Tuolumne County

Behavioral Health Department

March 29, 2010

Tuolumne County
Behavioral Health
www.tcbehavioralhealth.com
NOTICE OF INITIATION OF 30-DAY PUBLIC REVIEW PERIOD
Mailing Address: RE: MHSA INNOVATION COMPONENT PLAN
2 South Green St.
Sonora, CA 95370

24 hour crisis line: Dear Community Members and Stakeholders,

(209) 533-7000

Beatrice W. Readel, LCSW
Director
breadel@co.tuolumne.ca.us
Sue McGuire, ASW, MSW
Quality/Managed Care
Manager
smcguire@co.tuolumne.ca.us.
Tracie Riggs
Fiscal Manager
triggs@co.tuolumne.ca.us
Business locations and
contact information:
Behavioral Health Admin.
105 Hospital Rd.
Sonora, CA 95370
Phone: (209) 533-6245
Fax: (209) 588-9563
CAIP (Crisis Assessment &
Intervention Program)
105 Hospital Rd.
Sonora, CA 95370
Phone: (209) 533-7000
(800) 630-1130
Fax: (209) 533-7007
Tuolumne County Behavioral Health Department is holding a 30-day public review and
comment period for the Mental Health Services Act (MHSA) Innovation Component Plan.
This review period begins March 29, 2010 and ends April 30, 2010. A public hearing is
tentatively planned at our Behavioral Health Advisory Council Meeting of May 5, 2010.
The meeting will take place at Tuolumne County Behavioral Health Department’s
Conference Room at 105 Hospital Road, Sonora, California.
The Innovation Plan outlines a learning project that will contribute to the transformation
process of our mental health system of care. A Public Comment Form is available at the
end of this document. Please review our Plan and send comments, and/or questions to the
staff member noted below:
MHSA Innovation Plan: Public Comments submitted to:
Susan Sells, MHSA Coordinator
susells@co.tuolumne.ca.us
Telephone: (209) 533-6245
Standard Mail: Tuolumne County Behavioral Health Department
Attn: MHSA Innovation
2 South Green Street
Sonora, California 95370

Mono Clinic
197 Mono Way
Sonora, CA 95370
Phone: (209) 533-5400 Sincerely,
Fax: (209) 533-5411

Cabezut Clinic Beatrice Readel

12801 Cabezut Rd.
Sonora, CA 95370
Phone: (209)-533-3553 Beatrice Readel, LCSW
Fax: (209) 533-8259
Executive Director
Lambert Community Center
347 West Jackson St.
Sonora, CA 95370
Phone: (209) 533-6695
(209) 533-4879
Fax: (209) 588-2781
 EXHIBIT B

INNOVATION WORK PLAN

Description of Community Program Planning and Local Review Processes

County Name: Tuolumne County

Work Plan Name: Building a Life at Home
Innovation Plan

Instructions: Utilizing the following format please provide a brief description of the
Community Program Planning and Local Review Processes that were conducted as
part of this Annual Update.

1. Briefly describe the Community Program Planning Process for development of the
Innovation Work Plan. It shall include the methods for obtaining stakeholder input.
(suggested length – one-half page)

The Community Program Planning Process consisted of a range of focus groups and
key informant interviews that generated valuable input specific to Tuolumne County’s
Mental Health Services Innovation Plan. Presentations to NAMI Chapter members,
Tuolumne County Behavioral Health Advisory Board, and the Tuolumne County Mental
Health Leadership Council were held in February, and a focus group made up of
consumers participating at the Peer Help Lambert Center occurred in March. Other
critical key stakeholders interviewed over this two month period included
representatives from the Tuolumne County Adult Protective Services, Public Guardian,
Probation, Children's Welfare Services, Omsbudsman, County Council, and Sheriff
Departments. The Sonora Police Chief provided input for this plan, as well as
representatives that provide advocacy and outreach services to the Spanish-speaking
and Native American residents in our community. Because the Innovation component of
the MHSA is different from other components of the Tuolumne County MHSA (CSS, PEI
and WET) in that its primary focus is learning rather than service delivery, the MHSA
Coordinator made sure that the attendees of both focus groups and key informant
interviews were made aware of this novel approach to plan development.

Priorities and discussions generated between 2004 and 2008 and documented from the
CSS, PEI and WET planning processes were revisited and shared when interviewing
individuals and groups in February, and March of this year. Input shared included
summaries from both the PEI and WET planning processes in 2007 and 2008 - which
had been obtained through a large community forum with 70 residents in attendance;
five community stakeholder meetings averaging a total of 50 participants each; 45 focus
groups and key informant interviews; and 375 surveys completed. Input from the CSS
community planning process completed in 2004 and 2005 was also summarized and
shared. The CSS planning strategy resulted in excess of 1,100 individuals participating
in the planning process and providing nearly 6,000 comments regarding mental health
needs, impacts, and issues facing Tuolumne County.
 Enclosure 3

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

Process.

The following stakeholder entities were involved in Tuolumne County’s MHSA

Innovation Component Commmunity Planning Process:

Tuolumne County Mental Health Leadership Council,

Tuolumne County Behavioral Health Advisory Board
Tuolumne County NAMI Chapter Board and Members
NAMI Housing Director
Peer Help Center staff and volunteers
A focus group of consumers participating at the Peer Help Lambert Center
Tuolumne County Behavioral Health staff and clinicians
Outreach and Engagement advocates/case managers representing both the
Spanish-speaking and Native American residents
Representatives from Tuolumne County Sheriff Department, Public Guardian,
Probation, Adult Protective Services, Children's Welfare Services, and County
Council
Director of Ombudsman Program
Police Chief, Sonora Police Department

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

The 30 day review was from March 29th to April 30th , 2010. The Public Hearing is
tentatively planned for May 5, 2010 at 4:00 pm at The Tuolumne County Behavioral
Health Department located at 105 Hospital Road, Sonora, CA in the Community
Conference Room.

Copies of the MHSA Innovation Plan were made available to all stakeholders through
the following methods:
• Electronic format: the Tuolumne County Behavioral Health Department website:
www.tuolumnecounty.ca.gov
• Print format was available at the Tuolumne County Behavioral Health Department, the
Tuolumne County Peer Help Support Center, and the Tuolumne County Library
• The Tuolumne County MHSA Innovation Plan was e-mailed to Tuolumne County
Behavioral Health Advisory Council, and the MHSA Leadership Council
• Plans were e-mailed or mailed to all persons who requested a copy
• An informational flyer was sent to stakeholders regarding the Plan’s availability,
including where to obtain it, where to make comments, and where/when the public
hearing would be held

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County: Tuolumne

Program Number/Name: “Building a Life at Home” Innovation Plan

Date: March 25, 2010

Select one of the following purposes that corresponds to Increase access to underserved groups
the Innovation’s key learning goal. Please note that while Increase the quality of services, including better outcomes
the program might embody all four purposes, a learning Promote interagency collaboration
goal cluster around a single Essential Purpose. Increase access to services

1. Describe which of the four essential purposes of Innovation is most relevant to your learning goal and why is
this purpose a priority for your county.
Throughout both the MHSA Innovation and CSS community planning process, family members and
peers raised concerns and complaints about the high number of severely mentally ill residents that
are conserved and placed in out- of -county residential facilities. Family member and familiar peer
networks are unable to provide support and assistance to help persons with mental illness to be
active members in the community in which they themselves have chosen or desire to live. –
Tuolumne County rates for LPS conservatorships have been consistently higher per capita then
two thirds to three-fourths of the counties in California. Rates have stayed consistently high over
the years (34 in 2007/2008, 23 in 2008/2009, and 27 in this fiscal year). A major factor in the high
conservatorship ratio is due to long term consecutively renewed LPS conservatorships for
consumers who have become dependent on residing in facilities outside our community in
neighboring counties. These somewhat permanent relocations and renewed conservatorships are,
in part, attributed to stigma and barriers associated with concerns and attitudes about persons
suffering from severe mental illness and their ability to live successfully and independently in the
rural community setting. For Innovation planning, we have interviewed key stakeholders
representing diverse organizations, systems, and representatives. The organizations represented
included the Public Guardian’s Office, Adult Protective Services, Child Welfare Services, Law
Enforcement (Police and Sheriff Departments), Probation, Ombudsman, and Tuolumne County
Behavioral Health Department staff. Additionally, outreach and engagement consultants that
represent the needs of both the Spanish-speaking and Native American residents, along with NAMI
family members and consumers were included. These persons and organizations collectively
contribute or embody the resources that would be necessary to prevent the need to conserve
severely mentally ill residents in long term residential facilities and provide collective support in the
community. It was discovered that there are strong, diverse and negative systemic cultural attitudes
and beliefs that may affect our community’s decision makers about what is best for severely
mentally ill peers. There are two core attitudes incorporated into this belief system. First is the view
that severely mentally ill clients must be placed in long term residential placement as they are
unable to meet their basic needs or develop independence from caretakers. Secondly, that keeping
persons suffering from severe mental illness in facilities will protect the community, based on vague
fears and stigma attributed to perceived dangerous behaviors arising from mental illness which has
often been dramatically promoted in the media. One contributing factor for these community
attitudes and beliefs is the previous reliance on an acute locked psychiatric unit (as part of the
Tuolumne General Hospital) to stabilize severely mentally ill residents. Inpatient care has been
synonymous with appropriate treatment for the mentally ill since 1988. Our Board of Supervisors
closed this unit on December 31, 2008 due to the prohibitive rising costs of inpatient service
provision. In response, Tuolumne County Behavioral Health Department developed a strengthened
outpatient system including a 23 hour crisis stabilization program, and augmented after hours walk-
in service, and crisis and assessment service integration with the new systems. This more
intensive outpatient model functions as the successor system from the involuntary locked inpatient
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treatment for acute psychiatric needs to a voluntary accessible crisis management system. Many
residents and community agencies were concerned that closing the acute psychiatric unit reflected
a decline or weakening in our department’s commitment to our peers and family members, when in
fact it reflected a move toward more efficient, less restrictive and ultimately more effective practices
to serve people in the community environment. Along with the 23-hour crisis stabilization and walk-
in services, the Peer Help Center activities have been strengthened with MHSA funds and have
included the employment and contracting of peers as a powerful model in the recovery process. In
the last six months, there has been a 31% increase in local peer participation in a range of
activities, including six peer run support groups at the Center.

Despite these successful changes and enhancements, our community’s culture (attitudes and
beliefs) mitigates against bringing consumers home to live independently with family and peers who
are available for support and assistance. Overall, these core attitudes and beliefs need to be
addressed so that peers who have been institutionalized out of county can return home to
participate successfully in the commitment to peer recovery, wellness and resilience activities and
to benefit from families and friends who can be available to provide the community support network
needed for healthy living.

For these reasons, we are proposing an Innovation strategy to develop an effective community
collaborative partnership that will work together to improve and strengthen coordination and
collaboration and reduce stigma between mental health and the varied stakeholders. We are
excited to share that we have received agreement from all the key stakeholders who participated in
our initial planning and interview to join in a Task Force, and will also include two case manager
consultants that provide outreach and engagement to both Spanish-speaking families and Native
American residents. This is our essential purpose - to learn if better ways of collaborating with our
community (who hold many diverse beliefs) can over time address cultural attitudes, improve
services for our mentally ill residents, reduce stigma, and create a more active community
engagement that supports mental health peer recovery, wellness and resilience strategies.
Our Innovation Plan is titled “Building a Life at Home”. This Innovation Plan hopes to create new
planning processes across a range of social service agencies, new training and education practices
and approaches, and ultimately new treatment and recovery services or interventions that improve
mental health services for our mentally ill residents in Tuolumne County. It is important to note that
effective community collaborations that have formed to address community concerns is not a new
concept to Tuolumne County, but the type of interagency collaboration we propose in this plan is
innovative related to the severely mentally ill population that has been viewed as the predominantly
sole responsibility of the Tuolumne County Behavioral Health Department. For many years our
community has collaborated on coalitions directed toward teen drug and alcohol abuse prevention, and
suicide prevention issues– but the critical difference is that these community-wide collaborations have
always had common agreement across all the members from the start about how to work together to
impact and lessen a mutually agreed upon community issue and/or problem. Our proposed Task Force
does not necessarily agree on the nature of the problems or solutions specific to our severely mentally
ill residents. The collaboration we propose will utilize the successful building strategies currently used in
the non-mental health focused community coalitions (Tuolumne County Suicide Prevention Task Force,
YES Coalition supporting youth drug and alcohol prevention strategies). These strategies will be
adopted for our current Innovation project. We plan to bring the community representatives and key
stakeholders to the table including those who have expressed strong differences –many who are
adamantly opposed or skeptical of the peer recovery, wellness and resilience models. These key
community stakeholders representing strong and diverse beliefs have never met regularly to discuss
and reach census on how best to provide services and support our community’s severely mentally ill
clients. Key stakeholders have agreed to participate on this newly formed Task Force to discuss, listen

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to and evaluate the diverse range of community beliefs and perspectives specific to addressing the
needs of mentally ill residents in our community and reconsidering the practice of long term out of
county institutional placement and diversion. We hope to learn that, if successful, stigma can be
reduced by directly addressing the cultural attitudes and beliefs through unifying key organizational
decision makers with peers and family members and Behavioral Health staff on the Task Force. Also,
we hope to demonstrate the Task Force members can work together over a three year period to
effectively assess, engage and substantiate that the interventions proposed will be effective
alternatives to residential housing out of county. Supportive interventions will be assessed by this Task
Force to evaluate whether consumers can transition out of long term residential homes and return to
our community to live successfully as members of the community over time. The Task Force will also
assess the initiation of supportive intervention to reduce the number of first time and repeat placements
of mentally ill consumers currently living in the county who are at risk of higher or more restrictive levels
of care. The Task Force will document and track what worked and did not work with this plan, including
assessing and documenting the community services that work well for people with mental health
disabilities (i.e. are job training and placement activities effective, are public transportation opportunities
accessible to peers?). What we learn by the end of the project will be shared with both our community
and other rural counties faced with similar issues and barriers throughout California.

2. Describe the INN Program, the issue and key learning goals it addresses, and the expected learning outcomes,
State specifically how the Innovation meets the definition of Innovation to create positive change; introduces a
new mental health practice; integrates practices/approaches that are developed within communities through a
process that is inclusive and representative of unserved and underserved individuals; makes a specific change
to an existing mental health practice; or introduces to the mental health system a community defined approach
that has been successful in a non-mental health context.
Innovation Project Description:
The Building a Life at Home Project proposes an innovative collaboration between our existing
Behavioral Health Department, consumers and families, representatives of Spanish-speaking and
Native American residents, and key and diverse stakeholders representing organizations and
systems (Public Guardian, Adult Protective Services, Law Enforcement, Probation and
Ombudsman programs) who all play a part in the decision to conserve severely mentally ill
residents in long term residential in and out-of-county facilities or who would refer community
members for more restrictive services. Our Innovation Plan meets the definition of Innovation as
the project introduces our local mental health system to a community defined approach of
collaboration that has been successful in a non-mental health context. We hope to ultimately create
positive change with a process that is inclusive and representative of unserved and underserved
individuals. We propose to form a Task Force that meets regularly to address community- issues
related to the mentally ill (addressing fears, concerns, and hopes) and alternatives to restrictive
higher level placements.. This type of collaboration has never existed before in our county specific
to behavioral health issues for the conserved population, as the prevailing community attitudes
have been that mentally ill issues are the sole responsibility of Tuolumne County Behavioral Health
Department and its’ professionals.. The “Building a Life at Home” Task Force will oversee the
development, implementation, and assessment of best practice case management and peer
recovery and resiliency strategies that target mentally ill consumers currently living at home but
requiring a higher level of care, and mentally ill peers residing in residential facilities in and out of
county that need to return home to live safe and independent lives. While the clinical practices we
propose to pilot are not philosophically new, the composition, structure, diverse attitudes and
beliefs, and role of the newly formed community collaborative with regard to oversight and
assessment to these practices is innovative to our community, and crucial to our goal to change
community attitudes, cohesion and engagement over time.

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Task Force members will create and engage in a process to explore and make a commitment to
establish alternatives to long-term institutionalization. Specific Task Force activities will include:
 Developing a collaborative structure to guide the three year learning project, ensuring that
relevant government agencies, consumers, and family members, and representatives of
Spanish-speaking and Native American residents are actively participating;
 Developing formal collaborative agreements to guide the Task Force and three year
learning project (i.e. number of collaborative members who sign a Memorandum of
Understanding as a commitment to the collaborative process);
 Guiding, assessing and selecting the learning project’s relevant data needed for both
process and outcome evaluation to assess changes in attitudes of Task Force members and
community over time, and how to best communicate results specific to what works and does
not work with the project’s service model interventions (e.g. document anecdotal stories
specific to personal experiences, successful service methods applied over three year period,
peer recovery success stories, use of blogging, videotaping, and/or pictures to share project
activities, Task Force participation in regular site visits?);
 Offering ongoing training and outreach to Task Force members, as well as the staff from
members’ organizations and advocacy groups and the community at large regarding stigma
and mental illness, as well as information about intensive case management and peer
recovery services implemented as part of this project.

The heart of our Innovation Project addresses the learning goal “Can we change/shift cultural
attitudes and beliefs in community systems over time in Tuolumne County from the current
standard that institutionalization of severely mentally ill is best for the consumer and safest for
community - to the understanding that consumers can live at home independently and safely, with
recovery, wellness and resilience services available as needed, and that the consumers can
become contributing members of our community?. What is the best way to organize and structure
the Task Force to produce this kind of significant change in understanding, attitude, engagement,
and ultimately service delivery? Over time, can we reduce the high number of permanent
conservatorships by marshalling the cooperation, resources and expertise of consumers, families
of consumers, and all county and community agencies that respond to or are involved with the
necessity and determination to place our severely mentally ill residents in long-term out-of-county
residential facilities? And… is there stigma related attitudes about severely mental ill clients that
can be addressed through an ongoing Task Force?

Through the key informant interviews we have received agreement from all critical partners that
they are willing to attend regular meetings as Task Force over the next three years.

The primary learning goals of this project are:

1. To determine the best way to develop a new approach to organizing, structuring and
convening a community Task Force to increase awareness, agreement, cooperation,
collaboration, and implementation of a better way to deliver services in Tuolumne County for
individuals with serious mental illness and their families; and in the process successfully
address the understanding, attitudes and beliefs among members of the Task Force and ,
the agencies and social networks they represent;
2. To determine if there is a corresponding change in community understanding, attitudes,
collaboration, engagement, and cohesion regarding positive treatment options within
Tuolumne County for people with serious mental illness and their families;
3. To determine if fewer mentally ill in crisis are placed in out of county residential facilities,
and/or are allowed to return home more quickly with client-driven peer support services and

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case management assistance as a result of the project’s development of increased
cooperation, collaboration and awareness through a Task Force,; and if the number of
permanent conservatorships can be reduced over a three year period;
4. To determine if this innovative collaboration can be replicable in our community to address
other difficult cultural differences locally specific to mental health, and is this project
replicable for other small rural counties in California if successful in aiding a transformation
of our local cultural beliefs about the abilities of the mentally ill to live at home.

A pilot of integrated case management and peer recovery services is proposed as part of the
strategy to change our understanding, culture and attitudes. This service component of the project
will be implemented while forming and supporting the new Building a Life at Home Task Force. This
service component of the Innovation Plan is not conceptually new, though innovative in the degree
of peer support integration planned and critical to our learning goal of changing cultural beliefs and
attitudes. We know that change is difficult - as it contradicts well-developed views and the medical
and public health models currently in place. Change often questions the common practice of
protection against anticipated negative effects of problems rather than empowerment to deal with
them; reversing these tendencies requires change from a focus on problems to a focus on human
growth and development. For this reason, and with support, buy-in and guidance from the newly
formed Task Force, we hope to demonstrate to our community that best practice case management
and peer support activities can be safe alternatives to out-of-county residential facilities and
reduction of permanent conservatorships, in order to successfully affect change in our community
understanding over time. We have prepared members of the newly formed Task Force that our plan
may not succeed by the end of the grant period.

The service component for this project , as currently envisioned, is as follows:

Hire three new full time case management staff, including a nurse case manager and with a
preference for peers. All three case managers will be trained in the Peer Recovery, Wellness and
Resilience model – to ensure that peers are empowered with training and help as needed, as well
as assistance developing and/or strengthening current Peer Support Systems for individuals
transitioning from crisis or short-term hospitalization and/or residential care (e.g. a community-
based team to provide encouragement and support after crisis events with follow-up calls and
reminders for appointments). The new staff will not be asked to impose a structure of support in the
peer community population, but instead would support these volunteers in leadership roles to help
strengthen peer support systems already in place. Case managers will also work closely with the
Tuolumne County Behavioral Health LPS Conservatorship Case Manager to bring conserved peers
back into Tuolumne County, and coordinate closely with the Full Partnership Services (FSP) staff to
ensure effective continuum of care services and team support as needed to those peers
transitioning from a higher level of care. Funds would also be budgeted to help subsidize housing
and transportation costs for consumers returning to live in the county from residential and acute
settings both in and out of county. Shared housing models could be developed, where four to six
consumers share a home close to resources, with intensive case management support offered as
needed. Training in basic daily living skills (budgeting, shopping and preparing meals, managing
money, doing housework, prioritizing daily tasks, accessing community resources, medication
usage, etc.) could be offered, with the goal for newly conserved consumers and peers at risk to be
able to take care of their needs and be self-sustaining over time. This new case management
model will ensure that peers are assessed quickly during home visits in order to help identify
symptoms, implement early stabilization and avoid hospitalizations. The newly hired nurse case
manager would help educate peers in monitoring medication, and would selectively monitor and
track medication usage All case managers would educate peers identified as at risk of a higher
level of care by assessing/identifying warning symptoms of their disease and assisting with setting

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goals for the ongoing recovery process. They can also help peers to advocate and communicate
clearly with their primary physicians about their medical needs. New services would be provided for
three years, with the goal of bringing home 6 consumers by the end of each year (saving the BHD
budget $135,000 each year for three years, totaling $405,000 by end of year three), with a total of
18 of the 27 conservators stabilized and living independently (or in less restrictive environments) by
the end of year three. Funds saved from placements could help to sustain the new case
management staff positions over time, and provide ongoing transportation and housing funds to
consumers. This intensive case management model for consumers at risk of placement would also
reduce future conservatorship costs. Additionally, it is anticipated that 30% of the new staff’s time
specific to case management could be Medi-Cal billable – ensuring additional funds to sustain
these activities.

As a result of developing and implementing and assessing this innovative, county-wide

comprehensive Task Force – and implementing best practice intensive case management and
strengthening our peer recovery, wellness and resiliency community - it is our hope that a number
of positive changes and learning outcomes will result:

1. The community’s understanding shifts over time, so that members believe that mentally ill
residents can live safely and independently at home with ongoing case management
services and strong peer community support,
2. Increased level of cooperation, confidence and mutual understanding will occur among Task
Force members regarding peer recovery, wellness and resiliency strategies, thereby building
3. community capacity to better support our mentally ill consumers,
4. Changes may occur in administrative processes/organizational practices of Task Force
agencies specific to permanent conservatorships county-wide,
5. There will be fewer severely mentally ill placed out of county in residential care, and more
consumers living safely and independently in our community with community-based peer
support and case management services available as needed,
6. As peers will be brought home from residential facilities out of county over a three year
period, there will be an increase in consumers involved in peer support community programs
and activities, as well as an increase in families, friends, and Task Force members involved
and engaged with peers in our community,
7. Ongoing education and training will be available regarding stigma and mental illness, as well
as information about intensive case management and peer recovery services implemented
as part of this project, and this will change the extent to and ways that Task Force members
and agencies they represent (as well as other community members) will engage with
consumers and families, which will lead to changes in information, attitudes and behaviors
toward mentally ill consumers in Tuolumne County.

If successful at the end of the three year plan period, the Building a Life at Home Task Force will
continue to meet and collaborate, and intensive case management and peer driven support
services will continue and be self-sustaining, due to savings from cost of residential care.

2a. Include a description of how the project supports and is consistent with the applicable General Standards as
set forth in CCR, Title 9, Section 3320.
This Innovation work plan incorporates the six standards applicable to all MHSA activities:
#1 Community Collaboration – Community Collaboration is a key to the development of this Innovation
Project. The Building a Life at Home Task Force represents an interagency collaboration between
peers, families of peers, agencies and organizations who all play a part in the decision to conserve
severely mentally ill residents in long term residential out-of-county facilities. This project initiates and

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strengthens collaboration and linkages in our community.
#2 Cultural Competence –This plan demonstrates cultural competency and capacity to improve overall
health outcomes for all residents of Tuolumne County with serious mental illness. An active Task Force,
with representatives of both the Spanish-speaking and Native American residents, as well as peers and
families of peers will assess and oversee culturally relevant intensive case management, and peer
support services as an alternative to long term residential placement for local consumers.
#3 and #4 Client and Family Driven Mental Health System – This plan includes the ongoing
involvement of consumers and family in roles such as, but not limited to, program development, task
force participation, case management services, and peer recovery, wellness and resiliency services.
Both peers and the local chapter of NAMI family members have agreed to participate on the Building a
Life at Home Task Force.
#5 Wellness and Family Driven Mental Health System – This plan’s intent is to increase resilience and
promote recovery and wellness for peers with serious mental illness who are currently in residential
facilities by bringing them home safely over time, as well as peers who are currently at risk of higher
levels of care in our community. Our project will provide targeted peers with a continuum of care
ranging from specialty intensive case management mental health services with a focus on peer
recovery best practices, to peer support services and programs. This plan addresses overall health and
wellness for mentally ill residents in Tuolumne County.
#6 Integrated Service Experience – Through a stronger collaboration with interagency Task Force
members, this plan will encourage and provide support to help peers with access to a full range of peer
recovery and support services that includes Peer Help Center’s PRIDE Support Groups; Benefits
Specialist; Senior Peer Counseling; Mother Lode Job Training; Food Bank; NAMI and MHSA Housing
opportunities; Teen Center for transition age youth; Meals on Wheels; Lifeline; Energy and
Weatherization Services; Catholic Charities outreach and engagement; and more. Engaging peers in
community support services will help to ensure they receive the help and assistance needed to live
safely and independently when they return back into our community.
2b. If applicable, describe the population to be served, number of clients to be served annually, and demographic
information including age, gender, race, ethnicity, language spoken, and situational characteristic(s) of the
population to be served.
Our target population to be served will be 60 or more severe mentally ill peers who have experienced at
least one hospitalization and/or psychiatric emergency visit and/or a placement in residential facilities in
and out of the county. Description of the population to be served is as follows: Age: 2% youth 17, 3% -
transitional age youth, 80% - adults, and 15% - older adults. Gender: 47% - male, and 53% - female.
Race: 89% - white, 4% - Native American, 2% - Black, and 5%- unreported. Primary Language: 100% -
English, Ethnicity: 92% - non-Hispanic, 4% - Mexican/Mexican American and 4% - unreported.
3. Describe the timeframe of the program. In your description include key actions of the time line and milestones
related to assessing your Innovation and communicating results significance and lessons learned. Provide a
brief explanation of why this timeline will allow sufficient time for the desired learning to occur and to
demonstrate the feasibility of replicating the Innovation.
June, 2010 Anticipated DMH/MHOAC approval
July, 2010 – June, 2013 Innovation Project three year project period
July –September 2010 Form Interagency Task Force, and with Task Force members set dates
for meetings, define purpose, role and level of oversight with Innovation
Project; develop a collaborative structure to guide the three year learning
Project; develop formal collaborative agreements; assess and select the
learning project’s relevant data needed for both process and outcome
evaluation to assess changes in attitudes of Task Force members and
community over time, and how to best communicate results specific to
what works and does not work with the project’s service model
interventions.
July -September 2010 Initiate project service model, hire and train case managers, develop

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strategies with Peer Help Center staff and volunteers to support and
strengthen Peer Support/ Recovery services; and develop
trainings for Task Force members, as well as the staff from members’
organizations and advocacy groups, regarding stigma and mental illness.
October- December 2010 With Task Force, provide a preliminary assessment and evaluation of
early project implementation activity.
Sept., 2010 – June, 2013 Full implementation of service component of Innovation Plan (Case
management and Peer Support/Recovery services in place).
July, 2011 Medi-Cal Feasibility Study completed for first year service activities
January, 2011 – June, 2013 Make project adjustments as necessary based on Task Force process
evaluation assessments.
January 2011 Mid year process evaluation of Task Force effectiveness and services
provided to date, and then evaluation of project every six months until
end of project.
May - July 2013 Full evaluation/assessment of Innovation Project, including effectiveness
of Task Force, case management and peer recovery services, and rates
of permanent conservatorships and out of county residential facilities
placements – determination of efficacy and feasibility or replication and
dissemination of results.

We are confident that this three year timeline will allow sufficient time to learn if we change/shift
cultural attitudes and beliefs in community systems over time in Tuolumne County; and over time
reduce the high number of permanent conservatorships. We also anticipate that the project period
will allow us the time needed to provide a full evaluation/assessment of the Innovation Project to
disseminate results, and determine the project’s efficacy and feasibility for other small counties in
California.
4. Describe how you plan to measure the results, impacts, and lessons learned of your Innovation, with a focus on
what is new or changed. Include in your description how the perspectives of stakeholders will be included in
assessing and communicating results.
We hope to learn from this project if we can change/shift cultural attitudes and beliefs in community
systems over time in Tuolumne County from the current standard that institutionalization of
severely mentally ill is best for the consumer and safest for community - to the understanding that
consumers can live at home independently and safely, with recovery, wellness and resilience
services available as needed, and that the consumers can become contributing members of our
community. Additionally, we hope to learn the best way to organize and structure the Task Force to
produce significant change in understanding, attitude, engagement, and ultimately service delivery;
and if we can reduce the high number of permanent conservatorships by the end of our three year
project.

To capture change in Task Force attitudes and beliefs, we will develop attitudinal pre and post
surveys prior to forming the Task Force – to ensure we have baseline data from inception of
project. Once the Building a Life at Home Task Force is formed, the members and staff will
together plan and design both process and outcome evaluation strategies in the first three months
of project implementation to assess and communicate results of the project’s short and long term
goals over time (see primary learning goals listed under question #2 above) - as part of a
comprehensive evaluation to measure the results, impacts and lessons learned from this project.
Data collection methods to assess both the ongoing involvement and support of Task Force
members, as well as the success of the project’s service component could include (but are not be
limited to): pre and post attitudinal surveys of Task Force members; documentation of Task Force
members’ participation at regular meetings, peer recovery activities and site visits; documentation

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of trainings provided to agencies and organizations; and anecdotal stories collected of peer
recovery successes, possible use of blogging, videotaping, and/or pictures to share project
implementation strategies. The data collected will be analyzed on an ongoing basis to evaluate and
modify the implementation, as needed.

Ultimately, the Task Force’s engaged and active review, assessment and direct involvement of the
project’s service component; attitudinal surveys indicating a shift in cultural attitudes and beliefs
toward peer recovery, wellness and resilience models; as well as the overall reduction of conserved
mentally ill residents institutionalized out of the county– but living successfully at home – will
determine the success of this project, and whether this project can be replicated in other rural
counties in California.

Data, outcomes, and the experience in learning during the course of implementation will be shared
regularly at the Task Force meetings, as well as on a minimum of an annual basis with a diverse
group of stakeholders to gather their input and feedback and make changes to project
implementation. The Building a Life at Home Task Force members will also provide feedback
regularly to the Tuolumne County Behavioral Health Department Advisory Board, MHSA
Leadership Council, on our Tuolumne County Behavioral Health and Network of Care websites,
and finally through the Board of Supervisors at the end of the three years. A full evaluation report
will be completed during the final year of the Build a Life at Home project using the measurements
designed in the first three months of project implementation. The results will be shared with Task
Force members, stakeholders, and throughout the community to share learning and gather input
regarding efficacy of the project and long term funding strategies.

5. Please provide a Budget Narrative that includes the entire budget for each Innovation Program, and also
provide for each Innovation Program projected expenditure dollar amount by each fiscal year during the
program time frame. (For Example, Program 01-XXXX, the entire project is $1,000,000. The first year projected
amount will be $250,000, the second year projected amount is $250,000, the third year is $250,000 and the fourth year
is $250,000.) Please also describe briefly the logic for this budget; how your proposed expenditures will allow
you to test your model and meet your learning and communication goals. Please also describe briefly the logic
for this budget; how your proposed expenditures will allow you to test your model and meet your learning and
communications goals.
The Innovation budget will include support a portion of the MHSA Coordinator (10% FTE) to
oversee the project process and outcome evaluation and facilitate the Task Force meetings
and strategies, and a Clinical Program Manager (20% FTE) to supervise the project's service
component staff as well as provide support and assistance with the “Building a Life at Home”
Task Force.

In addition to these two positions, the department will also budget for two Recovery Counselors
and one Nurse Case Manager, for a total of $195,000 each year. Travel expenses are another
important component of the Innovation budget, as half of the target population currently reside
in residential facilities primarily outside the county, and staff will be required to travel
extensively in county to provide support to peers in crisis. Mileage is estimated using the
county mileage per diem rate of $.50 per mile. Transportation subsidies will also be provided
as needed for clients, estimated at $50 per client, per month.

The department estimates that 20-30% of the case manager time will be billable to Medi-Cal.
The first year will be at a much lower rate as we collaborate with other county agencies to bring
our conserved clients home, once they are home they each will receive intensive case
management from the individuals listed above. The three case managers will also provide
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crisis services to clients who require a higher level of care, therefore negating the need for
placement within a residential care facility.

As the clients are brought home, the placement costs will decrease, the savings from bringing
these clients home will allow us to continue with the program beyond the first three years. It is
estimated we will bring home six clients in the first year, estimated savings as a result of
bringing these clients home is $135,000. For each year we bring clients back home, we reduce
the cost of out of county placement, resulting in additional resources for services to be provided
within the county. The department will budget to provide housing subsidies out of the savings
recognized from the reduced level of care to independent housing; subsidies have been
estimated at $250 per client, per month.

Year One:
Case Managers $ 194,000
MHSA Coordinator 9,279
Clinical Program Mgr 18,679
Housing Subsidies 18,000
Travel 39,000
Transportation Subsidies 3,600
Administration 42,384
Total Annual Estimate $ 324,942

Year Two:
Case Managers $ 194,000
MHSA Coordinator 9,279
Clinical Program Mgr 18,679
Housing Subsidies 36,000
Travel 39,000
Transportation Subsidies 7,200
Administration 45,624
Total Annual Estimate $ 349,782

Year Three
Case Managers $ 194,000
MHSA Coordinator 9,279
Clinical Program Mgr 18,679
Housing Subsidies 54,000
Travel 39,000
Transportation Subsidies 10,800
Administration 48,864
Total Annual Estimate $ 374,622

6. If applicable, provide a list of resources to be leveraged.

Tuolumne County Behavioral Health Department will provide an estimated cash match of $135,000
each year for three years to support the Innovation Project, with funds from the placement reduction
and Medi-Cal match. Additionally, by the end of the first year of case management services, a feasibility
study will be generated to estimate the amount of Medi-Cal revenue that could be generated if Medi-
Cal is billed for appropriate case management services, and this will be included as leveraged

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resources to continue supporting this project in years two and three, and beyond. We anticipate
between 20 to 30% of the three case managers’ time will be Medi-Cal billable. If successful, funds
saved from the ongoing residential placement costs will be made available to continue the ongoing
Task Force and service component of this project once the three year project comes to an end.

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 EXHIBIT D

Innovation Work Plan Description

(For Posting on DMH Website)

County Name Annual Number of Clients to Be

Served (If Applicable)
Tuolumne County
60 Total
Work Plan Name
Building a Life at Home Innovation Project

Population to Be Served (if applicable):

Our target population to be served will be severe mentally ill peers who have
experienced at least one hospitalization and/or psychiatric emergency visit and/or a
placement in residential facilities in and out of the county.

Project Description (suggested length - one-half page): Provide a concise overall

description of the proposed Innovation.
The Building a Life at Home Project proposes to change cultural attitudes and beliefs
through an innovative collaboration between our existing Behavioral Health Department,
consumers and families, representatives of Spanish-speaking and Native American
residents, and key and diverse stakeholders representing organizations and systems
(Public Guardian, Adult Protective Services, Law Enforcement, Probation and
Ombudsman programs) who all play a part in the decision to conserve severely
mentally ill residents in long term residential in and out-of-county facilities or who would
refer community members for more restrictive services. Our Innovation Plan meets the
definition of Innovation as the project introduces our local mental health system to a
community defined approach of collaboration that has been successful in a non-mental
health context. We hope to ultimately create positive change with a process that is
inclusive and representative of unserved and underserved individuals. We propose to
form a Task Force that meets regularly to address community- issues related to the
mentally ill (addressing fears, concerns, and hopes) and alternatives to restrictive higher
level placements.This type of collaboration has never existed before in our county
specific to behavioral health issues for the conserved population, as the prevailing
community attitudes have been that mentally ill issues are the sole responsibility of
Tuolumne County Behavioral Health Department and its’ professionals. The “Building a
Life at Home” Task Force will oversee the development, implementation, and
assessment of best practice case management and peer recovery and resiliency
strategies that target mentally ill consumers currently living at home but requiring a
higher level of care, and mentally ill peers residing in residential facilities in and out of
county that need to return home to live safe and independent lives. While the clinical
practices we propose to pilot are not philosophically new, the composition, structure,
diverse attitudes and beliefs, and role of the newly formed community collaborative with
regard to oversight and assessment to these practices is innovative to our community,
and crucial to our goal to change community attitudes, and create cohesion and
engagement over time.
 EXHIBIT E

Mental Health Services Act

Innovation Funding Request
County: Tuolumne Date: 24-Mar-10

FY 09/10 Estimated Funds by Age Group

Innovation Work Plans
Required (if applicable)
MHSA
Funding Children, Transition
No. Name Adult Older Adult
Youth, Age Youth
1 Building a Life at Home 435100 8702 13053 348080 65265
2

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26 Subtotal: Work Plans $435,100 $8,702 $13,053 $348,080 $65,265

27 Plus County Administration

28 Plus Optional 10% Operating Reserve

29 Total MHSA Funds Required for Innovation $435,100

 EXHIBIT F

Innovation Projected Revenues and Expenditures

County: Tuolumne Fiscal Year: 2009/10

Work Plan #:
Work Plan Name: Building a Life at H
New Work Plan
Expansion
Months of Operation: 07/10-06/13
MM/YY - MM/YY

Community
County Other Mental Health
Mental Health Governmental Contract
Department Agencies Providers Total
A. Expenditures
1. Personnel Expenditures 802,746 $802,746
2. Operating Expenditures 246,600 $246,600
3. Non-recurring expenditures $0
4. Training Consultant Contracts $0
5. Work Plan Management $0
6. Total Proposed Work Plan Expenditures $1,049,346 $0 $0 #########
B. Revenues
1. Existing Revenues $0
2. Additional Revenues
a. Realignment 200,000 $200,000
b. FFP 414,246 $414,246
c. (insert source of revenue) $0
3. Total New Revenue $614,246 $0 $0 $614,246
4. Total Revenues $614,246 $0 $0 $614,246
C. Total Funding Requirements $435,100 $0 $0 $435,100

Prepared by: Tracie M. Riggs Date: 3/24/2010

Telephone Number: (209) 533-6265
 Tuolumne County Behavioral Health
Mental Health Services Act

INNOVATION COMPONENT PLAN

30 Day Public Comment Form

March 29, 2010 to April 30, 2010

PERSONAL INFORMATION (optional)

Name: ________________________________

Agency/Organization: ________________________________

Phone Number: ____________ Email address______________

Mailing address:
______________________________________________________

MY ROLE IN THE MENTAL HEALTH COMMUNITY

__ Client/Consumer
__ Family Member
__ Education
__ Social Services
__ Service Provider
__ Law Enforcement/ Criminal Justice
__ Probation
__ Other (specify) _________________

WHAT DO YOU SEE AS THE STRENGTHS OF THE PLAN?

IF YOU HAVE CONCERNS ABOUT THE PLAN, PLEASE EXPLAIN.

_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

Tuolumne County Administration Center (Mailing Address:) 2 South Green Street Sonora, CA
95370 Phone: 209/533-6245 Fax: 209/588-9563