRAP) cycles per year 6 ● Contractor shall provide peer support groups during weeks between WRAP cycles 7 ● Contractor shall provide family support groups two times per month 7 ● Contractor shall provide Multi-family Groups two times per month 8

B. Outcome Measures 9 ● Improve client role functioning 9 ● Demonstrate that the average prescribed daily medication dose..(meets WHO Standard) 10 ● Reduce number of prescribed antipsychotic medication 10 ● Reduce psychiatric hospitalizations by 50%

11 Additional PREP Program Activities and Updates 11 Web Based Outreach Activity 11 Successes Derived from Program Activities and Services 13 Changes in Project Design, Operations and Deliverables 14 Summary, Challenges, Recommendations 14 Recommendations 16 Summary 17

1

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 73

The PREP (Prevention and Recovery in Early Psychosis) Program was originally funded by a BHCS contract in early 2010 to identify and intervene with transition age youth (16-24 years) experiencing an initial episode of psychosis associated with schizophrenia and their families. The contract specified that an annual report be submitted to Alameda County that included all of the information specified in the contract Exhibit A. This report summarizes activities and evaluation results for the time period covering July 1, 2015 through June 30, 2016.

Enrollment and Characteristics of Clients Served During the FY 15/16 fiscal year, 29 transition age youth were referred for admission to PREP. Of this total, 19 (65%) were enrolled in treatment, while 10 (35%) were found to be ineligible or declined to join PREP and were referred back to the TAT team for alternative placement. Overall PREP served 88 clients during FY 15/16 with an average of 55 clients served each month. PREP ended the fiscal year with 48 active clients in the program. During the fiscal year, of the clients who were enrolled (i.e., received at least one therapy session), 36 clients were discharged from the PREP program. Among these discharged clients, a majority 83% (n = 30) graduated after successfully completing 2 years in the program and/or accomplishing some or all of their treatment plan goals. Of the remaining 6 clients, 2 relocated out of county and could no longer participate in PREP, 2 became disengaged with PREP and staff were unable to locate them, and 2 clients decided that they do not want services. The racial/ethnic background of these clients is displayed in Figure 1.

2

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 74 As displayed above, the PREP program served a diverse group of clients during FY 15/16. The largest percentage of clients served self-identified as “African/American/Black” (51%), while the smallest percentage of clients identified as “Multi-Racial” (3%). Comparing the demographic characteristics of PREP families to the Alameda County population, the current client families generally match the profile of the county in racial and ethnic background, in that all of the major racial/ethnic groups are represented. However, some disparities are still evident; African-Americans were over-represented among PREP program participants, while Caucasian, and Asian/PIs were under-represented. We saw slight increases from last year in the participants who identified as Hispanic and African American/Black, and a slight decrease in those that identified as Caucasian/White and Multi-Racial. The race/ethnicity of PREP clients may also be more consistent with the Medi-Cal population in Alameda County, whom the program serves, as compared to the general population. The age and gender of active clients during FY 15/16 is provided in Figure 2.

The largest proportion of participants fell within the 19 to 21 age range (36 clients; 41%). The average age of clients was 21.4 years with an overall range of 17 to 26 years. Almost 3 times as many males (N=65) as females (N=23) were enrolled in the PREP program during FY15/16. The overrepresentation of males reflects the same distribution within the larger TAY system of care, and is consistent with other programs described within the early psychosis literature. After the underrepresentation of females was identified in the previous annual reports, PREP outreach began educating referral sources regarding the presenting symptoms often seen in females with psychosis (e.g. mood symptoms are often more prominent than in men), and targeting community programs that serve young women. Ever since, there has been an increase in the percentage of female clients (with the exception of the FY 13/14). In FY 15/16, we had a slight increase compared to the previous year, but a considerable 7 point increase when compared to FY 11/12.

3

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 75 Out of 88 clients served in FY 15/16, two clients had a diagnosis that did not fit any of the four categories of psychosis (as seen in Table 1)--the two diagnoses were PTSD and bipolar disorder. Primary diagnoses at intake for the remaining 86 clients were extracted from the SCID and are summarized in Table 1. Table 1. Primary SCID Diagnoses of Clients Active During FY 15/16 Frequency Percent Schizophrenia 37 43.0 Schizoaffective 13 15.1 Schizophreniform 20 23.3 Psychosis, Not Otherwise Specified (NOS) 16 18.6

The focus at PREP is early intervention and remediation/stabilization of psychosis. Clients must be diagnosed with one of the primary psychotic disorders mentioned above within a two-year window which ensures that the focus is on treating psychosis in its early stages. It is important to note that Schizophreniform disorder applies when active psychotic symptoms have been present for less than one month, and all related symptoms of mental illness have been present for less than 6 months, representing a very early state of psychosis. The same symptoms present for longer duration are included in the classifications of schizophrenia or schizoaffective disorder. Therefore, the fact that 24.1% of individuals came to PREP with a diagnosis of Schizophreniform reflects that PREP is indeed conducting prevention/early intervention work.

4

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 76 PREP Program Performance and Evaluation Results Program performance and outcome objectives are organized within the two categories of Process Measures and Outcomes. Status in accomplishing objectives and evaluation results within each of these domains is provided in the sections below. The following data sources were used to evaluate and report outcome data on PREP program participants: ● Client opening and closing paperwork. Data on specific functional measures, including educational attainment and employment at baseline and discharge were extracted from the opening and closing paperwork within client charts and CIRCE, PREP’s information and practice management system, to analyze change in these variables over time. ● IPS Data. PREP’s Education and Employment Specialist collected data on clients who were enrolled in school and/ or work during FY 15/16. This data was used to provide more detail about those clients who were actively seeking to return to school or work. The IPS data allowed for a more reasonable comparison of employment statistics for PREP clients compared to the population in general. ● Clinician’s Gateway. Clinician’s Gateway provides a running list of all county services each client receives. It was used to capture the exact type and length of each hospitalization PREP clients received during FY 15/16. ● Group Attendance Logs. Data is collected from sign-in sheets for all PREP groups (MFG, WRAP, Wellness Support Group, Family Support Group and Activities Group).

A. Process Measures Contractor’s staff shall provide 8,060 annualized staffing services hours and serve 55-60 clients at any time. Contract Process Measures Deliverables Staff Staff Staff Staff Staff Staff Hours Hours Hours Hours Hours Hours EBCRP EBCRP FSA FSA TOTAL TOTAL Outpatient Services (Target) (Actual) (Target) (Actual) (Target) (Actual) Mental Health Services 3642 2,090.22 2,651 1,275.89 6,293 3,366.11 Case Management 488 657.31 244 164.42 732 821.73 Medication Support 0 0 975 673.36 975 673.36 Crisis Intervention 30 6.62 30 30.9 60 37.52 Total 4,160 2,754.15 3,900 2,144.57 8,060 4,898.72

Productivity reported in the matrix above pertains to Medi-Cal billable units of service as reported by Alameda County for Fiscal Year 2015/16. For the first quarter productivity averaged 66.38% (combined EBCRP & FSA PREP). In the second quarter productivity decreased to 61.70% (combined). The third quarter combined productivity was 62.02%. And the fourth quarter combined was 53.01%. Overall combined productivity for billable hours during the Fiscal Year 2015/16 for EBCRP and FSA PREP was 60.78%.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 77 In addition to the above billable units of service, PREP Alameda tracks non-billable encounters that occur each month. Such encounters include staff support to clients who are hospitalized, incarcerated, no shows, family support activities. Non-billable encounters amounted to 409.10 hours during Fiscal Year 2015/16. Adding the non-billable hours to billable hours (409.10 + 4898.72 = 5307.82/6080 target) yields a rate of 65.85% which is a more accurate reflection of total productivity for the year. Two additional notes should be made regarding UOS percentages. While mental health units of service percentages averaged 53.49% per month combined, case management percentages averaged 112.26% with nearly every month exceeding 100%. This suggests that all staff are not only providing case management as is the expectation, but that case management has taken precedence over therapeutic interventions in many cases. This may be something to look at further from a program design standpoint. Additionally, the Med Support category appears to be low at 69.06%, however, this number does not accurately measure the billing nor the scope of the duties of the Nurse Practitioner. It is well known by all at PREP Alameda that our Nurse Practitioner plays a vital role on the team as a field- work NP. She has also played a crucial role in managing the numerous client and family crises and has supported and guided staff and families through the 5150 process. As such, she bills not only for medication support for crisis, collateral, and occasionally for brokerage. Finally, PREP exceeded the objective by serving a total of 88 unique clients during FY 15/16. An average of 55 clients were served each month, during a period of staff turnover, and subsequent reduction in intakes.

Contractor shall oversee the delivery of up to three Wellness Recovery Action Planning (WRAP) cycles per year. MHAAC contracted with two WRAP facilitators to run two cycles of WRAP during the FY 15/16. PREP additionally contracted with PEERS to run a WRAP cycle in the final quarter of FY15/16. Collectively there were a total of 26 WRAP group days. During these WRAP cycles, we had an average of 1-2 participants per group. Attendance ranged from 0 - 5 participants in a group. We had 16 unique enrolled PREP participants attend at least once. We also had 2 graduates attend a WRAP group at least once. In the third quarter (Q3), the Peer Support Specialist made extensive efforts to offer PREP graduates (as well as some enrolled PREP participants near discharge) the opportunity to be trained by PEERS as WRAP facilitators for PREP. Of the 5 young adults interested, 3 were identified as very committed. However 1 of these participants was unable to attend the training due to personal reasons. The other two participants attended the full training and are now trained as WRAP Facilitators.

Contractor shall provide peer support groups during the weeks in between the WRAP cycles. Mutual Peer Wellness Support groups were held in-between cycles of WRAP and facilitated by the Coordinator of Peer and Family Support Services and the newly hired Peer Support Specialist. PREP graduates and peer leaders were invited to co-facilitate wellness and recovery topics. Eight Special Messages groups were offered. Other topics included:

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 78 ● “The Power of Language and Narrative in Recovery” ● “Mindfulness and Establishing Reminders for Wellness” ● “What Do We Mean by Recovery? Non-linear Journeys” Over the course of FY15/16 we had an average of 1-2 participants, 28 unique clients, and two graduates attend peer-run groups. Attendance for WRAP, Special Messages and Wellness Support groups ranged from 2-10 and was lower than usual during Q3 and Q4, since having moved to the new office in Hayward. During this time, we made great efforts to attempt to increase attendance including creating an outside hangout space (including tables/chairs, basketball hoop, ping pong table, foosball table and a vegetable/herb garden), offering gift cards for attendance to for attendance to groups, and hosting barbecue/playtime events to foster a sense of community. These events brought 11 clients and 3 families to the outdoor office place. It was a fun and energetic event and we are planning on hosting more throughout the next fiscal year. Individual Peer Support was also provided to support young adults currently in the PREP program and to former PREP participants through the graduate program. Throughout FY 15/16, 22 current participants and 18 graduates received individual peer support. Additionally, peer-support was offered to 5 families of enrolled and/or graduated PREP participants, through sharing personal lived experience of the recovery journey in order to foster hope in family members for the young adult’s recovery process.

Contractor shall provide family support groups two times per month. Our Family Support Specialist provides individual support to 6-8 families on an ongoing weekly basis and has individually supported 40 families over the course of this fiscal year. Additionally, our Family Support Specialist reached out to nearly every family of enrolled PREP participants to let them know about Family Support Group, MFG, and other community supports available to them, like the Family and Education Resource Center (FERC) as well as PREP play day, picnics, psycho- ed and graduations. We continue to strive to introduce new PREP families to the Family Support Specialist early on in their orientation to PREP in hopes of solidifying her as a source of support. Our Family Support Specialist led a Family Support Group to further encourage the networking of family members and to minimize the isolation experienced by families whose loved ones have been diagnosed with early psychosis. This group does not have a clinician present and is available for family members and other supporters of current and graduated PREP clients. It provides the opportunity for family members to share their experiences and have a place of mutual support with others family members. This group is open to both families whose loved one is currently enrolled in the program and family members of those who have progressed through the 2-year span of the program. In the first quarter of FY 15/16, the Family Support Group (FSG) was held on the 2nd and 4th Thursday afternoon of each month. Because the FSG has had continued low attendance on Thursdays we decided to reschedule it in the second quarter to the 2nd and 4th Tuesday of each month as this is a time when it is more likely that family members would be transporting PREP clients to the office for group activities and would be available to attend FSG. Results continued to show low to no attendance. In the third and fourth quarter FSG returned to the Thursday schedule. During this time in our ongoing effort to increase attendance we began planning a new approach to the FSG in FY 16/17 which will include PREP families and the larger community either in the evening or on the weekend.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 79 We are very excited to roll out this new approach to a PREP family support group. Beginning in fall of 2016 our Family Support Specialist will be offering a monthly Saturday group to accommodate the schedules of PREP families who work during the weekday. Our goal is make FSG more accessible to families of current PREP participants as well as those of PREP alumni. Our intention in opening this Saturday group to the larger community of families with young adults who experience psychosis is to garner better attendance and more sustainable support for families of young adults even as they begin to “age out” of the TAY system of care. In addition to this Saturday meeting we will continue offering FSG at the Hayward office on the third Thursday of each month

Contractor shall provide Multi-Family groups two times per month. PREP’s Family Support Specialist co-leads the MFG with a staff therapist. The Family Support Specialist outreaches to families between MFG meetings as well. Our Multi-Family Group is a Spanish and English language group co-facilitated through the use of a dedicated Spanish-speaking interpreter. The Multi-Family Group continued to meet twice a month from July 2015 to early February 2016. This is a supportive educational group for clients and their families formed of 5-6 families who commit to meeting two Monday nights per month for one year. It encourages the identification and implementation of problem solving skills for the youth and families. While family psycho-education has been determined to be an effective treatment method, working with multiple families in this group setting has demonstrated similar responses and allows the PREP program to support a larger number of people with fewer resources. It also allows families to socialize and connect with each other, decreasing social isolation and feelings of guilt and shame that many families experience when a family member develops psychosis. A range of topics were covered in the MFG group including: ● Techniques a client can use to start conversations and make new friends ● Strategies for parents to get their daughter’s attention without feeling they are nagging her ● Working around sedating effects of medication so a client can have a satisfying social life ● Ways to address a mom’s concern re: her son’s depression ● Ways a parent can find continued support in their community beyond MFG A total of 10 different family members and 5 young adults from 6 different families attended this year’s Multi-Family Group cycle. Multi-Family Group (MFG) continued in the first three quarters of the fiscal year with the current one year cycle ending in February 2016. In the third and fourth quarters PREP staff provided MFG psycho-education nights to retain family participation. Joining sessions for the next MFG session began in March of 2016. Staff offered families the opportunity to join MFG. Eight families in various stages of readiness are possible candidates for the 2016-2017 cycle of MFG. The Family Support Specialist outreaches to families between MFG meetings as well. She also co- presents to families at psycho-educational evenings and is instrumental in organizing bi-annual graduation. Eleven family members and 5 young adult clients attended the three psycho-education nights of 2015-2016. A total of 25 unique family members and 15 unique youth representing 17 different families attended either psycho-education nights, Multi-Family Groups, PREP Playday and/or the Healing Voices film screening.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 80

B. Outcomes Measures Improve client role functioning (engagement in school or work) to 70% if clients from baseline (prior to entering treatment). A total of 48 clients were enrolled in PREP Alameda for at least 12 months during FY 15-16. 35 of these 48 clients (73%) expressed interest in employment/educational opportunities and sought services from PREP’s Educational/Vocational specialist.

Drilling down into outcomes for those who engaged with PREP Ed/Voc services versus those who did not, 77% (27/35) of the ‘engaged’ clients were in school or working after 12 months in PREP compared to 54% (19/35) at baseline (i.e. when they first entered the program). Among those 13 clients who did not engage in Ed/Voc services, only 2 clients (of 13; 15%) were in school or working after 12 months compared to 8% (1/13) at baseline. These findings are illustrated in Figure 5.

Overall, out of PREP Alameda’s total 48 active clients during FY 15-16, 60% (29/48) were engaged in school or work after 12 months in PREP compared to 42% (20/48) at baseline, a 45% increase. 9 clients increased their school/work functioning and 20 were able to maintain initial school/work functioning.

Demonstrate that the average prescribed daily dose of antipsychotic medication for 80% of clients will be within 20% the World Health organization (WHO) defined daily dose of medication. Data was extracted from CIRCE and clients’ e-prescribing records to determine the number and dosage of prescribed antipsychotic medications for clients who were active during FY 15/16. Clients

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 81 must have been in the program for at least 2 month and must have received medication management support from PREP. Point of entry measures included all medications the client was prescribed coming out of the hospital or from an outside provider before being assessed by the PREP medication support team.

A total of 48 clients were active during FY 15/16, in the program for at least 12 months and receiving medication support from PREP. The average dosage of prescribed antipsychotics at point of entry was 121.1% of the WHO Defined Daily Dose (DDD). After 12 months in PREP, the average dosage was reduced to 113.9% of WHO DDD. Out of 48 clients, 25 (53%) had a daily dose that was ≤120% of WHO DDD.

Reduce the number of prescribed antipsychotic medications for those clients who have entered the program on more than one antipsychotic medication by 50%. In FY 15-16, PREP had only 1 client who entered the program on 2 antipsychotic medications. After 12 months with PREP, this client was prescribed only 1 antipsychotic, a reduction of 50%.

Reduce psychiatric hospitalizations by 50%. Hospitalization data for 48 clients enrolled in FY15-16 for at least 12 months were collected via Clinician’s Gateway and entered into CIRCE. Out of these 48 clients, 28 (58%) experienced at least one inpatient psychiatric hospitalization in 12 months prior to their enrollment in PREP. After 12 months of treatment, only 10 of these clients (21%) experiences any psychiatric hospitalizations. Out of the remaining 20 clients (42%) with no prior inpatient psychiatric hospitalizations, 13 clients (65%) did not experience any hospitalizations during their first year in PREP. Overall, there was a 57% overall reduction in the number of psychiatric hospitalizations during the first year of enrollment. The results are shown in the Figure 3. Figure 3. Psychiatric Hospitalizations in FY15‐16 (N=48)

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 82

Additional PREP Program Activities and Updates

Web-Based Outreach Over FY 15/16, we have had a total of 1,966 unique visitors to the PREP Alameda County website. As of the end of the fiscal year, we have 448 likes on Facebook and 1,640 followers on Twitter, for a total of 4,054 contacts made through web-based media.

PREP Group Activities

Group activities. Care Advocates continue to support and facilitate groups for clients of the program. Group activities focus on subjects that coincide with client’s wellness goals, building skills related to their treatment goals, and connecting clients to community resources. To increase group attendance and support clients with balancing their weekly schedules, both wellness and activity groups are held on the same day. Many clients continue to use the skills they have learned in the group to pursue their goals related to education and obtaining employment. Clients are developing close relationships with each other and engaging in community activities with one another, while sharing personal experiences. Care advocates continue to work on transportation skill building with clients. Care advocates will continue to contact all clients on a weekly basis in order to offer information and remind clients about upcoming groups. Attendance at groups this year has been lower than in previous years. Attendance has averaged 2-4 clients per group. Group attendance initially dropped off with the move to Hayward as clients were more familiar with navigating the Oakland location and navigating public transportation routes to that venue. Efforts to increase client attendance have included: changing group days, adding lunch, increasing availability of fun activities on site, trying new group activities. PREP staff continues to contemplate possible options to increase client interest and motivation. PREP Graduations and Other Activities & Events. This year, as in previous years, PREP held a number of events to which our entire community of young adults, their families, friends and supporters and PREP staff past and present are invited. In the 2015-2016 FY we scheduled two graduation ceremonies at six month intervals. The first, held in December, was attended by 4 graduates, 10 family members and staff. Our second graduation, normally scheduled for June, was rescheduled to early July due to the Oakland Warriors finals game. PREP held three psycho-education evenings in FY 15/16 as well as our annual Thanksgiving Feast. With the leadership of the PREP’s Peer and Family Support specialists we initiated some new kinds of PREP community events. These included a film screening and discussion of “The Devil and Daniel Webster” a gifted and renowned musician who hears voices. With our office move to Hayward and the end of our MFG cycle in January and February respectively, we felt it important to bolster staff and family morale. We responded by planning and holding two events. MFG families and the Family Support specialist organized a Saturday potluck BBQ which included MFG grads and their families as well as new families and alumni. We met at a neighborhood park for an afternoon of BBQ, horseshoes, basketball and relaxing. Four young adults, 10 family members, family support specialist and peer specialist and 3 family dogs attended.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 83 The second event involved the transformation of our new office’s outdoor space into a TAY “hangout space”. With the help of the dad of one of our young adults the Peer and Family Support specialists gathered and installed a BBQ, basketball hoop, ping pong table, foosball table, built and planted a vegetable/herb garden and space for mural painting. This preparation culminated in our grand opening event Playday at PREP on May 17th. We had a wonderful turnout of 11 young adults, 4 family members and most of our staff. This space has since been used for staff lunches, groups and a PREP graduation ceremony and it will continue to host community-building events. PREP Events: ● 8/12/15 Picnic at Snow Park (1 FM, 7 clients, 6 staff) ● 9/2/15 Medication Education Night (3 clients, 2 family, 3 staff) ● 10/12/16 Film Screening: The Devil & Daniel Webster. (1 clt, 1FM, 3 staff) ● 11/23/15 Thanksgiving Feast (1 client, 1 FM, 3 staff) ● 12/14/16 Graduation (Oakland, 4 clients, 10FM, and staff) ● 2/22/16 What is Psychosis Night (Hayward - 2 clients, 6 FM, 4 staff) ● 3/7/16 Medication Education Night (Hayward, 2 clients, 3FM, 4 staff) ● 4/2/16 Potluck Picnic Strawberry Park (4 clients, 10 FM, 2 staff, 3 dogs) ● 4/29/16 Healing Voices Field Trip to SF (2 clients, 1 FM, 5 staff) ● 5/17/16 Play Day in the PREP Hayward yard (11 clients, 4 FM, 10 staff)

Successes Derived from Program Activities and Services In the last year, PREP’s Employment and Education Specialist assisted young adults achieve success in their specific education and employment goals. This year, while enrolled in PREP, two young adults completed their high school educations and earned their diplomas. One young man completed his degree in Computer Science from Santa Clara University. 23 clients began employment in FY15/16. During this last year just about 29% of clients receiving services for 12 months or less were working in part time or full time jobs. One young woman began her first ever part time position and worked there for two months before moving on to another employer who better met her needs for scheduling, work environment, and general wellness. A few more successes of note from this past year: One young man began working part time, then full time with his family’s construction business. He met with the EES, who introduced him to working with staff from the Center of Independent Living to navigate his benefits and Medi-Cal eligibility as he began working more frequently and consistently. His confidence in returning to work after knowing that his eligibility could remain intact was vastly improved. The young woman mentioned previously who began a job and then moved on to a better job was also in school for the entire year. This young woman had previously struggled academically due to the impact of her symptoms on her attendance and focus. She had a hard time completing her last few credits of high school. Since beginning community college she has made continuing progress and success in her classes. A young man who had gotten a job at a neighborhood café was let go when the owner needed to downsize staff. This young man, while still in high school and working diligently to graduate, decided he wanted to work in one the local fast food restaurants nearby to his home. With support from his PREP team and school-based supports, he graduated high school, got his food handler’s card, spoke to the manager at the Wendy’s near his home, and then began working there. This

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 84 young man has also been working on his application and enrollment process for the local community college. A young man who has struggled with housing, symptom-related distress, and has been participating in behavioral health court took a huge step this year by applying for and then completing the BESTNOW! Peer Specialist training program. This program involves 10 weeks of classes and then a 6 month internship at an Alameda County mental health program. This young man was the very first PREP participant to complete the program. Throughout the program he had the support of his entire PREP team. The team saw him struggle at times, but ultimately rise to the challenges and shine in his internship at Youth in Mind. Per their website, Youth in Mind is a California-based nonprofit organization founded and steered by youth affected by the mental health system. Youth In Mind members participate in multiple levels of leadership and advocacy, including member leadership summits, mental health conferences, and local advocacy activities with the purpose of promoting positive change through authentic youth engagement. One young man, who is now a PREP graduate, has made huge successes during and after his time in PREP. When he came to the PREP program he could hardly talk or be in an appointment for more than 5 minutes. He would pace back and forth in a room and walk out into traffic without paying attention to the crosswalk signal. He was very dependent on his family and care advocates for transportation to and from the PREP office. And, even though he had been a good student before coming to PREP, he was unable to stay in school after experiencing psychosis and was even thought to be on the Autism spectrum. With the support of the PREP team, he began attending regular therapy appointments, attending groups and being supported to have short social interactions in the community like ordering at a café. He was supported by our Care Advocate Intern from the Best Now Program to learn how to ride public transportation. In his final few months in the PREP program he was able to come to groups and the office completely on his own. He has been doing well in school and is planning his transfer to a four-year university. As part of the PREP graduate program, we offered him the opportunity to become a WRAP facilitator because he had attended almost three full cycles of WRAP. He initially turned down the opportunity multiple times as he was too nervous to talk in front of a group of people and did not think he could handle being a facilitator. However with continued encouragement, he recently attended the WRAP facilitator training and had no problem getting there on his own, staying all day and participating for five days straight! He is looking forward to being a co-facilitator of our next WRAP cycle at PREP training.

Changes in Project Design, Operations and Deliverables Evaluation In the final two months of FY 15-16, under the leadership of the newly assigned Director of Research and Evaluation, PREP started to implement changes in the evaluation process to make sure that outcomes meet higher scientific standards, and the program is able to serve clients and clinicians better. The research team solicited feedback from clinicians and other PREP staff about the potential ways to improve the evaluation structure. This feedback demonstrated that the length of evaluations might be a reason for some clients, especially those who are very symptomatic at the time of evaluation, to refuse completing the forms. Furthermore, the research team detected a need to collect qualitative data about clients’ experiences through interviews and focus-groups. The result of these investigations is a change in the evaluation process that is happening as this report is being prepared. We believe that these new measures, once established, are going to aid in further program improvement.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 85

Summary, Challenges, Recommendations:

Productivity: PREP Alameda ended the Fiscal Year 2015/16 with a productivity rate of 60.78% and a rate of 65.86% when non-billable encounters are added. There have been a series of challenges during this fiscal year such as the office relocation, staff vacancy, high discharge rate, and declining enrollment which have had a direct effect on productivity. The move in November/December: This had a direct effect on staff morale as well as ability to be productive due to disruption caused by the move. Staff had to rearrange their schedules and re- educate clients about transportation, location, and create new expectations for family members and clients. While the move was handled smoothly once the final decision was made, the three months of uncertainty created by the long search process in a hot downtown office rental market, and staff not knowing where we would be going until the 11th hour was difficult for all concerned. Client turnover: A significant client turnover over began in January (approx. 30%). This was a much larger rate of discharge than previously experienced. This sudden surge in turnover occurred due to a decision that was made two years prior in late 2013 during a staffing vacancy to place a “hold” on intakes during the hiring period. This then created a “bulge” in intakes when the “hold” was removed and a corresponding surge in discharges two years later in January of 2016. At the same time as discharges surged, the County resources required for placement of clients leaving PREP began to back up such that it was taking longer and longer to obtain placements with other teams as well as to link clients with psychiatric care. Due to this linkage difficulty, the PREP staff found themselves forced to extend clients in the PREP program beyond their two years in order to ensure appropriate linkage and warm handoffs at discharge. This significantly backed up the PREP client discharge process. Staff Turnover: There were two staff vacancies within this fiscal year. A Staff Therapist resigned in January, 2016 and was not replaced until May, 2016. This required remaining staff to maintain current client caseload, continue to manage the caseload of the vacant position, continue with high level of discharges, as well as continue to do intake of new clients. The Research Assistant for PREP also resigned and was replaced. Client disengagement: There was a period of client disengagement, particularly among clients who were used to coming into the Oakland office which occurred following the move to Hayward. . It took some effort on the part of the staff to re-engage, since many of these were had difficulty navigating public transportation required to come to Hayward. While client no shows and withdrawal from services is recognized as inherent in the recovery process from psychosis, there was a significant “interruption” of the normal flow of business that occurred this fiscal year due to the relocation and subsequent re-orientation of staff and client procedures required. Group Stability: Client groups have dropped off since the move to Hayward (all groups). Much energy and creativity has gone into attempting to increase client participation in groups: Monthly events, creating a welcoming and fun environment, lunches on group days, combining groups into one day to capture more clients, purchasing fun “equipment” (basketball hoop, tetherball, fuzeball). MFG group ended in January and has not started up again mainly due to the large client turnover and slow buildup of new clients. Operational groups plays a significant role in productivity for staff.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 86 Low Census: There has been an increase in discharges since January 2016 and this has occurred at the same time as there has been a reduction in referrals. Client Enrollment: There have been fewer referrals this year than last year from the County. There have been fewer referrals in the first six months of this year as compared to last year during the same period. In the first 6 months of 2015 PREP received 28 referrals. In the first six months of 2016 PREP received 20 referrals. This represents a significant reduction. The response to this has been to start an outreach campaign to re-introduce PREP to various potential referral sources. The Program Manager has begun to outreach to some of the most obvious referral sources: John George, Jay Mahler, Woodroe. and is developing list of other potential agencies to continue outreach into the fall. Training: September 2015 Staff training by Ian Brennan on violence prevention/risk management September 2015 Clinical staff trained and certified in CANS/ANSA-T May 2016 All staff received annual compliance and HIPPA training June 2016 Peer and Family Services Director provided training in Core Competencies And guidelines for peer staff All staff continue to receive training and supervision from Felton Institute as Part of Path of Learning Training Requirement. New staff receive training In: CBTp, MI, Psychosis 101, QSANS/QSAPS, SCID, Case Management.

Recommendations ● Productivity: ○ Continue to monitor staff individually and collectively in individual meetings with supervisor, in staff meetings with a view to making a team effort. ○ Continue to provide “tips” on how to improve productivity on an ongoing monthly basis. ○ Program Manager to continue to cheer staff on when things go well ○ Hold staff accountable when productivity reaches unacceptable levels utilizing corrective action procedures as necessary. ○ Investigate an incentive program? What to offer if everyone achieved high % productivity for one month? ● Low census: Factors to consider: ○ What has changed since last year? Track monthly referrals and discharges and report out in Operations and Executive team meeting ○ Is the rate of discharges the same? ○ Has something changed in the larger system? Research referral sources in the County and report back monthly to Operations and Executive meetings ● Plans to increase client census: ○ Do outreach at least 2x per month in the form of direct outreach to agencies or networking

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 87 ○ Outreach planning and execution has begun with two scheduled in May, 2016. Report back to the Operations and Executive meetings monthly. ● Client Disengagement: ○ Take a serious look at engagement and retention at the Operations Meeting and discuss strategies for change/improvement.. ○ Engage staff in discussion of client engagement and retention ○ Look into research being done on engagement and retention - Dr. Nev Jones will be doing staff education and training on her research ○ Create follow up plan in Operations meetings that include staff roles and reporting ● Group Stability ○ Engage staff in discussion of how to keep groups running smoothly ○ Develop internal client surveys on what works for them ○ Brainstorm ideas for new group topic possibilities ○ Engage staff in discussion of the function of transportation as potential barrier. What are other options? Transportation training, family support. ● Staff Retention - What are current internal and external factors affecting staff turnover? ○ Create internal staff satisfaction survey ○ Role Clarification related to overlapping job duties has been brought up as a source of confusion and staff frustration and pointed to as a barrier to effective job performance. ● Training ○ Increase in-service training on a monthly basis and calendar it so that staff know when trainings will occur ○ Regularize documentation training ○ Continue training staff on optimal integration of services (ACT Model)

Summary PREP Alameda has a lot to be proud of this year:.

❖ PREP served a total of 88 clients and averaged 55 clients per month during a period of staff turnover, a major agency relocation, and a period of increased discharges. ❖ PREP ran a very successful MFG group serving 5-6 families during the year which has formed the basis of ongoing “alumni” support for PREP. ❖ PREP has created a wonderful TAY welcoming environment at its new location in Hayward complete with vegetable garden, basketball hoop, ping pong, BBQ, and fuzeball. Our Peer Specialist has been especially effective in developing this environment. ❖ PREP provided two WRAP cycles during FY 15-16 led by PREP peer staff ❖ PREP has run weekly groups and although attendance has been a challenge since the move, staff continues to think “outside the box” finding creative solutions such as providing lunch, holding groups on different days. ❖ PREP organized and provided 10 events over the course of the year, that’s nearly one every month even in the face of location changes, showing the true spirit of PREP is dedication to service. ❖ Out of all active clients in PREP during FY 15-16, 73% of those clients met with the Employment and Education specialist. Of the clients who received supported

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 88 employment and education services, 77% were in school or working after 12 months in the program. ❖ There was a 57% reduction in the hospitalization rate of PREP clients during the first year of participation in the program. ❖ PREP completed a major move from Oakland to Hayward with virtually seamless provision of services to clients.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 89

Geriatric Assessment and Response Team (GART) Funded by Mental Health Services Act

GART is a mobile geriatric behavioral health team that SERVICE provides support services to older adults ages 60 and The GART Program provides short-term assessments, above with serious behavioral health care needs. GART treatment coordination, medication support, counseling, provides brief voluntary behavioral health care services case management, and crisis support services. Older with the aim of resolving immediate behavioral health adults who are in need of specialty mental health care needs. The GART Program staffing includes a multi- receive GART services for up to sixty (60) days to resolve disciplinary team and support staff. their immediate behavioral health crisis and access support services. CLIENTS Service Provided FY 15/16 GART started providing services in Fiscal Year (FY) 2011-12. GART has had over 3000 contacts with older adults. 143 clients met the screening criteria and were opened to the GART Program. Clients who did not meet the screening criteria were referred to other support services.

Unduplicated Clients Served by Age Groups FY 15/16

Age 75+, (9) DIAGNOSIS In FY 2015-16, Twenty (17), or 51%, of the 42 unique Age 60‐64, Age 70‐74, clients were diagnosed primarily with a Depressive (19) (5) Disorder. Another 15% (6) was primarily diagnosed with Schizophrenia Disorders.

Age 65‐69, (8) Unduplicated Clients Served by Diagnosis Group FY 15/16

N=42

REFERRAL SOURCES Referrals for GART services often come from providers such as ACCESS, Crisis programs, emergency rooms, Psych hospitals, community skilled nursing facilities, residential care homes for the elderly, or Adult Protective Services. Referrals may originate from the client or the client’s family/support system.

Geriatric Assessment Response Team (GART) 409 Jackson Street, #200, Hayward, CA 94544 (510)891-5650

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 90

COMPLETION OF GART SERVICES Of the 42 episodes GART closed in FY 2015-16, treatment goals were reached or partially reached in 27 of these discharges.

EVALUATION RESPONSES

“I am very satisfied with your services”

“You helped me solve many of my problems”

“Thank you for the special home visit services”

“Wish more folks knew about this great Alameda County Program”

“Thank you so much for being there”

Geriatric Assessment Response Team (GART) 409 Jackson Street, #200, Hayward, CA 94544 (510) 891-5650

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 91 ALAMEDA COUNTY UNDERSERVED ETHNIC LANGUAGE POPULATION (UELP) PROGRAMS Prevention and Early Intervention Community Survey and Focus Group Results FY 15/16

October 24, 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 92

Acknowledgements

This report was produced in coordination and partnership with the Alameda County Behavioral Health Care Services and their partners.

 Afghan Coalition,  Portia Bell Hume Center,  Asian Community Mental Health Services,  Community Health for Asian Americans,  Center for Empowering Immigrants and Refugees,  Native American Health Center, and  La Clinica de La Raza

Authors

Lauren Pettis, MSW Program Evaluator Alameda County Public Health Department Community Assessment, Planning, Evaluation and Education Unit

Tracy Hazelton, MPH Prevention Coordinator Alameda County Behavioral Health Care Services

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 93 Table of Contents

Executive Summary ...... 4 Summary of Key Findings ...... 4 Introduction ...... 5 Type of Services, Location and Length of Service ...... 6 Description of clients served ...... 7 Demographic Profile of UELP Survey Respondents ...... 7 Self Report of Physical and Mental Health ...... 9 Self Report of Feelings and Overall Health ...... 10 What participants gained from the program ...... 11 Emotional Benefits of participation ...... 11 Understanding of How to Access Mental Health Services and the Effects of Stress ...... 12 Open-ended Responses ...... 14 Most Beneficial Services and Supports ...... 14 Additional Client Needs ...... 15 What Would Have Been Different Without These Services ...... 16 Anything Else to Share ...... 17 Focus Group Responses ...... 18 Community Strengths and Needs ...... 18 Access to Services ...... 19 Benefits of UELP Services ...... 20 Discussion ...... 22 Methodological Limitations ...... 23 Appendix ...... 24 Appendix A. Full List of Ethnicities Reported in the Survey ...... 24 Appendix B. Focus Group Questions ...... 25 Appendix C. Alameda County Prevention and Early Intervention Community Survey Tool ...... 26

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 94 EXECUTIVE SUMMARY

Alameda County Behavioral Health Care Services (BHCS) worked with seven Underserved Ethnic Language Population (UELP) programs to develop an outcome-based survey. The survey was first given in 2014, and again in 2015. This report is about the 2015 administration.

The survey was disseminated to the UELP community in 11 different languages: English, Spanish, Vietnamese, Chinese, Dari, Hindi, Khmer, Nepali, Korean, Thai, and Burmese and covered the following domains:  Connecting individuals and families with their culture;  Forming and strengthening identity;  Changing knowledge and perception of mental health;  Building community and wellness, and  Improving access to services and resources.

To better understand the meaning of survey responses, BHCS also conducted focus groups with four of the seven UELP providers.

Each UELP program is built on a framework of three core strategies: 1) Outreach & Engagement, 2) Mental Health Consultation and 3) Early Intervention services. These strategies are implemented through a variety of services, including: one-to-one outreach events; psycho-educational workshops/classes; mental health consultation sessions with a variety of stakeholders (families, teachers, faith community; community leaders); support groups; traditional healing workshops; radio/television/ blogging activities; and short term-low intensity early intervention counseling sessions for individuals and families who are experiencing early signs and symptoms of a mental health concern.

SUMMARY OF KEY FINDINGS

A total of 318 respondents from three of the seven UELP programs completed the survey (ACMHS, Hume Center, La Clinica) in 2015. The results from each survey question were assessed by service type: prevention and early intervention. The survey found that UELP clients benefitted in all five domains. Respondents reported a strong sense of cultural pride and feeling confident and good about themselves. The data showed clients understanding risk factors and their impact on mental health, receiving support, and building relationships and community within their respective programs. Respondents also reported knowing how to get help when in need and what to do in the event of a crisis. This is extremely critical because barriers to access can lead to increased stress, anxiety, isolation depression and other mental health concerns. UELP programs offer services to help clients better understand the system, especially if they need higher levels of care including crisis services. While the data on current levels of social and emotional support is positive, the data also shows that the majority of all clients perceived their overall health status to be “poor” or “fair” as compared to “very good” or “excellent” (about 60% vs 40%, n=274). Although, this is a 10% improvement from the 2014 findings, it still indicates that program participants have very high needs. See page 9 and Figures 4 & 5 for details.

Clients from four organizations (ACMHS, CERI, CHAA, La Clinica) were invited to participate in focus groups in order to assess community strengths and needs, access to care, and benefits of service for program improvement and program impact within the identified domains (connection, identity, knowledge, community, or access). Key strengths and needs included: hardworking communities and the need for safety in the community. Key themes in access to care include: lack of awareness of County resources available to them, a general mistrust of service providers, and barriers to access such as not having the proper documentation or lack of insurance. Key benefits of services include: feeling supported, services in their own language, and connection and referrals to other services.

Although this second year of evaluation data shows positive results, it is important to note several limitations in our assessment methods. The number of survey respondents (n=318) is low and is just a small sample of the total number of clients that are served by the UELP programs. It may not be representative of the entire population served. Also, the small sample size limits our ability to measure statistical significance between groups. The survey data was collected at just one point in time and represents a snap shot of the clients during the time they took the survey, which and limits our ability to assess whether the UELP prevention and early intervention services led to any longer-term change in each of the five domain areas (connection, identity, knowledge, community, or access). Please see pages 22-23 for the full list of limitations.

BHCS will work with the Public Health Department’s Community Assessment Planning and Evaluation (CAPE) Unit to better capture the results of PEI programs and the longer-term impact on clients. 4 | P a g e

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 95 INTRODUCTION

Alameda County currently provides mental health prevention and early intervention (PEI) services to underserved and unserved populations through funding from the Mental Health Services Act (MHSA) also known as Proposition 63. Prop 63 was passed by California voters in November 2004 to develop and expand community-based mental health programs based on principles of wellness and cultural competence. PEI services are viewed as a key strategy to:

 “Prevent mental illness from becoming severe and disabling” and

 Improve “timely access for underserved populations.”

Alameda County is an incredibly diverse population of over 1.5 million people. and as such Alameda County Behavioral Health Care Services (BHCS) has developed and implemented seven programs to provide culturally responsive PEI services to community and state-identified underserved populations, which include the communities of: Afghan/South Asian; Asian/Pacific Islander (API) including newcomers and refugees; Native American, and Latino. These seven programs are called the Underserved Ethnic and Language Population (UELP) programs. The providers of these programs include:

 Afghan Coalition,  Center for Empowering Immigrants and Refugees,  Portia Bell Hume Center,  Native American Health Center, and  Asian Community Mental Health Services,  La Cliníca de La Raza  Community Health for Asian Americans,

Each UELP program is built on a framework of three core strategies: 1) Outreach & Engagement, 2) Mental Health Consultation and 3) Early Intervention services. These strategies are implemented through a variety of services, including: one-to-one outreach events; psycho-educational workshops/classes; mental health consultation sessions with a variety of stakeholders (families, teachers, faith community; community leaders); support groups; traditional healing workshops; radio/television/ blogging activities; and short term-low intensity early intervention counseling sessions for individuals and families who are experiencing early signs and symptoms of a mental health concern.

In FY 15/16 these seven UELP providers in total:  Produced 6,210 prevention events  Served 40,833people were served at these prevention events; (duplicated count) and  Served 533 unique clients through early intervention services, which was almost identical to the number of clients served in FY 14/15.

In an effort to begin to understand if the impact of these services on the clients served, BHCS in partnership with the seven UELP programs, collaboratively designed a survey tool to assess both client satisfaction and outcomes. The survey was first given to clients in 2014. The survey was administered again in 2015 to assess the impact and success these programs. The survey has been translated into English, Spanish, Vietnamese, Chinese, Dari, Hindi, Khmer, Nepali, Korean, Thai, and Burmese.

The survey assessed impact of the three core strategies (Outreach & Engagement; Mental Health Consultation and Early Intervention services) across the following domains:  Connecting individuals and families with their culture;  Forming and strengthening identity;  Changing knowledge and perception of mental health;  Building community and wellness, and  Improving access to services and resources.

The survey tool has been piloted and revised several times over the past two years in order for the questions to more accurately In fall of 2015, the survey was administered to clients who had significant contact with the one of the UELP program, which was defined as:  Receiving ongoing early intervention services at least four times;  Finishing an early intervention or a prevention support group  Completing a training series consisting of four or more sessions.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 96 A total of 318 respondents from three of the seven UELP programs completed a survey (ACMHS, Hume Center, La Clinica).

In addition to the survey, focus groups were conducted in order to assess community strengths and needs, access to care, and benefits of service. Four of the seven UELP programs participated in focus groups (Asian Community Mental Health Services, Community Health for Asian Americans, La Clinica de la Raza and Center for Empowering Immigrants and Refugees).

TYPE OF SERVICES, LOCATION AND LENGTH OF SERVICE

UELP providers offered services in two main categories: 1) prevention programs, for clients who are at greater than average risk of developing a significant mental challenge 2) and early intervention programs, designed for clients who were showing early signs and symptoms of a mental health concern.

Figure 1. Type of Service (n=281) The majority of survey respondents (211, 75%) received their services in prevention programs. One quarter of 25% Prevention respondents (70, 25%) received their services in early intervention programs. Early See Figure 1. Intervention 75%

Figure 2. Length of Service in UELP Prevention Programs (n=211) Among the 211 clients receiving 0% prevention services at the time they 8% <3 completed the survey, all of the 0% respondents had been receiving services 4-6 months for six months or less. Most (192, 91%) 7-11 months of the respondents were fairly new to services as they reported their time in 12+ months prevention programs as three months or 91% less. See Figure 2.

Figure 3. Length of Service in UELP Early Intervention Programs (n=70) The majority (27, 39%) of respondents had been receiving early intervention services for only three months or less.

33% <3 Thirty-three percent of respondents had 39% been receiving early intervention 4-6 months services for at least a year or more. This 7-11 months suggests that UELP programs are indeed 13% serving clients with the highest needs. 16% 12+ months Early Intervention clients are also staying in services for long periods of time, indicating a need for more intensive services. Almost half (46%) of respondents were in services for seven months or more. See Figure 3.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 97 DESCRIPTION OF CLIENTS SERVED

DEMOGRAPHIC PROFILE OF UELP SURVEY RESPONDENTS

Table 1. Gender Three-quarters (75%) of the total number of survey Prevention Early Intervention All Respondents respondents were female. (n=175) (n=65) (n=265) One quarter of the Male 26% 25% 25% respondents were male. Female 74% 75% 75% See Table 1.

Table 2. City The majority of respondents (42%) lived in Oakland. The next Prevention Early Intervention All Respondents highest number of respondents (n=177) (n=64) (n=269) came from the Tri-City area as Alameda 1% 0% 1% well as South County; including: Berkeley 0% 2% 0% Livermore (17%), Hayward Castro Valley 1% 3% 1% (11%), and Newark (10%). Dublin 0% 3% 1% See Table 2.

Fremont 3% 11% 5% Hayward 10% 17% 11% Livermore 23% 8% 17% Newark 5% 3% 10% Oakland 47% 34% 42% Pleasanton 5% 3% 4% San Leandro 2% 8% 3% Union City 2% 8% 4% Other/Out of County 2% 0% 1%

Table 3. Age Half of respondents (50%) were Prevention Early Intervention All Respondents 24-years-old or younger. (n=211) (n=70) (n=318) However, the most commonage group of <5 17% 9% 16% respondents (26%) was 35-44 5-14 years 9% 11% 9% years of age. See Table 3. 15-24 years 14% 4% 11% 25-34 years 11% 16% 13% 35-44 years 23% 31% 26% 45-54 years 11% 20% 13% 55-64 years 5% 1% 4% 65-74 years 7% 4% 6% 75-84 years 1% 3% 1% 85+ years 1% 0% 1%

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 98 Table 4.

Race/Ethnicity The majority of respondents were Prevention Early Intervention All Respondents either Latino (67%) or Asian (n=182) (n=67) (n=274) (34%). This reflects the fact that the majority of the respondents Afghan/South Asian 3% 13% 5% came from La Clinica (315, 72%) Asian/Pacific Islander 16% 51% 24% and (64, 20% from ACMHS. The Black African Am. 1% 0% 1% remaining respondents (24,8%) Latino 77% 31% 67% came from the HUME Center. See Alaska Native Table 4. American Indian 1% 0% 0% For a more detailed breakdown White 1% 4% 1% for the specific ethnic groups Multi-race 2% 0% 1% within these broad categories, see Appendix A.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 99 SELF REPORT OF PHYSICAL AND MENTAL HEALTH

Along with the impact of the program on clients, BHCS also wanted to assess the he health-related quality of life (HRQOL) of the individuals served. HRQOL survey questions about perceived physical and mental health and function have become an important component of health surveillance and are generally considered valid indicators of service needs and intervention outcomes1.

The following questions asked respondents, how are you feeling today, in the past 30 days and overall? The responses were offered in a four point scale ranging from poor to excellent. (Figure 4 & 5)

Note: These questions have been adopted from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey (BRFSS). More information on these questions please go to http://www.cdc.gov/nccdphp/brfss/

Figure 4. Assessment of Feelings and Overall Health for Almost half (49%) of respondents receiving Prevention Program Participants prevention services reported their overall health as “very good”, and 9% reported it as “Excellent”. Only 12% of respondents reported their overall health as “poor”. Feeling today (n=182) 32% 42% 23% 3% See Figure 4.

Thirty-nine percent of respondents Feeling past 30 days (n=181) 13% 40% 39% 7% reported feeling “Very Good within the last 30 days, while 7% reported feeling Overall Health (n=205) 12% 30% 49% 9% “Excellent.” Unfortunately, 32% of respondents reported feel “poor” today (the day they completed the survey. See 0% 20% 40% 60% 80% 100% Figure 4. Poor Fair Very Good Excellent

Figure 5. Assessment of Feelings and Overall Health for Early Intervention Program Participants The majority of respondents receiving early intervention services reported Feeling today (n=60) 13% 35% 45% 7% feeling “very good” today (45%), in the past 30 days (52%), and for their overall health (57%). See Figure 5. Feeling past 30 days (n=56) 11% 27% 52% 11%

Fewer respondents (13%) than above (Figure 8) reported feeling “poor” today Overall Health (n=70) 6% 29% 57% 9% (the day they completed the survey) and only 6% of respondents reported having 0% 20% 40% 60% 80% 100% “poor” overall health. See Figure 5.

Poor Fair Very Good Excellent

1 Measuring Healthy Days Population Assessment of Health-Related Quality of Life, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Division of Adult and Community Health November 2000 http://www.cdc.gov/hrqol/pdfs/mhd.pdf

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 100 SELF REPORT OF FEELINGS AND OVERALL HEALTH

The following set of questions asked respondents, how many days during the past 30 days has your health been poor and how many days did your health keep you from doing your usual activities such as self-care, work or recreation? The responses offered ranged from six or more days to zero days (Figure 6 and 7).

Of the respondents who received Figure 6. Assessment of Feelings and Overall Health for Prevention Program Participants prevention services, the majority of respondents reported having poor physical health (35%) and poor mental health (38%) for only 1-2 days within the last 30 days. Poor Physical Health (n=206) 34% 35% 19% 12% See Figure 6.

More than half (54%) of the respondents Poor Mental Health (n=205) 30% 38% 20% 13% reported that poor health prevented them from participating in their usual activities zero days within the last 30 days. See Prevents Usual Activities (n=206) 54% 27% 13% 6% Figure 6.

0% 20% 40% 60% 80% 100% Only a few (6%) reported that poor mental and physical prevented them from doing 0 Days 1-2 Days 3-5 Days 6+ Days their usual activities six or more days in the past 30 days. See Figure 6.

Figure 7. Assessment of Feelings and Overall Health for Early Intervention Program Participants Of the respondents who received early intervention services, the majority of respondents reported having poor physical Poor Physical Health (n=70) 31% 33% 19% 17% health (33%) and poor mental health (33%) for only 1-2 days within the last 30 days. See Figure 7. Poor Mental Health (n=70) 26% 33% 19% 23% Consistent with the data above, half (50%) of respondents reported that within the Prevents Usual Activities (n=70) 50% 26% 16% 9% last 30 days, poor health prevented them from participating in their usual activities zero days in the last month. See Figure 7. 0% 20% 40% 60% 80% 100% 0 Days 1-2 Days 3-5 Days 6+ Days Only 9% of respondents reported that poor mental and physical health prevented them from doing their usual activities six or more days in the past 30 days. See Figure 7.

Respondents seemed to be experiencing

similar amounts of poor physical health as they are with poor mental health. There was also no significant difference between the amount of poor health experienced by prevention and early intervention clients. See Figures 6. & 7.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 101 WHAT PARTICIPANTS GAINED FROM THE PROGRAM

EMOTIONAL BENEFITS OF PARTICIPATION

Respondents were asked eight questions about how strongly they agreed or disagreed with a statement of positive impact (community connection, cultural pride, etc.) that could be attributed to their participation in one of the UELP programs.

The results below are based on a five point Likert scale ranging from strongly disagree to strongly agree. In order to address potential literacy issues, they surveys were translated into clients’ native language and the scale also included smiley faces that changed based on the scale text. See Appendix C. for the complete survey tool. Responses to these survey questions were analyzed separately for prevention programs and early intervention programs.

Figure 8. Emotional Benefits of Participation in Prevention Programs Of the respondents who received prevention services, most Feel confident and good about agreed/strongly agreed that they (90%) 6% 31% 58% myself (Identity, n=210) knew people who would listen and support them, they felt confident in Engage with others in activities 12% 37% 46% themselves (89%), and connected to (Community, n=205) their culture and community (85%). In Feel connected to my culture and addition, 83% engaged with others. See 10% 33% 51% community (Connected, n=210) Figure 8.

Know people who will listen and 6% 31% 59% Only 5% of respondents support me (Community, n=210) disagreed/strongly disagreed with the statements, “I feel connected to my 0% 20% 40% 60% 80% 100% culture and community and “I engage Strongly Disagree Disagree Neutral Agree Strongly Agree with others in activities such as cooking meals, eating together, outings, attending community events, spiritual events, etc.” See Figure 8.

Figure 9. Emotional Benefits of Participation in Early Of the respondents who receive early Intervention Programs intervention services, the majority reported knowing people who would Feel confident and good about myself 12% 18% 37% 26% listen and support them (91%) and felt (Identity, n=68) connected to their culture and Engage with others in activities community (77%). A smaller percentage 13% 13% 46% 25% (Community, n=68) agreed/strongly agreed that they felt confident and good about themselves Feel connected to my culture and (63%), and engaged with others in 6% 16% 39% 38% community (Connected, n=69) activities (71%). See Figure 9.

Know people who will listen and 3%4% 49% 43% However, a few respondents (19%) support me (Community, n=70) disagreed/strongly disagreed with the 0% 20% 40% 60% 80% 100% statement, “I feel connected to my culture and community” and 16% of Strongly Disagree Disagree Neutral Agree Strongly Agree respondents disagreed/strongly disagreed with the statement, “I engage with others in activities such as cooking meals, eating together, outings, attending community events, spiritual events, etc.” felt neutral. See Figure 9.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 102 UNDERSTANDING OF HOW TO ACCESS MENTAL HEALTH SERVICES AND THE EFFECTS OF STRESS

The majority of respondents in prevention programs (83%) agreed/strongly agreed with the statement, “I believe lacking basic needs can impact my overall health” and 87% of respondents agreed/strongly agreed with the statement, “I believe stress, worries, and happiness can impact my mental and emotional health.” Only a few respondents (5-6%) disagreed/strongly disagreed with those statements. This data suggests that respondents have a firm understanding of

how stress can impact their mental, emotional, and overall health. With greater understanding comes the potential for positive change, self-care and wellness awareness.

Eighty-seven percent of respondents in prevention programs agreed/strongly agreed with the statement, “I know how to get the services or community resources I or my family need” and a (86%) of respondents agreed/strongly agreed with the statement, “I know where to get help in a crisis”. This is extremely important because barriers to access can lead to increased stress, anxiety, isolation depression and other mental health concerns. Very few respondents (5-6%) disagreed/strongly disagreed with the above statements.

Minority populations that are monolingual and/or LEP (Limited English Proficiency), may have trouble navigating the behavioral health care system and accessing services or resources when they are in need and/or in crisis. These UELP programs assist with this navigation and access piece. Mild or moderate mental health conditions related to the client’s environment (lack of housing, lack of understanding of our public systems, poverty) can become more serious mental health conditions without this mental health service of resource/referral and service navigation. These PEI programs help prevent the need for more intensive and costly levels of care.

Figure 10. Knowledge of How to Access Mental Health Services and the Effects of Stress in Prevention Program Participants

Know where to get help in a crisis (Access, n=206) 8% 39% 47%

Know how to get services or resources when in need 8% 45% 42% (Access, n=208)

Believe lacking basic needs can impact my overall health 12% 32% 51% (Knowledge, n=209)

Believe stress, worries, and happiness can impact my 7% 26% 60% mental and emotional health (Knowledge, n=208)

0% 20% 40% 60% 80% 100%

Strongly Disagree Disagree Neutral Agree Strongly Agree

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 103

Ninety percent of respondents receiving early intervention services agreed/strongly agreed with the statement “I believe stress, worries, and happiness can impact my mental and emotional health,” and only 3% of respondents strongly disagreed/disagreed with this statement.

The majority of respondents (94%) agreed/strongly agreed with the statement, “I believe lacking basic needs such as adequate money, food, or housing etc. can impact my overall health and only 3% of respondents strongly disagreed/disagreed with the statement.

Eighty-one percent of respondents in early intervention programs agreed/strongly agreed with the statement, “I know how to get the services or community resources I or my family need” and 84% agreed/strongly agreed with the statement, “I know where to get help in a crisis”. Less than 10% disagreed/strongly disagreed with those statements.

As mentioned above, this is critical be it’s such a challenge for populations that are LEP to navigate the behavioral health care system or tap into community resources, and part of the services offered by UELP programs is to help clients better understand the system, especially if they need higher levels of care including crisis services.

Figure 11. Knowledge of How to Access Mental Health Services and the Effects of Stress in Early Intervention Program Participants

Know where to get help in a crisis (Access, n=69) 7% 42% 42%

Know how to get services or resources when in need 13% 48% 33% (Access, n=69)

Believe lacking basic needs can impact my overall health 3% 38% 57% (Knowledge, n=69)

Believe stress, worries, and happiness can impact my 7% 31% 59% mental and emotional health (Knowledge, n=70)

0% 20% 40% 60% 80% 100%

Strongly Disagree Disagree Neutral Agree Strongly Agree

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 104 OPEN-ENDED RESPONSES

Four open-ended questions were asked on the survey to better understand: 1) if and how respondents felt services were beneficial to them; 2) what kind of needs they currently have; 3) if and how their lives would be different if they were not receiving prevention or early intervention services; and 4) anything else they thought would be helpful for service providers to know.

During the analysis, answers to each question were grouped into themes to help assess which topics were most important to respondents. The following tables list each theme by the number of respondents who reported it. Responses for participants in prevention and early intervention programs have been combined. To further illustrate the frequency of certain themes, each table is followed by a “word cloud” of the 20 most common themes. The larger the word, the more frequently it appeared in the answers given for each question. Each word cloud was generated using the software called NVivo 10.

Note: there were more themes than what is listed in each of the tables; the cutoff was a minimum of ten responses to be considered critical information.

MOST BENEFICIAL SERVICES AND SUPPORTS

Table 5. Benefits of the # of “Someone to listen program Respondents to my stresses!” Reporting That Benefit Someone to Talk to/Listen 30 to Me Increased Understanding & 26 Awareness Generally Beneficial 26 Communication 23 Family 21 Feeling Strong Support 18 Mental Health 18 New Skill Development 18 Relationships, Community, 15 Socializing Other Answers 12 Individual Counseling 11 Support Groups 11 Information & Resources 10 *222 survey participants responded to this question.

Someone to Talk to/Listen to Me was the most common theme in this section. According to respondents, it was extremely important for them to just have someone to talk to, and just as important, someone to listen to them. Many respondents have said they would be experiencing more problems or be worse off if it were not for these services (Table. 7). Having a place to go where clients can speak to someone and be heard seemed to be invaluable to respondents. “I am grateful to have these services and someone to speak to.”

Increased Understanding & Awareness refers to respondents gaining insight into their lives and/or their current/past situations. Many participants expressed that through these programs, they had an opportunity to learn about child development and therefore was able to better understand their children. Other participants described situations in which they were more aware and better prepared to handle situations that came their way. “Feel more assured and self-confident to deal with the developing crisis.”

Communication was another important recurring theme. Respondents referred to their experiences of learning how to communicate properly and effectively. Respondents discussed finally being able to express themselves and learning how to listen as well. “Learn to understand my daughter and listen to her.”

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 105 Other Answers were less common or did not fit into a specific theme.

Generally Beneficial included positive statements about the program or agreement with the question, without identifying specific aspects.

Other key themes about beneficial services that generated ten or more responses included: help and services for families, mental health supports, individual counseling, support groups, information and resources for accessing services, and opportunities for relationship-building, socializing and developing a community.

ADDITIONAL CLIENT NEEDS

Table 6. Needs of Clients # of Respondents “I need Reporting That help/assistance Need regularly!” None 46 More help & Support 35 More Activities & Classes 31 Communication 13 Counseling Services & 13 Treatment Health Services 13 Parenting Support & 12 Childcare *185 survey participants responded to this question.

None yielded the largest responses from respondents and this is very consistent with last year’s data. One possible reason is that they are currently getting their needs met in the programs and services they are receiving and do not have any additional needs at this time.

More Help and Support was another large theme. Respondents were very interested in continuing their services. “Keep talking to someone, more sessions.” The data above shows the majority of respondents reporting their overall health as poor (Figures 4 & 5). This really speaks to the need of these particular populations. Another possibility is that respondents were reporting that these services were extremely beneficial, so it is no surprise that they wished to continue participating in services.

More Activities & Classes were more specific requests than just needing more help and support. Respondents very similarly reported wanting to continue services but this focused on having more workshops or classes specifically for folks to participate in. “Would like more programs, workshops like this one.” Respondents seemed to really enjoy the workshops and classes they were participating in. Some respondents even went as far as making suggestions with some classes or topics they would like to see going forward, such as workshops on bullying, classes on motivation, parenting classes.

Communication expressed respondent interest n learning how to communicate more effectively. For example, some respondents wanted to know how to talk about certain topics with their kids.

Other key themes about client needs that generated ten or more responses included counseling services and treatment, health services, parenting support and childcare needs.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 106 WHAT WOULD HAVE BEEN DIFFERENT WITHOUT THESE SERVICES

Table 7. Different Experiences # of Respondents Without Receiving Services Reporting That “I would not Difference know how to Learning Opportunities 35 help myself or another person!” Continued Previous Path 19 Lonely, Depressed, Sad 15 More Problems, Worse Off, 15 Doing Bad Stressed, Worried, Anxious 15 Uniformed About Services, 15 Programs and Resources Other Answers 12 Without Direction, Awareness 12 *179 survey participants responded to this question.

Learning Opportunities was the largest theme in this section. Respondents reported that without their participation in these programs, they would not have had the opportunity to learn what they did in the program. “I wouldn't have the opportunity to learn everything I did here.” “I would like to have known how to treat my adolescent daughter. I learned a lot.”

Continued Previous Path was the second most recurring theme. Respondents explained that without these services, they would have continued doing what they were doing, prior to the program, such as making mistakes or getting into trouble, fighting with family. “I would have continued making the same mistakes.” “I would be the same or more hysteric, it help me to be more calm.”

Other Answers included responses that were vague or arbitrary and did not necessarily fit in this section. Some of the answers seemed like responses to other questions.

Without Direction/Awareness is a larger theme than it has been in the past. Respondents reported feelings of being unaware of what to do, feelings of being in the dark or ignorant about certain issues had they not been participating in their UELP programs. “I wouldn’t be living each day with more conscience.” “I would have been in ignorance.”

Other key themes that generated ten or more responses included: feeling lonely, depressed, sad, worried or anxious; having more problems or being worse off in general, or being uniformed about services, programs and resources available to them.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 107 ANYTHING ELSE TO SHARE

Table 8. Anything Else # of Respondents “That I am very Reporting that thankful to this Additional program!” Information Appreciation 58 No 35 Expand or Continue 25 Services Great/Enjoyed, 17 Program/Service Learned/Improved 14 Helpful/Supported 10 *160 survey participants responded to this question.

Appreciation was the largest theme in this category. Respondents were so thankful for the services they have been receiving. Again, this is consistent with the word cloud above, as “Thank” was the most frequently occurring word in respondents’ answers to the question.

Expand or Continue Services is an important and consistent theme as respondents kept reiterating the need/want for more services. Just as in the Needs section, respondents would like to continue with their services and believe there should be more of them (i.e. classes and workshops). Some respondents talked about expanding classes because they enjoyed the people in their groups and expressed wanting to invite more people from the community and possibly meet more frequently. “More group sessions so we can see each other more.” “Want to have this meeting every week.” “Would like for these classes more often.”

Learned/Improved is a theme where respondents expressed that through their participation in services and the learning they have done, their lives have improved in some way. “I learn how not to hurt my love one with my actions.” “I am happy because my daughter would like to come with me her father.” “I know better to control my stress.” “This program…help me to be a better person and a better mom for my kids.”

Helpful/Supported is another theme seen throughout where respondents report how happy they with the services they have received and how they felt helped and supported by the program “I’m very happy with this program and the support that they provide.” “These services are very helpful to low income people.”

Other key themes that generated ten or more responses included: no, which meant respondents had nothing else to share, and great/enjoyed program/service, as respondents wished to again express how much they liked, had fun and enjoyed the services they received.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 108 FOCUS GROUP RESPONSES Focus groups were conducted with UELP prevention programs to get a deeper look into the client perspective as well as a better understanding of access to care and benefits of service.

Out of the seven UELP programs, four providers volunteered their programs to participate in the focus groups. Each of the focus groups were conducted in December 2015 and the number of participants ranged from as few as four to as many as twelve. The following programs participated in the focus groups where all of the participants receive prevention services.

 Asian Community Mental Health Services, (ACMHS) o Cantonese-speakers (and some participants spoke English) o Seven women and three men in their 40s-60s o Translator/interpreter was used during the session

 Community Health for Asian Americans, (CHAA) o Mongolian-speakers (and some participants spoke English) o Four women in their 30s-40s o Translator/interpreter was used during the session

 Center for Empowering Immigrants and Refugees, (CERI) o Burmese and/or English-speakers o Ten women and two men in their teens and 20s

 La Clinica de La Raza, (La Clinica) o Spanish Speakers (and some participants spoke English) o Five women and two men in their 40s-50s o Translator/interpreter was used during the session

Each of the four groups were recorded using notes as well as audio devices to ensure a record of exact quotes. Transcriptions were created from the audiotapes. Content analysis was used to analyze the data and group them into themes. Each of the questions focused on three major aspects: Community Strengths and Needs, Access to Services, and Benefits of UELP services in order to align with the community health and wellness surveys.

The following section highlights the themes resulting from the focus groups.

Note: Some of the themes in this section contain direct Quotes from focus groups participants as well as indirect quotes or paraphrases translated by the interpreters labeled as Example.

COMMUNITY STRENGTHS AND NEEDS

Hardworking Hardworking was the main theme that surfaced within two groups while discussing community strengths. Participants expressed pride in the fact that came from and/or belonged to communities that worked hard.

Example: He said he is proud of his community because it's a hard-working community. They start small businesses which is a lot of hard work.

Safety Feeling unsafe in the community was a major theme that came to light when discussing community needs. This resonated with most participants from both CERI and La Clinica. Participants from CERI reported feeling unsafe because of drugs and gang violence (i.e. rowdy teenagers, drive-by shootings) that they see in their communities. Most, if not all, participants reported having at least one friend that had been shot. Many of the participants from La Clinica reported being scared to walk down their street or take their children to school, and that they had no faith in the police department to protect them.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 109

Quote: “People cannot walk by themselves in the street and feel safe. How can we feel proud of our community if there is a lot of violence wherever they go?”

Example: “But she feels like it is personal safety because they lost the trust. They don't know who is going to rob them, they don't know if they can trust the police or other people.”

ACCESS TO SERVICES

Accessed County Services A few respondents from both ACMHS and CERI reported having seen a therapist or having a case manager at some point while living in Alameda County. The respondents from CERI appeared to have more access to clinics, as many of them were still in school and could access services on campus.

Language Barrier Limited English proficiency was reported across most of the groups as a barrier to getting the services they need. Specifically at ACMHS, the participants, a primarily Cantonese-speaking group, reported how limited services were for them because they were mostly held in English or Mandarin.

Culture Conflict Saving face and the struggle between their cultures and the US culture is a very important theme that surfaced most for the ACMHS and CHAA focus group participants. In the Asian communities, needing services for physical or mental health needs, may be seen as weak and/or shameful. According to participants, a lot of their stress seemed to manifest as physical symptoms, but when they went to the doctor, it was often recommended that they see a counselor, which is heavily stigmatized in their cultures.

Example: “Also I think that for the Chinese, because we're very -- we always keep things to ourselves, it is especially helpful for this type of course to be held in Chinese. They don't know it, they don't know where to find help. And they tend to think that, this kind of problem is -- lost face…Yeah, shameful. And they do not want to talk to anybody else about it. So this is really helpful for people, too, because they can come among strangers and [be] really open about it. And once they find out what it does to them, I'm sure they will keep coming and it'll be very helpful for them. It's just that not a lot of people know about this. We need to really -- outreach. I think outreach is really important, yeah”.

Lack of Awareness of County Services Available For most of the focus groups, there was a general consensus among participants that they were unaware of County services or resources available to them outside of what they were currently receiving within their UELP provider organizations.

Example: “He says that the County doesn't offer those services, that one (himself or herself) has to look for the services. He says that when he feels stressed, he goes to the park to walk with their children and that is the way that he handles the stress.”

Quote: “Mongolians, because we’re new arrivals and new to behavioral health… but there’s nothing…”

General Barriers to Service Respondents across all four of the focus groups reported experiencing other barriers to accessing county services, including lack of insurance, cost, and/or not having the proper documentation. Not being able to receive those services has led to additional stress and for some, and one in particular had psychotic break that resulted in hospitalization before they could access needed services.

Example: So she is saying that a lot of times, they have to go home and deal with the emotions, and then at the breakdown, then they are sent to the hospital.

Quote: “Being undocumented. Because usually you need a social security card and here they don't start from that point. So it is a barrier, really tough, because they feel as though they don't belong. When they ask for the documents, they feel that people say 'you don't belong”.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 110 Mistrust of Service Providers Across all of the focus groups, participants discussed how unnerving it could be sharing their personal information with a therapist or a case manager, especially when there is so much stigma around mental health. The respondents from CERI, explained that talking to therapists sometimes felt disingenuous and that there was no investment on the part of the therapist.

Quote: “It feels strange. It feels strange…Because she doesn’t know anything about me and I don’t know anything about her. And it doesn’t feel right explaining your true feelings or personal business to someone you don’t know. “

Housing Participants from CERI reported having a lot of challenges navigating the system and securing housing. Many of the participants discussed situations in which they had been denied housing. One participant with children had been denied; while another said that she had to prove she was homeless first before she could qualify. She became emotional, explaining how her mother had poor credit and rental history and how they were always fearful they were going to be denied when looking for housing.

Quote: “They even told me that, too, for certain places nowadays, you have to apply and by like, ‘oh yeah, I’m homeless,’ like you got to really make it thick, like oh you been out on buses and sleeping in streets and stuff like that. They don’t really care if you’ve been couch hopping – you got a place to go”.

Employment Group participants from both CERI and CHAA explained how difficult it has been for them to secure employment. Respondents specifically from CHAA explained that new Mongolians coming over to the US are well-educated and often over-qualified for employment available in the US. Due ot language barriers, they may still be unemployed and/or homeless. Additionally, because of the culture and the need to save face, they often choose not to return to their native countries.

Quote: “I have a job now but for some reason I feel the need for a second job. Or going to school. I think going to school would be better but I still think I need more money. Like it’s always money with me, like, it’s always in my mind. ‘Oh, how am I gonna pay for this later on?’ And that’s what’s stopping me – because I work so many hours, it’s like how am I going to find another job, just to have a second job? Or it stops me from starting to apply for classes or something. But I don’t know what the fee might be, what the charges are gonna be. It’s like, confusing.”

BENEFITS OF UELP SERVICES

Gaining Skills/Learning Techniques In most of the focus groups, participants reported learning new skills or techniques to help with their mental health and well-being. Some focus group participants even self-reported a complete reduction in symptoms.

Example: “He is sharing that when he first came, he had a lot of anxieties and stress and from this class he learned 3 things. One is how to let go. Second is to think about other positive methods. Three is 'turn around' or choose another way to handle it -- positive way to handle it. “

Example: “He's saying now he learn about triggers, early warning signs, and he know how to avoid them, and also how to plan -- in case things like this happen, what he can do, positive way to handle those problems. “

Feeling Supported Participants across all of the groups reported feeling supported from their prevention providers. They told stories of how they were struggling or in a bad place and that it was through the guidance and support of their programs that they were able to improve their situations. Others talked about the comfort in knowing that should a problem ever arise, that there was someone they could always talk to. This is consistent with the data reported in the health and wellness surveys. See Table 1.

Example: “He is he used to be very isolated, trying to use his own method to solve his problem, his struggle, and he mentioned that from this group he learned to -- he learned a way to release the stress and emotional struggles.”

Example: “She said that [name] is a very special person, and whenever she feels like she needs to talk to somebody or feels like she has a problem, she knows she can come. She doesn't look anywhere else, she comes straight here.”

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 111 Solidarity Across most of the focus groups there was a level of comfort that was expressed among participants. They reported a strong connection to the members in their wellness groups and that they felt more at ease to see the common experiences they all shared between them. They reported feeling a bond with their group members and some referred to themselves as a family.

Recommend to Others Across most of the groups, participants reported wanting to connect more people to the services they were receiving in their prevention programs. This is consistent with the results from the survey. Respondents reported the need for more outreach and wanting to include more folks from the community in these services.

Services in Own Language Across most of the focus groups, participants reported receiving services in their own language as a very important component of their program. As mentioned earlier, most of the participants have experienced difficulty when communicating with providers outside of their UELP programs, which can be a large barrier to receiving County services. It goes without saying that a large credit to their success is that fact that these UELP services are actually provided in participants’ own languages. Participants felt comforted in knowing that their UELP providers also understood their culture, which ultimately made them feel more like home, like community.

Example: “He thinks that when they had the help outside, it has been a little bit more difficult. You go to a community that you don't know. Here they can speak their own language, be among their own people, and you feel at home. It is difficult -- this is the place of starting to look for other types of help. He thinks so. “

Connections and Referrals Participants across all of the focus groups reported that if they are unable to get the services they need in-house, the program will always try and connect them and refer them to another resource in order to meet their need.

Example: “If the program doesn't offer the services or the help that she is in need of, they refer her to other programs that have the ability to help her out. She thinks that the services are very beneficial and that they are most needed in this area, in this community.”

Without the Program’s Existence: Participants in most of focus groups reported that they would be worse-off without the services of their UELP providers. This again is consistent with the responses found in the survey. See Table 3.

Quote: “Well, I would still have anger issues. I would still be in the abusive relationship I was in”.

Example: “He is sharing that without this class, he would, like – spinning around with his depression and the problem, sleeping problem.”

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 112 DISCUSSION

Findings from both the survey and the focus groups suggest that both prevention and early intervention clients are benefitting from the ethnic-specific and culturally- sensitive mental health services provided through UELP.

The survey found that UELP clients benefitted in all five domains as follows:

Connecting individuals and families with their culture The data shows that both prevention and early intervention clients reported a strong sense of cultural pride. A little over 80% of clients agreed/strongly agreed feeling connected to their culture and community as a result of their UELP participation.

Forming and strengthening identity The data shows that the majority of clients developed strong identities. Eighty-nine percent of prevention respondents and 63% of early intervention respondents reported feeling confident and good about themselves.

Changing knowledge and perception of mental health The survey data reflects impacts in respondents’ knowledge and perception of mental health. Ninety percent of respondents receiving early intervention services agreed/strongly agreed with the statement “I believe stress, worries, and happiness can impact my mental and emotional health”. The majority of early intervention respondents (94%) also agreed/strongly agreed with the statement, “I believe lacking basic needs (such as adequate money, food, or housing etc) can impact their overall health. This data suggests that the education component in the UELP programming has been successful in helping clients to understand risk factors for poor mental and physical health, and, ways to mitigate this risk.

Building community and wellness Survey result suggest, that clients have been able to build relationships and community within their respective programs. And that they have found support within those programs as well. Eighty three percent of prevention respondents and nearly three-quarters of early intervention respondents (71%) reported engaging in activities with others. The bulk of prevention (90%) and early intervention (91%) respondents reported knowing people who will listen and support them.

Improving access to services and resources Many respondents reported that they know how to get help when in need and what to do in the event of a crisis as result of their UELP participation. Aforementioned, this is extremely critical because barriers to access can lead to increased stress, anxiety, isolation, depression and other mental health concerns. UELP programs offer services to help clients better understand the system, especially if they need higher levels of care including crisis services. Eighty-seven percent of respondents in prevention programs agreed/strongly agreed with the statement, “I know how to get the services or community resources I or my family need” and about the same amount (86%) of respondents agreed/strongly agreed with the statement, “I know where to get help in a crisis”. Very few respondents (5-6%) disagreed/strongly disagreed with the above statements. Eighty-one percent of respondents in early intervention programs agreed/strongly agreed with the statement, “I know how to get the services or community resources I or my family need” and 84% agreed/strongly agreed with the statement, “I know where to get help in a crisis”. Less than 10% disagreed/strongly disagreed with those statements.

While the data on current levels of social and emotional support is positive, the data also shows that the majority of all clients perceived their overall health status to be “poor” or “fair” as compared to “very good” or “excellent” (about 60% vs 40%, n=274). Although, this is a 10% improvement from the 2014 findings, it still indicates that program participants have very high needs. See page 9 and Figures 4 and 5 for details.

Focus group findings corroborated survey findings about program benefits. When asked an open-ended question about the benefits of their participation in a UELP program, participants mentioned themes that reflected the five domains assessed through the survey: Most commonly, focus group themes fit under the domain of “building community and wellness,” including: Someone to Talk to/Listen to Me; Increased Understanding and Awareness; Feeling Strong Support; Relationships, Community, Socializing.” In addition, UELP improved access to services and resources, such as [resources] for Family, Mental Health, Individual Counseling, Support Groups, Information and Resources.

Additional focus group questions assessed community strengths and needs, access to care, and benefits of service for program improvement and program impact. Key strengths and needs included: hardworking communities and the need for safety in the community. Key themes in access to care included: lack of awareness of County resources available to them, a general mistrust of service providers, and barriers to access such as not having the proper documentation or lack of insurance. This is important to note

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 113 because these populations are still facing stigma and experiencing significant challenges when trying to access much needed services. The UELP providers administer services to such unique and distinct populations in Alameda County. Through the focus group themes, it is evident that the UELP programming is an ideal set-up for these populations; improving health and wellness by meeting their cultural, language and support needs.

METHODOLOGICAL LIMITATIONS

Although this second round of data shows positive results, it’s important to note the following limitations of surveys and focus groups:

1. The number of respondents for this survey is higher than last year’s survey, however: Since the number of respondents (n=318) is just a small sample (about one-third) of the total number of clients that are served by the UELP programs, it may not be representative of the entire population served. Also, the small sample size limits our ability to measure statistical significance between groups.

2. Considering this survey was conducted at just one point in time, the data only represents a snapshot of clients during the time they took the survey, which limits our ability to assess whether the UELP prevention and early intervention services led to any long-term change in each of the five domain areas connection, identity, knowledge, community, or access). The lack of a comparison group makes it difficult to distinguish the effects of the program from other factors in clients’ lives.

3. There are a total of seven UELP programs, however only three UELP providers are represented in this data. And the majority of respondents (72%) came from just one provider- La Clinica. Twenty percent of respondents came from ACMHS and the remaining 8% were from the HUME Center. Therefore, it is important to note that the data in this may not accurately reflect all of the UELP programs.

4. There were a lot of similar or repeat answers in the open-ended section of the survey tool. This might suggest that some respondents completed their surveys in a group setting and may have shared answers. It is possible that some of the answers to the open-ended questions reflected some else’s ideas and not their own responses.

5. Three of the four focus group sessions needed translation services. Many of the focus group questions did not translate well or the same across the different groups, so the intended meaning behind the questions could have been “lost in translation”. Also, the responses from participants were interpreted and translated back to the facilitator in English, and therefore we have some paraphrasing rather than direct quotes from participants.

6. Lastly, the focus groups were conducted with four out of the seven UELP providers. Out of those four providers, all participants were enrolled in prevention services. Early Intervention client perspective was not represented in the focus group data.

For future survey rounds, BHCS will be working with the Public Health Department’s Community Assessment Planning and Evaluation (CAPE) Unit to strengthen its evaluation to better capture any changes and the long term impacts of these PEI programs.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 114 APPENDIX

APPENDIX A. FULL LIST OF ETHNICITIES REPORTED IN THE SURVEY

Afghan Japanese African American Korean American Indian Latina Anglo-Saxon Latina, Mexicana Asian Indian Latino Asian-Khumu Latino/ Native American Bangladeshi Latna Black Mexican Caucasian Mexicana Chinese Mexicano Espano Mexico European American Mien Filipina Mixed Filipino Pakistani Hawaiian Peru Hispana Salvadorian Hispanic South Asian Hispanic/Latino Tibetan Honduran Vietnam Indian Vietnamese Ispano Vietnamese Ispanu White/Mex

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 115 APPENDIX B. FOCUS GROUP QUESTIONS

(Community strengths & needs)

1. The County wants to hear from you, in your own voice. What do you think are your community’s strengths? What issues does your community face? What would you like health providers to know about your community?

(Access)

2. When feeling stressed or going through life changes here in the U.S., what do you do? We have county resources to help you when feeling stressed or going through life changes. Do you know about these services? (List some examples?) Have you tried to use these services? If you did, what was your experience when trying to get help?

3. If you did receive help, what was your experience in using the services? If you were not able to get services, what were some of the reasons? What challenges or barriers did you face?

(Benefits of services)

4. You answered these questions in the survey and the answers were very touching, but I wanted to take this time to talk more about it. In thinking about the services and supports you received through this program, what has been the most beneficial or helpful to you?

5. What would have been different if you hadn’t found this program or these services?

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 116 APPENDIX C. ALAMEDA COUNTY PREVENTION AND EARLY INTERVENTION COMMUNITY SURVEY TOOL

Alameda County Prevention and Early Intervention Community Survey

Agency/Program:______Date

Please check which service the participant is receiving: Prevention Service EI Service How long (in months) has participant received services: ______------Please help us improve our services and activities by telling us how you feel about the following statements. Read each statement carefully and then circle the number that best represents how you feel about the statement.

Mark only one response per question. Please circle the number corresponding to your answer. Strongly Strongly AS A RESULT OF PARTICIPATING IN THESE Disagree Disagree Neutral Agree Agree N/A SERVICES………

1. I know people who will listen and support me 1...... 2...... 3...... 4...... 5…..…....NA when I need to talk to someone.

2. I feel connected to my culture and community. 1...... 2...... 3...... 4...... 5…..…....NA

3. I engage with others in activities such as cooking meals, eating together, outings, attending 1...... 2...... 3...... 4...... 5…..…....NA community events, spiritual events, etc.

4. I feel confident and good about myself. 1...... 2...... 3...... 4...... 5…..…....NA

5. I believe that stress, worries, and happiness can 1...... 2...... 3...... 4...... 5…..…....NA impact my mental health or emotional health 6. I believe lacking basic needs such as adequate money, food or housing, etc. can impact my overall 1...... 2...... 3...... 4...... 5…..…....NA health.

7. I know how to get the services or community 1...... 2...... 3...... 4...... 5…..…....NA resources I or my family need.

8. I know where to get help in a crisis. 1...... 2...... 3...... 4...... 5…..…....NA

Please turn over to answer a few more questions

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 117

Health Questions

1. How are you feeling today? Please circle one answer. О Excellent О Very Good О Fair О Poor

2. How you have been feeling in the past 30 days?

О Excellent О Very Good О Fair О Poor

3. Would you say that your overall health is excellent, very good, good, fair, or poor? Please circle your answer.

О Excellent О Very Good О Fair О Poor

4. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health poor?

0 1-2 3-5 6+

5. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health poor? 0 1-2 3-5 6+

6. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

0 1-2 3-5 6+

*****Final Thoughts***** ****Staff please complete the below section with clients in English****

Client Info:

ETHNICITY: ______AGE: ______

GENDER: ______CITY WHERE YOU LIVE: ______

1) In thinking about the services and supports you received through this program what has been most beneficial or helpful to you? ______2) What needs do you still have that you would like or need help with? ______3) What would have been different if you hadn’t found this program or these services? ______4) Is there anything else you’d like to tell us about? ______Thank you for taking the time to answer these questions.

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ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 118

Text Line Program Year End Report FY2015-2016

“I didn't know talking to someone could make my chest feel light again, thank u so much – Texter

“Thanks for making sure I didn't hurt myself – Texter

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 119 Table of Contents Text Line Year End Report | 2

Introduction, Acknowledgement, Text Line Basics, How Texters Find the Text Line . . . . 3

Year At a Glance...... 6

Suicide Risk and Distress Level ...... 8

Non-Suicidal Self-Injury...... 13

Reasons for Texting ...... 15

Post Text Plans, Referrals & Feedback ...... 19

Youth Ambassadors ...... 23

Looking Forward...... 25

References...... 26

Appendix I: Out of Area Texters ...... 27

Appendix II: High Risk NSSI Example ...... 29

Appendix III: CSS Counselors Talk About the Text Line ...... 32

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 120 Introduction Text Line Year End Report | 3

This report includes Crisis Support Services of Alameda County Text Line Program (Text Line) statistics for Fiscal Year 2015-2016. The Text Line continued to serve youth who were on any place along the continuum of crisis during Fiscal Year 2015-2016.

Alameda County is unique because it affords youth more crisis services than many other counties in California (Children’s Crisis Services Workgroup, 2015). The range of services, including crisis stabilization services and community based programs, are integral parts of the safety net for Alameda County youth. This net helps youth access appropriate mental health support and avoid expensive and traumatic hospitalizations when not necessary.

The Text Line is another way Alameda County pays particular attention to the needs of youth during crisis (Children’s Crisis Services Workgroup, 2015, p 14). Youth reach out to the Text Line in all stages along the crisis continuum. Some youth text while in partial hospitalization programs or after a recent discharge from inpatient hospitalizations. Some reach out when worried about a friend, or just feel “down”. Youth also reach out when they do not feel comfortable, or ready, to talk to a provider, but want extra support anonymously. Sometimes these sessions help texters realize they do deserve support and that there are, in fact, avenues for help even when they feel helpless.

At the beginning of one session a texter wrote: “i haven't told anyone about this because i feel like i don't feel comfortable telling others face to face and i just feel like there's a huge boulder that is crushing me and no one is there to help”.

They wrote that they decided to reach out because: “there was a guest speaker for my class and i learned about this there”.

Later in the session after validating them for reaching out to the Text Line the counselor asked if the texter had considered talking to a school therapist. The texter wrote: “i haven't tried that out but i might think about it”.

At the end of the session they wrote: “thanks for helping me today. i gotta go now and finish up my homework.”

In subsequent text sessions, the texter let us know they started seeing a school therapist and a few months later they texted in again, during a crisis after a break up.

The Text Line goal is to continue to enhance Alameda County youths’ access to care in crisis – helping them to make sense of those crushing boulders and navigate around them.

At the end of a session another texter summed up well why we do what we do: “Thanks for being here for me, I feel safe”.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 121 Introduction Text Line Year End Report | 4

Acknowledgement The Text Line would not be able to exist without the skilled caring of trained volunteers and dedicated shift supervisors. Their passion for serving the community is what makes all of what follows in this report possible.

A special thank you to Benjamin Pauw for help with coding text sessions, to Jasmine Ramezanzadeh, who contributed an anonymized description of a text session (see Appendix II), and to the Text Line counselors who commented on the Text Line for this report (see Appendix III).

Text Line Basics

 When: The Text Line operates 7 days a week, from 4:00 p.m. to 11:00 p.m.

 How: Alameda County middle and high school students “opt-in” to the service by texting the keyword “Safe” to 20121.

 Free: Most major cell companies, including Verizon and Sprint, do not charge texters when they reach out to hotlines on 20121.

 Off Hours: If a texter opts-in when the Text Line is closed, the texter will receive an auto message with the Text Line hours and the 24 hour National Suicide Prevention Lifeline’s phone number.

 Educational Message Services (EMS) continues to be our vendor for the Text Line software.

 Phone to computer: Teens text us from phones, and we engage in sessions with them from CSS computers. The software prevents anyone from texting to the Text Line through an app such as google voice or WhatsApp – it must be from a cell phone number.

Note to Readers: Any reference to texters in this report will have been anonymized for confidentiality. Often the pronoun will be “they” and other identifiers will have been changed.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 122 Introduction Text Line Year End Report | 5

How Most Texters Find the Text Line Most texters find out about the Text Line through the CSS Community Education Teens for Life program. Presenters from Crisis Support Services give classroom-based youth suicide prevention workshops to middle school and high school students in Alameda County. The workshops are designed to enhance a young person’s ability to identify a peer who may be in crisis. Participants are encouraged to reach out to a trusted adult. They receive a Teens for Life card that reviews the curriculum, such as “Warning Signs of Suicide” and “How to Help a Friend”. The card also includes the Text Line, Crisis Line and The National Suicide Prevention Lifeline’s contact information.

With the nature of how social media relationships develop and the spread of information over the internet, the news of our Text Line travels beyond geographic boundaries. We are beginning to see texters reach out to us from across the country. Many hear about us via friends through social media. For instance, according to a Pew Report, 57% of teens have met a new friend online (Lenhart, Smith, Anderson, Duggan, Perrin, 2015). See Appendix I regarding our “Out of Area Texters” policy.

What texters are saying about Teens for Life presentations

“if a guy named Ben is there, can you tell him I said thanks for his presentation? —Texter

“In health class today we had a guest speaker talking about depression and suicide and i figured it might be a good place for me to talk to someone – Texter

“i remember a man named matt came to my school and gave me a little card to text this number and i get bullied a whole lot. Later in the text session the texter wrote: im really glad

matt gave me the card – Texter

“Ben talked a lot of depression and i felt like i could relate to it .. It also was so coincidentally the right time because i felt like i needed to talk to someone – Texter

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 123 Year at a Glance Text Line Year End Report | 6

Text Sessions and Contacts by Year since Launch “Contacts with opt-in only”, means no interaction with a counselor occurred when the texter opted in. The most common reason is when texters opt in when the Text Line is closed.

1000 Text Contacts: FY 2011-12 - FY 2015-16 900

800

700

600 685 Sessions: Opt-in & 500 Counselor contact 578 400 Contact with Opt-in only 300 385 312 200

100 202 96 127 157 74 0 32 2011-12 2012-13 2013-14 2014-15 2015-16 (8months)

Individual Texters by Year since Launch Some texters reached out more than once during the year, and some had texted prior years. 350 Individual Texters: FY 2011-12 - FY 2015-16 300

250

200 New Texters 264 150 216 Returning Texters from prior years 100 177 165

50 58 33 46 0 15 17 2011-12 2012-13 2013-14 2014-15 2015-16 (8months)

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 124 Year at a Glance Text Line Year End Report | 7

Gender FY 2015-2016 2

Female (124) 124 Male (19)

161 Transgender (4) Unknown (161)

Questioning (2) 19

4

Gathering demographic information can be challenging over text. It involves a decision tree that weighs the following questions:

1. Will asking for this information further create safety for this texter right now? 2. Is it related to the topic the texter is presenting? 3. Will it help or hurt the rapport?

We no longer always assume a texter’s gender based on their name. Many names are gender neutral. Sometimes asking a gender identity question helps a texter know the counselor is comfortable with the subject and enhances the texter’s comfort in sharing about their stressors. Other times it might take valuable time and attention away from the matter at hand. This year we labeled people as “Unknown” if the gender identity was not explicit. These issues also relate to our data on age, sexual orientation, and school.

7 Text Sessions Resulted in a report to Child Protective Services

When we realize a mandated report is necessary, we will let the texter know that we want to get them additional help to keep them safe, and get resources to their family. Texters learn about mandated reporting requirements during Teens for Life presentations, on the Text Line Program web page, and during a text session when a texter asks about it.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 125 Suicide Risk and Distress Level Text Line Year End Report | 8

Suicide Risk While Alameda County creates a stronger continuum of crisis care for youth compared to other California counties, many youth still experience distress. Suicide is the third leading cause of death among youth aged 10-14, and the second leading cause of death for youth aged 15-34 years, in the United States (CDC, 2015). In Alameda County in 2013 there were 12 documented youth suicides (California Department of Public Health, 2015), and 19.5% considered suicide each year in 2011-2013(California Department of Education).

The measures below indicate ratings of suicidality as determined by counselors during text sessions.

LEVEL OF SUICIDALITY FY 2015-2016 400 353 350

300

250

200

150 101 100 64 50 35 25 0 0 0 1 2 3 4 5

EXPLANATION OF SUICIDE RISK RATINGS 0 = No talk or thoughts of suicide 1 = Has suicidal thoughts or feelings; has no plan or means to enact plan 2 = Thinks of suicide, has devised a plan to die, does not have intent or means for suicide attempt 3 = Has persistent suicidal thoughts, has a plan & is actively trying to obtain the means to die 4 = Has a plan for suicide, easy access to the means, but has not yet taken any action to harm self 5 = Has recently made or is about to make a suicide attempt, wants to die, and is alone

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 126 Suicide Risk and Distress Level Text Line Year End Report | 9

Counselor Rated Suicide Risk Change - From Start to Finish Below is a chart of counselor ratings for suicidality change at the beginning to end of sessions. 4.5 Suicide Risk Change: Average Start - Finish

4 4

3.5 3.28 3 3

2.5

2 2 2

1.5

1.18 1 1

0.69 0.5

0 Start @ 0 end @ 0 (353) Start @ 1 (101) Start START@ 2 (64) Start @ 3 END(35)

Discussion of Suicide Ratings at Level 4 Of the 25 sessions at a level 4 at start, 14 ended at level 4. Eight individual texters had the 25 sessions. Seven of those 25 sessions were with one adult texter, who now calls and utilizes the Crisis Line. In the majority of the sessions these texters agreed to text or call back if the suicidal urges grew. They also engaged in safety planning, including exploring the My3app. Usually texters do not also call us, but with texters who experience high suicide ratings, it is more common that they use both methods to reach us.

We are grateful to be part of their support system. For instance, in one session that started and ended at a 4, the texter said that the session was “A little calming” yet the level of suicidality was still high. At the end of the session they wrote that they would be safe that night and agreed to text back the next day. The next day they started the session by saying: “I'm better than last night I texted Joe last night he told me to check in today”. The hope is that this texter (and all texters) consistently feel the sessions are supportive so they will call or text again in times of need.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 127 Suicide Risk and Distress Level Text Line Year End Report | 10

Counselors also tracked distress levels and the change of distress level from the beginning of the session to the end. It is a subjective measure used by the counselors. One way we can track the distress level change is mention of a positive post text plan, thank you’s, and the texters stating they feel better.

Counselor Reported Texter Distress Level Change: Start -> Session End 6

5 5

4 4 Start @ 1 Start @ 2 3 3 Start @ 3 2.48 2 2 2 Start @ 4 1.65 Start @ 5 1 1 1 0.52 0 START END

Explanation of Distress Level Ratings 0 = No Apparent Distress 1= Minimal Distress 2 = Mild Distress 3 = Moderate Distress 4 = Significant Distress 5 = Very High Distress

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 128 Suicide Risk and Distress Level Text Line Year End Report | 11

Example Suicide Risk and Distress Level Below is an excerpt of a text session with someone who was expressing suicidal ideation, and had a plan. The counselor rated the texter’s level of suicide at the start of the session at a 2 (2 = Thinks of suicide, has devised a plan to die, does not have intent or means for suicide attempt) and at the end of the session she rated the texter at a level 1 (1 = Has suicidal thoughts or feelings; has no plan or means to enact plan). The counselor rated the distress level at the beginning of the session at a 4 (4 = Significant Distress) and at the end at a level 2 (2 = Mild Distress). All of these ratings are subjective, and the suicide ratings are not linear.

The texter started the session expressing distress about a romantic relationship.

Texter: I'm feeling really depressed and a guy just broke my heart and I really need someone to talk to. I don't know what I did wrong

After establishing rapport, the counselor assessed for suicide:

Counselor: Casey this sounds so hard, are you having any thoughts of suicide?

Texter: It's always a lingering thought I suppose but I've had harder times than this. I'm keeping myself calm by listening to music and drawing. Those things always help the thought of suicide dissipate

Counselor: Thank you for answering, I'm glad that you know of ways to cope with your thoughts of suicide

Counselor: And I just want to clarify, have you only had thoughts or do you have a plan of how you would kill yourself or any prior attempts?

Texter: I have attempted once and I do have a plan. I live in a tall house and I plan to jump

Counselor: I'm really glad that you texted in tonight and thank you for being open about your thoughts of suicide. I just want to make sure that you are safe, are you home alone right now?

Texter: No I'm with my family and I would never jump when they are here. It's feels good being able to tell someone what I'm really thinking

Counselor: Suicide can be a difficult thing to talk about, Im glad that you know this is a safe place to talk about what you're really thinking

Texter: Thanks for listening...when I tell people I'm suicidal they look at me like I'm a monster

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 129 Suicide Risk and Distress Level Text Line Year End Report | 12

During the session the counselor normalized the texter’s feelings around the breakup, gave space for the texter to come up with a plan for next steps with the troubled relationship and also explored their resources for more support. The counselor also continually checked in on their distress level.

Towards the end of the session the counselor continued to mirror the texter’s emotions and the texter said they would reach out again if they needed to:

Counselor: That must be really frustrating, to not know what caused him to stop talking to you and him not responding to you when you reach out.

Texter: Yes it is and thank you for all the advice and help that you have given me

Counselor: You're welcome, I'm glad that talking helped you feel better :)

Texter: It did and I'll probably reach out to you in the future and notify you if needed

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 130 Non-Suicidal Self-Injury Text Line Year End Report | 13

Non-Suicidal Self-Injury Non-suicidal self-injury (NSSI) can be of particular concern to Text Line counselors. Onset of use of this coping mechanism is often during Middle School or High School (Walsh, 2014). The function of the behavior is usually to deal with emotional overwhelm or to ground oneself while feeling a sense of dissociation (“out of body”) (Self-Injury Outreach & Support, 2015). While most people who are engaging in NSSI are doing so to cope, and not to die, there are a significant number of people - up to 40% - who are at other times experiencing suicidality (Whitlock, Minton, Babington, & Ernhout, 2015).

We will often explore the triggers and encourage safety plans during text sessions involving NSSI. It is a balance to take a harm reduction stance while also consistently assessing for current safety and suicidality. Our goal is to create a safe space for texters who find themselves in the NSSI cycle, so they will continue to reach out to us in the future. We want them to know when they text us that we can help them stay safe while also not stigmatizing them.

People who are struggling with NSSI often need extra support, so we validate them for utilizing us as a safe place, and also encourage more help seeking behaviors, such as working with school counselors, and other mental health professionals.

This fiscal year a significant number of sessions involved mention of NSSI (although there were fewer than last year). We coded most of those sessions and divided them into 4 main categories for why the texter mentioned NSSI.

Focus of Text Sessions with NSSI Content 30

25

20

15

10

5

0 To Avoid Past Use Mentioned Just Did NSSI Third Party Concern

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 131 Non-Suicidal Self-Injury Text Line Year End Report | 14

Please see Appendix II for a description of a session related to NSSI. Below are quotes from sessions that included NSSI:

Texter: I'm 8 months clean from self harm and I want to cut really bad right now

Texter: Last year I became depressed and started cutting. I attempted to suicide multiple times and went to a hospital for a month

Texter: I cut myself yesterday for the first time in three months I didn't feel like I had anyone who would listen

Texter: My current friend can't let go of a girl who used to be her friend and its hurting her mentally which leads her to physically harming herself

Texter: I just don't feel anything any more and I keep cutting to try and feel and thats not working, I just don't want to be alive anymore

Texter: It was shallow and it's already gone but it still upset me.

Texter: I'm texting because I don't want to cut myself

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 132 Reasons for Texting Text Line Year End Report | 15

Reasons for Texting Youth all across the US are routinely experiencing mental health challenges. In 2014, 11.4% of adolescents aged 12–17 in the United States (an estimated 2.8 million adolescents) had at least one major depressive episode, and yet more than half did not receive treatment (Substance Abuse and Mental Health Services Administration, 2015).

While Alameda County offers many avenues for help, we can assume that a significant number of youth fly under the radar just due to the sheer numbers who experience hardship as well as the stigma attached to seeking help for mental health difficulties. One study revealed that nearly 1/3 of Alameda County 7th – 11th graders experienced feelings of depression in 2011- 2013 (California Department of Education). In Alameda County in 2013-2014 13.2% of youth ages 12-17 reported needing help for emotional or mental health problems (UCLA Center for Health Policy, 2015).

The top five reasons texters reached out to us in Fiscal Year 2015-2016 echoes the data. Many expressed feelings of depression, isolation, stress, and brought up serious mental health challenges and non-suicidal self-Injury. The very top issue expressed was relationship strife, and usually with primary relationships such as family, friends or a romantic partner. Some texters were ready to reach out to professionals for help in addition to the text line, or they were using us as an adjunct to therapy between sessions. Other texters preferred to stay under the radar for the time being.

When coding text sessions this year, just as in prior years, we noticed that texters expressed multiple stressors in their lives. We created “themes” for recurring reasons. Most of these themes are used in the California Mental Health Services Authority (CalMHSA) common metrics project. Some text sessions had more than one theme. Coded text session themes were determined via:

1. Coding of counselor write ups in our data base 2. Reading and coding the actual scripts

The next page shows content themes with the largest number of text sessions during Fiscal Year 2015-2016.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 133 Reasons for Texting Text Line Year End Report | 16

TEXT SESSION THEMES FISCAL YEAR 2015-16

MENTAL ILLNESS/EMOTIONAL PROBLEMS 62

NON-SUICIDAL SELF-INJURY 82

LONELINESS/ISOLATION 207

DEPRESSION 209

RELATIONSHIPS:FAMILY/FRIENDS/ROMANTIC 258

0 50 100 150 200 250 300

TEXT SESSION THEMES FY 2015-16

LGBTQQI 20

SUICIDE THIRD PARTY 23

BULLYING 23

MENTAL HEALTH PSYCHIATRY 25

BEREAVEMENT/GRIEF 44

SCHOOL STRESS 47

0 5 10 15 20 25 30 35 40 45 50

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 134 Reasons for Texting Text Line Year End Report | 17

Below are a few quotes from sessions that relate to these themes:

RELATIONSHIPS: ROMANTIC Texter: I want to break up with my boyfriend but every time I say we should break up he claims he'll kill himself and I feel like the best way out of this is to just kill myself At the end of this session the texter wrote: Okay thank you for your help!

RELATIONSHIPS: FAMILY Texter: I had gotten into an argument with my dad and it kinda jus reminded me of how my mom left and got that thought in my mind that he would leave just like my mom did At the end of this session the texter wrote: thank u so much I feel better

RELATIONSHIPS: FRIENDS: Texter: I have a really big friend group, but I'm not close to anyone anymore At the end of this session the texter wrote: Thanks for taking the time to text me.

DEPRESSION: Texter: Peer advocates gave us this number in class today just in case we want to talk to someone about our problems. So I sorta would like to vent My depression is just eating at me At the end of the session they wrote: Thank you so much :)

LONELINESS/ISOLATION: Texter: Everyday at lunch now i go to the library and pretend to read. But i cant focus because everywhere i look i see people that use me or people that look so happy At the end of the session they wrote: Ok tysm

MENTAL ILLNESS/EMOTIONAL PROBLEMS Texter: I was on a 5150 two weeks ago and now im depressed again and ive been skipping school At the end of the session they wrote: I have to go now but thank u

LGBTQQI: Texter: Yea I'm agender and he keeps calling me his son At the end of the session they wrote: thanks for talking to me!

SUICIDE THIRD PARTY: Texter: Yeah, he tried to commit suicide after father's day. He's dad died on father's day At the end of the session they wrote: Ok, thank you so much for these resources

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 135 Reasons for Texting Text Line Year End Report | 18

BULLYING: Texter: I'm constantly being told I'm going to go to hell I lost all of my friends when I came out, I was tired of denying a part of myself, but sometimes I feel like it would be easier to just be straight At the end of the session they wrote: Thank you, I'm beyond grateful. I will try my hardest :) Goodnight!

MENTAL HEALTH PSYCHIATRY: Texter: I went to the psych hospital, and then back to the E.R. and then recently I started cutting again I have major depression disorder and severe anxiety At the end of the session they wrote: thank you so much I most definitely will [text again]

BEREAVEMENT/GRIEF: Texter: Hi Danny. I just wanted to talk to someone because today I went to my uncles funeral and this just doesn't feel real to me At the end of the session they wrote: Thank u for talking to me goodnight:)

SCHOOL STRESS: Texter: Another thing that stresses me out my grades have been dropping and I've been ignoring homework Is my future it feels like I'm under so much pressure At the end of the session they wrote: Ok thank you for talking with me goodnight

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 136 Post Text Plans, Referrals & Feedback Text Line Year End Report | 19

Post Text Plans Many text sessions are ended by the texter after their safety has been established and they have had a chance to explore the triggering event, or in our texters’ jargon – “vent”. But sometimes, and often in the case of texters who have had prior contacts with us, counselors also have the opportunity to engage them in exploring a plan for the next few hours.

The most common answers were:  Listen to Music and favorite musician  Watch movies or Youtube  Homework  Spend time with friends  Sleep  Spend time with family and pets  Write in journal  Eat

Referrals and information resources There are times when texters are open to receiving resources and referrals at the end of a session. Texting is an especially effective way to transmit that kind of information as the texter will have it readily accessible – and not stored on a scrap of paper to be lost. Usually our texters are youth, but on the few occasions that we have texted with adults, often the text session involved a referral and information resource.

The most common referrals were:  National Suicide Prevention Lifeline  TeenLineOnline.org  ACCESS and Sausal Creek: to adults  USReachOut.com  Community Mental Health agencies  24 hour Crisis Text Line  My3app.org  24 hour Crisis Chat Line  Trevor Space  RAINN National Sexual Assault Hotline:  PFLAG to adults

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 137 Post Text Plans, Referrals & Feedback Text Line Year End Report | 20

“I really appreciate it <3” – Texter

Feedback: This year we created a post text survey, with the help of our provider for the Text Line software, EMS. We had originally considered using a HIPAA compliant survey platform, such as the paid version of Survey Monkey, but when EMS offered to help us create a survey that not only could handle quantitative answers, but also a qualitative answer, we took them up on the offer. The survey is SMS based and we offer it at the end of a text session. Texters can text SURVEY to the same short code as our Text Line: 20121. The survey has 4 scaled questions (on a scale of 0 – 5 how would you rate x) and the last question allows for a longer narrative text answer.

So far, however, we have yet to receive an answered survey. When we explored this lack of response with youth volunteers, many said that incentives are helpful. However, because we want to keep confidentiality, this seems unlikely.

In the meantime we continue to receive positive feedback from texters. See a sample below:

Texter: Okay thank you so so much you may have saved my life

Counselor: You were able to reach out to us tonight though which is a huge and brave thing

Texter: Yeah I've used this twice before and it really helped

Texter: It's good to feel like someone cares because even I wasn't taking myself seriously

Texter: I'm feeling way better thank you for helping me

Texter: Hi, I wasnt sure to txt or not, I have been wanting to try the hotline many times.

At the end of the session they wrote: Thank you for hearing me out thank you!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 138 Post Text Plans, Referrals & Feedback Text Line Year End Report | 21

Texter: THANK YOU SO MUCH you were so so helpful

Texter: Ok thank you it's just easier to talk things not face to face

At the end of the session they wrote: Thank you for listening to me and stuff I'm feeling ok I'm watching a show and eating icecream :))

Texter: Yeah. Having support like this can be really helpful especially because I can be embarrassed to constantly ask my friends for help and support

At the end of the session they wrote: I think I'll be good for now. Talking about things helped a lot. Thanks for the help and support

Texter: I don't know why I hurt. I just want to curl up and start crying. I already got put in a hospital for just having those thoughts

At the end of the session they wrote: Thank you for taking the time to talk to me. I think I'm good for tonight. I feel better now.

Texter: Haha yeah thank you for your support I am safe now thank you so much I will text again if I do feel like this

Texter: I like texting, it is a discrete way so that no one knows that I am doing so.

At the end of the session they wrote: I've never felt like this before in my life, especially something of this intensity thanks for helping me

Texter: I just got dumped thru a text message

At the end of the session they wrote: I am feeling much better thank you for your time Thank you! Have a good night

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 139 Post Text Plans, Referrals & Feedback Text Line Year End Report | 22

Texter: Very true :) thank you for talking to me you really helped me not worry as much as I was earlier

Texter: THANK YOU SO MUCH you were so so helpful

Texter: It's almost time for the line to close. I have a question is it open 7 days a week?

Texter: i never talk this much about her. its scary to talk though, i think thats why I’m texting instead. i actually don’t feel as crazy as i did when i first started talking to you

Texter: Thank you for giving me really good advice to use in the future (:

Texter: Im glad that you're there to listen...

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 140 Youth Ambassadors Text Line Year End Report | 23

Youth Ambassadors It is important to hear the voices of the community that the Text Line serves. Every year we find ways to collaborate with youth. This year, as in past years, the Text Line Program benefited from a local high school’s senior year community “Quest” service project. Three high school seniors had multiple meetings with the Text Line Coordinator to learn and exchange information with the Text Line Program. Their focus was youth suicide prevention and youth depression. Not only did the students benefit from the program but they also served as a helpful teen focus group for the Text Line Program.

The Text Line Coordinator also benefited from an intern from a program organized by La Clinica de la Raza, FACES. La Clinica’s program is supporting youth of color to consider and gain access to careers in mental health.

All the youth received an abbreviated crisis Text Line training from the Text Line Coordinator, discussed ways to disseminate suicide prevention information to other youth, and how to mitigate the damage from irresponsible social media and enhance positive mental health social media messaging aimed at youth.

Student final project slide – pictured: two Quest students with the Text Line Coordinator Quest student Victoria Houston (pictured left) created a presentation for her final project. Her research targeted the question of why youth attempt suicide, and the extent of high school students’ knowledge of suicide and suicide prevention pathways. Her ability to internalize the training adult Text Line counselors receive at CSS exemplifies how youth can understand and utilize basic crisis counseling skills with each other. Her project will be used as an example by her school for other future QUEST students.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 141 Youth Ambassadors Text Line Year End Report | 24

Another QUEST Student explored the concept of safety planning and in her own words and surveyed her network of friends to gain a sense of what they know about prevention and how to reach out for help. As with all Youth Ambassadors, in the process or her work, she was simultaneously educating her peer network about suicide prevention and how to reach out for help.

CSS Logo by a QUEST student volunteer

Quest student, Walter Lee (above), gathered friends together to participate in a Text Talk Act (http://www.creatingcommunitysolutions.org/texttalkact) exercise that involves the use of text messaging to survey groups of youth who are together on their knowledge and experience with mental health. The aim is education and stigma eradication. He presented on the experience at a CSS staff meeting.

A Quest student wrote in a letter to the Text Line Coordinator: “I was able to observe how well and how helpful a crisis line can help teens and even adults, thank you for that. Seeing how much talking or texting someone about their situation can help them get through another day, thanks to the organization.”

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 142 Looking Forward Text Line Year End Report | 25

COMMUNITY LINKS We will continue to let area youth serving agencies know about the Text Line.

BUILD ADDITIONAL TEXT CAPACITY This year we will be working on developing a small team of counselors who can volunteer an extra shift or more a month as Text Line counselors. When texts are not coming in, they would be working on suicide prevention youth centered and/or new media related projects for the Text Line.

YOUTH ISSUES & SPECIALIZED TRAINING In prior years the Text Line developed tip sheets for the Crisis Line and Text Line on issues especially pertinent to youth (NSSI, Bullying and Electronic Bullying, Third Party Social Media, and Youth Resources). We will continue to refine those existing tip sheets and develop more youth related trainings and tips sheets.

YOUTH INVOLVEMENT The Text Line always benefits from the voices of youth. We will continue to work with youth volunteers. Currently the Text Line coordinator is working with a youth who is developing a self- care template for high school – early college years.

PREPARE FOR EXPANSION OF POPULATIONS Counselors have begun to see more Alameda County TAY and adults texting in. Often our target population is on social media, which has no geographic boundaries. As a result, we are receiving more out of county texters. We strive to connect them to their local resources, but we will likely continue to be challenged by this.

OUTCOME MEASUREMENTS We want to continue to measure the success of our program. In Fiscal Year 2015-16 we developed a SMS based post text survey to offer texters after a session. No texter has attempted to take it yet, however. This Year we will continue consulting with youth and experimenting with ways to encourage the use of the survey.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 143 References Text Line Year End Report | 26

California Department of Education, California Healthy Kids Survey and California Student Survey (WestEd). As cited on www.kidsdata.org, a program of the Lucile Packard Foundation for Children's Health. Retrieved July 2016.

California Department of Public Health, Death Statistical Master Files; CDC, Mortality data on WONDER (Apr. 2015). As cited on www.kidsdata.org, a program of the Lucile Packard Foundation for Children's Health. Retrieved July 2016.

Center for Disease Control, (2015). Suicide Facts at a Glance, http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf (retrieved July 2016)

Children’s Crisis Services Workgroup, (2015). Kids in Crisis: California’s Failure to Provide Appropriate Services for Youth Experiencing a Mental Health Crisis. http://www.cccbha.org/PublicFiles/CCCBHA/KidsinCrisisWhitePaper_FINALrev4_08_15.pdf Retrieved July 2016.

Hasking, B., Rees, C., Martin, G., Quigley, J. (2015). What happens when you tell someone you self- injure? The effects of disclosing NSSI to adults and peers. BMC Public Health 15:1039 DOI 10.1186/s12889-015-2383-0

Lenhart, A., Smith, A.., Anderson, M., Duggan, M., Perrin, A., “Teens, Technology and Friendships.” Pew Research Center, August, 2015. http://www.pewinternet.org/2015/08/06/teens-technology-and- friendships/

Self-Injury Outreach & Support, (2015). Self-Injury – A Guide for Mental Health Professionals. http://sioutreach.org/learn-self-injury/mental-health-professionals/#ffs-tabbed-17 Retrieved July 2016.

Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: United States, 2015. HHS Publication No. SMA–16–Baro–2015. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.

UCLA Center for Health Policy Research, California Health Interview Survey (Dec. 2015). As cited on www.kidsdata.org, a program of the Lucile Packard Foundation for Children's Health. Retrieved July 2016.

Walsh, B. (2014, February 12). Understanding, Managing, and Treating Non-Suicidal Self-Injury [Webinar]. In Injury Control Research Center for Suicide Prevention series Retrieved from: http://suicideprevention-icrc-s.org/understanding-and-treating-complex-puzzle-non-suicidal-self-injury

Whitlock, J., Minton, R., Babington, P., & Ernhout, C. (2015). The relationship between non-suicidal self- injury and suicide. The Information Brief Series, Cornell Research Program on Self-Injury and Recovery. Cornell University, Ithaca, NY.

Report submitted by Karen Oberdorfer, CSS Text Line Coordinator, July 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 144 Appendix I: Out of Area Texters Text Line Year End Report | 27

Out of Area Texters We have been receiving a number of texts from people outside of Alameda County. When we ask these texters how they found us, most say through on line friends or via google – although most google searches for crisis text lines seem to bring up the national Crisis Text Line site.

Because youth historically do not often choose to reach out for help, we do not want to turn them away until we assess for suicide and safety, validate them for reaching out and encouraging them to reach out to local or national sources. We will never assume a texter is not in Alameda County based on their area code, so if their phone number has a different area code we first ask them what city they reside in before we refer them to other resources.

*Note: Our counselors are dedicated and want to help, and often do not remember about our out of area policy when faced with someone who wants help, even if the person is not in imminent danger.

One texter savvy with social media had a session with a counselor who forgot about our out of area policy:

Texter: I don't know if you know what kik is but its like a worldwide texting app and I have a friend who is talking about hurting someone or himself

At the end of the session they wrote: Thank you for your help! I texted another line like yours and they didn't reply till after you had and they didn't help me at all. Afterwards I told them how I felt and they gave me horrible attitude. So thank you for helping me

Out of Area Triage Session – Example Below is an example of a “triage” session CSS shift supervisor, Will Gutierrez, had with a texter. From start to finish, this session with took 40 minutes. Sometimes these types of sessions can take more time, depending on the severity of the situation.

Counselor: Hi, my name's Will, how are you doing tonight?

Texter: Hi. I've been feeling different for these past months :/

Counselor: From the looks of that face, I'm guessing that's not such a good thing :/ How are you feeling now?

Texter: Like, just really sad, and I've been keeping it from everyone

Counselor: OK, really sad, and keeping it a secret from everybody… Are you feeling suicidal tonight?

Texter: I don't feel suicidal, but the thing is wouldn't mind dying, i wouldn't cause my death

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 145 Appendix I: Out of Area Texters Text Line Year End Report | 28

but it's not a problem

Counselor: Hmm yeah, I see the difference there. Sounds like life's not too hot right now, so you're less afraid of dying. What's your name?

Texter: Sam, turning 16 in a few months

Counselor: Hey Sam, thanks for reaching out tonight. Is this your first time contacting a line like this?

Texter: Yes it is

Counselor: Sam, that's great. It's not easy reaching out like this about something that's hard to talk about. Where are you texting from? I'm in California.

Texter: I'm from North Carolina

Counselor: Sam, thanks. I should tell you our service is just for texters in our area. But I can give you some text/chat resources that you could talk with. Is that OK?

Texter: Okay

Counselor: OK. You can text START to 741-741 . More info: www.crisistextline.org/get-help- now/

Counselor: There's text, chat, e-mail and phone help available here: http://www.yourlifeyourvoice.org/pages/ways-to-get-help.aspx

Counselor: Also, here's the National Lifeline Crisis Chat Line: www.crisischat.org/chat/

Counselor: Check them out Sam, I'm sure there will be someone there to talk with

Texter: Okay,thank you

Counselor: OK Sam, good night

Texter: Goodnight

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 146 Appendix II: High Risk NSSI Example Text Line Year End Report | 29

High Risk Text Session Involving Non-Suicidal Self-Injury For many youth who text in while dealing with non-suicidal self-injury (NSSI) we are an adjunct to therapy they are already receiving. We then are useful as a boost of support when the texter is triggered, or sometimes a sounding board and guide while they are deciding whether to access a higher level of care. However, there are times when we might be the first adult they have spoken to about the NSSI.

Early disclosure of psychological difficulty by adolescents to a responsible adult often mitigates long term future struggles for that adolescent (Hasking, Rees, Martin & Quigley, 2015). Studies have shown that youth will more likely disclose first to other youth, rather than to an adult, any difficulties they may be having, including the practice of NSSI (Hasking, et al, 2015). An obvious factor in a youth deciding to disclose to an adult is the anticipation of a supportive and non- judgmental reaction (Hasking, et al, 2015).

The text session described here is one example of a counselor facilitating a youth’s willingness to confide in their parent. The text session started with a texter saying they felt bad.

Texter: I am really feeling bad about myself and I'm afraid I'm going to do something I'll regret

The texter, an 11th grader, said they were having problems with friends and with school. They said they did not want to kill themselves, but they did engage in NSSI:

Texter: I've been self harming for a long time now and it's too hard to stop

Texter: I just don't want to go too far on accident sometime and I'm afraid that will happen if I continue like this

The counselor who took this text, Jasmine Ramezanzadeh, recounted later that “when I hear that someone cuts, it always ups the severity of the situation for me.”

Most Text Line sessions that include NSSI as a theme, while very concerning, do not need to have confidentiality broken, such as calling parents/guardians or the police, as the process of texting helps texters regulate emotions and remain safe. According to studies, 90% of NSSI actions do not need medical attention (Walsh, 2012). What set this text session with Jasmine apart from many sessions was the texter’s fear they would not be able to keep themselves safe when they cut, their strong desire to cut then, and availability of the means - razors.

Jasmine continued to assess the situation while also developing the rapport. She did not immediately take a directive stance. She was aware, however, that there was a possibility she might need to break confidentiality if the texter did not agree to reach out to caregivers if the text session did not suffice to keep the texter safe.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 147 Appendix II: High Risk NSSI Example Text Line Year End Report | 30

Jasmine reflected on what this session was stirring up for her: “I remember being young and so prone to not taking the best care of myself, and more importantly, being so afraid of telling anyone, especially my parents.”

Jasmine found out that the texter had a safe relationship with their parents and then encouraged the texter to reach out to the parents.

Texter: My mom is downstairs I'm just scared if I tell her she's going to be upset with me

As the session progressed the texter eventually agreed to talk to the mother.

Texter: Okay do you think I can go talk to my mom and you stay on the phone and then I'll text you back? Or not? I totally understand if not!

Jasmine assured the texter she would be there.

Jasmine reflected on the session at this point: “What I think is a challenge with the text sessions is the lack of tone. It can be really hard to know the severity of a situation or whether someone really intends to follow up with the safety plan. Building rapport can make that easier. I find that it's easy to do that by validating and normalizing the texter's experience, which I think I was able to do with this texter when it came to how they self-harm to cope.”

The texter sent a message a half hour later. They said they had confided to their mother that they were regularly in great emotional pain, and that they self-harmed. The texter’s mother was concerned and very supportive, and told the texter she would get a counselor. Jasmine asked how the texter was feeling about it.

Texter: Pretty good, but I'm going to be honest with you and when I got off the phone with you I broke down and I cut, quite bad, but then I talked to my mom and told her that it happened tonight, so she knows but it still hasn't stopped bleeding so I'm a little nervous but whatever

Jasmine recalls upon reading this: “I felt a bit of disappointment in myself that they had in fact self-harmed. Looking back on it, I asked them to not self-harm during our interaction, but after building a good rapport I should have asked them to try not to do anything until they had spoken with their mother.”

Note: Usually counselors do not try to convince texters to not do the NSSI if the behavior is not putting the person at immediate risk, but in this case the texter had revealed the fear that their cutting would go too far.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 148 Appendix II: High Risk NSSI Example Text Line Year End Report | 31

Jasmine encouraged the texter to reach out again to the mother. She reminded the texter that they took care of themselves before by confiding in their mother and they could do so again.

Texter: I know but I told her it wasn't too bad, mostly bc I thought it would stop quicker and it hasn't yet

Jasmine: it's okay, you didnt know how bad it was. I think she would prefer you told her that you underestimated it and ask for help rather than let it get very bad, she won’t be upset

Texter: But I don't want to go to the hospital because something might happen there

Jasmine: that's a very legitimate fear and you have a right to feel that way. but something really bad can also happen if you don’t get it fixed up. what if you ask ur mom to help stop the bleeding and you guys can try and if it doesnt stop in 10/15 minutes you can consider it then?

Texter: I'm so scared

Jasmine: I know, and you are being brave. You took care of yourself before and u need to do it again by making sure you stop bleeding. Your parents need to know it is very serious.

Jasmine continued reflecting the texter’s fear and also the need to take care of the wound. When the session ended the texter had assured Jasmine they would tell their mother about the wound. Just as in crisis phone calls, we rarely have absolute proof in a text session that a person has or will follow through with a plan. Based on the amount of connection they had, the texter’s self-disclosure throughout, and the likelihood that the texter had talked to the mother the first time, Jasmine felt confident the texter would let the mother know about the wound.

Jasmine spoke of connection with the youth, even though it was all via text:

“At the time of the second session, there was a significant amount of worry in me since they said they were actually bleeding continuously. Yet I feel like we were able to really work together in a positive way to make sure they got the help they needed. The texter had reached out for help in a moment of isolation and worry, when they thought no one really cared. I think through texting with a counselor and being able to establish that their mother cared, the session was likely beneficial. The texter was able to actually confide in their mother through the conversation and encouragement of our texts. Just knowing someone cares is so important. I hope, and believe, that I was able to express that genuinely.”

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 149 Appendix III: CSS Counselors Text Line Year End Report | 32

CSS Counselors Talk about the Text Line

“When I ask youth during my presentations in the community why they like to text, very often a youth mentions that it's easier to talk about tough emotional issues if the person you're talking to can't see or hear you. It seems that texting gives youth control over their communications with adult counselors and gives them the space necessary to feel safe expressing their emotional needs in a world that has taught them that their feelings don't matter. I see the text line as an opportunity for youth to access support in a way that feels natural to them.” Ben Pauw – CSS Crisis Line and Text Line counselor, and Teens for Life Presenter

“As a teen I was reluctant to reach out for support in part because I felt ashamed and too proud to do so. When I began training as a community volunteer I was excited to learn that CSS offered a Text Line. It’s clear to me from my experiences that it is possible to make a connection with someone who is in crisis via text and that this is a tool I could have benefited from when I was younger. I believe the value of the Text Line Program is that it offers texters (especially teens) an opportunity to anonymously access crisis counseling while maintaining a sense of self- reliance.” Sam Kessel – CSS Shift Supervisor

“I have two teenage sons who seldom pick up the phone to call anyone about anything. I think it is likely that if my kids were in crisis, they would choose a texting option to get help. I have had a couple of text sessions with teens who were very depressed who were texting while their parents were in another room, and one texting to get help for a suicidal friend. It is so important that we have this available to young people - that they can at least be in their comfort zone in terms of mode of communication when they are facing life and death situations.” Juliana – CSS Crisis Line and Text Line Counselor

“The text line is a wonderful tool in that it makes crisis counseling that much more accessible to a whole demographic of people for whom texting is the most comfortable form of communication.” Tatille Jackson – CSS Crisis Line and Text Line Counselor

“Working with teens, I am acutely aware that they do not like to use the phone. When I offer them the number for the CSS hotline, they often respond that they don't like to talk on the phone. But when I share the textline information, I can see their relief in knowing that they can access support in a way that is in keeping with their preferred modes of communication.” – Crisis Line Counselor, CSS Counseling intern

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 150 Appendix III: CSS Counselors Text Line Year End Report | 33

“I think that the text line is an integral part of our community's mental health services. In order to reach youth, we must listen to them and talk to them in a form that they feel most comfortable. The youth are on their phones texting so that means that we must be on the text lines. I have had youth on the Text Line thank me for being available via text. I have thoroughly enjoyed counseling over text. It brings its own skill sets, challenges and rewards.

A large portion of our community would not be served if we did not have the Text Line. The infrastructure is up and running. That is the most difficult barrier of entry for any service. Now we need to spread the word to more texters that we are an available resource. Texting is a necessity for all help lines. I am proud that we have our line available.” Sharon Pieczenik – CSS Shift Supervisor

“In today's society where most young people primarily use texting as their preferred method of communication, it's extremely important that as a mental health agency we have text counseling so that we can provide a comfortable and safe environment for people to reach out for help that wouldn't otherwise do so by calling. Just as phone counseling was revolutionary, I think text counseling is for our generation.” Jaya Roy – CSS Crisis Line and Text Line Counselor

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 151 Community Education Program Year End Report 2015-2016

The 2012 National Strategy of Suicide Prevention (NSSP), is a call to action to guide suicide prevention efforts. It’s objectives and goals work together to promote wellness, recovery, risk reduction, and effective treatment. The overall theme promotes that everyone has a role to play in preventing suicide. The NSSP outlines four strategic directions, the first of which is: “Create supportive environments that promote healthy and empowered individuals, families, and communities”.

This call to action invites all voices to the table: legislators, providers, researchers, those grieving and have felt the impact of suicide, and most importantly, the voices of those who lived. Attempt survivors have provided a critical voice to interventions that work, the recovery process, and the way forward to wellness. The NSSP invites us to have a positive conversation to counter shame, discrimination, and silence and other barriers to seeking help.

Crisis Support Services of Alameda County (CSS) has a voice in this conversation. CSS as provided suicide prevention, crisis intervention, and postvention services in Alameda County for 50 years. While no single intervention can prevent all suicides, according to the Suicide Prevention Resource Center and Jed Foundation, research has shown that a comprehensive approach is most effective. A comprehensive approach to suicide includes nine key strategies (image below) most of which are utilized and supported by our agency in some capacity.

Our Community Education Program enhances our agency’s capacity to fulfill the goals of this approach, by fostering a public dialogue within our local communities who are natural safety nets for those who are vulnerable and are at risk for suicide. In doing this, we recognize the power of connectedness. Connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention, which is among the protective factors for suicidality. The Center for Disease Control (CDC) defines connectedness as the degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups. We connect our communities by providing increasing knowledge and de-stigmatizing suicide and empowering our communities that we are all in positions of helping.

Everyone has a role in preventing suicide.

Image from www.sprc.org

Submitted by: Mercedes Coleman !1 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 152 Our Community Education Program adheres closely to the following goals and objectives of NSSP’s strategic effort for suicide prevention on a local level:

Goal 2. Implement research-informed communication efforts designed to prevent suicide by changing knowledge, attitudes, and behaviors.

Objective 2.3: Increase communication efforts conducted online that promote positive messages and support safe crisis intervention strategies.

Objective 2.4: Increase knowledge of the warning signs for suicide and of how to connect individuals in crisis with assistance and care.

Goal 3: Increase knowledge of the factors that offer protection from suicidal behaviors and that promote wellness and recovery

Objective 3.2: Reduce the prejudice and discrimination associated with suicidal behaviors and mental and substance use disorders.

Objective 3.3: Promote the understanding that recovery from mental and substance use disorders is real and possible for all.

Goal 7: Provide training to community and clinical service providers on the prevention of suicide and related behaviors

Objective 7.1 Provide Training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors

Objective 7.2: Provide training to mental health and substance abuse providers on the recognition, assessment, and management of at- risk behavior, and the delivery of effective clinical care for people with suicide risk.

Crisis Support Services of Alameda County is pleased to submit a Year End Summary of our Community Education Program from July 2015 through June 2016 for services provided through the following type of programing:

Teens for Life: School Based Suicide Prevention Community Gatekeeper Training Mental Health Consultation Community Suicide Awareness

Submitted by: Mercedes Coleman !2 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 153 TEENS FOR LIFE PROGRAM: SCHOOL BASED SUICIDE PREVENTION

Program by the Numbers July 2015 - June 2016

Teens for Life Total Number of Youth: Youth Curriculum for Middle School & High School Youth 9,121

1 Our classroom-based youth suicide prevention workshops for middle school and Goal: high school youth enhances a young person’s ability to identify a peer who may 9,000 be in crisis.The workshop covers depression and suicidal warning signs and how to help. We encourage youth to connect with a trusted adult and/or our 24-Hour Crisis Line and Teen TextLine.

Teens for Life: School Gatekeeper Training Total Number of Early Identification and Referral for Teachers and other School Staff Teachers: 152 2 The reluctance of youth to seek out helpful adults is considered to be a risk factor, however, research has shown that contact with helpful adults may be considered Goal for Teacher and a protective factor (Prevention Division of the American Association of Suicidology, School Mental Health Guidelines for School Based Suicide Prevention Programs, 1999). Teachers play Counselors (see below) a role as natural helpers. Our training educates teachers on how to recognize Combined: suicidal warning signs, risk factors, how to ask about suicide directly, and when to connect a student to school mental health services. 320

Teens for Life: School Gatekeeper Training Total Number of Youth Suicide Assessment and Intervention for School Mental Health School Mental Health 3 Counselors Counselors: In both our youth curriculum and teacher workshop, we encourage our youth 98 and our teachers to connect a student to school mental health counselors. Our clinical training provides information on current best practices on suicide assessment and intervention tools.

Teens for Life: School Gatekeeper Training Total Number of Youth Suicide Prevention for Parents Parents: 192 4 Vital to a teen’s mental health wellness is a strong and supportive network at home. A family plays an important role in being aware of the early signs and symptoms when their child may be experiencing a mental health crisis that may Goal: place a child at suicidal risk. 100

Submitted by: Mercedes Coleman !3 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 154 TEENS FOR LIFE PROGRAM Curriculum for Middle School & High School Youth Program Presence Unified School District Middle School High School

Alameda USD Lincoln MS Alameda HS

Berkeley USD Martin Luther King Jr. MS St. Mary’s College HS (private) Longfellow MS Teens Tackle Tabacco Conference* Willard MS

Castro Valley USD Castro Valley HS

Dublin USD Dublin HS

Fremont USD Hopkin’s Jr. High Irvington HS Centerville Jr. High Mission San Jose HS

Hayward USD Cesar E. Chavez MS Hayward HS

New Haven USD Alvarado MS Cesar Chavez MS James Logan HS

Oakland USD Life Academy College Preparatory School (private) Madison Park Academy Anna Yates Elementary Unity Middle School

Piedmont USD Piedmont HS

Pleasanton USD Harvest Park MS Foothill HS Village HS

San Lorenzo USD Washington Manor MS Arroyo HS

Submitted by: Mercedes Coleman !4 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 155 A few things about our youth from our Teens for Life program....

No Response 45

African- American 107 Asian- American 559

Filipino-American 150

Pacific Islander 23

White-American/Caucasian 308 Hispanic/Latino(a) 474 Ethnicity

American-Indian/Alaskan 22 Self- Reported Arab-American/Middle demographics from 57 Eastern 2,254 Youth surveyed Mixed Ethnicity 431 reflecting the diversity Other 78 of Alameda County

0 100 200 300 400 500 600 # of youth

1500 1,370

1000

500 19 376 282 Number of youth who approached a speaker after a presentation 78 70 78 concerned about a friend or 0 themselves. These are opportunities 6th 7th 8th 9th for our speakers to connect a youth to Mixed MS Mixed HS support as part of our circle of care. Grade Our curriculum is designed for 6th - 12th grade. Our most common grade we see is 9th grade.

Submitted by: Mercedes Coleman !5 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 156 I can recognize if someone close to me is 3 Q1 feeling depressed.

Q2 I can recognize if someone close to me is feeling suicidal 2.5 Q3 I am willing to get help for a friend who is feeling depressed

Q4 I am willing to get help for a friend who is feeling suicidal

2 If I had a friend who was feeling depressed or suicidal, I Q5 would be willing to tell an adult

If I had a friend who was feeling depressed or suicidal, I Q6 1.5 would be willing to call a crisis line

If I had a friend who was feeling depressed or suicidal, I Q7

1 (strongly agree) to 5 (strongly disagree) (strongly agree)5 to (strongly 1 would be willing to text a crisis line 1 If I was feeling depressed or suicidal, I would be willing to Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q8 get help for myself

I personally feel that receiving information on suicide is Pre Post Q9 helpful to others Average Response Per Student Survey Question

Most Common Themes Total # crisis line calls from 1,034 youth under 20 years old from youth on our crisislines 1. Relationships/Family Issues

2. Suicidal Desire Calls willing to self-report as being from Alameda 3. Anxiety/Stress 17% County 4. Depression

Calls willing to self-report 5. Loneliness/Isolation that they received our crisis 2% line resource from our Teens For Line presentation.

Submitted by: Mercedes Coleman !6 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 157 TEENS FOR LIFE PROGRAM Curriculum for Middle School & High School Youth Self-reported Pre/Post Surveys* from 2,254 Youth surveyed out 9,000 youth total Average Response Per Item

Definitely Agree 10% Pre Post 37% 36% Agree Somewhat 46% 36% Neither Agree or Disagree “I can recognize if 13% someone close to me 15% Disagree Somewhat is feeling suicidal” 3% 2% Definitely Disagree 1%

0% 50% 100%

Pre Post Definitely Agree 29% 48% “If I had a friend who 36% Agree Somewhat was feeling depressed 35% or suicidal, I would be 29% Neither Agree or Disagree willing to call a crisis 15% line.” 4% Disagree Somewhat 2% 2% Definitely Disagree 1%

0% 50% 100%

Submitted by: Mercedes Coleman !7 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 158 Definitely Agree 31% 47% Pre Post 37% Agree Somewhat 36% “If I had a friend who was feeling depressed or Neither Agree or Disagree 26% 15% suicidal, i would be 4% willing to text a crisis Disagree Somewhat 2% line.” 2% Definitely Disagree 1%

0% 50% 100%

Definitely Agree 52% 64% Pre Post

Agree Somewhat 33% 26% 13% Neither Agree or Disagree 8% “I personally feel that receiving education about 1% Disagree Somewhat suicide is helpful to 1% others” 1% Definitely Disagree 1%

0% 50% 100%

*Our evaluation tool is composed of 9 content areas that address the 3 main goals of the Teens for Life Program: Youth Curriculum. These content areas allow us to measure whether our goals are being met. The above are highlights. Results of all content areas are available on request.

Submitted by: Mercedes Coleman !8 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 159 TEENS FOR LIFE PROGRAM School Gatekeeper Training Program Presence

Type School /Organization

Early Identification and Referral for Teachers and Unity High School other School Staff Patten Academy of Christian Education Newark Memorial High School Oakland High School Northern California Educators Conference

Youth Suicide Assessment and Intervention for Piedmont High School School Mental Health Counselors Center for Healthy Schools & Communities James Logan High School Hayward Unified School District

Youth Suicide Prevention for Parents Tiburcio Vasquez Health Center (Spanish/Bilingual presentation) Foothill HS Center for Health Schools & Communities (Spanish/Bilingual presentation)

Submitted by: Mercedes Coleman !9 of 20!

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 160 TEENS FOR LIFE PROGRAM School Gatekeeper Training Survey Outcomes* for Teachers and other School Staff Average Response Per Item

Definitely Agree 5% 32% Pre Post

Agree Somewhat 31% 60% 40% Niether Agree or disagree “I know how to 8% intervene with a Disagree somewhat 20% 0% young person who 4% is suicidal” Definitely Disagree 0% 0% 50% 100%

Definitely Agree 23% Pre Post 38%

Agree Somewhat 24% 52%

Neither or Disagree 35% 8% “I feel confident in 18% Disagree Somewhat my ability to ask 2% directly about 1% Definitely Disagree 0% suicide’” 0% 50% 100%

*Our evaluation tool is composed of 8 content areas that address the 3 main goals of the Teens for Life: School Gatekeeper Curriculum. These content areas allow us to measure whether our goals are being met. Above are highlights. Results of all content areas are available on request.

Submitted by: Mercedes Coleman !10 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 161 Community Gatekeeper Training

What do we know about suicide in our communities? Suicide is preventable.

Most suicidal individuals give definite warnings of their suicidal intentions, but others are either unaware of the significance of these warnings or do not know how to respond to them.

What is Gatekeeper Training? Gatekeeper training generally refers to programs that seek to develop individuals' "...knowledge, attitudes and skills to identify (those) at risk, determine levels of risk, and make referrals when necessary.”(Gould et al., 2003)

Who are Community Gatekeepers? Individuals who have face to face contact with community members as part of the usual routine and are trained to identify individuals at risk for suicide and refer them to supportive services. (U.S. Department of Health & Human Services Office The Surgeon General, National Strategy for Suicide Prevention, 2012)

Gatekeepers may range from lay citizens to mental health professionals who may be in a position to be among the first to detect signs of suicidality and respond appropriately according to their role.

How do we address suicide in our community? The mission of our community gatekeeper trainings is to reduce suicide attempts and suicide completions by training and educating community gatekeepers.

Our Community Gatekeeper trainings cover the basics of suicide assessment and intervention; our workshops are routinely tailored to meet specific roles and settings of the audience so that they can more effectively and appropriately engage with their communities. We recognize that due to unique characteristics of different age, racial, and ethnic groups, and other historically underserved populations, there are significant disparities in access, availability, and quality of mental health care. There are also key differences in belief systems about suicide and mental health that may affect help-seeking behaviors.

How do Community Gatekeeper Trainings and Connectedness relate? Overall, studies show that connectedness is a protective factor for suicide. According to the Center for Disease Control, connectedness between individuals leads to increased frequency of social contact, lowered levels of social isolation, and an increase in positive relationships. Gatekeepers who have a higher degree of connectedness to individuals in their lives have a greater ability to recognize when someone in their lives are is at risk for suicide. A greater sense of connection also fosters positive coping behaviors (ex. help-seeking) in those who are vulnerable. Our gatekeepers are trained to respond when someone is seeking help through active listening skills and being willing and confident to ask about suicide directly.

Connectedness between individuals and their families to community organizations increase a sense of belonging and provides access to community supports.

Submitted by: Mercedes Coleman !11 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 162 COMMUNITY GATEKEEPER TRAINING Program Presence

Type of Gatekeeper Organization Name Audience Training Kaiser Permanente Educators Depression & BiPolar Alliance Community Casey Family Programs Schreiber Center/Algeria Community Living Health Care Providers Samuel Merritt Professional College Family Violence Law Center Service Providers Ohlone College Cal State University Hayward College Staff Community Gatekeeper HSSACCC Health Services Association Training (basic) Alta Bates Summit Medical Center Faith Community Santa Clara University Jesuit School Best Now EXHALE BAWAR Peer Counselors Berkeley Free Clinic Crisis Support Services of Alameda County Law Enforcement & Oakland Police Department Dispatchers Tiburcio Vasquez Health Center Horizon’s Family Services Abode Services Community Gatekeeper Crisis Support Services of Alameda County Mental Health Training for Mental Telecare Services Professionals Health Professionals Alameda County Behavioral Health Care Services East Bay Community Recovery Project California Association of Social Rehabilitation Girl’s Inc. TOTAL # OF 971 GATEKEEPERS Goal: 600

Submitted by: Mercedes Coleman !12 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 163 COMMUNITY GATEKEEPER TRAINING Survey Outcomes* for Mental Health Staff Average Response Per Item

11% Definitely Agree 41% Pre Post

59% Agree Somewhat 56%

22% Neither Agree or Disagree 3% “I can recognize when a person may 5% Disagree Somewhat 0% be suicidal”

3% Definitely Disagree 0% 0% 50% 100%

Definitely Agree 7% 41% Pre Post 50% Agree Somewhat 53%

Niether Agree or disagree 32% 6% 8% “I know how to Disagree somewhat 0% intervene with a 3% suicidal person” Definitely Disagree 0% 0% 50% 100%

*Above are highlights from 8 content areas we surveyed. Results of all content areas are available on request.

Submitted by: Mercedes Coleman !13 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 164 COMMUNITY GATEKEEPER TRAINING Survey Outcomes* for Community members (non-MH) Average Response Per Item

Definitely Agree 3% 24% Pre Post

36% Agree Somewhat 63%

43% Neither Agree or Disagree 12% “I can recognize 15% Disagree Somewhat when a person may 1% be suicidal” 4% Definitely Disagree 0%

0% 50% 100%

Definitely Agree 3% 25% Pre Post

Agree Somewhat 22% 59%

28% Neither or Disagree 15% “I know how to 37% Disagree Somewhat intervene with a 1% suicidal person” 10% Definitely Disagree 0% 0% 50% 100%

*Above are highlights from 7 content areas we surveyed. Results of all content areas are available on request.

Submitted by: Mercedes Coleman !14 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 165 Mental Health Consultation Trainings

Our Mental Health Consultation Trainings are workshops that pertain to general mental health issues, in particular to issues associated with suicide risk. While each workshop are non-suicide specific, they each address suicide and how to help. All workshops, except Mental Health First Aid are created and developed based on community needs and requests. Our most common training provided in this category is Mental Health First Aid (MHFA).

Mental Health First Aid is an 8-hour public education program that helps the public identify, understand, and respond to signs of mental illnesses and substance use disorders. Mental Health First Aid USA is an evidence-based curricula that is provided worldwide. This training is a wonderful example of a program that enhances connectedness in our communities. It fosters the fact that we can all play a role in helping someone who may be developing a mental health problem or is experiencing a mental health crisis. Those trained as “mental health first aiders” become part of the safety net of our communities.

Our agency currently has 5 certified Adult MHFA Instructors, three of which are also certified as Youth MHFA Instructors.

Submitted by: Mercedes Coleman !15 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 166 MENTAL HEALTH CONSULTATION Program Presence

Training Organization Name Audience

Mental Health Wellness and North Berkeley Senior Center Older Adults Older Adults South Berkeley Senior Center St. Joseph’s Center

Bullying, Cyberbullying, and Parents our Youth Tiburcio Vasquez Health Center Overview of Non-suicidal Tiburcio Vasquez Health Center Mental Health Self-Injury Crisis Support Services of Alameda County Professionals Piedmont HS Teachers Piedmont HS Parents Longfellow MS

Mental Health First Aid Alameda County Behavioral Health Care Service Providers Services Property Managers City of Albany Refugee Service Providers Crisis Support Services of Alameda County General community Families

Youth Mental Health First Aid Cal State East Bay Faculty Nurses Las Posits College Wellness Clinic staff Oakland High Shop55 Wellness Center

Mental Health Wellness on Ohlone College Faculty College Campuses Bullying and Suicide Hume Center Mental Health Professionals Bullying among South-East Asian Youth Crisis Response for The Public Authority of IHSS Service Providers Telephone Counselors Crisis Support Services of Alameda County Suicide Prevention: Newark Memorial USD Parents Upstream Approach

Submitted by: Mercedes Coleman !16 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 167 Training Organization Name Audience

Trauma Response Team Crisis Support Services of Alameda County Service Providers 101 Trauma Informed Systems Alameda County Behavioral Health Care County Staff and other Services providers Total # of Adults: 773

Goal: (combined MH Consultation Training + Mental Health First Aid + Trauma Informed Systems): 605

Submitted by: Mercedes Coleman !17 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 168 Community Suicide Awareness A vital aspect of suicide prevention is not only to educate the community, but also to promote awareness of suicide prevention resources and foster connectedness to mental health resources.

As an agency, Crisis Support Services of Alameda County takes the opportunity to attend as many health fairs in the community to raise our visibility as a resource.

Organization/Event Name Audience College of Alameda College Students Holy Names University Berkeley City College Merritt College

United Seniors of Oakland & Alameda County Older Adults City of Newark Senior Center St. Mary’s Center North Berkeley Senior Center Hayward Area Recreation Department City of San Leandro Health & Human Services City of Fremont Senior Health Expo

Native American Health Center General Community Newark Unified School District Crisis Support Services “Healing Hearts” Run/Walk

Oakland Technical High School Youth

TOTAL # OF YOUTH AND ADULTS 1,605

Goal: 1500

Submitted by: Mercedes Coleman !18 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 169 CHALLENGES Access Access to teachers and parents in school systems are still an ongoing challenge and process. This can be explained in part that, while we have developed wonderful relationships with a number of the District Mental Health Liaisons, who have been vital in helping us access school administrators, it still takes time to continue to develop individual relationships with school administrators to determine their needs and capacity.

SUCCESSES & MOVING FORWARD Trauma-Informed Care Systems Training 101 Alameda County Behavioral Health Care Services has asked our Community Education Program to create a 4-hour “floor training” on trauma-informed care principles to county staff and its community partners. The goal of this training is to encourage our providers to become a trauma informed provider with the hope that clients who receive care do not experience re-traumatization as they receive service.

We are pleased to announce that we spent this Fall creating a training adapted from San Francisco Public Health’s curriculum called: “Transforming Stress and Trauma” curriculum by Joyce Dorado and Lyn Dolce. We were able to pilot the training this Spring and went through a process of refining and adjusting to feedback. Our curriculum is now in it’s final form and has been provided to county staff once a month since April 2016. The goal is to provide this training once a month for this fiscal year. Feedback has been quite positive. Another goal this year is to create a facilitator’s guide for the curriculum.

Trauma Response Team Crisis Support Services of Alameda County has always responded (based on availability) to community requests when there has been a death in the community. This past spring, we have enhanced that capacity by providing a 2- part training to volunteers, interns, and interested staff on Trauma Response (common grief reactions, death anxiety, and protocols). Our goal was increase the number of people who have the ability to respond to sudden and traumatic deaths within our community. We have already begun the training process this past Spring by having someone observe a lead facilitator when we’ve had to respond in the community.

Connectedness Between Community Organizations and Social Institutions This past year we have had the opportunity to collaborate with two organizations as partners on their federal and local grants. As part of their 3-Year strategic plan to foster mental health wellness and suicide prevention on campus, Ohlone College has asked us to be the providers for suicide prevention education for faculty, staff, and students. This past August 2015, we provided the first set of trainings to faculty: 1) Suicide Prevention among College Students 2) Mental Health Wellness Among College Students. This Fall, we will be providing Youth Mental Health First Aid.

La Clinica de la Raza also asked us to be a partner in their project. They established an Internship Program for youth at community based organizations who provide behavioral health care services. The goal of this program is foster the interest of youth from underserved communities in the behavioral sciences. This past Fall 2015, we took on board one intern from October to December. It was an enriching experience to have his presence and youth perspective in our program.

Another ongoing collaborative effort is with the Oakland Police Department. The Oakland Police Department (OPD) provides a training named Crisis Intervention Training (CIT). The CIT program is a model community initiative designed to improve the outcomes of police interactions with people living with mental illnesses. CIT programs are built on local partnerships between law enforcement agencies, mental health providers and advocates, such as the National Alliance on Mental Illness (NAMI). This training involves individuals living with mental illnesses and families at all levels of decision- making and planning. CIT programs typically provide 40 hours of training for law enforcement on how to better respond to people experiencing a mental health crisis.

Submitted by: Mercedes Coleman !19 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 170 For the last 5 years, our community education department has been a part of the week-long training by providing Suicide Assessment & Intervention for Law Enforcement. In addition to providing suicide prevention training to current Law Enforcement officers and Dispatchers, we will now be providing training at the Oakland Police Academy.

Targeted Outreach According to the Center For Disease Control, suicide is now the second leading cause of death of young people under the age of 24 years old. While we have a curriculum on youth suicide provided both to the general community and providers, it is also important to address other risk factors that are connected with suicide risk among young people. We will be advertising Youth Mental Health First Aid training to our schools. This curriculum provides information on how to recognize symptoms and warning signs of common mental health problems among youth. Most importantly, Youth Mental Health First Aid, provides information on how best to engage with young people to convey concern and enhancing connectedness. We are also aiming to use this outreach as an opportunity to advertise our “Early Identification and Referral” workshop to our teachers.

Thank You One of the most common things said about our crisis lines among staff and volunteers is that when we we pick up the phone, we hold the privilege of being a part of a person’s journey to wellness and recovery from despair, hopelessness, and profound isolation. Our role is to reflect a mirror of hope. These are experiences that our education staff bring with them to the community that we hope inspires others to connect and become part of someone else’s journey. Thank you so much for your time and your tremendous support. For questions or to request full data sets: [email protected] or 510-420-2473

Submitted by: Mercedes Coleman !20 of ! 20

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 171

Clinical Program 2015-2016 Annual Report

Total Clients Served: 472 265 School Based Counseling Students K-12 139 Older Adults (26 funded in part by the Area Agency on Aging) 68 Grief Counseling Clients

Gender

305 Female Clients 162 Male Clients 3 Transsexual Clients 1 Non-binary Client 1 Fluid Client

Sexual Orientation

309 Heterosexual Clients 108 Clients Not Asked - Students aged 5 to 11 21 Lesbian Clients 10 Gay Clients 10 Bisexual Clients 9 Clients Declined to Answer 2 Questioning Clients 2 Pan Clients 1 A-Sexual Client

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 172 (2)

Ethnicity

1Japanese Client -1%

2 Afghani Clients - 1%

4 Pacific Islander Clients -1%

4 Clients Declined to Answer - 1%

7 American Indian Clients 1%

9 Filipino Clients 2%

9 Chinese Clients 2%

125 African American Clients 27%

142 Caucasian Clients 30%

167 Hispanic Clients 35%

Age 16 Clients aged 80-89 4%

43 Clients aged 70-79 9%

69 Clients aged 60-69 15%

26 Clients aged 55-59 6%

25 Clients aged 40-54 5%

14 Clients aged 30-39 3%

5% 25 Clients aged 18-29 35% 163 Clients aged 12-17 18% 88 Clients aged 6-11 -1% 3 Clients aged 0-5

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 173 (3)

Crisis Support Services (CSS) began as a nonprofit, volunteer-based crisis intervention and suicide prevention agency in 1966. For 50 years, CSS has provided a variety of mental health services to a wide range of persons in varying degrees of crisis.

To help meet the needs of at-risk Alameda County residents, we are proactive participants in the development of and adherence to best practice modes of treatment, education and quality assurance. The agency embraces the ideals of Cultural Humility and staff has had opportunities to participate in ongoing Cultural Humility trainings and discussions. The agency also continued to provide opportunities for LGBTQI2 and Trauma Informed Care trainings and discussions. We commend Alameda County Behavioral Health for providing several vital trainings at no cost to partner agency staff which support the effort of CSS to fully integrate these principles into the very fabric of everyday behaviors and business practices.

Our primary mission is to assist people in emotional distress, to offer supportive counseling to those in crisis and to prevent suicide. We accomplish this by incorporating evidence-based treatment. Trauma-informed approaches incorporate some or all of the following elements:

Establishing Safety Defusing the Immediate Crisis Building a strong rapport Therapeutic collaboration Normalizing trauma responses Family and/or social support Emotional regulation tools Anxiety management tools Strength and resiliency focused Cognitive reframing and practice

As a training agency, CSS strives to ensure that all clients receive trauma informed, culturally sensitive, LGBTQI2 and outcome based mental health services. The task of providing training and mentorship to graduate and post-graduate counseling students is one that CSS takes very seriously. Our training program is unique in that CSS provides the only suicide prevention, crisis assessment and best practices, least invasive interventions many counselors in training ever receive. CSS Below is our fall and spring training schedule. Attendance is required of all counselors (interns) providing direct services.

2015-2016 Fall Intern Training Classes 42 Hours

Saturday 9-12-15 9am to 12pm Intern Orientation Saturday 9-12-15 1pm to 4pm Clinical Program: Nuts and Bolts Sunday 9-13-15 9am to 12pm Trauma-Informed Care Sunday 9-13-15 1pm to 4pm Establishing the Therapeutic Alliance Saturday 10-3-15 9am to 12pm Outcomes and Quality Assurance Sunday 10-4-15 9am to 12pm Suicide Assessment & Intervention for Special Populations Sunday 10-4-15 1pm to 4pm Counseling Older Adults Saturday 10-24-15 9am to 12pm Case Formulation and Treatment Planning Saturday 11-21-15 9am to 12pm Co-Facilitating Groups Saturday 11-21-15 1pm to 4pm Counseling Adolescents Sunday 11-22-15 9am to 12pm Counseling Grade School Children Sunday 11-22-15 1pm to 4pm Grief Counseling Saturday 12-5-15 9am to 12pm Non-Suicidal Self Injury Saturday 12-5-15 1pm to 4pm Dialectical Behavioral Therapy

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 174 (4)

2015-2016 Spring Intern Training Classes 36 Hours

Saturday 1-23-16 1 pm to 4 pm Gerotransendance Sunday 1-24-16 9 am to12pm Dreaming Saturday 2-6-16 9 am to 12pm Counseling LGBTQ Youth: Project Eden Sunday 2-7-16 9 am to 12pm Counseling LGBTQ Elders: Sunday 2-7-16 1 pm to 4 pm Burnout Prevention/Therapist Self Care Saturday 2-27-16 9 am to12pm Substance Abuse and Addiction Saturday 2-27-16 1 pm to 4 pm C0-Occuring Disorders Sunday 2-28-16 9 am to 12pm Termination Sunday 2-28-16 1 pm to 4 pm Eating Disorders Saturday 3-5-16 1 pm to 4 pm Collaborative Counseling Sunday 3-20-16 9 am to12pm Suicide Assessment & Intervention Sunday 3-20-16 1 pm to 4 pm Trauma Informed Care

2015-2016 Fall Intern Crisis Line Training 42 Hours

Saturday 9-19-2015 9am to 12pm Welcome to CSS and the Crisis Lines Saturday 9-19-2015 1 pm to 4 pm Micro Counseling Skills Sunday 9-20-15 9am to 12pm Crisis Intervention Counseling Sunday 9-20-15 1 pm to 4 pm Practicing Crisis Intervention Skills Saturday 10-17-15 9am to 12pm Suicide Assessment and Intervention (part 1) Saturday 10-17-15 1 pm to 4 pm Suicide Assessment and Intervention (part 2) Sunday 10-18-15 9am to 12pm Emergency Procedures Sunday 10-18-15 1 pm to 4 pm Practicing Suicide Prevention Skills Sunday 11-8-15 1 pm to 4 pm Role Play Cultural Humility Saturday 11-14-15 9am to 12pm Text Line Saturday 11-14-15 1 pm to 4 pm Referrals/After Hours Programs Sunday 11-15-15 9am to 12pm Helping Regular Callers with Mental Health Concerns Sunday 11-15-15 1 pm to 3pm Mandated Reporting Sunday 11-15-15 3pm to 4pm Stress Line Calls Saturday 12-12-15 9am to 12pm Debriefing the Training Program

CSS counselors in training are graduate and/or post-graduate students gaining hours toward licensure. We typically have a mix of pre and post graduates on the MFT, MSW, PCC, PhD and PsyD tracks. For convenience, we refer to all volunteer counselors in training as interns.

Interns receive 120 hours of didactic and experiential weekend trainings. In addition, every intern receives weekly individual and group clinical supervision. CSS is a highly desirable intern site for interns seeking expertise in suicide prevention, crisis intervention, post-intervention, traumatic loss, geriatric mental health and school aged child counseling.

For the past few years, CSS has welcomed on average 12 new interns each fall. Non-profit intern placement sites are beginning to offer stipends and/or monetary compensation in exchange for intern labor. Unfortunately, CSS has yet to fully evaluate this trend and the Impact it may have for CSS. For many years, CSS has reimbursed intern for roundtrip miles travelled to serve clients off-site.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 175 (5)

It would be impossible for Crisis Support Services to provide and sustain service to 472 at-risk Alameda County residents without our volunteer interns. And, we could not possibly provide the clinical training, mentoring, oversight and supervision of 32 interns without the 20 licensed supervisors who volunteer their time and expertise.

Volunteer clinical supervisors meet weekly to provide individual supervision, training, mentoring, and oversight to their assigned intern(s). Clinical supervisors attend a monthly consultation group provided by CSS to review best practices and review intern performance.

Many supervisors also volunteer to teach intern classes in the fall and spring. Many are or were professors teaching in the field of mental health. All have private practices and all donate their precious time, adding their unique contribution to the mission of CSS to prevent suicide.

Interns attend weekly group supervision provided by the CSS Clinical Director. Interns also receive comprehensive training manuals which further detail best practice expectations in the field. Mandated reporting, client charting, case presentations, self-evaluations, evaluations by clinical supervisors, easy access to consultation, peer review, silent monitoring, and the clinical review of taped recorded sessions and monthly summaries of all client contacts support a culture of personal responsibility and professionalism required of a training agency serving at-risk populations.

As future clinicians of Alameda County, interns receive their most valued training directly from the clients they serve. This is achieved by listening to clients, minimizing the potential for re-victimization and/or re-traumatizing vulnerable populations, and holding true for each client the belief that full recovery is possible.

Interns are trained to become what the client needs them to be. Collaborative, client driven, trauma informed and culturally sensitive clinical care begins with the first phone call, the first appointment and right through until the last appointment and the final Client Satisfaction Survey.

Counseling Program No. of Clients N0. of Sessions No. Calls

School Based Counseling K-12 265 3427 309

Counseling for Older Adults 139 2185 2761

Grief Counseling 68 549 782

Total: 472 Clients 6161 Sessions 2761 Calls

The CSS Clinical Program has surpassed every expectation and obligation to Alameda County which helps fund our School, Older Adult and Grief Counseling Programs. CSS has also exceeded our own mission and pledge to be responsive to the needs and demographics of Alameda County residents. The majority of our counseling services are utilized by at risk, minority clients, living at or below the poverty level, who would otherwise, not have access to mental health services.

Compared to the previous year, CSS served 6 fewer clients provided 742 more counseling sessions and 45 more logistical and/or supportive telephone calls.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 176 (6)

265 School Based Counseling Clients

Providing therapeutic services to students at school reduces barriers to mental health treatment that may occur due to stigma or lack of resources. Students who receive attention for their mental health needs often improve their attention and ability to learn and have fewer referrals for disciplinary reasons.

Our interns provide individual and group counseling to an increasing number of children, many of whom are depressed and at risk for self-destructive behavior and/or suicide. Often these students are dealing with loss and trauma in the wake of violence, substance abuse, family discord, parental incarceration or lack of parental support. Our counselors play an important role in providing assessment, referral, consultation and ongoing supportive counseling in school settings.

CSS increased the number of at-risk students we provide services to in the 2015-2016 schoolyear. The previous year we were approached by a number of schools requesting crisis intervention and preventative supportive school based counseling. All were hoping to partner with CSS. We chose 3 new schools and are very excited to have provided counseling to students at Anna Yates K-8 in Emeryville, Emeryville High School and Unity Middle School in Oakland.

CSS interns provided a number of Student Support Groups:

Hayward High School  Cognitive Behavioral Support Group  Family Conflict Resolution Support Group  Social Support Group for Girls

Anna Yates K-8 School  Social Skills Support Group

Henry Haight Elementary School  Social Support Group for Boys  Social Support Group for Girls  Social Support Group for Boys and Girls

Unity Middle School  Social Support Group for Girls

Name of School Number of Clients Number of Sessions Number of Calls Emeryville High 11 147 62 Hayward High 58 443 47 Unity High 70 1093 16 Unity Middle 32 597 13 Wood Middle 4 27 0 Anna Yates 27 320 19 Henry Haight 33 348 83 Lorin Eden 25 380 69 Maya Lin 5 72 0 Total: 265 Clients 3427 Sessions 309

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 177 (7)

Ethnicity

W AA H AI FL AFG CH PI O Total Emeryville High 8 3 11

Hayward High 9 10 34 2 3 58 Unity High 1 8 54 5 2 70

Unity Middle 6 26 32

Wood Middle 2 2 4

Anna Yates 1 20 4 1 1 27

Henry Haight 4 11 10 4 2 2 33

Lorin Eden 4 11 7 1 1 1 25

Maya Lin 2 1 2 5

Totals: 21 77 142 5 9 4 3 3 1 265

Ethnicity Key

W-Caucasian AA-African American H-Hispanic AI-American Indian FL- Filipino AFG-Afghani CH-Chinese PI-Pacific Islander O-Other

Top Areas of Concern

11% Stress Emotional Regulation 17% Anger Management 20% Depression 21% Social Anxiety 24% Family Conflict 29%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 178 (8)

Utilizing Dr. Barry Duncan’s Session Rating Scale (SRS) at the end of every session, interns are able to determine the effectiveness of each session. This instrument was used with each client at each session. Please see adult (SRS) child (CSRS) and young child (YCSRS) versions respectively.

Session Rating Scale (SRS V.3.0)

Name ______Age (Yrs):____

ID# ______Sex: M / F

Session # ____ Date: ______

Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

Relationship I did not feel I felt heard, heard, understood, I------Iunderstood, and and respected. respected.

Goals and Topics We did not work We worked on and on or talk about I------Italked about what I what I wanted to wanted to work on and work on and talk talk about. about.

Approach or Method The therapist’s The therapist’s approach is a good fit approach is not a I------I for me. good fit for me.

Overall There was Overall, today’s something missing in I------Isession was right for the session today. me. The Heart and Soul of Change Project

www.heartandsoulofchange.com

© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 179 (9)

Child Session Rating Scale (CSRS)

Name ______Age (Yrs):____

Sex: M / F

Session # ____ Date: ______

How was our time together today? Please put a mark on the lines below to let us know how you feel.

Listening

______did not always listened to me. listen to me. I------I

How Important What we did and talked What we did and about were talked about was not important to really that important me. to me. I------I

What We Did

I did not like what I liked what we did today. we did today. I------I

Overall

I wish we could do I hope we do the something different. same kind of things next time. I------I

The Heart and Soul of Change Project

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 180 (10)

Young Child Session Rating Scale (YCSRS)

Name ______Age (Yrs):____

Sex: M / F_____

Session # ____ Date: ______

Choose one of the faces that show how it was for you to be here today. Or, you can draw one below that is just right for you.

The Heart and Soul of Change Project

www.heartandsoulofchange.com

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 181 (11)

For school based clients, we utilize two instruments, Dr. Duncan’s Outcome Rating Scale (ORS) below and our own Client Satisfaction Survey.

Outcome Rating Scale (ORS)

Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.

Individually (Personal well-being)

I------I

Interpersonally (Family, close relationships)

I------I

Socially (Work, school, friendships)

I------I

Overall (General sense of well-being)

I------I

The Heart and Soul of Change Project

www.heartandsoulofchange.com

© 2000, Scott D. Miller and Barry L. Duncan

Students are invited to give a value to each of the four core areas of their lives each week. By comparing the initial value rating with the final value rating, a substantive outcome is generated at the conclusion of counseling. Using the Outcome Rating Scale in conjunction with the Session Rating Scale contributes to positive outcomes.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 182 (12)

School Based CounselingSchool Counseling Outcome Ratings

ME FAMILY 90% 100% 80% 90% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% LOW MEDIUM HIGH LOW MEDIUM HIGH

INITIAL FINAL INITIAL FINAL

SCHOOL EVERYTHING 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% LOW MEDIUM HIGH LOW MEDIUM HIGH

INITIAL FINAL INITIAL FINAL

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 183 (13)

School Based Counseling Client Satisfaction Survey Results

For each statement, students were asked to put an X in the circle that best represents his or her experience with school counseling services. Surveys were returned by post or completed and given to their counselor at the last session. The table below left shows the answers chosen to items 1 – 11. The narrative to the right is a summary of comments and suggestions for improvement given by students when asked to, “Please write in any suggestions on how we might improve?”

NARRATIVE ANSWERS 1. Was the intake process (initial telephone contact, Two students made suggestions for returning your phone calls, scheduling your first improvement. One suggested having more appointment, and so on) satisfactory to you? counseling days available to see a counselor. Definitely Mostly Neutral or Mostly Definitely Another stated that it would be helpful to No No Unsure Yes Yes meet more than one time per week. 0% 0% 23% 8% 69

2. At your first appointment, was your counselor caring and respectful? Definitely Mostly Neutral or Mostly Definitely No No Unsure Yes Yes 0% 0% 0% 0% 100%

3. Did your counselor help you form a realistic view of what you could expect from counseling? Definitely Mostly Neutral or Mostly Definitely No No Unsure Yes Yes 0% 0% 0% 23% 77%

4. Did you feel safe and clear about confidentiality issues in your counseling? Definitely Mostly Neutral or Mostly Definitely No No Unsure Yes Yes 0% 0% 8% 8% 84%

5. Did your counselor act professionally (arrive on time, promptly return messages, and so on)? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 0% 7% 93%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 184 6. Was your counselor sensitive about and responsive NARRATIVE ANSWERS to issues of diversity and culture? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 15% 8% 77%

7. Did your counselor help you clarify and work toward a goal or goals in your counseling? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 0% 25% 75%

8. Did you feel you accomplished what you wanted to in counseling? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 8% 30% 62%

9. Overall, were you satisfied counseling? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 0% 25% 75%

10. If you never used the telephone crisis line, please check here □ and skip this question. If you used the crisis line, did you find it helpful? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 33% 33% 33%

11. If you never used the text line, please check here □ and skip this question. If you used the text line, did you find it helpful? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 0% 33% 67%

12. Would you refer a friend to Student Counseling? Definitely Neutral or Definitely Mostly No Mostly Yes No Unsure Yes 0% 0% 8% 15% 77%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 185 (15)

68 Grief Counseling Clients

Cause of Grief

1 Multiple Losses 1%

3 Anticipatory Grief 4%

8 Deaths Due to Homicide 12%

10 Deaths Due to a Sudden Traumatic Event 15%

13 Deaths Due to Natural Causes 19%

33 Deaths Due to Suicide 49%

Top Areas of Concern Anger, Anxiety, Depression, Suicidal Ideation, Insomnia, Isolation

Gender Ethnicity

27% Men

3 Chinese Clients 4% 72% Women 17 African American Clients 26% 1% Transsexual

32 Caucasion Clients 47%

15 Hispanic Clients 22% 1 1 Client Declined to State 18 1%

49 Age of Grief Clients

Grief Client Sexual Orientation

55 Heterosexual 38% 5 Lesbian 22% 21% 5 Bi-Sexual 2% 4% 9% 4% 2 Pan-Sexual 1 Declined to State Ages: 0-12 13-17 18-29 30-39 40-54 55-69 70-79

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 186 (16)

Grief Counseling Outcomes

Grief counselors recognize and directly addresses client coping skill and specifically screen for depression, anxiety, panic, anger and suicidal ideation. Dr. David Burns Brief Mood Survey is administered at their initial session to establish a base line assessment, every ten sessions thereafter and at their final grief counseling session. Scores for depression, anxiety, anger, panic and suicidal urges are recorded and compared over the course of treatment. Clients are informed that the information gathered will be held in the strictest confidence and may only be used:

 To aid in developing a treatment plan for the client  To compile statistical data of counseling outcomes  To modify counseling program as needed to better serve clients

The criteria for utilizing survey outcomes are as follows:

 Client agreed to take mood surveys at initial and final session  Client received 20 grief counseling sessions  Data collected was complete, signed and dated appropriately

The Dr. David Burns Brief Mood Survey is a series of 22 questions. Five questions each for depression, anxiety, panic and anger and two questions regarding suicidal urges.

Clients answer the questions presented by the therapist by referring to an answer sheet which list: 0- Not At All; 1-Somewhat; 2-Moderately; 3-A Lot; 4-Extremely. Grief counselors record client answers directly onto the survey and add the values to reach a final score for each section. Surveys become part of the client record and are compared over time.

Inquiring directly in this way, not just about depression but all their concerns, informs the client, in the very first session, that the challenges they are struggling with are important to talk about and that their feelings matter. Most clients experience a sense of relief and a glimmer of hope. Finally to be able to speak openly and confide in their counselor brings enormous comfort.

The five survey questions related to depression inquire about loss of pleasure or satisfaction in life. Clients are asked “in the last week including today” if they feel sad or down in the dumps, if they feel discouraged or hopeless and if they feel worthless and/or inadequate. The graph below shows the decrease in depression by comparing initial survey scores noted at their first grief counseling session with the scores noted at their final grief counseling session.

Depression Initial Final 50% 40% 30% 20% 10% 0% None Boderline Mild Moderate Severe Extreme

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 187 (17)

The five questions related to anxiety to ask “in the last week including today” if the client worries about things over and over, if they feel frightened, nervous, tense or on edge and if they feel anxious.

Anxiety Initial Final

50% 40% 30% 20% 10% 0% None Boderline Mild Moderate Severe Extreme

The five Questions related to panic ask “in the last week including today” about having sudden feelings of terror or overwhelming fear, sudden terrifying panic attacks that come out of the blue, suddenly feeling like you are going crazy or cracking up, or feeling like you are about to suffocate or pass out, suddenly feeling you’ll have a stroke, heart attack or die.

Panic Initial Final 60% 50% 40% 30% 20% 10% 0% None Boderline Mild Moderate Severe Extreme

The five questions related to anger ask “in the last week including today” about feelings of frustration, annoyance, resentfulness, anger and irritation.

Anger Initial Final 40% 35% 30% 25% 20% 15% 10% 5% 0% None Boderline Mild Moderate Severe Extreme

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 188 (18)

The two questions related to assessing for Suicidal Urges inquire directly “in the last week including today” about suicidal thoughts and the desire to end your life.

Suicide Initial Final 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% None Boderline Mild Moderate Severe Extreme

As shown in the five previous charts tracking the initial and final measurements for depression, anxiety, panic, anger and suicidality, improvement in these areas was achieved.

This does not mean that the longing and deep grief for deceased loved ones ended. As a crisis intervention agency, we know that any loss and especially traumatic loss requires time. Grief is a process and the shock of a loss can knock us off balance and sometimes even push us over the edge for a time or what we may feel might be forever.

Loss by suicide and homicide often casts guilt, suspicion and doubt upon oneself complicating feelings of grief. The stigma of dying by suicide that loved ones feel can prevent them from receiving the support they need. Improvement in depression, anxiety, panic, anger and suicidality signifies improved coping skills, acceptance, improved perspective and hope.

This past year we provided three, Survivor of Suicide Support Groups, one Homicide Survivor Support Group and one General Bereavement Support Group in addition to providing individual Grief Counseling to folks who came from all around the bay area for CSS Grief Counseling Services.

Clients & City Clients & Referral Source Clients and Medical Insurance

54 Clients or 79% of CSS Grief Clients 34 Oakland 18 Family/Friends 12 Berkeley 17 Helping Professional reported having medical insurance. Top carriers: 6 Albany 12 CSS Website/Internet 5 Hayward 11 CSS Crisis Line 14 Kaiser 4 Alameda 5 Hospice 7 Alameda Alliance 2 Fremont 2 Sausal Creek 6 Medi/Medi 2 Piedmont 1 211 6 Medical 1 Livermore 1 Victims of Crime 3 Medicare 1 Union City 3 Blue Shield 1 Vallejo 3 Blue Cross 5 Clients claimed to have no coverage at all.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 189 (19)

Individual Grief Client Satisfaction Survey

At their last counseling session, grief counseling clients were presented with a stamped CSS addressed envelope, a Client Satisfaction Survey and an invitation to complete the survey at home and send it back to CSS via snail mail. Some clients opted to fill out the surveys in their last session.

For each statement, clients were asked to put an X in the circle that best represents his or her experience with their grief counseling experience. Surveys were returned by post or completed and given to their counselor at the last session.

The table below shows the answers indicated by grief clients to the items 1 – 11. The narrative to the right is a summary of suggestions and comments responders wrote to answer this open ended question: Please write in any suggestions on how we might improve? The results of the survey follow.

1. Was the intake process (initial telephone NARRATIVE ANSWERS contact, returning your phone calls, scheduling your first appointment, and so on) satisfactory to you? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

2. At your first appointment, was your counselor caring and respectful? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

3. Do you feel your counselor understood why you came for counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 67% 33%

4. Do you feel safe and clear about confidentiality issues in your counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 190 (20)

5. Did your counselor act professionally NARRATIVE ANSWERS (arrive on time, promptly return messages, and so on)? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 33% 67% 6. Were your counselor sensitive about and responsive to your culture and ethnicity? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

7. Did your counselor help you clarify and work toward a goal or goals in your counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 67% 33%

8. Did you feel you accomplished what you wanted to in counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 67% 33%

9. Overall, were you satisfied with your grief counseling experience? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100% 10. If you never used the telephone crisis line, please check here and skip this question. If you used the crisis line, did you find it helpful? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 100% 0%

11. Would you refer others to crisis Support Services for counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 191 (21)

Group Grief Counseling Satisfaction Survey NARRATIVE ANSWERS 1. Was the intake process (initial telephone Question 1: This suicide grief contact, returning your phone calls, scheduling group with Debbie & Nicole your first appointment, and so on) satisfactory helped me to start to move to you? beyond my sadness & regret Definitely Mostly Definitely and to know that Christopher Neutral Mostly Yes No No Yes is here with me; something I 0% 0% 0% 25% 75% didn't imagine would happen when I started. Thank you!!! 2. At your first group meeting, were your counselor (s) caring and respectful? Question 2: "Very Helpful!!” Definitely Mostly Definitely Neutral Mostly Yes No No Yes 0% 0% 0% 0% 100%

3. Did you feel your counselor (s) help you form a realistic view of what you could expect from counseling? Definitely Mostly Definitely Neutral Mostly Yes No No Yes 0% 0% 25% 25% 50%

4. Did you feel safe and clear about confidentiality issues in your counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 25% 75%

5. Did your counselor (s) act professionally (arrive on time, promptly return messages, and so on)? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

6. Were your counselor (s) sensitive about and responsive to your issues of diversity and culture? Definitely Mostly Mostly Definitely Neutral No No Yes Yes

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 192 (22)

10. If you never used the telephone crisis line, NARRATIVE ANSWERS please check here and skip this question. If you used the crisis line, did you find it helpful? Definitel Mostly Mostly Definitely Neutral y No No Yes Yes 0% 0% 0% 0% 0%

11. If you never received individual counseling at Crisis Support, check here and skip this question. If you did, did you find it helpful? Definitel Mostly Mostly Definitely Neutral y No No Yes Yes 0% 0% 0% 0% 100%

12. Would you refer others to crisis Support Services for counseling? Definitel Mostly Mostly Definitely Neutral y No No Yes Yes 0% 0% 0% 0% 100% 0% 0% 0% 25% 75%

7. Did your counselor (s) help you clarify and work toward a goal or goals in your counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 25% 75%

8. Did you feel you accomplished what you wanted with your group counseling? Question 8 Side Note: Definitely Mostly Mostly Definitely "more than what I imagined" Neutral No No Yes Yes 0% 0% 0% 50% 50%

9. Overall, were you satisfied with your group counseling experience? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 25% 75%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 193 (23)

Interns provided 300 individual grief sessions, 249 group grief sessions and 782 logistical and/or supportive telephone calls to grief clients.

Outreach to the public has expanded to include weekly ads on Craig’s List and frequent updates to our webpage @ crisissupport.org. In addition, and especially to reach out to possible homicide survivors, CSS has participated in Oakland’s First Friday. By hosting a table with outreach materials for our Grief Counseling Services, Older Adult Counseling Services, Crisis Line and Text Line and Community Education, our volunteers engage in conversations with event goers. As always, CSS flyers are posted throughout Alameda County through our network of County Partners and Community Partners.

The tasks of mourning are multifold, complicated and definitely not linear. This is especially true when the death is the result of suicide, homicide or a sudden traumatic event. Yet death is an intrinsically intertwined component of life. We feel that the world must stand still. No matter how many have died before, the intrinsic value of this particular loved one is not diminished. Below is a grief handout available to help normalize and psych-educate clients about common grief reactions and symptoms.

Most eventually accept and come to terms with the reality of the loss, work through the pain, adjust to a world without the deceased and emotionally move forward with life.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 194 (24)

Counseling for Older Adults 139 Clients

94 On-Site Older Adult Clients 45 Off-Site Older Adult Clients

Couples Counseling 4 Men’s Grp. No. Oak. Sr. Center 7

Older Adult Grief Group 5 County In-Home Older Adults 12

Older Adult Women’s Grp 5 AAA In-Home Older Clients 26

Individual Counseling 80

City of Origin of On-Site Older Adults City of Origin of Off-Site Older Adults Oakland 43 N. Oak. Sr. Center Agency on Aging County In-Home Berkeley 24 Alameda 8 Oakland 5 Oakland 9 Oakland 5 Richmond 5 Fremont 1 Berkeley 7 Berkeley 5 Hayward 4 Richmond 1 San Leandro 4 Alameda 2 San Leandro 4 Castro Valley 2 Fremont 1 Albany 1 Redwood City 1 San Lorenzo 1 Newark 1 Hayward 1 Pinole 1 Emeryville 1 El Sobronte 1 San Francisco 1

Top Areas of Concern for All Older Adults Older adults are especially CLIENTS CONCERN As you can see, the top 4 areas vulnerable. Coping with so 65 or 47% Isolation of concern are isolation, many of life’s challenges 53 or 38% Poverty poverty, depression and loss. definitely takes a huge toll. 53 or 38% Depression Counselors work very hard to 52 or 37% Grief/Loss fully meet folks where they Many of our older adult 48 or 35% Declining Health are. Counselors also work clients report living with 40 or 29% Anxiety really hard to connect folks to many of these concerns. 36 or 26% Family Conflict to all supportive resources.

Gender Sexual Orientation

2 1 2 Questioning 36 Gay 4 Lesbian 12 100 Heterosexual 111 A-Sexual 1 Declined to Answer 4 FEMALE, MALE, TRANS, FLUID Bi-Sexual 5

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 195 (25)

Ethnicity Pacific Islander Client 1 American Indian Clients 2 Clients Decline to State 2 Chinese Clients 3 Japanese Client 3 Hispanic Clients 5 African American Clients 35 88 Caucasian Clients

Age

80-89 Clients and Medical Insurance 16 72 County Older Adult Clients

70-79 40 or 64% reported having medical insurance. 60-69 Top carriers: 60 19 Medi/Medi 12 Medicare 55-59 23 12 Kaiser

Older Adult Program Number of Clients Number of Sessions Number of Calls In-Home AAA 26 712 466 In-Home County 12 254 145 No. County Sr Center Grp 7 134 14 On-Site Counseling 84 1019 920 On-Site Women’s Grp 5 63 113 On-Site Sr Grief Grp 5 3 12 Total: 139 Clients 2185 Sessions 1670 Calls

Our older adult counseling program offers unlimited individual, couple, family and group sessions. On-site clients are charged on a sliding scale and no one is turned away because of inability to pay. Off-site counseling is free to all in-home individual, couple, family and group counseling older adults although we do request a donation. Clients are not obligated to make a donation to receive services.

Even with unlimited sessions, older adults utilize our services as they determine is beneficial in collaboration with their counselor. Time spent in Counseling for Older Adults varies with the majority of clients moving on within 3 years.

Number of Years 1 2 3 4 5+ Year Client Began 2015-2016 2013-2014 2011-2012 2009-2010 2008 - Before Number of Clients 69 47 17 5 1 Percent of Clients 50% 34% 12% 4% -1%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 196 (26)

Older Adults are also invited to utilize Dr. Duncan’s Outcome and Session Rating Scales each week. Not all clients find these instruments helpful. When this is the case, it becomes second nature for interns to weave all or part of these surveys into their time with clients informally.

Dr. David Burns Mood Survey is also used with older clients and again, not all older adults fine the instrument useful. When counselors ask in conversation with open ended questions, clients readily unburden themselves. Additions questions which screen for trauma, cognitive functioning, alcohol and drug use, abuse and tasks of daily functioning are standard.

Older Adult Counseling Mood Survey Outcomes

Depression Initial Final 40% 35% 30% 25% 20% 15% 10% 5% 0% None Boderline Mild Moderate Severe Extreme

Anxiety Initial Final 60%

50%

40%

30%

20%

10%

0% None Boderline Mild Moderate Severe Extreme

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 197 (27)

Panic Initial Final 50%

40%

30%

20%

10%

0% None Boderline Mild Moderate Severe Extreme .

Anger Initial Final 50%

40%

30%

20%

10%

0% None Boderline Mild Moderate Severe Extreme

Suicide Initial Final 100%

80%

60%

40%

20%

0% None Boderline Mild Moderate Severe Extreme

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 198 (28)

On-Site Older Adult Client Satisfaction Survey NARRATIVE ANSWERS 1. Was the intake process (initial telephone Question 1. A client commented that contact, returning your phone calls, holidays prevented counseling from scheduling your first appointment, and so on) getting started. satisfactory to you? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 7% 93%

2. At your first appointment, was your counselor caring and respectful? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 7% 93%

3. Did your counselor help you form a realistic view of what you could expect from counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 13% 87%

4. Did you feel safe and clear about confidentiality issues in your counseling? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

5. Did your counselor act professionally (arrive on time, promptly return messages, and so on)? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 0% 100%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 199 (29)

NARRATIVE ANSWERS 6. Was your counselor sensitive about and responsive to issues of diversity and culture Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 7% 93%

7. Did your counselor help you clarify and Questions 7 – 9: Clients commented work toward a goal or goals in your that environmental allergies counseling? triggered by furniture and carpeting Definitely Mostly Mostly Definitely kept counseling from being fruitful Neutral No No Yes Yes and that their scores on these items 7% 0% 7% 20% 66% were due to their inability to attend.

8. Did you feel you accomplished what you Another client commented on this wanted to in counseling? item, “I need to continue”. Definitely Mostly Mostly Definitely Neutral No No Yes Yes 0% 0% 0% 33% 67%

9. Overall, were you satisfied with your senior counseling services? Definitely Mostly Mostly Definitely Neutral No No Yes Yes 7% 0% 0% 7% 86%

10. If you never used the telephone crisis line, please check here and skip this question. If How did you hear about our you used the crisis line, did you find it helpful? agency? Definitely Mostly Mostly Definitely Grief Counselor, One-Stop (WIB), Neutral No No Yes Yes South Berkeley Sr. Center, Alta Bates 25% 75% nurse, friend, a counselor, and City of Berkeley Social Services.

11. Would you refer a friend to the Senior Suggestions for improvement: Counseling Program at Crisis Support Team meeting with supervisor, and Services? Daytime group for seniors. Definitely Mostly Mostly Definitely Neutral No No Yes Yes 100%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 200 (30)

In-Home Older Adult Client Satisfaction Survey

1. My counselor always arrived when Item 6 asks: If you have had expected. more than one counselor, how Most of Some of Always Occasionally Never was the change from one to the Time the time another for you? 50% were 100% 0% 0% 0% 0% positive, 50% were negative.

2. My counselor was easy to talk to. Item 7 asks: What has been most Most of Some of helpful to you about the Senior Always Occasionally Never the Time the time Program? 100% of these 75% 25% 0% 0% 0% responses were positive. Most comments reflected on the 3. My counselor was respectful and acted fulfillment of the need to have as I expected in my home. someone to talk to, the consistency Most of Some of Always Occasionally Never of the support and the the Time the time convenience of having the 100% 0% 0% 0% 0% counselor come to their home.

4. I trust my counselor to keep things we Item 8 asks: What would make talked about confidential. our service better? 25% of the Most of Some of Always Occasionally Never responses asked for assisted the Time the time listening devices, 25% suggested 100% 0% 0% 0% 0% that a better K-12 education would be an improvement, 25% said 5. I looked forward to appointments with everything is fine and the last my counselor. quarter made no response. Most of Some of Always Occasionally Never the Time the time 50% 25% 25% 0% 0%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 201 (31)

Survey responses from clients always provide valuable information which we utilize to inform and reshape services to better respond and reflect client need and the clients themselves. In the case of older adults, recruitment of older interns is essential. This year we developed a Trauma Symptom Survey which we hope to utilize. By administering a pre and post survey we can track outcomes and show that trauma symptoms were reduced and/or eliminated during the course of treatment.

Trauma Symptom Survey (moderated to fit page)

0 2 3 4 5 Intrusive Thoughts & Feelings 1. Repeated, disturbing memories, thoughts, or images related to the traumatic experience? 2. Repeated, disturbing dreams related to the traumatic event? 3. Suddenly feeling or acting as though the traumatic event was happening again with a loss of awareness of your present surroundings (as if you were reliving it)? 4. Intense or prolonged physical reaction (heart pounding, trouble breathing, sweating) when something reminds you of the traumatic experience? Please Total your Score on Items 1 to 4 Here -> Avoidance 1. Avoiding, or trying to avoid, distressing memories, thoughts, or feelings about or closely associated with the traumatic event? 2. Avoiding, or trying to avoid, people, places, conversations, activities, objects or situations that are closely associated with the traumatic event? Please Total Your Score on Items 1 & 2 Here -> Thinking & Feeling 1. Having trouble remembering an important aspect of the traumatic event? 2. Thinking that you are bad? 3. Thinking that no one can be trusted? 4. Thinking that the world is completely dangerous? 5. Thinking the traumatic event was your fault? 6. Blaming others for the traumatic event? 7. Feeling afraid, horrified, angry, guilty or ashamed? 8. An inability to feel happy, satisfied or to have feelings of love. 9. Feeling as though you are in a dream, an outside observer, detached from your body, or that your body and time are moving slowly. 10. Feeling as though your surroundings are unreal, distant or distorted. Please Total Your Score on Items 1 to 10 Here -> Behavior 1. Irritability, unprovoked angry outbursts, physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Feeling super alert or watchful or on guard? 4. Feeling jumpy or easily startled? 5. Difficulty to concentrating? 6. Difficulty falling asleep, staying asleep or restless sleep? Please Total Your Score on Items 1 to 6 Here -> ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 202 (32)

Some challenges are more difficult to address. The request for services always exceeds our capacity to serve. In August the waiting list really begins to builds with interns finishing up with CSS and new interns not ready to take clients until late September.

We have questioned the service model of unlimited session to see if the model was creating a log jam of clients that continued counseling beyond their need. We found that our service model of unlimited session did not create a log jam. In fact, as noted on page 25, 84% of older adult clients concluded counseling within two years. Our service model supports adherence to Trauma Informed Care, Cultural Humility and Client Centered Counseling. Our commitment to older adults is based on assessment, client need and client treatment goals.

NUMBER OF OLDER ADULT CLIENTS TOP REFERRAL SOURCE 25 Css Crisis Line 20 Older Adult Network of Care 12 Internet/Website/Craigslist 9 Pacific Center 9 CSS Flyers 8 Senior Centers 6 Over 60’s Clinic/Life Long Medical 6 Family/Friends

In closing I would like to bring attention to the culture of excellence the team at Crisis Support Services of Alameda County strives to achieve. A good example is reflective in a collaborative effort between the CSS Community Education Department and the CSS Clinical Counseling Department.

As part of our county contract, CSS is one of several agencies that may be called by the county or directly from the public to respond to requests for debriefings and/or defusing to help manage a traumatic event in the community. Only three very busy staff were adequately trained and experienced to respond when a request for trauma services came in. CSS was asked to respond to several such events in a relatively short period of time after not getting a call for months.

We decided to we needed to shore up a qualified work force in order to become better able to meet a need we could not anticipate. We advertised within our agency for fully trained crisis line counselors, screened, interviewed, and provide 6 hours of classroom training to 12 new potential responders. We soon will have a robust Trauma Response Team (TRT) quadrupling our capacity.

Crisis Support Services, as a partner of Alameda County Behavioral Health, is dedicated to providing trauma informed, culturally humility and evidence based crisis intervention and prevention services to all who find their way to CSS.

.

Devah DeFusco Marjorie Darrow CSS Clinical Director CSS Clinical Program Coordinator 510-420-2475 510-420-2485 Crisissupport.org Crisissupport.org

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 203

Crisis Line Program Year End Report FY2015-2016 Connecting People in Need With People who Care

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 204 Table of Contents Year End Report | 2

Introduction ...... 3 Year At a Glance...... 4 Suicide Related Calls...... 7 Dispositions of Calls with High Suicidality Rating...... 8 Follow Up Calls ...... 12 Crisis Line Trainee Demographics...... 13 Crisis Line Volunteer Perspective ...... 15 Callers Demographics ...... 16 Caller Concerns and Reasons for Calling...... 18 Crisis Line Program Values Evaluation...... 21

Suicidal feelings are among humanity’s worst forms of suffering: the response we give is a call to our greatest humanness. - Will Hall, mental health advocate, counselor, writer, and teacher

Special thanks to Daren Cribley, Emma Germer, Will Gutierrez, Kelly Wilhelm, Sam Kessel, and Sherry Matthewson for gracing the cover.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 205 Introduction Year End Report | 3

I would like to dedicate the year-end report to the shift supervisors at Crisis Support Services of Alameda County. They are the backbone of our crisis lines. Collectively, our shift supervisors have covered the crisis lines for a total of 12,784 hours this year. Our shift supervisors not only answer the crisis lines, they provide support, guidance, and oversight to our volunteers. Whether it is 4am on an overnight shift, or 4pm on a Saturday afternoon, you can count on our highly skilled shift supervisors to provide compassionate care to our most vulnerable people in our community.

CSS responded to 64,977 calls on our three Alameda County call lines. (24 hour Crisis Line, Alameda County Behavioral Health ACCESS Afterhours Lines, National Suicide Prevention Lifeline.) That is a 7% growth from last year’s call volume of 60,734 calls. CSS serves as a safety net for people who are at risk for suicide. We answered 345 calls with high risk to suicide. In 51 calls, a suicide attempt was in progress. Only 1 in 3 high risk calls resulted in police intervention and hospitalization. Utilizing collaborative problem solving and safety planning, our crisis line counselors deescalated suicidal crisis over the phone, evaluating and connecting the callers with suicidal desire and intent to their coping skills and their support network. Not only is this cost saving to the county Behavioral Health Care system, it also reduces further traumatization that may occur when interacting with law enforcement agencies or mental health institutions.

We rely heavily on our volunteer workforce. For the Crisis Line Program alone 201 volunteers and interns contributed 20,008 hours on the crisis lines this year. This is a tremendous cost savings to the county. It is difficult to put a dollar amount on the service provided by our volunteers. As an estimate, if we were to pay our volunteers and interns $17.00/hour, it would equate to roughly $425,170 for their service. We had a very successful recruitment effort this year, hiring and training 79 community volunteers and counseling interns.

Sincerely, Our Life Saving Mission To reach out and offer support to people of all ages and backgrounds during times of crisis, to work to prevent the suicide of

Binh Au those who are actively suicidal, and to offer hope Crisis Line Program Director and caring during times of hopelessness. October 2016

Acknowledgement Our good work would not be possible without the dedication of our crisis line volunteers. We have a poster in our crisis line call room that says “Volunteers Are the Heart of CSS” and we whole-heartedly believe it.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 206 Year At a Glance Year End Report | 4

Total Call Volume FY2015-2016 Total Call Volume 5900 5731 64,977 calls 5700 5579 5577 5469 5529 5500 24 Hour Crisis Line 5333 5497 5312 5300 5307 5122 5279 5242 54,386 calls 5100 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN National Lifeline 24 Hour Crisis line 5,996 calls 1-800-309-2131 5000 BHCS ACCESS 4804 Afterhours 4800 4667 4624 4592 4541 4531 4600 4469 4478 4,595 calls 4400 4532 4537 4286 4325 4200 Total Crisis Line JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Volunteers/Interns National Suicide Prevention Lifeline 201 people 1-800-273-TALK (8255) Total NEW 600 555 563 538 544 Volunteers/Interns 550 521 508 493 478 500 457 79 people 452 445 442 450 400 Total Volunteer Hours JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN 20,008 hours

Alameda CBHCS ACCESS Afterhours Total Volunteer 1-800-491-9099 Training Class Hours 800 607 651 2,511 hours 528 600 454 352 332 330 400 263 263 263 279 273 200 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 207 Year At a Glance Year End Report | 5

Total Number of People Served Due to the nature of the crisis lines people share minimum identifying information. This creates challenges in tracking the number of people served. This table summarizes the number of individuals served each month. The same person, who called in one month, can be a returning caller in another month, so that person is counted twice in the table. The second column represents anonymous calls and brief/information only calls. Known Individuals Anon and Information Calls July 2015 836 callers 468 calls Aug 2015 802 callers 468 calls Sept 2015 821 callers 493 calls Oct 2015 834 callers 387 calls Nov 2015 830 callers 452 calls Dec 2015 806 callers 394 calls Jan 2016 830 callers 524 calls Feb 2016 795 callers 444 calls Mar 2016 837 callers 360 calls April 2016 862 callers 374 calls May 2016 867 callers 372 calls June 2016 861 callers 366 calls

Total Number of Returning Callers Returning callers are people who have called two or more times in a given month. This data was calculated per month, and so it is duplicated. The same person, who is a returning caller in one month, can be a returning caller in another month, so that person is counted twice in the table. Returning Repeat Total Calls % On average Callers Calls July 2015 271 callers 2484 calls 5470 calls 45.4% Aug 2015 259 callers 2329 calls 5279 calls 44.1% Sept 2015 265 callers 2387 calls 5333 calls 44.7% 44.7% Oct 2015 256 callers 2363 calls 5307 calls 44.5% Nov 2015 278 callers 2616 calls 5579 calls 46.9% of our calls are from people Dec 2015 259 callers 2577 calls 5242 calls 49.2% who have called two times Jan 2016 274 callers 2393 calls 5731 calls 41.8% or more in any given Feb 2016 266 callers 2280 calls 5497 calls 41.4% month. Mar 2016 251 callers 2439 calls 5577 calls 43.7% April 2016 264 callers 2411 calls 5529 calls 43.6% May 2016 279 callers 2454 calls 5312 calls 46.2% June 2016 272 callers 2322 calls 5122 calls 45.3%

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 208 Year At a Glance Year End Report | 6

Top 10 Alameda County Cities Oakland 2866 calls Fremont 634 calls Berkeley 2829 calls Alameda 596 calls Livermore 1496 calls San Leandro 514 calls Hayward 931 calls Emeryville 408 calls San Lorenzo 651 calls Union City 312 calls

Non-English Languages (N = 221) Spanish 189 calls Arabic 2 calls Mandarin 13 calls Russian 2 calls Cantonese 11 calls Cambodian 1 call Vietnamese 3 calls To connect with callers who do not speak English, we utilize a translation service that can translate in over 140 languages.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 209 Suicide Related Calls Year End Report | 7

On the crisis lines, we measure suicidal content in crisis calls with three different methods. 1) Each call is rated on a suicidality scale of 0-5 by the crisis line counselor. 2) For callers with suicidal thoughts or feelings, counselors ask the caller to self-report on suicide intent at the start of the call, and at the end of the call. 3) Lastly, we have a thematic approach to capture data regarding suicide related calls.

Total Number of Calls with Suicide Rating 1 and above 5,554 calls Number of Unique Callers with Suicide Rating 1 and above 2,275 Unique Callers Number of Returning Callers where one of their calls had a 865 Returning Callers suicidality rating of 1 or above (They called at least 2 times this year) Number of Callers with Suicide Rating 1 and above who connected 1,410 One Time Callers to the crisis line only one time

4000 3885 Call Count by Suicide Risk Rating 3500

3000

2500 2000 345 1500 1053 High Risk Calls 1000

500 271 264 81 0 1 2 3 4 5

EXPLANATION OF RATINGS 0 = No talk or thoughts of suicide 1 = Has suicidal thoughts or feelings; has no plan or means to enact plan 2 = Thinks of suicide, has devised a plan to die, does not have intent or means for suicide attempt 3 = Has persistent suicidal thoughts, has a plan & is actively trying to obtain the means to die 4 = Has a plan for suicide, easy access to the means, but has not yet taken any action to harm self 5 = Has recently made or is about to make a suicide attempt, wants to die, and is alone

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 210 Suicide Related Calls Year End Report | 8

Dispositions of Calls with Suicidality Rating at 4 or 5 A suicidality rating of 4 or 5 is considered high risk for a suicide attempt or suicide death. The caller had a specific plan, access to means, or had already harmed themselves. A total of 345 calls from 264 unique callers were rated with high suicide risk. 140 high risk callers (53%) utilized the crisis lines more than once. 35 calls involved a firearm.

For many callers, talking with the crisis line counselors will de-escalate the stress level and urgency of the callers which means police and hospital intervention is not necessary. Our counselors are trained to work collaboratively with the caller to find alternate ways to manage their suicidal thoughts and feelings. Below is a table of high suicidality call dispositions. Disposition Count Disable the means - This might include putting the pills or knife in another 80 room, or it would mean moving away from a dangerous location like a train track. Transported Self to Hospital – Sometimes, the caller was on the way to the 10 hospital when they called, and they needed a little encouragement to walk in. Family Member Transported Person at Risk to Hospital – Crisis counselors work 9 to find the least invasive course of action to support the caller’s safety. Having a friend or loved one transport the person to the hospital is ideal. Self-Soothing Skill – This is an important component of safety planning. These 150 may include going for a walk, playing video games, or doing art. Personal Care – These are basic needs activities including eating, sleeping and 119 bathing Take Medication – Taking medication as prescribed can help reduce stressful or 9 uncomfortable feelings or thought patterns. Social Support – Friends, family members, church or other community can help 93 reduce feelings of isolation. The caller agreed to reach out to the loved one or to have someone visit. Professional Care – This includes seeking help from a clinician, therapist or 68 medical personnel Referral – Sometimes, the crisis line counselor gave the caller a referral to a 20 community based organization Accept Follow Up Call – Sometimes, the crisis line counselor would arrange for a 45 follow up call usually within an hour and up to 24 hours from the end of the initial call. The follow up calls may occur repeatedly throughout the day until the suicidal urges have passed. Breaking up the day into short manageable chunks of time can help the caller get through the crisis. Nothing – Some calls ended with no clear safety plan. 24 Abrupt Ending – Some calls ended abruptly and the counselor was unsuccessful 32 in reconnecting with the caller.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 211 Suicide Related Calls Year End Report | 9

Emergency Procedures by Call Line ACCESS Afterhours 3 calls Crisis Support Services of Alameda Crisis Lines 1-800-309-2131 70 calls National Suicide Prevention Lifeline 1-800-273-TALK 39 calls TOTAL 112 calls If a person is at imminent risk for suicide or if a person has already harmed themselves with the intent to die, then crisis counselors will call for a wellness check from the local police department, with or without the person’s permission. 112 out of 345 high risk calls resulted in police intervention. This means that more than 66% of high risk calls were deescalated over the phone without the use of police intervention. We work collaboratively with callers in crisis to find a plan to keep them safe that is the least invasive and has the least potential of traumatization.

Stories from the Crisis Lines Caller’s suicidal ideation has increased over the last two years. This morning she felt impulsively suicidal and bought anti-nausea pills and alcohol to try to kill herself. She drank until she fell asleep and her boyfriend found her. Her mom wants her to go to a hospital but she does not want to. The counselor told the caller they can explore their options together. Counselor worked on building rapport, listening closely to the caller’s needs. The caller was encouraged to get some food and water. By the end of the call, a safety plan was made to involve the boyfriend. Her boyfriend disposed the alcohol and over the counter medication. To pass the time when her suicidal urges were the toughest to manage, the caller and her boyfriend chose to watch a non-triggering movie and have a big dinner. With the caller’s permission, the counselor spoke with the boyfriend, providing psycho education on suicide assessment and how to determine if hospitalization was necessary. The boyfriend was surprised at how bad his girlfriend was feeling, and he was grateful for the support from the crisis lines. He was committed to keeping his girlfriend safe, and to researching low fee and holistic counseling in the morning. Early in the call, it was clear the caller ingested substance with the intent to die, though she repeatedly refused to say what and how much. The suicide attempt was made shortly before the call. The caller disclosed she had let a friend know about her attempt. Caller said it was "too late" and "already done," and she was calling just to make a record of what had happened in the hopes the message will get to her daughter. She was an older woman with limited mobility. She was having trouble filling out papers and paying rent, and it sounded like the landlord was actively trying to push her out. She was extremely angry and feared she would soon be out on the streets. She is a survivor of trauma. She said "it's time" and she's "at peace" with her suicide attempt. The counselor highlighted her ambivalence, and got her to talk about the people she loves, and about her life which she described as "beautiful." The counselor worked on lowering her resistance and she eventually gave her location. During the call, she described that her feet were feeling numb and she was feeling heavy and sleepy. In spite of the counselor’s encouragement for her to stay on the phone, she ultimately hung up when she insisted on going to lie down. She did not pick up the phone when our counselor reached out to her numerous times. Eventually, we confirmed with Oakland Police Department that the caller was transported safely to the local hospital. Since that day, the caller has continued to utilize the crisis lines for support with much lowered suicidal feelings and intent. She still is struggling with housing issues.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 212 Suicide Related Calls Year End Report | 10

Calls with Suicide Related Concerns (N = 7,285) There were many other calls that were related to suicide, even if the caller themselves had no current risk of suicide.

A call is related to suicide if it fits one or more of these categories A Suicide Attempt in Progress 51 A caller has expressed Suicidal Intent 267 A caller has expressed Suicidal Desire 5476 A call is regarding a loss due to suicide 39 A third party is calling in regards to someone they are concerned about 719 A caller is asking for information on suicide (i.e. warning signs) 87 A caller discusses past suicidal ideation or past suicide attempt 379

More than one concern may be have been present in a call. Distinguishing between Suicidal Intent and Suicidal Desire helps crisis counselors more accurately assess suicide risk. Suicidal Intent and Suicidal Desire are often confused. Suicidal Desire refers to suicide ideation (thoughts of suicide), intense psychological pain, feelings of hopelessness and helplessness, feeling trapped or intolerably alone. In contrast, Suicidal Intent refers to an expressed intent to die, a plan to kill self/other, an attempt in progress, and/or preparatory behaviors. Helping callers distinguish between the two can be very empowering for the caller. It can encourage callers to explore ways to feel better without acting on the suicidal thoughts and feelings.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 213 Suicide Related Calls Year End Report | 11

Self-Reported Suicidal Intent Rating Our counselors asked callers with suicide risk at the beginning and at the end of call to self-rate their suicide intent.

“On a scale of 1-5, how likely are you to act upon your suicidal thoughts and feelings at this time? Where 1 represents “Not Likely” and 5 represents “Extremely Likely.”

Suicidal intent is a good measure because it is most likely to change during the call. Asking the caller to self-rate, instead of using counselor’s rating of caller’s risk, decreases subjectivity. Self- rating can be helpful to the caller because it helps the caller distinguish between feelings and actions. It can also be therapeutic for the caller to understand that talking about their pain and feelings is different than acting upon them. And finally, the assessment can assist the counselor and caller to collaboratively decide on the level of intervention.

Suicidal Intent Ratings Self-Rated Intent (N= 5,127) N Average Rating at End of Call If caller rated 1 at Beginning of Call 3,398 calls 1.00 If caller rated 2 at Beginning of Call 1,079 calls 1.70 If caller rated 3 at Beginning of Call 447 calls 2.38 If caller rated 4 at Beginning of Call 139 calls 3.12 If caller rated 5 at Beginning of Call 64 calls 4.42

Suicidal Intent Trajectories 5 5 4.42 4 4 3 3.12 3 2.38 2 2 1.7 1 1 1 0 Start of Call End of Call

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 214 Follow Up Calls Year End Report | 12

Follow-up can promote collaboration between counselor and caller and provides an opportunity to reassess the caller for safety. It is important to report on both the number of people contacted and the number of times a counselor tried to reach the caller. This reflects the effort and resources needed to contact callers. There are various times a crisis line counselor would reach out to a caller or follow up after a crisis line call. This table summarizes the most common scenarios.

Types of Follow Up Follow Up after Emergency Procedures Within 3 days and up to 2 weeks after Emergency Procedures, the crisis line counselor will follow up with the caller. In this call, caller and counselor will have the opportunity to repair any rapport that may have been damaged, and we assess suicidal potential and continue to collaboratively build a safety plan.

Follow Up after an Abrupt Ending Call Sometimes, the call ends abruptly. If the caller had indicated high lethality or easy access to means, the counselor will try to reconnect with the caller.

Follow Up as part of a Safety Plan The crisis line counselor may offer to call the person back after a short interval to help the caller manage suicidal thoughts and feelings. These calls usually occur within an hour of the original call. In the time in between the first crisis call and the follow up call, the caller is encouraged to utilize a self-soothing strategy, or reach out to a support person.

Follow Up as part of a Third Party Call Sometimes, we receive calls from a third party, and from a preliminary assessment, we may deem the caller at higher risk for suicide. At this point, the crisis counselor may reach out and talk directly to the person at risk. The counselor can then provide a more thorough suicide assessment, and to work collaboratively to find the most appropriate intervention.

Follow Up to give Caller Additional Resources Sometimes the crisis line counselor must do additional research to find an appropriate referral for the caller and will call back with the referral.

Total Follow Up Efforts Number of People Eligible for Follow Up 225 calls Number of Calls with Successful Contacted 101 calls Number of Follow Up Calls Initiated 260 calls Unfortunately, I only have aggregate follow up data. I cannot break it down by follow up call types.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 215 New Trainee Demographics Year End Report | 13

As an agency that values diversity, it is important for us to measure the makeup of our community. Diversity in our pool of crisis counselors fosters a richer experience for our callers. We asked each incoming trainee to fill out the demographic survey. We received 51 completed surveys out of 79 total trainees (65% Response Rate)

Contact with people who have different backgrounds than their own strengthens crisis counselors’ ability to work with callers from diverse communities. Biases and judgments are explored in the training program. Crisis counselors often times share stories of their own lived experience. The sharing helps ameliorate the “othering” effect of our callers when crisis counselors reflect on their life experiences and realize that their own experiences are not too different than the experience of the callers.

Disability, race, gender, age, and language capacity were also measured in the survey. The results are summarized on the following pages. Lived Experience Question On the Survey Yes Percentage of Surveys Do you or someone close to you live with one or more mental health concerns? 39 76.5% Have you or someone you care about dealt with suicidal thoughts and feelings? 43 84.3% Has someone close to you died by suicide? 15 30%

What race do you identify with most? (Self defined categories) Count White (non-Hispanic) 29 Asian or Pacific Islander 7 Bi-racial or Multi-racial 7 Hispanic 2 Other (unspecified) 1 White (non-Hispanic), Asian or Pacific Islander, Bi-racial or Multi-racial 1 Afghan 1 White (non-Hispanic), Hispanic, Native American, Bi-racial or Multi-racial, Other 1 (unspecified), Latina Black 1 North Asian Indian 1 Black, Hispanic, Bi-racial or Multi-racial 1

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 216 New Trainee Demographics Year End Report | 14

Age Range Count Gender Female 39 75% 20-24 17 Male 12 23.08% 25-29 14 Unspecified 1 1.92%

30-39 9 40-49 3 Self-identified as living with a disability 50-59 6 Yes 4 7.69% 60+ 2 No 48 92.30%

Self-identified as LGBTIQ Yes 9 17.64% No 42 82.35%

Language Count Language Count Bengali 1 Mandarin 4 Cantonese 2 Portuguese 1 Farsi/ Dari 1 Punjabi, Hindi 2 French 2 Russian 1 Italian 1 Spanish 5 Kiswahili 1 American Sign 1 Language Korean 1 Urdu 1

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 217 Crisis Line Volunteer Perspective Year End Report | 15

Below is a story from a crisis line volunteer’s experience.

When I answered the phone I immediately heard the caller cry, “I have a whole bottle of pills in my hand and I’m going to take them. I don’t want to live anymore.” Hearing these words, I could feel my entire body tense and my mind start to work in overdrive to recall the next steps I had been trained to take as a crisis counselor. I took a deep breath and calmly asked the caller to put the pills away while we were talking. He agreed to put the pills in a drawer, out of sight. Over the next two hours, I tried every counseling intervention I knew to keep our caller from hurting himself. Ultimately, when safety planning was not enough, the decision was made, with the support from my shift supervisor and agreement from our caller, to send an ambulance to take him to the hospital to prevent him from killing himself.

As a volunteer for CSS, I have been trained in a number of counseling techniques that helped me to keep the caller safe that day. I built rapport with him, I actively listened, and I empathized with his struggles. I did not judge him and I did not try to minimize his feelings. I called upon his strengths and helped him remember that he had reasons to want to live. Many aspects of his situation made this difficult for me. He described living a very hard life; he has no social support, has been homeless many times, carries diagnosis of bipolar disorder, and is a transgender individual. What brought the most success in this call was actively listening to what was important to our caller and what brought him joy, which included being successful at his job. Calling upon this strong work ethic and enjoyment of work allowed me to be able to soothe him. Most importantly, this intervention built trust between us, which eventually led our caller to disclose his address so that I could send an ambulance. I came away from this experience feeling emotionally drained, but with an overpowering sense of satisfaction.

In the months since that call, I have been thinking about him and reflecting on the challenges that he faces in his life. I am curious about his behaviors, thoughts, and whether work is going well for him. While it can be difficult to only have a small window into our callers’ worlds, I feel fulfilled knowing I could help in a distressing and critical moment in his life.

Deborah, Crisis Line Volunteer who started February 2016

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 218 Caller Demographics Year End Report | 16

Demographic data continues to be a challenge. Due to the nature of the crisis lines, our crisis counselors prioritize crisis intervention and safety of the caller over taking demographic data. However, this data is important in informing our outreach and training objectives. Race/Ethnicity (11,580 calls or 17.8% of total calls) Race Count African American 2,388 Asian 1,121 Caucasian/ White 4,679 Fillipino 427 Latin American 1,145 Native American/Alaska Native 7 Native Hawaiian/Pacific Islander 1 Other 907 40%

21%

10% 10% 8% 4%

African Asian White/ Fillipino Latin American Other American Caucasian (Unspecified)

Gender (41,804 calls or 64.3% of total calls) Call Count by Gender

Trans Man 2 Questioning 81 Trans Woman 1671 Unknown 4023 Male 14846 21181 Female

0 5000 10000 15000 20000

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 219 Caller Demographics Year End Report | 17

Age by Percentage (29,313 calls or 45% of total calls)

25.8% 24.1%

15.0% 15.7%

8.7% 9.2%

0.5% 0.6% 0.5%

05-14 15-24 25-34 35-45 45-54 55-64 65-74 75-84 85+

American Association of Suicidology National Suicide Rates by Age (per 100,000)

Age information is available for 45% of callers. Included is the distribution of suicide rates nationally. People age of 65+ have comparable death rates as those aged 55-64, yet on the crisis were from transitional age youth lines, we see low rates (16.8%) of callers age 65 16-25 years of age. and up. This indicates a need for further outreach to people 65 years of age and up.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 220 Caller Concerns and Reasons for Calling Year End Report | 18

Mental health concerns were the most common reasons for calling the crisis lines. More than one concern may have been discussed in a single call. This data is representative of number of incidents, not number of calls. Not all callers self-report on all concerns of prevalence. These numbers are under-reported due to inconsistency in crisis counselors data input. Overall Caller Concerns (N=59,386)

Referral 1717

Health Related 3070

Other Concerns 6690

Abuse/ Violence 803

Social Issues 12828

Mental Health 34278

Mental Health Concerns (N=34,278)

Edutation 122 Trauma/ PTSD 1054 Substance Use Disorder 915 Non-Suicidal Self Injury 225 Psychiatric Services 1460 Difficult Emotions and Thoughts 6363 Loneliness and Isolation 7358 Depression 5358 Grief 1373 Anxiety and Stress 10050

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 221 Caller Concerns and Reasons for Calling Year End Report | 19

Social Issues Concerns (N=12,828)

Social Media 60

Stigma 282

School Stress 278

Other Social Issues 3390

Relationship/Family Issues 8306

Military Related Issues 104

LGBTIQ 203

Bullying 205

Abuse/Violence Concerns (N= 803)

Other Violence 164

Senior/ Dependant Adult Abuse 65

Rape/ Sexual Assault 175

Domestic Violence 250

Child Abuse 149

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 222 Caller Concerns and Reasons for Calling Year End Report | 20

Additional Caller Concerns (N = 6,680)

Transportation 208

Disaster 19

Financial Problems 1739

Unemployment 1931

Housing Related 1735

Homelessness 727

Food 331

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 223 Crisis Line Program Values Evaluation Year End Report | 21

At Crisis Support Services of Alameda County, we believe everyone deserves utmost respect and dignity to receive comfort and care from our crisis line counselors. Cultural Humility and Trauma Informed Care principles help provide a framework to achieve that goal. We continually examine our internal processes to make sure that our work meets the best client care standards as outlined by Alameda County Behavioral Health Care, the American Association on Suicidology, and the National Suicide Prevention Lifeline. This fiscal year, we prioritize incorporating and enhancing Cultural Humility and Trauma Informed Care principles throughout the Crisis Line Program. Some of the things we have done include:

1. Review and update our operations manual. Our team read through our Training and Operations Manual and removed any language that was stigmatizing or pathologizing of people with mental health challenges. We use person-first language, and we talk about mental health challenges in a hopeful, holistic, empowering, and person-centered way. We believe in a strength based approach. We changed the language of “commit suicide” to “die by suicide.” By shifting the language we have the power to reduce the shame associated with having suicidal thoughts or loss due to suicide. 2. Create additional training modules in the new crisis line volunteers and counseling interns orientation. All volunteers actively engage with the Cultural Humility principle of “lifelong learning and self-reflection.” In a training module, volunteers examine their bias and assumptions about people who may be different than themselves. By bringing these thoughts and ideas to the surface, we can actively choose how we interact with our callers, clients, and colleagues. We also discuss some of the institutions (ie racism, transphobia, gender, homophobia, etc) that can create barriers to access to care. 3. Review crisis line policy through a Trauma Informed Care lens. A committee was formed to evaluate and update crisis line program policy. The committee includes representatives from all levels of the program (managers, staff, volunteers and interns) and will adhere to Trauma Informed Care principles. It will provide an opportunity for participants to actively engage with the principles and improve our service delivery.

Pictured here is the first committee meeting. We had staff and volunteers ranging from 1 year to 17 years of experience.

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 224 Crisis Line Program Values Evaluation Year End Report | 22

The committee wrote this value statement to provide a framework for working with our callers.

We believe that recovery1 is possible for everyone.

We acknowledge that our understanding of caller’s lives is necessarily imperfect. Thus we must listen deeply and be willing to change course when callers redirect us. We seek to incorporate caller input and feedback into policies and practices whenever possible.

We seek to build a person-centered2, collaborative model for communicating the needs and wishes of our callers. We wish to empower3 the callers to define their own wellness. Our goal is for caller profiles to convey a holistic picture of our callers and who they wish to become.

We recognize the devastating impact of trauma4 on individuals and seek to honestly explore the effects of trauma in our interactions with callers. We will actively work towards minimizing further traumatization of our callers. We must recognize and address not only the caller’s traumas but also strive to examine and understand our own responses to trauma.

Finally, we wish to honor the courage required in reaching out to a stranger for help. We strive to pursue our work with the same courageous spirit.

1 Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, 2012)

2 Person-centered models are based on the belief and practice that the consumer is ultimately responsible for their own well-being. The counselor’s primary role is to facilitated growth towards well- being by providing unconditional positive regard, empathy, opportunities for collaboration, and authenticity.

3 Empowerment is the “process of increasing personal, interpersonal, or political power so that individuals can take action to improve their life situations.” (Gutierrez, 2001, p. 210).

4 Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (SAMHSA, 2014)

ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 225 Theresa Razzano, Interim Director 7200 Bancroft Ave, Suite 125B Vocational Program - MHSA Oakland, CA 94605 Ph. (510) 777-4240 / Fax (510) 777 ACVP Placement Outcomes

January 2016 - February 2017 (rolling 12 months) Consumers Opened to VOC in 2015* (a longitudinal glimpse @ 2015 Cohort) Employment Rate Time to 1st Job Placement vs. 1st Loss

60% Seeking Working 53% Work 51%  239 Unique Individuals served by VOC Unit 49% 50%  121 worked in competitive employment 47% 40%  118 seeking work 30% 27%  89% of jobs people held classified as Part-Time 20% 14%

10% 6% 7% 3% Working Seeking Work 0% 1% 0 to 3 Months 4 to 6 Months 7 to 9 Months 10+ Months

Job Placement Job Loss Wage Distribution

40% 38%  All jobs hourly non-exempt, ranging from  143 people with VOC Program episode opening in

35% $10.00 to $30.00 per hour. Median hourly 2015 wage $12.00 30%  73 of these individuals worked competitive employ- 25%  $12 hour range 2nd highest wage rate due ment (51% employment rate) 20% 19% to Oakland min. wage (currently $12.86)  25 of the 73 had multiple job starts; 15% 13% 11%  If CA SSI payment for single person with 10%  More than half of working consumers were placed 7% 6% independent living status is $889 per month: 5% at jobs within three months 2% 1% 1% 1% 1%  That same participant working 20 0%  80% placed within six months $10 $11 $12 $13 $14 $15 $16 $19 $20 $25 $30 hours per week at $10.50hr can gross $1,352 ($840 wages + $463  55% of working people (40) opened in 2015 are  Mid-Level / Intermediate Job Titles include: Construction SSI) Foreman, Computer Technician, Design Engineer, Financial still working, or were working at time of VOC Assistant, Graphic Designer, Pharmacy Technician, Oil Program exit Change Technician, Elementary School Paraprofessional, Screen Printer, Uber Driver * VOC Program Episode Opened 01/15 - 12/15

C. Llorente, March 2017 ACBHCS FY16-17 PLAN UPDATE PROVIDER REPORTS ATTACHMENTS, P. 226