2015
Alcohol and Drug Strategic
Implementation Plan
Monterey County Health Department
Behavioral Health Bureau
County of Monterey
Thank You to Our Strategic Planning Management Committee
Carr, Kacy—Deputy Director, Behavioral Health
Hanni, Krista— Health Department Planning, Evaluation and Policy Manager
Heald, Andy—Behavioral Health Services Manager & Strategic Planning Project Co-Lead
Maddock, Lynn—Behavioral Health Services Manager
Miller, Amie—Behavioral Health Director & Strategic Planning Project Co-Lead
Miller, Cheryl—Health Department Administration
Robles, Lucero—Quality Improvement Manager
Smith, Sid—Deputy Director, Behavioral Health
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Thank You to Our County Partners, Contract Providers and Community
Stakeholders Who Participated in the Strategic Planning Focus Group Session
Service Area
Stakeholders Who Participated
(in addition to Behavioral Health Staff)
Alcohol and Other Drug
Treatment
Staff and consumers from Community Human Services,
Door to Hope, Sun Street Centers, Valley Health
Associates, San Benito County Behavioral Health
Department
Access to Treatment
Consumers and staff at Community Human Services,
staff from Monterey County Health Department, Clinic
Services Division
Monterey County Probation Department, Marina Police
Department
Adults Involved in the Criminal
Justice System
Adult Residential
Placement/Supported Housing
Consumers and staff from Interim Inc., Consumers
from Pajaro Wellness Center and the Consumer
Advocacy Council
Homeless Adults
Interim, Inc., Monterey County Probation Department,
Monterey County Department of Social Services
Crisis & Hospitalization
ER staff at Community Hospital of the Monterey
Peninsula, Salinas Valley Memorial Hospital,
consumers and staff from Interim, Inc.
Juvenile Justice
Monterey County Probation Department, Marina Police
Department, Door to Hope
Children Involved with Social
Services and Transition Age
Youth
Department of Social Services, Family and Children
Services, PREP (Prevention and Recovery In Early
Psychosis)
Dual Diagnosis Treatment
Consumers and staff from Interim, Inc., Door to Hope
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Contents
Executive Summary ................................................................................................................................................................ 5
Prologue ...................................................................................................................................................................................... 7
Data/Forces of Change ........................................................................................................................................................ 10
Key Indicators of Community Alcohol and Drug Use, Monterey County ................................................... 11
Demographic Disparities in Monterey County ..................................................................................................... 11
Calculation of Anticipated Need ...................................................................................................................................... 13
Treatment Levels of American Society of Addiction Medicine ASAM......................................................... 15
Levels of Withdrawal Management........................................................................................................................... 16
Other Treatment Service Requirements of the Waiver Implementation .................................................. 17
Current Environment........................................................................................................................................................... 18
Prevention....................................................................................................................................................................... 18
Adult Outpatient Treatment .................................................................................................................................... 18
Adult Residential Treatment ................................................................................................................................... 19
Opioid (Narcotic) Treatment .................................................................................................................................. 19
Sober Living Environments ..................................................................................................................................... 20
Driving Under the Influence (DUI) Services ..................................................................................................... 20
Deferred Entry of Judgment .................................................................................................................................... 21
Proposition 36 ............................................................................................................................................................... 21
Entry Level Drug Treatment Court ....................................................................................................................... 21
Drug Treatment Court ............................................................................................................................................... 22
AB109 ............................................................................................................................................................................... 22
Gaps in Current System and Proposed Next Steps .................................................................................................. 23
Gap: Early Intervention Services ........................................................................................................................... 23
Gap: Full Continuum of Outpatient Services ..................................................................................................... 23
Gap: Withdrawal Management Services ........................................................................................................... 24
Gap: Recovery Services (aftercare) ..................................................................................................................... 25
Gap: Case Management Services .......................................................................................................................... 26
Gap: Physician Consultation Services ................................................................................................................. 27
Gap: Full Continuum of Residential Services .................................................................................................... 27
Gap: Additional Medication Assisted Treatment ........................................................................................... 28
Gap: Partial Hospitalization .................................................................................................................................... 29
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Gap: Justice Involved Individuals ......................................................................................................................... 30
Gap: Co-Occurring Treatment Programs .......................................................................................................... 31
Gap: Youth Outpatient Treatment ....................................................................................................................... 31
Gap: Youth Residential Treatment....................................................................................................................... 32
System Shifts ........................................................................................................................................................................... 33
System Shift: Implement ASAM and centralized screening ...................................................................... 33
System Shift: Case Management Services (Care Coordination)............................................................... 34
System Shift: Increase Primary Care Providers use of SBIRT ................................................................. 34
System Shift: Physician Consultation ................................................................................................................ 35
System Shift: Continuous Quality Improvement (QI) .................................................................................. 35
System Shift: Utilize Electronic Health Record ............................................................................................... 36
System Shift: Evidence Based Practices ............................................................................................................ 36
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Executive Summary
Introduction
Monterey County Behavioral Health, a bureau of the Health Department, provides mental health
and substance use disorder services to residents of Monterey County. From April 2015 to October
2015, Behavioral Health engaged in a community-wide alcohol and drug strategic planning process,
to review and assess the multi-regional treatment and recovery services provided to a culturally
diverse population.
The strategic planning process examined the current level of substance use disorder services
provided by community-based agencies including prevention, early intervention, outpatient,
residential and aftercare; existing “gaps” within the service delivery system were also reviewed and
assessed. The completed plan serves as a structural foundation for the development and
implementation of a comprehensive, integrated continuum of care that is modeled after the
American Society of Addiction Medicine Criteria (ASAM).
The Planning Process
The Strategic Planning Process was coordinated by the Bureau’s Behavioral Health Director and the
Behavioral Health Service Manager/Alcohol and Drug Program Administrator. The alcohol and drug
services administrative team and the Health Departments’ Planning, Evaluation and Policy Manager
provided additional support.
Key strategies and goals of the plan were identified by incorporating information from the
California Department of Health Care Services, Special Terms and Conditions, Drug Medi-Cal
Organized Delivery System, The American Society of Addiction Medicine, electronic medical records
and state/federal databases. The coordinators distributed the Data Driven Decisions (D3) reports
that the Quality Improvement Team produces for bureau supervisors and managers. Data in this
report is generated from the bureaus Electronic Medical Record system and reflects services
entered into the system, regardless of payer source. A summary of Alcohol and Other Drug Service
data is listed on the following pages.
Community partners, stakeholders and consumers were invited to participate in a structured
strategic planning session lead by David Mee-Lee, MD to assist in prioritizing alcohol and drug
treatment needs and developing a conceptual framework for the development of a continuum of
care. Service providers contracting with the bureau also contributed to the planning process by
providing feedback during a series of meetings facilitated by the bureau’s alcohol and drug services
administrative team.
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The strategic planning session represented a collaborative process where participants learned
about the ASAM criteria and reviewed the current service delivery system and needs for treatment
services in the future. Interactive group exercises followed the criteria and data review, where
participants identified and determined the following:
 Alcohol and drug treatment services required for the development and implementation of a
comprehensive, organized delivery system of care
 Consumer capacity for each of the required alcohol and drug treatment services
 Alcohol and drug treatment service gaps and strategies for developing new services
 Opportunities and methods to improve service capacity, enhance collaborative partnerships
and explore potential barriers to meet the comprehensive treatment needs of consumers
Stakeholders participating in the planning process included alcohol and drug treatment provider
staff and administrators, Interim Inc., Monterey County Behavioral Health Bureau staff and
managers, San Benito County Behavioral Health Department, Department of Social and
Employment Services, Family and Children’s Services, Department of Probation, regional hospital
staff and administrators, Public Health, law enforcement, criminal justice partners and consumers.
The strategic plan coordinators worked with participants to identify and prioritize alcohol and
drug treatment service needs. Approximately 1,400 responses were recorded by participants and
used to formulate capacity needs, recommendations for system change, and the improvement of
service delivery detailed in the Strategic Plan.
A draft of the final plan was submitted to key stakeholders for review. Stakeholders included the
alcohol and drug services administrative team, contract providers, Behavioral Health management
and staff, county partners and the Mental Health Commission.
Summary of Alcohol and Other Drug Service Data
 FY 2014/15 local agencies provided alcohol and drug services to 1,179 clients; 69% had a
substance use disorder diagnosis, 28% received mental health counseling services.
 More than 250 clients received medically supervised methadone maintenance treatment, 508
received outpatient services, and 484 received residential services.
 Of 1,318 individuals receiving services by the Monterey County Behavioral Health Crisis Team,
48 % have a substance use diagnosis.
 61% of patients placed in the Natividad Medical Center Inpatient Psychiatric Unit have a cooccurring substance use disorder.
 26% of individuals seeking mental health services through Access to Treatment have a
substance use diagnosis.
 Of adults served with serious and persistent mental illness, 44% have a co-occurring substance
use disorder.
 52% of the adult homeless services population has a substance use disorder.
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 58% of residents in a licensed, community-based short-term crisis residential program have a
substance use disorder.
 78% of Medi-Cal eligible in Monterey County are Latino; 48% of individuals served by Alcohol
and Other Drug Services are Latino.
 Regional health inequities are impacting alcohol and other drug service access throughout
Salinas Valley.
 18% of the Medi-Cal eligible population resides in South County. Only 6% of individuals
receiving Alcohol and Other Drug services were from South County.
 31% of mentally ill adults placed in intensive residential services are diagnosed with substance
use disorders; 37% of mentally ill individuals receiving supportive housing have a substance
use disorder.
 61% of adults involved in criminal justice related services have a substance use disorder.
 46% of adults receiving services from the Forensic Team have a secondary substance use
disorder diagnosis.
 Of 82 adults served in Access AB109 program, 91% have a substance use disorder.
 40% of the 191 children receiving out-of-home placement services have a substance use
disorder.
 69% of the youth served in the juvenile justice system were diagnosed with a substance use
disorder.
Prologue
Monterey County is in the process of embracing historical changes to the way alcohol and drug
services are delivered to individuals who have been diagnosed with substance use disorders. The
Federal Government’s Center for Medicare and Medicaid Services recently approved California’s
application for a Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver. California
submitted the waiver in January 2015 and is the first state to receive federal approval of this type. It
represents the most significant change to drug medi-cal since its creation 35 years ago and will
support an integrated safety-net service delivery system by improving the coordination and
integration of substance disorder treatment, mental health treatment and physical health care
services.
The goal of the waiver is to move toward a recovery-oriented continuum of care that will improve
the success rate of substance use disorder treatment by providing a broad range of services to
people who need it and to follow their progress so that they are at less risk for falling out of
treatment. Providing a continuum of care will give beneficiaries the opportunity to receive
individualized treatment based upon their specific needs. In addition to improving treatment
outcomes, the waiver will also reduce other health care related costs associated with substance use
disorders.
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The Drug Medi-Cal Organized Delivery System (DMC-ODS) will serve as a new contract between
California and the federal government. Our hope is that establishing an organized delivery system
of care in Monterey County will maximize services for beneficiaries through improved coordination
of substance use treatment with Behavioral Health, public safety systems, primary care and other
community service providers.
The anticipated need in the strategic plan is based upon estimates for numbers and percentages of
the Monterey County population 138% or less of the Federal Poverty Level by citizenship status. It
is important to acknowledge that this estimate does not include members of specific populations,
such as individuals who are incarcerated, in need of immediate or future alcohol and drug
treatment services.
Development of an Organized Delivery System of Care
Developing an organized delivery system of substance use disorder care involves significant
changes to the existing substance use service delivery system in Monterey County.
Key elements of Monterey County’s organized drug medi-cal delivery system will include:









Providing beneficiaries with a continuum of care based upon the American Society of
Addiction Medicine (ASAM) Criteria for substance use disorder treatment services.
Broader range of services including early intervention, medical treatments, case
management and recovery support services.
Increased local control and accountability for services.
Greater administrative oversight.
Utilization controls to improve beneficiary care and efficient use of resources.
Increased coordination with other systems of care including mental health and medical
services.
Accessibility to substance use disorder treatment in all regions.
Use of culturally competent evidenced based practices and provision of services that meet
cultural and linguistically appropriate service (CLAS) standards.
Development of a centralized access and authorization unit.
The ASAM Criteria defines treatment as a continuum of care that involves four broad levels of care
and an early intervention level for both adolescents and adults. The levels of care represent
intensities of service along a continuum (see diagram, page 4). Treatment is delivered across a
continuum of services that reflect the varying severity of illnesses treated and the intensity of
services required. This model of service delivery supports person-centered treatment that is
responsive to an individual’s specific needs and progress in treatment.
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ASAM Criteria, Third Edition 2013
To implement the best practices in the new service delivery system a robust referral network
will be used that includes the following parties.
Family
Mental Health
Criminal Justice/
Probation
Schools
Primary Care
Other community
members
ASAM Criteria, Third Edition 2013
9|Page
Data/Forces of Change
The California Department of Alcohol and Drug Programs, in
collaboration with the Center for Applied Research Solutions
(CARS) Inc. developed a list of key indicators which have readily
available and standardized data. The indicators are meant to assist
state and local prevention planning and policy-making by providing
a means to assess substance use problems and can be used to
optimize prevention planning and outcome measurement efforts in
communities.
Locations of Community Outreach
Sessions
Data for the key indicators were summarized in the 2010 county
report, Indicators of Alcohol and Other Drug Risk and
Consequences for California Counties: Monterey County 2010. In
general, from 2001 through 2008, rates for admissions to alcohol
and other drug treatment, arrests for drug-related crime, arrests
for alcohol-related crime, alcohol-involved motor-vehicle accidents
was for 18 to 24 year olds. While the rate for each indicator was
similar to or lower than the state rate, increases over the time
period were seen for admissions to alcohol and other drug
treatment facilities, hospitalizations due to alcohol and drug use,
while the arrests for drug-related crime, arrests for alcohol-related
crime, and deaths due to alcohol and drug use decreased over the
same time period. The 2001 to 2008 data from this report and the most current data (where
available) for these seven indicators are in the following table.
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Key Indicators of Community Alcohol and Drug Use, Monterey County
Indicator
2000
2001
2002
2003
2004
2005
2006
1. Binge Drinking in Past
Year (%)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Year
2007
2008
2009
2010
2011
29.9 N/A
36.5%
N/A
36.0% 32.9% 30.4% 26.1%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
139.0
127.3
122.1
139.1
128.4 N/A
N/A
N/A
N/A
N/A
N/A
2. Admissions to Alcohol
and Drug Treatment (rate
373.5 543.8 517.5 511.4 526.5 539.6 483.9 463.8 402.3
per 100,000)
3. Arrests for Drug-Related
Offenses (rate per 100,000
792.7 716.0 669.3 708.3 765.6 837.2 818.9 782.8 731.6
age 10 to 69)
4. Arrests for AlcoholRelated Offenses (rate per 1,802.1 1,749.3 1,588.1 1,620.3 1,668.9 1,480.5 1,467.4 1,504.6 1,536.5
100,000 age 10 to 69)
5. Alcohol-Involved Motor
Vehicle Accident Fatalities
3.5
4.9
5.2
3.1
6.4
5.4
3.8
3.5
6.8
(rate per 100,000)
6. Alcohol and Drug Use
Hospitalizations (rate per
115.9 112.7 100.8 105.8 147.4 131.1 137.5 140.0 131.9
100,000)
7. Deaths Due to Alcohol
and Drug Use (age-adjusted
18.1 18.3 18.1 20.7 22.4 19.4 21.1 14.2 N/A
rate per 100,000)
2012
2013
2014
N/A
Source: 1. California Health Interview Survey, 2001-2014; 2. California Alcohol and Drug Data System (CADDS) Admissions Data 2000-2005,
California Outcome Measurement System (CalOMS) Admissions Data 2006-2008; 3.& 4. California Department of Justice, Office of the Attorney
General, Criminal Justice Statistics Center, California Arrest Data 2000-2008 ; 5. California Highway Patrol, Statewide Integrated Traffic
Records System (SWITRS) 2000-2008; 6. California Office of Statewide Health Planning and Development, Inpatient Discharge Data (from
Epicenter); 7. California Department of Public Health, Data Query System
Demographic Disparities in Monterey County
The Monterey County Health Department Community Health Assessment 2013 presented ageadjusted accidental poisoning/unintentional drug-related mortality rates per 100,000 by
race/ethnicity, gender and age groups from 1999 through 2010. There were significantly lower
mortality rates for Asian/Pacific Islander (non-Hispanics) and Hispanics compared to Whites (nonHispanics) in 2008-2010. Also, when looked at over time, there was a significant increase in the
accidental poisoning/unintentional drug-related death rate for multiple/other races (nonHispanics) and White (non-Hispanics) from 1999-2001 to 2008-2010.
11 | P a g e
Age-adjusted accidental poisoning/unintentional drug-related mortality rates per 100,000
by race/ethnicity
Age-adjusted rate per 100,000
99-01
00-02
01-03
02-04
03-05
04-06
05-07
06-08
07-09
08-10
Asian/Pacific Islander (nH)
0.0
0.0
0.0
0.0
1.1
1.1
1.1
0.0
0.0
0.0
Black (nH)
7.7
8.6
11.3
15.9
16.1
16.4
8.4
13.3
7.2
11.3
Hispanic/Latino, any race
5.9
4.9
6.5
7.1
7.0
6.8
5.6
4.1
5.3
6.4
Multiple/Other races (nH)
0.0
0.0
0.0
0.0
0.0
0.0
4.5
2.5
9.7
8.4*
White (nH)
8.0
8.4
9.6
12.4
14.2
16.4* 12.9* 17.9* 13.5* 16.3*
Monterey County
6.3
6.1
7.3
8.7
9.6
10.5
8.5
8.3
7.9
9.6
*Statistically unstable; interpret with caution.
(nH) = non-Hispanic
Source: California Department of Public Health, Health Information and Research Section, Death Statistical Master File 19992010; statistical analyses performed by Monterey County Health Department, Surveillance and Epidemiology Unit
Local Assessment Processes
In 2014 the Behavioral Health Bureau developed a strategic plan. This plan was developed over a
yearlong period and involved 15 focus groups and 9 community outreach sessions. Much of the
strategic planning process involved receiving feedback on the provision of alcohol and drug
services- specifically 11 of the 15 focus groups focused on the alcohol and drug services. The
priorities identified included:
1. Training all staff to provide services to Dual diagnoses clients (clients with substance use
disorders and mental health disorders)
2. Collaborating with key community partners to identify a provider of medically supported
detoxification services, providing a safe place for individuals to begin engagement in
recovery services and reduce substance induced hospitalizations. Identify grant funding
opportunities to increase availability of detox services.
3. Increasing aftercare/recovery support services for individuals completion dual diagnosis
residential programs
4. Increasing access to dual diagnosis residential treatment/recovery services.
5. Increasing collateral services to support family member and other support person of adults
served in dual diagnosis treatment programs.
6. Increasing treatment and recovery services to south county residents.
7. Increasing services to non-English speaking individuals seeking AOD treatment.
8. Evaluating the mental health needs of individual enrolled in substance abuse
treatment/recovery services.
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AOD Strategic Implementation Plan Process
The Alcohol and Drug Strategic Implementation Plan was developed from April 2015 to October
2015 and involved receiving feedback from stakeholders and community providers on the current
alcohol and drug treatment system and anticipated needs for developing an integrated, continuum
of care. The process involved a series of meetings with contracting service providers and a
comprehensive, community-based focus group facilitated by David Mee-Lee, M.D. The priorities
identified included:
1. Increasing regional availability of withdrawal management and intensive outpatient
services for youth, families and adults.
2. Expanding existing aod provider services; develop co-occurring residential programs and
high intensity residential services for individuals who have significant social/psychological
problems and high-risk felony offenders.
3. Increasing substance use disorder prevention, assessment and treatment referral service
availability within public education system and medical community.
4. Developing a network of existing addiction specialist physicians and primary care
physicians who are willing to collaborate with alcohol and drug treatment staff and provide
medication assisted treatment to patients.
5. Providing specific training in the diagnosis and treatment of substance use disorders to a
greater number of medical providers, county behavioral health and service delivery staff.
6. Creating a case management/recovery support team within behavioral health; establishing
contracts with provider staff who are credentialed in the field of addiction counseling.
7. Identifying available resources to support the growth of transitional housing programs and
sober living environments for individuals and families; improving aftercare support
services.
8. Ensuring that all levels of treatment service are available in underserved regions of the
county and offered in primary/threshold language of the consumer.
9. Utilization of Evidence Based Practices in all types of treatment, requiring providers to
collect outcome based measurement data for ongoing analysis/review.
10. Enhancing collaborative, multi-disciplinary teams across the health department bureaus
and among community-based partners dedicated.
Calculation of Anticipated Need
The goal of the new waiver in Monterey County is to work towards serving 2% of the safety net
population. The most recent California Health Interview Survey provides estimates for numbers
and percentages of the Monterey County population 138% or less of the Federal Poverty Level by
citizenship status. Of these uninsured and insured populations, approximately 87,000 people in
Monterey County would qualify for Alcohol and Drug services provided by the Behavioral Health
Bureau or funded partners as part of the health system safety net. Applying a range of 2 to 3% of
our estimated safety net population being served under the new waiver would result in an estimate
of 1,740 to 2,610 of the population in 2014 receiving alcohol and drug prevention and treatment
services. This is probably still only meeting a portion of the needs in the county for these services
since 9,000 people who were 138% or less of the Federal Poverty Level in Monterey County in 2014
reported they needed help for mental health/alcohol and drug services.
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Type of Insurance Coverage by Citizenship and Immigration Status for Persons age 18 and
older with Annual Incomes 0-138% of the Federal Poverty Level, Monterey County, 2014
Citizenship and immigration status (3 levels)
Type of current health
insurance coverage
U.S. born citizen
Naturalized citizen
Non-citizen
All
%
Population
%
Population
%
Population
%
Population
Uninsured
50.5*
18,000
37.9*
13,000
85.8*
28,000
57.5%
59,000
Medicare & Medicaid
2.1*
1,000
8.5*
3,000
-
-
3.6*
4,000
Medicare & Others
3.5*
1,000
-
-
-
-
1.2*
1,000
Medicare only
2.4*
1,000
-
-
-
-
0.8*
1,000
Medicaid
20.3*
7,000
36.3*
12,000
14.2*
5,000
23.7*
24,000
-
-
-
-
-
-
-
-
Employment-based
20.6*
7,000
-
-
-
-
7.2*
7,000
Privately purchased
-
-
17.2*
6,000
-
-
5.7*
6,000
Other public
-
-
-
-
-
-
-
-
100.0%
36,000
100.0%
34,000
100.0%
32,000
100.0%
102,000
Healthy Families/CHIP
Total
* = statistically unstable
Source: 2014 California Health Interview Survey
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Elements of the ASAM Criteria
Treatment Levels of American Society of Addiction Medicine ASAM
Implementing the ASAM treatment criteria for addictive, substance-related, and co-occurring
conditions or different levels is major requirement of the new service delivery system. The chart
below outlines the different ASAM levels of treatment and notes if the level is part of the current
county service delivery system. This chart helps to highlight some of the areas where there are gaps
in care.
ASAM
Level
Service
Description
Required
for phase
one?
0.5
Early
Intervention
Outpatient
Services
Screening, Brief Intervention
1
2.1
Intensive
Outpatient
Services
2.5
Partial
Hospitalizati
on Services
3.1
Clinically
Managed
LowIntensity
Residential
Services
Clinically
Managed
PopulationSpecific
HighIntensity
Residential
Services
3.3
3.5
Clinically
Managed
Part of
Current
System?
Current
Capacity
Anticipated
Need
Yes
Partial-in
NMC ER
Open
290
Less than 9 hours of
service/week (adults); less than
6 hours/week (adolescents) for
recovery or motivational
enhancement
therapies/strategies
9 or more hours of
service/week (adults); 6 or
more hours/week (adolescents)
to treat multidimensional
instability
20 or more hours of
service/week for
multidimensional instability not
requiring 24-hour care
24-hour structure with
available trained personnel; at
least *205* hours of clinical
service/week and prepare for
outpatient treatment.
Yes
Yes
400
340
Yes
No
0
550
No
0
30
Yes
480
290
24-hour care with trained
counselors to stabilize
multidimensional imminent
danger. Less intense milieu and
group treatment for those with
cognitive or other impairments
unable to use full active milieu
or therapeutic community and
prepare for outpatient
treatment.
24-hour care with trained
counselors to stabilize
No
No
0
235
No
0
365
No
Requi
red
for
phase
two?
No
Option
al
service
Yes
Yes
Requir
ed
within
three
years
No
Yes
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HighIntensity
Residential
Services
3.7
4
Medically
Monitored
Intensive
Inpatient
Services
Medically
Managed
Intensive
Inpatient
Services
OTP
Opioid
Treatment
Program
(NTP)
MAT
Additional
Medication
Assisted
Treatment
(MAT)
multidimensional imminent
danger and prepare for
outpatient treatment. Able to
tolerate and use full milieu or
therapeutic community
24-hour nursing care with
physician availability for
significant problems in
Dimensions 1, 2, or 3. 16
hour/day counselor availability
24-hour nursing care and daily
physician care for severe,
unstable problems in
Dimensions 1, 2, or 3.
Counseling available to engage
patient in treatment
Daily or several times weekly
opioid agonist medication and
counseling available to
maintain multidimensional
stability for those with severe
opioid use disorder
(ASAM OTP Level 1) ordering,
prescribing, administering, and
monitoring of all medications
for substance use disorders.
Opioid and alcohol dependence,
in particular, have wellestablished medication options.
Requir
ed
within
three
years
No
No
No
0
TBD
No
No
No
0
TBD
Yes
280
160
Partial,
in
primary
care
Small
case
load in
primary
care
390
Yes
No
Yes
Levels of Withdrawal Management
ASAM
Level
1WM
2WM
Service
Description
Required
for phase
one?
Part of
Current
System?
Current
Capacity
Anticipated
Need
Ambulatory
withdrawal
management
without
extended onsite
monitoring
Ambulatory
withdrawal
management
with
extended onsite
Mild withdrawal with daily or less
than daily outpatient supervision.
Yes
No
0
310
Moderate withdrawal with all day
withdrawal management and support
and supervision; at night has
supportive family or living situation.
No
No
0
130
16 | P a g e
3.2 WM
3.7 WM
4WM
monitoring
Clinically
managed
residential
withdrawal
management
Medically
monitored
inpatient
withdrawal
management
Medically
managed
intensive
inpatient
withdrawal
management
Moderate withdrawal, but needs 24hour support to complete withdrawal
management and increase likelihood
of continuing treatment or recovery.
No
No
0
45
Severe withdrawal, needs 24-hour
nursing care & physician visits;
unlikely to complete withdrawal
management without medical
monitoring.
No
No
0
25
Severe, unstable withdrawal and
needs 24-hour nursing care and daily
physician visits to modify withdrawal
management regimen and manage
medical instability.
No
No
0
25
Part of
Current
System?
Current
Capacity
Anticipated
Need
No
0
2610
No
0
2610
No
0
260
Other Treatment Service Requirements of the Waiver Implementation
Required
for phase
one?
Service
Description
Recovery
Services
Yes
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 may be provided
face-to-face, by telephone, or by telehealth
with the beneficiary and may be provided
anywhere in the community.
Yes
To assist beneficiaries to access needed
medical, educational, social, prevocational,
vocational, rehabilitative, or other
community services. These services focus on
coordination of SUD care, integration
around primary care especially for
beneficiaries with a chronic substance use
disorder, and interaction with the criminal
justice system, if needed. Case management
services may be provided face-to-face, by
telephone, or by *telemedicine telehealth*
with the beneficiary and may be provided
anywhere in the community.
Include physician consultation services with Yes
addiction medicine physicians, psychiatrist
Case
Management
Physician
Consultation
17 | P a g e
or clinical pharmacists. Consultation
services may address medication selection,
dosing, side effect management, adherence,
drug-drug interactions, or level of care
considerations. Counties may contract with
one or more physicians or pharmacists in
order to provide consultation services. *
Current Environment
Prevention - Alcohol and Drug (AOD) Program Prevention Services is funded through the
SAPT (Substance Abuse Prevention and Treatment) Block Grant. Sun Street Center and Sunrise
House provide primary prevention services in an effort to reduce alcohol, tobacco, marijuana and
prescription drug use and/or misuse among youth in Monterey County.
Capacity
Count of Clients Served
Location of Services
Key Partners
Funding Source/Special
Considerations
Open
Universal Population (Environmental Prevention is main focus of
Monterey County)
Throughout Monterey County (i.e. Salinas, South County,
Peninsula, North Monterey County)
Sunrise House, Sun Street Center and Regional Coalitions
SAPT Block Grant
Adult Outpatient Treatment
Outpatient treatment includes structured recovery services in a supportive environment for youth
and adults. Intake, individual, group and family counseling services are provided within the
community by Sun Street Centers, Door to Hope and Community Human Services.
Capacity
150-300
Count of Clients Served
Females-181, Males-188 = 369 (2014-2015)
Location of Services
Salinas
Key Partners
Sun Street Centers, Door to Hope, Community Human Services
Funding Source/Special
Medi-Cal, Self-Pay
Considerations
New Wavier Requirements ASAM Level 1-Outpatient Services; ASAM Level 2.1-Intensive
Outpatient Services. Components of Outpatient Services are:
Intake, Individual Counseling, Group Counseling, Family Therapy,
Patient Education, Medication Services, Collateral Services, Crisis
Intervention Services, Treatment Planning and Discharge Services
Suggested Next Steps
Facilitate Alcohol and Drug Strategic Planning Session to discuss
and prioritize service needs
18 | P a g e
Adult Residential Treatment
Residential Treatment includes 24-hour non-medical, short and long-term recovery services
provided in a highly structured supervised, drug-free residential environment. Door to Hope
provides a 4-6 month program for women with severe alcohol and/or drug problems and for
pregnant and parenting women with co-occurring disorders and their infants/young children.
Sun Street Centers provides a social model residential recovery program for adult men.
Community Human Services provides co-ed treatment for adults and for pregnant and parenting
women with young children.
Capacity
M: 54 (47 res, 7 detox) F: 14 M&F: 28 F/Perinatal: 14 = 110
Count of Clients Served
Females-131, Males-271 = 402 (2014-2015)
Location of Services
Salinas, Seaside
Key Partners
Door to Hope, Sun Street Centers, Community Human Services
Funding Source/Special
Medi-Cal, SAPT Block Grant, Private Insurance, Self-Pay
Considerations
New Wavier Requirements One ASAM Level of Residential Treatment Service is required for
approval of a county implementation plan in the first year; all
ASAM levels of Residential Treatment Services (Levels 3.1-3.5)
must be demonstrated within three years following
implementation plan approval. Components of Residential
Treatment are: Intake, Individual and Group Counseling, Patient
Education, Family Therapy, Safeguarding Medications, Collateral
Services, Crisis Intervention Services, Treatment Planning,
Transportation and Discharge Services.
Suggested Next Steps
Facilitate Alcohol and Drug Strategic Planning Session to discuss
and prioritize service needs
Opioid (Narcotic) Treatment
Opioid treatment services involve the direct administration of methadone and/or buprenorphine.
These are medications that relieve opiate withdrawal symptoms and reduce or extinguish cravings
for opioids. Use of these medications does not produce the euphoria, intoxication or withdrawal
symptoms that are associated with chronic use of opiates. This service does not involve
prescriptions; dosing and administration occurs at the Narcotic Treatment Program facility.
Opioid Treatment Program services are provided within the community by Community Human
Services and Valley Health Associates.
Capacity
280
Count of Clients Served
Females-133, Males-171 = 304 (2014-2015)
Location of Services
Salinas, Monterey
Key Partners
Community Human Services, Valley Health Associates
Funding Source/Special
Medi-Cal, Private Insurance
Considerations
New Wavier Requirements ASAM Opioid Treatment Program Level 1 services are provided in
Narcotic Treatment Program licensed facilities. The components of
Opioid Narcotic Treatment Programs are: Intake, Individual and
19 | P a g e
Suggested Next Steps
Group Counseling, Patient Education, Medication Services,
Collateral Services, Crisis Intervention Services, Treatment
Planning and Medical Psychotherapy.
Facilitate Alcohol and Drug Strategic Planning Session to discuss
and prioritize service needs
Sober Living Environments
Sober living homes provide a supportive, secure environment for individuals who are recovering
from alcohol and/or drug dependence. Sober living homes typically require participation in 12
step recovery programs and vocational activities. Sober living environments do not provide
structured treatment services and are self-governed by residents within the home. Sun Street
Centers provides a transitional housing program for adult men and a transitional housing program
for individuals in recovery with children. Community Human Services provides a Sober Living
Environment for single women.
Capacity
342
Count of Clients Served
Pueblo del Mar-96 7 Sun Street Center- 54 Elm House (CHS)- 14
= 164 (2014/2015)
Location of Services
Salinas, Seaside
Key Partners
Sun Street Centers, Community Human Services
Funding Source/Special
Housing Authority, Behavioral Health. Residents expected to
Considerations
actively seek employment, assessed fee based on ability to pay.
New Wavier Requirements Transitional Housing is not a current requirement of Waiver
Suggested Next Steps
Facilitate Alcohol and Drug Strategic Planning Session to discuss
and prioritize service needs
Driving Under the Influence (DUI) Services
Sun Street Centers is an authorized provider for the County of Monterey and licensed by the State
of California Department of Alcohol and Drugs to provide education and counseling to first and
multiple offenders who are referred to services by the Court. The program helps DUI participants
understand his/her relationship with alcohol and drugs and the inherent risk of driving while
under the influence. First and multiple offender services are available. Monterey County Superior
court provides referrals.
Capacity
open
Count of Clients Served
Approximately 3000 per year
Location of Services
Salinas, Seaside, Carmel and Soledad
Key Partners
Superior Court and Sun Street Centers
Funding Source/Special
Participants pay Sun Street Centers directly for DUI program
Considerations
services. The county assesses a fee for its administration and
monitoring of DUI program services. Financial assessment for low
income participants is available.
20 | P a g e
Deferred Entry of Judgment
The Deferred Entry of Judgment (DEJ) program provides alcohol and drug education services to
court ordered first offenders. Services are provided by Valley Health Associates, a community
based AOD program.
Capacity
Count of Clients Served
Location of Services
Key Partners
Funding Source/Special
Considerations
130-150
126/year
Salinas, Monterey and Greenfield
Superior Court and Valley Health Associates
DEJ participants pay VHA for services on a fee for service basis.
Sliding scale is available. Medi-Cal is not a funding source as the
DEJ services are education, not treatment.
Proposition 36
The Substance Abuse and Crime Prevention Act of 2000 (SACPA), also known as Proposition 36
was a California Voter Initiative in November 2000 that took effect on July 1, 2001. The initiative
was later de-funded. The last of the funds were expended in Monterey County in FY 2010-11.
Prop 36 outpatient individual and group services are provided to court referred individuals.
Capacity
150-200
Count of Clients Served
Approx. 120/year
Location of Services
Salinas
Key Partners
Superior Court and Door to Hope
Funding Source/Special
Door to Hope provides private pay, insurance and Medi-Cal funded
Considerations
outpatient treatment program for Prop 36 participants.
Entry Level Drug Treatment Court
Entry level Drug Treatment Court is a therapeutic program for drug offenders with misdemeanor
charges who need intensive substance abuse treatment. The court refers individuals to the
program who have failed the Deferred Entry of Judgment (DEJ) and Prop 36 program.
Capacity
100 – services are currently provided by two social workers and
one probation officer
Count of Clients Served
211 over the course of the grant
Location of Services
Salinas
Key Partners
Superior Court, Public Defender, District Attorney, Probation
Department and community based AOD treatment providers
Funding Source/Special
The grant period ran from 9/30/2010 to 9/29/14.
Considerations
21 | P a g e
Drug Treatment Court
Drug Treatment Court is a therapeutic program for high risk/high need repeat drug offenders who
have multiple charges, a long history of repeat offenses and incarceration. These offenders
require intensive supervision, residential substance abuse treatment and may have had a prior
prison term.
Capacity
50 – services provided by one social worker and one probation
officer
Count of Clients Served
57 in 2014
Location of Services
Salinas
Key Partners
Superior Court, Public Defender, District Attorney, Probation
Department and community based AOD treatment providers
Funding Source/Special
DTC I is funded by Behavioral Health sub-account dollars aka:
Considerations
2011 realignment funds.
AB109
The AB109 program provides behavioral health services to probationers who have been released
to Monterey County under Assembly Bill AB109 on Post Release Community Supervision. In
addition, the program serves high risk felony probationers and those who are on 1170(h)
mandatory supervision. Many justice involved participants have drug and alcohol problems that
require referral to substance abuse treatment.
Capacity
Count of Clients Served
Location of Services
Key Partners
Funding Source/Special
Considerations
150-200
225 in calendar 2014
Monterey County Probation Department, Salinas
Probation Department, Sheriff Department, community based AOD
treatment providers, Monterey County Day Reporting Center,
Turning Point, Transitions to Recovery, Interim Inc., KickStart/OET, Department of Social Services and California Forensic
Medical Group
AB109 funds
22 | P a g e
Gaps in Current System and Proposed Next Steps
When evaluating proposed solutions the criteria for a successful solution involves being: culturally
competent, evidence based, aligned with strategic plan and includes opportunities for cross sector
momentum.
Treatment Services Required Immediately
Gap: Early Intervention Services
Early Intervention Services include the use of time limited, structured, goal-oriented interventions
that typically last 30 minutes or less and are designed to reduce risky alcohol and illicit drug use
behaviors for low-risk users. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a
public health approach that is used in emergency room departments and primary care medical
clinics. The key components of SBIRT include: 1. Screening 2. Brief Intervention and/or Referral to
mental health and/or alcohol use disorder services when medically necessary.
Opportunity:
Prevent substance misuse from developing into chronic, difficult to treat
conditions that have high public and private costs.
Proposed Solution
Training primary care providers and BH Access staff on use of the
Screening, Brief Intervention and Referral to Treatment (SBRIT) with
beneficiaries who are at risk or may be at risk of developing a substance
use disorder.
Barrier
Lack of general substance use disorder education/training among
general medical provider population.
New Wavier
Required. Provided and funded through FFS/managed care
Requirements
Suggested Next Steps Develop SBIRT training protocols; facilitate regional training within
medical community and behavioral health bureau.
Gap: Full Continuum of Outpatient Services
Outpatient treatment includes structured recovery services in a supportive environment for
youth and adults. Evidence suggests that a chronic care model of treatment that incorporates a
full continuum of services results in more successful treatment outcomes for consumers. The
goal of an improved system of substance use disorder care and access to critical services can only
be realized through the expansion of service/provider capacity.
Opportunity:
Provide both outpatient and intensive outpatient services that will
enhance level of care service options; promote individualized care and
increase positive treatment outcomes.
Proposed Solution
Establish intensive outpatient services that meet the ASAM level 2.1
criteria available in all regions of county.
Barrier
Provider capacity, lack of specific funding to support start-up costs.
New Wavier
ASAM Level 1-Outpatient Services; ASAM Level 2.1-Intensive Outpatient
Requirements
Services. Components of Outpatient Services are: Intake, Individual
Counseling, Group Counseling, Family Therapy, Patient Education,
23 | P a g e
Suggested Next Steps
Medication Services, Collateral Services, Crisis Intervention Services,
Treatment Planning and Discharge Services.
Enhance existing outpatient treatment provider resources, facilitate RFI
process for intensive outpatient service programming, and provide
additional evidence based practice training to provider and bureau staff.
Gap: Withdrawal Management Services
Detoxification services are an essential part of the continuum of care for addicted individuals.
Detoxification services that require the presence of trained medical staff on-site are not currently
available in Monterey County. There is a need for increasing the accessibility of this level of
service to individuals who are ready to commit to treatment and begin the process of
detoxification. Sun Street Center provides non-medical detox services at their residential
treatment program for men in Salinas. Community Human Services provides non-medical detox
services to men and women at Genesis House.
Opportunity:
Develop capacity to provide medically monitored detoxification services
to treat physiological withdrawal symptoms, reducing risk factors that
may lead to sustained treatment and recovery.
Proposed Solution
Implement ambulatory withdrawal management services available to
consumers throughout the county that meet ASAM level 1 criteria
during the first year of waiver implementation.
Barrier
Provider and medical staffing capacity
New Wavier
A. Intake: process of admitting a beneficiary into a substance use
Requirements
disorder program
B. Observation: process of monitoring beneficiary’s course of
withdrawal, conducted as frequently as deemed appropriate
C. Medication Services: prescription or administration related to sud
treatment services, or assessment of side effects/results of that
medication
D. Discharge Services: process to prepare beneficiary for referral to
Another level of care, post-treatment return or reentry into
community
Suggested Next Steps Facilitate RFI process, support community based providers in
establishing certified, ASAM level modalities within existing residential
programs.
24 | P a g e
Gap: Recovery Services (aftercare)
Individuals engaged in substance use treatment often enter treatment with significant additional
challenges including homelessness, unemployment, legal issues, interpersonal problems and lack
of support. Aftercare recovery services provide the supplemental support that individuals need so
that they may continue to benefit from treatment received. Recovery services will allow
individuals to receive coordinated access to the services/resources that are necessary to achieve
sustainable recovery. Sun Street Centers, Door to Hope and Community Human Services offer
aftercare groups and community resource referrals to individuals participating in their outpatient
and residential programs.
Opportunity:
Provide a safety-net of aftercare services that are essential to reducing
the risk of relapse.
Proposed Solution
Establish recovery service programming throughout Monterey County.
Barrier
New Wavier
Requirements
Suggested Next Steps
Peer support/training, recovery coaches not currently employed
A. Outpatient counseling services in the form of individual or group
counseling to stabilize the beneficiary and then reassess if the
beneficiary needs further care
B. Recovery Monitoring: Recovery coaching, monitoring via telephone
and internet
C. Substance Abuse Assistance: Outreach, peer-to-peer services, and
relapse prevention, and substance abuse education
D. Education and Job Skills: Linkages to life skills, employment
services, job training, and education services
E. Family Support: Linkages to childcare, parent education, child
development support services, family/marriage education
F. Support Groups: Linkages to self-help and support, spiritual and
faith-based support
G. Ancillary Services: Linkages to housing assistance, transportation
Develop network of providers, utilizing existing social worker staff
within behavioral health bureau and establishing collaborative
partnerships within health department and among established consumer
advocacy groups.
25 | P a g e
Gap: Case Management Services
Case Management Services allow individuals to receive coordinated access to needed medical,
educational, social, pre-vocational, vocational, rehabilitative, or other community services. These
services focus on the coordination of substance use disorder care, integration with primary care
especially for individuals with a chronic substance use disorder, and interaction with the
criminal justice system if needed.
Opportunity:
Provide coordination of care and an integrated service delivery system
that ensures placement in the appropriate level of treatment for clients
with substance use disorders.
Proposed Solution
Establish case management service programming throughout Monterey
County.
Barrier
Peer support/training, recovery coaches not currently employed
New Wavier
A. Comprehensive assessment/periodic reassessment of individual
Requirements
needs to determine need for continuation of case management
services;
B. Transition to higher or lower level of substance use disorder care;
C. Development and periodic revision of a client plan that includes
service activities;
D. Communication, coordination, referral and related activities;
E. Monitoring service delivery to ensure beneficiary access to service
and the service delivery system
F. Monitoring the beneficiaries progress;
G. Patient advocacy, linkages to physical and mental health care,
transportation and retention in primary care services; and,
H. Case management shall be consistent with and shall not violate
confidentiality of alcohol and drug patients (42 CFR Part 2. and
California Law).
Suggested Next Steps Develop network of providers, utilizing existing aod provider staff and
social worker staff within behavioral health bureau; collaborate with
consumer advocacy/peer support groups such as NAMI.
26 | P a g e
Gap: Physician Consultation Services
Physician Consultation includes Drug Medi-Cal physicians consulting with addiction medicine
physicians, addiction psychiatrists or clinical pharmacists. Physician consultation services are
not provided directly to Drug Medi-Cal beneficiaries; rather, they are designed to assist Drug
Medi-Cal physicians with seeking expert advice with complex cases which may address
medication selection, dosing, side effect management, adherence, drug-drug interactions, or level
of care considerations.
Opportunity:
Establish a supportive network within the medical community that will
broaden critical service availability and increase positive treatment
outcomes
Proposed Solution
Establish agreement/contract with MD in community who provide
medication services to existing aod contractors; recruit/employ
addiction specialist psychiatrist
Barrier
Recruiting a psychiatrist/physician specializing in addiction medicine
may be difficult
New Wavier
Counties participating in the waiver are required to provide this service
Requirements
during the first year of implementation.
Suggested Next Steps Schedule contract meetings with local MDs; propose telemedicine as
option for delivery of specialty addiction services/consultation.
Treatment Services Required within Three Years
Gap: Full Continuum of Residential Services
Residential Treatment includes 24-hour non-medical, short and long-term recovery services
provided in a highly structured supervised, drug-free residential environment. Evidence suggests
that a chronic care model of treatment that incorporates a full continuum of services results in
more successful treatment outcomes for consumers. The goal of an improved system of substance
use disorder care and access to critical services can only be realized through the expansion of
service/provider capacity.
Opportunity:
Provide full continuum of residential services that will enhance level of
care service options; promote individualized care and increase positive
treatment outcomes
Proposed Solution
Establish evidence-based, high-intensity residential treatment services
that meet ASAM Levels 3.3 and 3.5 criteria within 3 years of
implementing waiver services.
Barrier
Provider capacity, lack of specific funding to support start-up costs
New Wavier
ASAM Designation for Residential Providers: All residential providers
Requirements
must be designated to have met ASAM requirements and receive a DHCS
issued ASAM designation. One ASAM Level of Residential Treatment
Service is required for approval of a county implementation plan in the
first year; all ASAM levels of Residential Treatment Services (Levels 3.1,
3.3, 3.5) must be demonstrated within three years following
27 | P a g e
Suggested Next Steps
implementation plan approval. Coordination with ASAM Levels 3.7 and
4.0 (provided and funded through FFS/managed care) is also a
requirement.
Components of Residential Treatment are: Intake, Individual and Group
Counseling, Patient Education, Family Therapy, Safeguarding
Medications, Collateral Services, Crisis Intervention Services, Treatment
Planning, Transportation and Discharge Services
Facilitate RFI process, support existing residential providers in
certification and ASAM designation of all required levels of service.
Optional Treatment Services
Gap: Additional Medication Assisted Treatment
Medication Assisted Treatment provides a safe, controlled level of medication to overcome the
use of opioids and alcohol. Research shows that when treating substance-use disorders, a
combination of medication and behavioral therapies is most successful. Medication assisted
treatment (MAT) is clinically driven with a focus on individualized patient care.
Monterey County is in need of increasing the accessibility of this treatment option; the
availability of comprehensive MAT is currently limited to a small percentage of medical
providers in primary care/integrated care settings. Community Human Services and Valley
Health Associates provide Methadone maintenance programs in Salinas. Providing additional
MAT will positively impact treatment retention rates and lower overall healthcare costs.
Opportunity:
Building MAT capacity in primary care settings has the potential to
greatly increase consumers’ access to these services in less stigmatized,
more familiar medical settings.
Proposed Solution
Collaborate with primary care providers and provide education in
utilization of various medications used to treat substance use
addictions; recruit/employ psychiatrist specializing in addiction
medicine.
Barrier
Lack of staff understanding of the medications, opposing
philosophy/beliefs about use of medications as a method of treatment.
New Wavier
MAT Drug Reimbursement through the DMC-ODS and Medical System
Requirements
Medication
TAR* Required
Availability
Methadone
No
Only in NTP/OTP
Buprenorphine
Yes, unless provided Pharmacy Benefit,
in an NTP/OTP
NTP/OTP
Naltrexone Tablets
No
Pharmacy Benefit,
DMC Benefit
Naltrexone longYes
Pharmacy Benefit,
acting injection
Physician
Administered Drug
Disulfiram
No
Pharmacy Benefit,
NTP/OTP
Acamprosate
Yes
Pharmacy Benefit
28 | P a g e
Naloxone
No
Pharmacy Benefit,
NTP/OTP
 MAT is not a current requirement under the 1115 waiver. However,
Medication Assisted Treatments are evidenced based interventions
that have been shown to increase patient retention, social
functioning, and days of abstinence, while reducing engagement in
criminal activities, infectious disease transmissions, and hospital
and emergency room admissions.
*Treatment Authorization Request (TAR)
Suggested Next
Steps
Facilitate RFI process; utilize telemedicine combined with services
provided by RN staff.
Gap: Partial Hospitalization
Partial Hospitalization is a non-residential treatment service providing psychiatric, medical and
mental health services for individuals who require more intensive services than outpatient, but
who do not require 24-hour residential care. Partial Hospitalization program services feature 20
or more hours of clinically intensive programming per week, as specified in the patient’s
treatment plan.
Opportunity:
Proposed Solution
Barrier
New Wavier
Requirements
Suggested Next
Steps
Developing Partial Hospitalization programming has the potential to
improve treatment outcomes and reduce the number of individuals in
need of residential treatment services.
Establish an evidence-based Partial Hospitalization program that meets
the ASAM level 2.5 criteria. These programs typically have direct access
to psychiatric, medical, and laboratory services, and are to meet the
identified needs of patients which may warrant daily monitoring or
management but which can be appropriately addressed in a structured
outpatient setting.
Fiscal challenges of start-up costs, identification and recruitment of
strategic partners.
ASAM Level 2.5 Partial Hospitalization is not a requirement under the
1115 waiver.
Facilitate meetings with hospital administrators and local alcohol and
drug service providers to develop collaborative project plan.
29 | P a g e
Recommended Services
Gap: Justice Involved Individuals
Monterey County is in need of substance abuse services to justice involved individuals
incarcerated at the jail. In-custody education and treatment for substance abusers is likely to help
interrupt the cycle of recidivism that is often fueled by drug abuse and criminal acts to pay for
drugs. There is also a need to develop a continuum of services that bridge in-custody drug and
alcohol education and treatment to community resources such as alcohol and drug treatment
programs, 12-step programs and the recovery community to help individuals successfully
reintegrate into the community while maintaining a sober lifestyle.
Opportunity:
Providing education and treatment for substance use disorders to
defendants in the jail has the potential of increasing motivation to move
from a substance based to a recovery driven lifestyle. Creating a
continuum of care that bridges in-custody services to community
services will help facilitate successful reintegration and likely decrease
recidivism.
Proposed Solution
1. Invite local substance abuse treatment providers to do “in-reach” at
the jail to inmates in need of substance abuse education and
treatment.
2. Engage treatment partners in designing a continuum of care that
bridges services from jail to community.
Barrier
Lack of resources and need for staff who are motivated to work with
justice involved individuals.
New Wavier
None. The intersection of the organized delivery system of services with
Requirements
the criminal justice system is acknowledged and additional service
provisions for this population have been proposed. Increasing length of
stay for withdrawal and residential services for criminal justice offenders
and use of promising practices such as Drug Treatment Court services is
recommended.
Suggested Next Steps Facilitate additional meetings with correctional facility administrators to
promote collaboration with aod treatment providers and to develop a
long-term plan for providing in-custody and post-release treatment
interventions.
30 | P a g e
Gap: Co-Occurring Treatment Programs
It is estimated that more than half of all adults diagnosed with severe mental illness are also
impaired by a substance use disorder. Individuals with co-occurring mental health and substance
use disorders are at an increased risk for homelessness, incarceration, medical illness, suicide
and early mortality. Compared with individuals who have been diagnosed with a single disorder,
individuals with dual disorders often require longer treatment, experience more crises, and
progress more gradually. Integrated care or co-occurring treatment has been associated with a
reduction in substance abuse, increase in psychiatric stability and improved quality of life.
Interim provides co-occurring treatment for adults at Bridge House; Door to Hope provides
Integrated Co-Occurring Treatment (ICT) for adolescents.
Opportunity:
The Monterey County Behavioral Health Strategic Plan, 2014 dual
diagnosis treatment goal is to increase access to dual diagnosis
residential treatment/recovery services; implement evidence based
practices to improve treatment/recovery outcomes and reduce relapse
rates. Focusing on this goal will include access to co-occurring
treatment in outpatient settings.
Proposed Solution
Implement evidence-based, co-occurring treatment programs
throughout the county.
Barrier
Current resources required to educate/train staff in use of evidencebased practices for co-occurring treatment are limited.
New Wavier
Service providers/programs will be required to demonstrate use of at
Requirements
least two evidence based practices.
Suggested Next Steps Evaluate current and past fiscal year residential occupancy rates to
determine service trends and predict both immediate and future needs.
Educate staff/implement evidence based practices/monitor use of
evidence based practice skills in clinical settings. Continue pilot project
and consider longer term contracting with Ingenuity Health company
providing medication monitoring via non-invasive urine testing to
identify areas of potential substance abuse and non-adherence to
psychotropic medication.
Gap: Youth Outpatient Treatment
The Monterey County Behavioral Health Strategic Plan, 2014 indicates that youth within the
county have high rates of alcohol and other drug use. Specific goals within the Strategic Plan
include reducing the use of alcohol, marijuana, prescription and over-the counter drug misuse, and
tobacco among current youth in Monterey County. National research shows that the effective
treatment of substance use disorders among youth/adolescents includes placement in outpatient
and/or residential treatment programs.
Monterey County has an impressive prevention program currently in place for youth. However,
core substance use treatment services are significantly limited within the community. Monterey
County is in need of additional outpatient and residential substance use services for
youth/adolescents who experience educational, social, legal and familial problems resulting from
their use of alcohol/other substances. Door to Hope provides adolescent outpatient treatment
services through their ICT (Integrated Co-occurring Treatment) program. Community Human
Services provides outpatient services to youth through DAISY (Drug and Alcohol Intervention
31 | P a g e
Services for Youth) at the Silver Star Resource Center, Juvenile Probation Department.
Opportunity:
Provide local services to youth that will compliment prevention services
in place and enhance service level of care options to a typically
underserved age group.
Proposed Solution
Establish county-wide, youth outpatient treatment programs using
evidence based practice modalities for services provided.
Barrier
Inadequate funding streams, lack of specific funding, coordinated system
of care at State level is not in place, lack of provider
capacity/infrastructure
New Wavier
None. Beneficiaries under the age of 21 who are at risk or have a
Requirements
substance use disorder are eligible to receive waiver services pursuant to
the Early Periodic Screening, Diagnostic and Treatment (EPSDT)
mandate.
Suggested Next Steps Support and enhance existing provider resources; Initiate RFI process.
Gap: Youth Residential Treatment
Monterey County is in need of increasing residential treatment services for youth/adolescents
who experience the psycho-social consequences of alcohol/other substance use. Consequences of
adolescent substance abuse can include academic failure, social and familial disruption, overdose,
automobile accidents, increased risk for human immunodeficiency virus infection and sexually
transmitted diseases, and arrest and incarceration. Residential treatment is a resource-intense
level of care, primarily for adolescents with severe levels of dependency whose mental health
issues, medical needs, and addictive behaviors require placement in a 24-hour structured
environment. Door to Hope provides residential treatment at Santa Lucia for adolescent females
who have a significant substance use disorder and a mental health disorder.
Opportunity:
Provide local services to youth so that youth and their families are not
faced with the hardship of out-of-county substance use treatment
placement
Proposed Solution
Consider cross-county collaborative for establishing residential
treatment services in tri-county area
Barrier
New Wavier
Requirements
Suggested Next Steps
Inadequate funding, lack of specific funding, lack provider capacity,
coordinated system of youth care at State level is not in place.
No specific requirements listed.
Establish multi-disciplinary task force to address fiscal resources for new
programs; propose collaborative, inter-agency service agreement with
supportive housing; initiate RFI process.
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System Shifts
System Shift: Implement ASAM and centralized screening
Monterey County will be required by the State Department of Health Care Services to provide a
continuum of care based upon the American Society of Addiction Medicine (ASAM) Criteria for
substance use disorder treatment services. Required services under the new service delivery
system waiver must be available and accessible to Medi-Cal beneficiaries. All services must be
provided by responding to immediate needs and ASAM placement criteria.
A primary goal underlying the ASAM Criteria is for the patient to be placed in the most
appropriate level of care. For both clinical and financial reasons, the preferable level of care is
that which is the least intensive while still meeting treatment objectives and providing safety
and security for the patient. The ASAM Criteria is a single, common standard for assessing
patient needs, optimizing placement, determining medical necessity, and documenting the
appropriateness of reimbursement.
ASAM Criteria uses six unique dimensions, which represent different life areas that together
impact any and all assessment, service planning, and level of care placement decisions. The
ASAM Criteria structures multidimensional assessment around six dimensions to provide a
common language of holistic, biopsychosocial assessment and treatment across addiction
treatment, physical health and mental health services.
The ASAM Criteria provides a consensus based model of placement criteria and matches a
patient’s severity of SUD illness with treatment levels that run a continuum marked by five
basic levels of care, numbered Level 0.5 (early intervention) through Level 4 (medically
managed intensive inpatient services).
Opportunity:
By creating a centralized access point, county staff can complete timely
assessments and use case managers to link clients to recommended
levels of care. ASAM criteria will guide services for both voluntary and
court ordered clients. The DMC-ODS waiver requires that licensed or
license eligible staff complete these assessments.
Proposed Solution
Recruit and train additional licensed/licensed eligible ACCESS staff.
Barrier
Significant amount of training will be required to fully implement ASAM
criteria, associated costs with initial and ongoing training
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System Shift: Case Management Services (Care Coordination)
Monterey County will be required by the State Department of Health Care Services to
coordinate case management services for all substance use disorder clients. Case management
services can be provided at DMC provider sites, county locations, regional centers, or as
outlined by the county in the implementation plan; however, the county will be responsible
for determining which entity monitors the case management activities. Services may be
provided by a Licensed Practitioner of the Healing Arts or certified or certified eligible
counselor
Counties are responsible for developing a structured approach to care coordination to ensure
that beneficiaries successfully transition between levels of SUD care (i.e. detoxification,
residential, outpatient) without disruptions to services. In addition to specifying how
beneficiaries will transition across levels of acute and short-term SUD care without gaps in
treatment, the county will describe in the implementation plan how beneficiaries will access
recovery supports and services immediately after discharge or upon completion of an acute
care stay, with the goal of sustained engagement and long-term retention in SUD and
behavioral health treatment. The county implementation plan will indicate whether their care
transitions approach will be achieved exclusively through case management services or
through other methods. The county implementation plan will indicate which beneficiaries
receiving SUD services will receive care coordination.
Opportunity:
The coordination of substance use treatment care will assist individuals
by monitoring effectiveness of service delivery and placement within the
system
Proposed Solution
We will need to hire and train care coordinators
Barrier
Program providers will also be delivering case management in both
outpatient and residential programming; a considerable amount of crosstraining will be necessary to operate seamless service delivery.
System Shift: Increase Primary Care Providers use of SBIRT
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health approach that
is used in emergency room departments and primary care medical clinics. SBIRT provides early
intervention services targeted at individuals who misuse alcohol and illicit drugs, but who may
have not yet developed dependence. SBIRT programs provide individuals with screening and
assessments, and delivery interventions that are appropriate to reduce risks related to alcohol and
substance abuse. Research suggests that SBIRT services provided in acute care settings are
associated with modest changes in recent alcohol and illicit drug use.
Opportunity:
Increase Primary Care Providers knowledge to provide appropriate
screening, brief intervention and treatment referrals in the primary care
setting.
Proposed Solution
1. Hire a consulting psychiatrist with a specialty in addiction medicine
2. Develop a training protocol with a continual re-education about local
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Barrier
AOD resources for primary care providers and supporting staff
(entire workforce, Nursing, Medical Assistants).
Time required for developing training and educational protocols
System Shift: Physician Consultation
Monterey County will be required by the State Department of Health Care Services to provide
or establish contracts for physician consultation services. Physician Consultation Services can
be provided by addiction medicine physicians, addiction psychiatrists or clinical pharmacists.
These services are not provided directly to beneficiaries; rather they are designed to assist
Drug Medi-Cal physicians with the development of treatment for beneficiaries. Consultation
services may address medication selection, dosing, management of side-effects, issues with
compliance, drug-drug interactions or level of care considerations. The County may contract
with one or more physician or pharmacist to provide consultation services.
Opportunity:
Create a support network for primary care providers and nurse
practitioners who will interface with SUD patients in integrated care and
community medical clinics.
Proposed Solution
Contract with one or more physicians in order to provide services.
Barrier
Training, associated costs
System Shift: Continuous Quality Improvement (QI)
Quality improvement consists of systematic and continuous actions that lead to measurable
improvement in the delivery of services and in client care. We recognize the need for ongoing use
of data when identifying quality improvement efforts that focus on client care and the functioning
of the overall delivery system with the aim in mind; provide high-quality services and identify
barriers that may impede this ability.
Opportunity:
Ongoing review of substance use disorder services to ensure individuals
have appropriate access to service and receive a high-standard quality of
care. Use of data to evaluate the services and outcomes to determine
areas of need.
Proposed Solution
Development of standardized policies and procedures for delivery of
substance use disorders, including a uniform method for evaluating and
monitoring of the service delivery and quality of services. Use of data to
evaluate and identify areas of need and improvement; from accessing
services to discharge and aftercare.
Barrier
Need for hiring staff (County and Providers) that have substance use
disorder training and staff that are trained to work with individuals who
have a dual-diagnosis. Need for current staff to be trained in assessment
and treatment of substance use disorders and dual-diagnosis. Need for
hiring and/or dedicating staff in QI to assist with oversight/utilization
review of Drug Medi-Cal organized delivery system.
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System Shift: Utilize Electronic Health Record
Monterey County Behavioral Health implemented the use of an electronic health record (AVATAR)
in 2009. The implementation of AVATAR provides a more in depth understanding of treatment
history and opportunities to provide treatment in a comprehensive manner. In a manner that
makes sense to the individual. Since the implementation of AVATAR, alcohol and other drug
providers have utilized AVATAR for submission of claims for reimbursement.
Opportunity:
Integration of services and treatment to maximize service delivery.
Proposed Solution
Behavioral health has offered contractors free use of their EMR system.
To help improve the continuum of care, contractors could consider using
this system as their record to increase information sharing and efficiency.
Barrier
Contractors agreement, financial capabilities
System Shift: Evidence Based Practices
Alcohol and Drug Service providers and Monterey County Behavioral Health Department staff
will be required by the State Department of Health Care Services to implement at least two
Evidence Based Practices (EBP) for each modality of service provided. The listing of required
EBP include: Motivational Interviewing: A client-centered, empathic, but directive counseling
strategy designed to explore and reduce a person's ambivalence toward treatment. This
approach frequently includes other problem solving or solution-focused strategies that build
on clients' past successes. Cognitive-Behavioral Therapy: Based on the theory that most
emotional and behavioral reactions are learned and that new ways of reacting and behaving
can be learned. Relapse Prevention: A behavioral self-control program that teaches individuals
with substance addiction how to anticipate and cope with the potential for relapse. Relapse
prevention can be used as a stand-alone substance use treatment program or as an aftercare
program to sustain gains achieved during initial substance use treatment. Trauma-Informed
Treatment: Services must take into account an understanding of trauma, and place priority on
trauma survivors’ safety, choice and control. Psycho-Education: Psycho-educational groups are
designed to educate clients about substance abuse, and related behaviors and consequences.
Psycho-educational groups provide information designed to have a direct application to
clients’ lives; to instill self- awareness, suggest options for growth and change, identify
community resources that can assist clients in recovery, develop an understanding of the
process of recovery, and prompt people using substances to take action on their own behalf.
Opportunity:
By integrating clinical expertise, academic research and client/care-giver
values high quality services will be available to individuals who have
been diagnosed with a substance use disorder.
Proposed Solution
Utilize evidence-based practice training provided by California Institute
for Behavioral Health Solutions; recruit training coordinator within BH
Bureau.
Barrier
Transferring skills from training to direct clinical practice, identifying
needs for ongoing consultation group and staff mentoring.
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