To: County of Sonoma Board of Supervisors
Department or Agency Name(s): Department of Health Services
Staff Name and Phone Number: Tina Rivera, 707-565-4774
Vote Requirement: 4/5th
Supervisorial District(s): Countywide
Title:
Title
Drug Medi-Cal Organized Delivery System Staffing Allocation - Cohort
End
Recommended Action:
Recommended action
A) Adopt a personnel resolution amending the Department of Health Services Department Allocation List to add 8.0 full-time equivalent position allocations as detailed in the attached resolution, effective January 9, 2024.
B) Adopt a resolution authorizing budgetary adjustments to the fiscal year 2023-2024 adopted budget, programming $1,094,200 of state and federal revenue to finance requested position allocations. (4/5th Vote Required)
end
Executive Summary:
The Department of Health Services (hereinafter, “DHS” or “the Department”) proposed to the Board of Supervisors on April 18, 2023 <https://sonoma-county.legistar.com/LegislationDetail.aspx?ID=6165249&GUID=A255811A-5581-4AD2-BBDD-98439DB36633&Options=Text|&Search=Drug+Medi-Cal+Organized+Delivery> the implementation of the Drug Medi-Cal Organized Delivery System (DMC-ODS) plan for the comprehensive delivery of substance use disorder (SUD) treatment services to Medi-Cal-eligible individuals. As a DMC State Plan, Sonoma County currently offers 9 services, which will expand to 15 with the ODS system. This includes expanded narcotic programs, withdrawal management, recovery service, care management, physician consultation, and partial hospitalization & medication assisted treatments.
For Sonoma County to execute the DMC-ODS plan, DHS requires eight (8.0) full-time equivalent (FTE) positions across the Behavioral Health and Administrative divisions, which will be financed 50% from 1991 Mental Health Realignment and 50% from anticipated increased Federal Financial Participation (FFP) projected amount of $853,450 annually from Medi-Cal reimbursement derived from expanding from 9 to 15 types of substance use disorder services.
As part of the Board’s April 18, 2023 <https://sonoma-county.legistar.com/LegislationDetail.aspx?ID=6165249&GUID=A255811A-5581-4AD2-BBDD-98439DB36633&Options=Text|&Search=Drug+Medi-Cal+Organized+Delivery> action, DHS was authorized to submit an initial implementation plan to the state, which included addressing any potential challenges that may arise from executing the proposed Plan. The Implementation Plan was submitted to the State on July 11, 2023. State preliminary approval was received on October 5, 2023. DHS Behavioral Health Division (BHD) is now in the Readiness Review process, having submitted the initial response to DHCS on December 7, 2023. We estimate that working through the Readiness Review process and putting the required DMC-ODS components in place will be complete by June 30, 2024. Meeting this timeline will set the DMC-ODS start date as July 1, 2024. The hiring of the positions in this Item will facilitate the further development and administration of the DMC-ODS implementation plan to operationalize the plan and how it will be implemented, including assessments, certification, training, and other such preparatory work.
The further defined implementation plan will be submitted to the State in the Spring of 2024 to seek final approval by the end of 2024.
Discussion:
Background
California’s DMC-ODS program was the nation’s first SUD treatment demonstration project under Medicaid Section 1115 authority, approved by the Centers for Medicare and Medicaid Services (CMS) in 2015. Since the DMC-ODS began in 2015, all California counties were given the option to participate in the program to provide their resident Medi-Cal beneficiaries with a range of evidence-based SUD treatment and recovery services in addition to those available under the Medi-Cal State Plan. As of today, 37 counties have opted into the program, representing 96 percent of the Medi-Cal population statewide.
Services Gap Analysis & Outreach
Since 2021, DHS has been monitoring the County’s need for enhanced substance use disorder (SUD) services through multiple focus groups, benchmarking conversations, an online stakeholder survey, as well as extant and aggregated data. Key findings from the unmet needs are:
• There has been a greater than expected increase in unintentional drug overdoses and the overall death rate due to drug overdose has increased significantly in the past several years. The DHS Community Health Dashboard shows that from 2018 to 2019, drug overdose deaths grew 26.75%. From 2019 to 2020, 50.75%.
• The majority of SUD referrals are to outpatient and residential treatment services (31+ days). In FY22-23, 547 clients received Opioid Treatment Services; 369 received Outpatient or Intensive Outpatient; 269 received residential or residential detox treatment.
• Under the current SUD system, residential treatment is not a covered Medi-Cal benefit for men and women (with exception of pregnant and post-partum women). As a result, the primary means of accessing this level of care is through the criminal justice system in Sonoma County. The result is that Medi-Cal beneficiaries in need of this level of care are unable to access it, unless court referred.
• There is a lack of services and treatment options particularly for: youth, those with co-occurring disorders, parents, seniors, in-custody and misdemeanor clients, immigrant/refugee, and veteran populations, as well as the more isolated geographic regions in the County.
In the summer of 2022, collaboration efforts included a series of Stakeholder Planning meetings, regular weekly internal planning meetings with key Health Services staff, and a series of Steering Committee meetings. The Stakeholder Planning meetings engaged stakeholders, such as those working in criminal justice and probation, youth services, and human services, in planning DMC-ODS services and developing the DMC-ODS implementation plan.
Over an eight-week period between June and August 2022, stakeholders participated in six planning meetings. During these meetings, participants were provided with an orientation to the DMC-ODS and the implementation of the DMC-ODS in Sonoma County. Additionally, outreach was conducted to substance use, mental health, and primary care providers to encourage participation in planning meetings relevant to their specialty areas to include their perspectives and ideas regarding the expansion of services and capacity.
Once the DMC-ODS plan is approved, Health Services will continue to facilitate meetings for the purposes of convening key stakeholders to collaborate on the implementation of the DMC-ODS. Groups and organizations who have participated in planning efforts to date will be actively involved in the implementation of the system of care. The DMC-ODS Steering Committee composed of DHS-BHD managers and consultants will continue, and committee membership will be expanded to include other members from Health Services, SUD contracted providers, contracted mental health providers, the health centers, Partnership HealthPlan of California (PHP), clients, and their family members.
Treatment Services of the Plan
Outpatient Services: Offer comprehensive, coordinated, and defined services that may vary in level of intensity. Outpatient programs may address a variety of needs, including, but not limited to, situational stressors, family relations, interpersonal relationships, mental health issues, life span issues, psychiatric illnesses, SUDs, and other addictive behaviors. These services consist of intake, assessment, individual and group counseling, client education, collateral services, crisis intervention services, treatment, and discharge planning. Outpatient Services consist of two types of sessions: (1) Group Counseling and (2) Individual Counseling.
Narcotic Treatment Program: Services are provided in facilities licensed by the California Department of Health Care Services (DHCS) and accredited by a federally approved accreditation provider. The medically necessary services are provided in accordance with an individualized treatment plan determined by a licensed physician or their licensed designee and approved and authorized according to Title 9 CCR Regulations.
Intensive Outpatient Services: Consist primarily of counseling and education about SUD-related problems, with specific components including intake, individual counseling, group counseling, family therapy, client education, medication services, collateral services, crisis intervention services, treatment planning, and discharge services.
Withdrawal Management: Habilitative and rehabilitative services when determined by the current standing Medical Director or Licensed Practitioner of the Healing Arts (LPHA) as medically necessary and in accordance with an individualized client plan. The Withdrawal Management services are intake, observation, medication services, and discharge services. With the implementation of DMC-ODS, DHS-BHD will ensure there is also medically supervised withdrawal management available to clients that would benefit from additional oversight.
Residential Treatment & Inpatient Services: The County of Sonoma currently provides a small amount of residential SUD services through contracted community-based organizations which include a non-institutional 24-hour non-medical, short-term (30 days or less) or long-term (31 days or more) program that provide rehabilitative services. Health Services will work with its community-based organization network to expand capacity as demand for services increases as a result of the DMC-ODS.
Recovery Services: As part of the assessment and treatment needs of Recovery/Living Environment, during the transfer/transition planning process, beneficiaries will be linked to applicable medically necessary recovery services, including Sober Living Environments (SLEs).
Beneficiaries may access recovery services after completing their course of treatment whether they are triggered, have relapsed, or as a preventative measure to prevent relapse. Recovery services will include outpatient individual or group counseling; recovery monitoring/coaching; linkages to services to enhance education and job skills; linkages to support groups and ancillary services; and peer-to-peer screening and navigation, supported by a clinical specialist. The clinical specialist will oversee a team of recovery coaches and will be a specialized behavioral health provider housed within DHS-BHD that works with high-utilizer clients.
DHS-BHD is anticipating adding 40 SLE beds, equating to 14,600 bed days annually to its SUD system of care. DHS will use the county Request for Proposal (RFP) process to acquire the needed beds and services. Individuals will be able to be placed in these SLEs for up to 6 months per episode. Services include supervised/monitored board and care provided by peer recovery providers as well as recovery support and education services.
Care Coordination: Care coordination will be utilized to assist a beneficiary in accessing needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. These services focus on the coordination of SUDs care, integration with primary care and mental health, and interaction with the criminal justice system if needed. Intensive case management services also will be utilized to serve the historically more challenging to engage populations with complex needs, such as frequent utilizers of multiple health, criminal justice, and social services systems, and older adults with co-occurring physical health and substance uses issues. It is expected that care coordination services for these highly complex populations will occur outside of a formal treatment episode.
Clinician Consultation: Services that are designed to assist physicians within the DMC-ODS network with seeking expert advice on designing treatment plans or problem lists and supporting DMC providers with complex cases. These cases may address medication selection, dosing, side effect management, adherence, drug-drug interactions, or LOC considerations. When needed, physician consultation services will be provided by the County’s Behavioral Health Medical Director or contracted psychiatrist and may occur when beneficiaries are placed into treatment.
Implementing DMC-ODS
Staffing resources will be required to administer the DMC-ODS plan. 8.0 new positions are required in the Behavioral Health Division of the Department of Health Services to setup the sequencing of Phase 1 and Phase 2 of the high-level Implementation Plan (IP) presented to the Board this past April 2023.
Phases of the Implementation Plan:
• Submit Implementation Plan (IP)
• Phase 1 (2.5-3 months from receipt of IP by DHCS - October 2023) - Cohort is hired.
o Receive and incorporate feedback from DHCS, if needed
o Receive preliminary approval from DHCS
o Submit Readiness Review
• Phase 2 (5-8 months from receipt of IP submission - End of March 2024).
o Conduct a fiscal review
o Submit a fiscal plan
o Conduct a readiness review
o Complete readiness review
o Carry out a network certification process
• Phase 3 (1-2 months prior to the “go-live” date - End of May 2024)
o Submit a Master Provider File
o DHCS will draft and finalize a county-specific intergovernmental agreement
o County may begin offering DMC-ODS benefits to eligible Medi-Cal beneficiaries starting 7/1/24
Cohort Composition
The staffing cohort will be comprised of the following 8.0 FTE:
• 1.0 Substance Use Disorder (SUD) Services Health Program Manager (2634-HPM)
• 1.0 Health Care Compliance Analyst (2420-PCA)
• 2.0 Quality Assessment Performance Improvement (QAPI) Program Planning & Evaluation Analyst (0880-PPEA)
• 1.0 SUD AODS Specialist (2684-AODSSPC)
• 3.0 SUD AODS Counselor (2683-AODSCOUNSII)
Members of the staffing cohort will work with the Department of Health Care Services (DHCS) to develop and administer the Implementation Plan. The Implementation Plan is meant to show DHCS that Sonoma County possesses comprehensive knowledge and operational resources to implement DMC-ODS. After initial submission which occurred on July 11, 2023, there will be collaborative communication between the Department and DHCS to finalize the Implementation Plan for resubmittal to the State for review and preliminary approval. Upon granting of DHCS preliminary approval, DHCS will enter into an inter-governmental agreement with the DHS to administer DMC-ODS through a Prepaid Inpatient health plan.
Administration of the DMC-ODS program may require a second cohort, but DHS management will need to re-assess program capacity after 12 months of operation. Once the assessment is completed and the results indicate that additional staffing is required and can be paid for with additional funding, DHS will return to the Board for further approval.
Strategic Plan:
This item directly supports the County’s Five-year Strategic Plan and is aligned with the following pillar, goal, and objective.
Pillar: Healthy and Safe Communities
Goal: Goal 1: Expand integrated system of care to address gaps in services to the County’s most vulnerable.
Objective: Objective 2: Identify gaps in the Safety Net system of services and identify areas where departments can address those gaps directly, and seek guidance from the Board when additional resources and/or policy direction is needed.
Prior Board Actions:
On April 18, 2023 the Board A) received a report on the Drug Medi-Cal Organized Delivery System Waiver Draft Implementation Plan and B) authorized the Director of Health Services, or designee, to enter into the Drug Medi-Cal Organized Delivery System Plan by submitting an application to the California Department of Health Care Services and work with the California Department of Health Care Services to develop the necessary Drug Medi-Cal Organized Delivery System structures.
Fiscal Summary
|
Expenditures |
FY 23-24 Adopted |
FY 24-25 Projected |
FY 25-26 Projected |
|
Budgeted Expenses |
|
$1,706,900 |
$1,775,200 |
|
Additional Appropriation Requested |
$1,094,200 |
|
|
|
Total Expenditures |
$1,094,200 |
$1,706,900 |
$1,775,200 |
|
Funding Sources |
|
|
|
|
General Fund/WA GF |
|
|
|
|
State/Federal |
$1,094,200 |
$1,706,900 |
$1,775,200 |
|
Fees/Other |
|
|
|
|
Use of Fund Balance |
|
|
|
|
Contingencies |
|
|
|
|
Total Sources |
$1,094,200 |
$1,706,900 |
$1,775,200 |
Narrative Explanation of Fiscal Impacts:
Current fiscal year increased expenses represent about 6 months of payroll expenses in the amount of $1,094,200. Subsequent fiscal years represent full-year payroll costs for the 8.0 FTEs. Funding for increased ongoing staffing and operational costs will be financed 50% from 1991 Mental Health Realignment and 50% from anticipated increased Federal Financial Participation (FFP) projected amount of $853,450 annually from Medi-Cal reimbursement derived from expanding from 9 to 15 types of substance use disorder services.
|
Staffing Impacts: |
|
|
|
|
Position Title (Payroll Classification) |
Monthly Salary Range (A-I Step) |
Additions (Number) |
Deletions (Number) |
|
Health Program Manager |
$9,105 - $11,068 |
1.0 |
0.0 |
|
Patient Care Analyst |
$9,647 - $11,726 |
1.0 |
0.0 |
|
Program Planning and Evaluation Analyst |
$7,755 - $9,426 |
2.0 |
0.0 |
|
AODS Specialist |
$7,271- $8,838 |
1.0 |
0.0 |
|
AODS Counselor |
$6,798 - $8,261 |
3.0 |
0.0 |
Narrative Explanation of Staffing Impacts (If Required):
Human Resources has reviewed and agrees with the classification selections. Upon Board approval, DHS will work with Human Resources to begin the recruitment process.
Attachments:
Attachment 1 - Personnel Resolution
Attachment 2 - Budget Resolution
Related Items “On File” with the Clerk of the Board:
None