In-reach Program Wins Quality Leader Award

County of Santa Clara Health System Awarded for Helping Cognitively Impaired Avoid Cycle of Incarceration

Santa Clara County, Calif. December 13, 2023 – The County of Santa Clara Health System has received the prestigious 2023 California Association of Public Hospitals and Health Systems (CAPH)/California Health Care Safety Net Institute (SNI) Quality Leaders Award (QLA) for their entry “An Integrated Transitions of Care Model for Vulnerable Populations: Developing Best Practices and Closing Gaps for Justice Involved Individuals with Executive Function Disorders.”
The in-reach pilot program is a cross-departmental initiative partnering with the County of Santa Clara’s Behavioral Health Services, Custody Health Services, and Technology Services and Solutions designed to address system gaps and health disparities for justice-involved patients who may benefit from a tailored approach for assessment and treatment planning upon discharge based on knowledge about executive function disorder (EFD).
“Santa Clara Valley Healthcare realizes the unique challenges many of our community members face and is committed to helping everyone achieve the best possible healthcare,” said Paul E. Lorenz, Chief Executive Officer for Santa Clara Valley Healthcare. “The teamwork of everyone in Behavioral Health Services, Custody Health Services, and Technology Services is what made this award possible.”
Those with EFD experience higher barriers to social determinants of health and are often limited in their ability to secure housing, employment, accessing primary care, mental health services, and are less inclined to adhere to treatment plans following discharge from custody.
“EFD patients have impairments and deficits that cannot be seen visually and represent an especially vulnerable population needing advocacy and active care coordination,” says Dr. Huy Ngo, Special Populations & Transitions of Care Medical Director. “They face serious challenges both prior to, during, and post-incarceration, and can frequently cycle between institutions while struggling to establish independence.”
The CAPH/SNI QLAs showcase their members’ most outstanding efforts to advance high-quality, equitable health care for Californians and include four categories of awards: equity, population health, care redesign and innovation. The goals of the QLAs are to highlight forward-thinking and innovative approaches in California’s public health care systems and to encourage the spread of effective strategies that improve and advance high-quality, equitable health care.
SCVMC received the QLA award for Innovation with their Integrated Care Team (ICT) pilot program. The program looks at patients that have significant cognitive impairments going through the carceral settings and having higher utilization of the health system. ICT consists of a physician-led multidisciplinary team including a community outreach specialist, rehabilitation counselor, nurse practitioner, and licensed vocational nurse.
“We are finding the gaps in care where people fall through the cracks so that we can support them in sustaining their optimum health in community, decreasing recidivism, and maintaining their housing and their social structure so they are able to maintain relationships as part of their healthy life,” said Michelle de la Calle, County of Santa Clara Health System’s Office of System Integration Director.
The ICT uses interventions that include cognitive assessments to evaluate a justice-involved patient’s EFD condition, which often remains undiagnosed, and determining more effective strategies to address their impairments. Patients with EFD and justice-involvement often require more support and intensive case management, resulting in improved compliance with mandated appearances and reduction of warrants and incarceration rates.
ICT patient in-reach, often within custody or hospital settings, initiates the crucial process of trust-building and rapport establishment. Utilizing a patient-centered approach, weekly case conferences are held to build an individualized transition plan to help stabilize and support the patient’s reintegration into the community.
Before patients can “graduate” from the ICT program, the team identifies and establishes connections for patients with primary care homes and case management programs that ensure the continuity of their care. An extended warm handoff model, designed to guide both the patient and their care team through this transitional phase, is implemented.
From August 2022 to August 2023, the pilot phase of the program included 20 ICT patients with successful outreach and engagement and 35 patients are in active outreach and monitoring efforts. Additional accomplishments for ICT patients include formal housing assessments resulting in new housing and/or housing stabilization, access to substance use treatment programs, and to medication-assisted therapy for substance use disorders.
After six months of ICT program support, preliminary data shows an 85% reduction of high-cost hospital utilization with a potential cost avoidance of $1.52 million.

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New initiatives to prevent overdose deaths in local communities

County Fights the Opioid Crisis with a Cutting-edge Approach

SANTA CLARA COUNTY, CALIF. — As the county grapples with growing numbers of deaths from overdoses of fentanyl and other opioids, the County of Santa Clara Behavioral Health Services Department (BHSD) is deploying a comprehensive series of initiatives to prevent overdose deaths in local communities.
A pivotal piece of this prevention approach is the County’s strategy to distribute naloxone – the life-saving medication that can reverse opioid overdoses – through vending machines. The County embarked on this project in fall 2022 with the goal of making naloxone available, at no cost, immediately to anyone in local communities. Leading the effort is the Santa Clara County Opioid Overdose Prevention Project, known as SCCOOPP. In the first year of the project, SCCOOPP partnered with county organizations to install five vending machines at the two County jails, Juvenile Hall, Santa Clara University, and Mission College. SCCOOPP has begun working closely with more area colleges to place vending machines and plans to install more machines at local community centers, health centers, clinics, and non-profit organizations.
To bolster access, Santa Clara Valley Healthcare has also begun providing free naloxone through nine of its Valley Health Center Primary Care Clinics located throughout Santa Clara County. In addition, BHSD offers free naloxone kits at three of its Addiction Medicine clinics. This expanded access will add to the 25,000 naloxone kits the County has distributed since 2017.
Mira Parwiz, BHSD’s Division Director of Medication Assisted Treatment Services, said of the efforts to improve access, “We’ve chosen to use a bold tactic to confront the opioid crisis in our county. This is a challenging effort, but addressing this crisis requires innovative thinking and immediate action. Giving our communities free access to naloxone can save lives.”
Another component of the County strategy is a new media campaign designed to raise awareness about fentanyl and other opioids. The campaign targets two primary audiences: youth and young adults and parents and guardians. Ads focused on youth prompt viewers to “save a life” by visiting www.FentFacts.org, a webpage with more facts on fentanyl, resources, and information on where to get naloxone. Developed in partnership with the national non-profit, Song for Charlie, PSAs for parents and guardians encourage them to talk to their kids about opioids and visit www.TheNewDrugTalk.org to learn what they can say to engage and what they can do to protect them.
Both English and Spanish ads are reaching audiences through various media platforms online, on public displays including billboards and buses, and on TV. The campaign’s first phase launched on November 20 and will be on-air until the end of the year, with additional phases going live in 2024. “Getting this information out through so many different media channels meets the public where they are,” said BHSD Director Sherri Terao. “The campaign is part of a social marketing strategy to motivate the community to learn and to act.”
To accompany the comprehensive response to the ongoing opioid crisis, the County offers training on overdose response and naloxone use. The County has trained thousands of community members from schools, law enforcement agencies, community centers, health care clinics, County agencies, and other organizations. Trainings are free and open to the public; all who attend receive a free naloxone kit. The County encourages everyone in the community to take action by getting trained and carrying naloxone. More information about training and the life-saving medication can be found at https://bhsd.sccgov.org/information-resources/opioid-overdose-prevention-project/rescue-and-training.
More about the impacts of fentanyl on Santa Clara County, and how to help, is available at www.FentFacts.org. Help with preparing and talking to your kids and loved ones about opioids can be found at www.TheNewDrugTalk.org.
ABOUT THE COUNTY OF SANTA CLARA, CALIFORNIA
The County of Santa Clara government serves a diverse, multi-cultural population of 1.9 million residents in Santa Clara County, Calif., making it more populous than 14 states in the U.S. The County provides essential services to its residents, including public health protection, environmental stewardship, medical services through the County of Santa Clara Health System, child and adult protection services, homelessness prevention and solutions, roads, park services, libraries, emergency response to disasters, protection of minority communities and those under threat, access to a fair criminal justice system, and many other public benefits.
Visit the County of Santa Clara Behavioral Health Services Department at https://www.bhsd.sccgov.org/

Graphic of different names for opioid drugs

Promising progress on the heels of FASD Awareness Month:

County Makes Strides in Addressing Fetal Alcohol Spectrum Disorders

Efforts to raise awareness, prevent, and address Fetal Alcohol Spectrum Disorders (FASDs) show promising progress on the heels of FASDs Awareness Month

SANTA CLARA COUNTY, CALIF. — With September nationally recognized as Fetal Alcohol Spectrum Disorders (FASDs) Awareness Month, the County of Santa Clara Behavioral Health Services Department (BHSD) is sharing the County’s work to confront FASDs and Executive Functioning Disorders more broadly, and pledging to build upon these efforts in coming years.

As of October 2023, BHSD has made progress in all objectives it laid out in an ambitious three-year workplan to prevent and address FASDs. The ongoing efforts have brought visibility to an issue deserving of attention and were acknowledged in an official proclamation recognizing September as FASDs Awareness Month from the Santa Clara County Board of Supervisors on September 19. Brought forward by Supervisor Cindy Chavez, the proclamation stated that “FASDs Awareness Month will help generate public awareness about the risks and consequences of alcohol use during pregnancy and inspire community-wide efforts aimed at preventing FASDs.”

Supervisor Chavez noted, “This proclamation is a powerful statement that puts a spotlight on this issue that has gone largely unrecognized. Santa Clara County is at the forefront of the movement to tackle FASDs. We are leading by example with our work to improve prevention, diagnosis, and treatment, helping to improve the lives of those affected by FASDs in our county. We have demonstrated commitment to the cause through concerted efforts to better understand these disorders. We will continue to do the work for the individuals, caregivers, and families who are affected by FASDs.”

BHSD has supported public awareness efforts around FASDs since 2021, when its NotEven1 media campaign was launched to improve knowledge and awareness about FASDs. The first three campaign phases generated nearly 49,000,000 digital impressions and were aired online, on local TV, and on local buses. The newest campaign phase launched on Monday, September 25, and will run through October. With this campaign, the County has set out to reach expecting mothers, mothers breastfeeding, those planning to get pregnant, as well as partners and potential caregivers. English, Spanish, and Vietnamese ads inform those groups that there is no safe amount or type of alcohol to drink during pregnancy and encourage them to visit the County’s campaign resource page www.NotEven1.org.

“To address FASDs we have to educate our communities,” said BHSD Access and Unplanned Services Director, Bruce Copley. “Our public awareness campaigns aim to get the information to those mothers and prospective mothers and families so that they can take steps to prevent FASDs. This issue is not widely discussed so it’s key that we alert the public about FASDs and let them know that FASDs are preventable.”

In addition, in recent months, BHSD and partner County agencies initiated a comprehensive training program on FASDs and prenatal substance exposure for service providers throughout Santa Clara County. The trainings aim to increase understanding among providers about FASDs and encourage agencies to increase screenings for prenatal substance exposure among the individuals they serve. To-date trainings have been delivered to staff working in behavioral health, Social Services, obstetrics-gynecology, and public health nursing. Additional trainings are planned for providers working in custody and education in September and October, with additional follow-up trainings under development.

The County has also taken a critical step in improving the diagnosis of FASDs, by defining the diagnostic criteria based on thorough review of the available evidence. On September 28 the County held a roundtable of medical and behavioral health care providers and experts from around the county, led by Dr. Ira Chasnoff, a nationally-recognized researcher in the field of child development and the effects of maternal alcohol and drug use on the newborn infant, child, and adolescent. The roundtable provided a foundation by establishing a standard for FASDs diagnosis for the county, leading to better detection and treatment supports for individuals who have FASDs.

ABOUT THE COUNTY OF SANTA CLARA, CALIFORNIA
The County of Santa Clara government serves a diverse, multi-cultural population of 1.9 million residents in Santa Clara County, Calif., making it more populous than 14 states in the U.S. The County provides essential services to its residents, including public health protection, environmental stewardship, medical services through the County of Santa Clara Health System, child and adult protection services, homelessness prevention and solutions, roads, park services, libraries, emergency response to disasters, protection of minority communities and those under threat, access to a fair criminal justice system, and many other public benefits.

Visit the County of Santa Clara Behavioral Health Services Department at https://www.bhsd.sccgov.org/

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Progress in preventing suicide and providing crisis services

County of Santa Clara Celebrates One Year with 988 during Suicide Prevention Awareness Month

September commemorates the successful first year of the new suicide prevention lifeline and highlights opportunities to promote suicide prevention and reduce stigma

SANTA CLARA COUNTY, CALIF. — In recognition of September’s Suicide Prevention Awareness Month, the County of Santa Clara Behavioral Health Services Department (BHSD) is noting the success of their 988-suicide prevention lifeline and an expansion of services for people in crisis and is encouraging partners and community members to get involved in other suicide prevention activities.

As an integral part of its efforts, BHSD continues to promote use of 988 and the innovative crisis services available to county residents when they call the three-digit lifeline. In its first year the line answered 20,980 calls.

According to recent Mental Health Services Act survey data, the lifeline has become a visible and accessible resource in Santa Clara County. The survey showed that residents identified 988 as a vital asset among BHSD services.

To further bolster crisis services, BHSD recently launched text messaging through 988, available in English and Spanish.

Behavioral Health Services Department Director Sherri Terao stated, “Expanding 988 to include text messaging increases access to these life-saving services. Some folks may feel more comfortable seeking support through a text instead of a call. Now there are even fewer barriers to finding help in a moment of crisis. It’s a huge development and one we want to share with the community during this special month.”

Supervisor Otto Lee stated, “The data shows that we have successfully implemented 988, and the results demonstrate our commitment to providing our residents the help they need when they need it most. We are excited to provide this crucial resource and make 988 operations and improvement a priority.”

The County’s pioneering in-person crisis services, available through 988, continue to meet community needs. The programs – Mobile Crisis Response Team (MCRT), Mobile Response Stabilization Services (MRSS), Trusted Response Urgent Support Team (TRUST), and In-Home Outreach Team (IHOT) – provide effective, compassionate crisis intervention, and reduce hospitalizations and unnecessary incarceration. Each program is grounded in cultural humility, with staff representing the diverse cultural and language backgrounds found in Santa Clara County communities. In the first year of 988, the lifeline’s crisis counselors referred 3488 callers to the County’s community mobile response programs.

Supervisor Susan Ellenberg stated, “We aim to offer comprehensive mental health service options to assist residents in the manner they want and need to receive that assistance. We are constantly iterating to ensure continuous improvement of the system – and most of those iterations arise from community members’ input and guidance. Santa Clara County is leading the state on meaningful crisis response services. Our multi-pronged approach to providing crisis support will ensure that the 988 tool will grow more and more effective for individuals, families, and children in Santa Clara County.”

September is widely recognized as Suicide Prevention Awareness Month. The recognition aims to raise suicide awareness, promote prevention efforts, and reduce stigma. Throughout the month, BHSD’s Suicide Prevention Program and local and national organizations will share events, opportunities, and resources to promote suicide prevention efforts. BHSD and the Suicide Prevention Program encourage everyone to get involved in commemorating the month, with some ideas featured below. Everyone can play a role in preventing suicide:

• Find out more about the County’s efforts: County Suicide Prevention Program
• Take a community helper training: Suicide Prevention Resource Center
• Promote the 988 National Suicide and Crisis Lifeline: SAMHSA
• Share the powerful California state suicide prevention campaign: Know the Signs
• Learn about suicide's impacts on different groups and engage your community: NAMI
• Elevate the conversation around suicide and encourage safe messaging: Action Alliance
• Get involved with National Suicide Prevention Week: AFSP
• Spread the word on social media: CDC

ABOUT THE COUNTY OF SANTA CLARA, CALIFORNIA
The County of Santa Clara government serves a diverse, multi-cultural population of 1.9 million residents in Santa Clara County, Calif., making it more populous than 14 states in the U.S. The County provides essential services to its residents, including public health protection, environmental stewardship, medical services through the County of Santa Clara Health System, child and adult protection services, homelessness prevention and solutions, roads, park services, libraries, emergency response to disasters, protection of minority communities and those under threat, access to a fair criminal justice system, and many other public benefits.

Visit the County of Santa Clara Behavioral Health Services Department at https://www.bhsd.sccgov.org/

woman receives phone help using 988

New home for TB, Refugee Clinics

Santa Clara Valley Healthcare Opens State-of-the-Art Primary Care Facility for the Tuberculosis Clinic and Refugee Health Assessment Program

Santa Clara County, Calif. – Santa Clara Valley Healthcare (SCVH), the hospital system for the County of Santa Clara, hosted a ribbon cutting for its new, state-of-the-art Valley Health Center (VHC) Lundy primary care clinic. VHC Lundy will be the new home for the Tuberculosis Clinic & Refugee Health Assessment Program. The new facility comes at a critical time as Santa Clara County faces the third highest case rate for tuberculosis (TB) among California jurisdictions, while also welcoming the highest numbers of refugees in the state, according to County health officials. VHC Lundy is located at 1996 Lundy Avenue in East San José.

The only such clinic and program of its kind in the county, VHC Lundy provides expert evaluation and treatment of active TB disease and preventive therapy for latent TB infections (LTBI). The new clinic also delivers comprehensive health assessments and medical treatment specifically designed for refugees, asylees, humanitarian parolees, special immigrant visa holders and victims of human trafficking who seek treatment in the county.

VHC Lundy is a cutting-edge airborne isolation facility designed to prevent transmission of TB and other airborne diseases and will provide a safe and welcoming care environment for staff and patients in need of services and support.

“While the clinic will serve as a huge asset to the entire county, I want to express my profound gratitude for the decision to open this in an area that is home to one of the largest immigrant populations in the county,” said County of Santa Clara Supervisor Otto Lee. “Moreover, it is of utmost importance that the clinic upholds our principles of language, cultural humility and competence, reflecting the values that we hold dear in Santa Clara County.”

“The assessment program housed at the new site will now have its own space, a place that provides care and counseling for County families; folks who are often using the program as their first entry point into our healthcare system,” added County Supervisor Joe Simitian, Chair of the County Health and Hospital Committee. “We’re really working to provide a warm environment, a safe space, to help these families navigate our healthcare system.”

Federal law requires new refugee arrivals to be screened for communicable diseases, including viral hepatitis, parasitic infections and tuberculosis, as well as chronic health conditions. In addition to the screenings, the Refugee Health Assessment Program also provides the following:

• Primary care services;
• Referrals to specialty care services and urgent care as needed;
• Required immigration vaccinations; and
• Mental health assessments and referrals to counseling and mental health services for adult patients through a partnership with the Asian Americans for Community Involvement (AACI)/Center for Survivors of Torture (CST).

Tuberculosis is a highly contagious and potentially life-threatening disease, so without early screening, it could lead to delayed treatment and undiagnosed people spreading the disease unknowingly to the broader community,” said Dr. Phuong H. Nguyen, SCVH Chief Medical Officer. “Completing our screening and LTBI treatment is critical to preventing transmissions and protects the health of the entire community.”

The new clinic is the only outpatient setting specializing in TB in the county, providing care to more than 60 percent of all active cases locally. The existing clinic treats up to 100 patients each day, on average. More than 50 percent of the clinic staff are certified interpreters in a second language, and many were also refugees themselves.

“We’ll now have a state-of-the-art facility that makes it easier for us to provide more consistent support and follow-up with our new patients, many of whom represent some of our most vulnerable populations,” said Sonia Menzies, Director of Ambulatory Community Health Services for Santa Clara Valley Healthcare.

The County has implemented an expanded LTBI testing as part of the standard patient Health Maintenance Plan in all VHC primary care clinic locations. This enables Primary Care Providers to identify and refer patients with LTBI for preventative treatment. Since August 2022, testing rates have more than doubled and referrals to the TB clinic have increased three times its usual monthly volume.

LTBI Services are now available in the following locations: VHC Downtown, VHC Gilroy, VHC San Jose, VHC Milpitas, and Vietnamese American Services Center (VASC) Clinic.

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