u

BOS Agenda Date : June 4, 2002
Agenda ttem No. 21

County of Santa Clara
Santa Clara Valley Health & Hospital

obu'A/>
-0,

'■'/r

System

T

Mental Health Services

HHSIO

Prepared by: Donna Guardino
Contracts Manager

Reviewed by: Jaime Lopez
Mental Health Division

Director Family and
Children Division

Submitted by: Nancy Pena, Ph.D
Director, Mental Health
Department
DATE:

June 4, 2002

TO:

Board of Supervisors

FROM:

Robert Sillen

Executive Director, Santa Clara Valley Health & Hospital System
SUBJECT:
Mental Health

Resolution Authorizing Submission of Application to 2002 CSAC Challenge Awards

Program

RF COM MENDED ACTION

Board of Supen'-isors: Donald F, Gage, Blanca Alvarado, Pete McHugh, Jim Beall, LizKniss
Countj' Executive: Richard Wittenberg

1

BOS Atjeiula Date: June 4, 2002
Agenda (tern No. 21

Adopt Resolution authorizing submission of the application titled "California's First Community Treatment Facility" to
the California State Association of Counties for the 2002 Challenge Awards Program.(Roll Call Vote)

FTSCAT. TMPTJCATTONS

There is no impact on the County General Fund as a result of this action. The awards program requires no matching
funds to receive the special award. The nominal fee ($35) to apply for a CSAC Challenge Award will be absorbed within
the Department's FY 03 budget.
REASONS FOR RECOMMENDATION

The California State Association of Counties(CSAC)will be presenting its 2002 Challenge Awards during its Annual

Meeting in November 2002. This award is designed to recognize the innovative and creative sprit of California county
governments for finding new and effective ways of providing programs and services to their citizens.
Given the immense coordinated effort between County agencies to implement the Community Treatment Facility (CTF),

this program exhibits the unique vision and resourcefulness of Santa Clara County. Furthermore, given the complexity
of program design, financing, contracting and licensing requirements, the CTF meets criteria set forth by CSAC as an
for programs of
innovative and unique program. Lastly, given that no historical data exists on which to build budgetsof
mental health
to
take
risks
to
improve
the
care
and
coordination
this type, the County demonstrated its willingness
services for its children.

BACKGROUND

to
In 1998, planning began for the development of a Community Treatment Facility (CTF)and key program elementsand
address an array of psychiatric symptoms and severe behavior problems of Dependent Wards, Delinquent Wards,
homes and

emotionally disturbed youth (AB 3632) in the County. Many of these youth were cycling in and out of group
were ending up in institutions (Children's Shelter and Juvenile Hall) to await placement.

the Bay
In September 1999, Santa Clara County was selected by the state as a host county to develop a new CTF for
more
than
Adolescent
Center,
Inc.
Santa
Clara
County
itself
has
Area region with a prospective contractor, Starlight
6,000 wards and dependents and an additional 500 AB3632 Special Education students who rely upon the MentaltheHealth
Department system for treatment. Many of these children and teens (referred by the Social Services Agency and
Probation Department) are placed out of home in foster care and residential group homes.

behavioral
In January 2000, a Behavioral Health Center concept paper was prepared for the Board that outlined specific
Board invested

health programs for youth that could be co-located in one facility, including a CTF. Later that May, themental health and
$9 million dollars purchasing real property at 455 Silicon Valley Blvd. with the intent to help meet the
substance abuse needs of youth in Santa Clara County. In addition, SI.2 million dollars were reserved within the Mental
Health Department's budget to address costs associated with the development of the behavioral health programs and any
unforeseen facility expense.

Board of Supervisors: Donald F Gage, Blanca .Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Richard Wittenberg

2

BOS Agenda Date: June 4, 2002
Agenda ttem No. 21

In May 2000, three workgroups (Legal, Program & Facilities/Coiitracts) were established to facilitate the

tasks with
implementation process. These groups met weekly for almost 6 months to prioritize and expedite the start-up admission
the provider. Mental Health Department staff and legal stakeholders met to resolve legal issues and formalize
and medication consents. Staff from the Mental Health Department, Social Service Agency, Juvenile Probation
Department, the Mental Health Advocacy Project and County Counsel developed training materials and held two
trainings for 75 placement workers. Juvenile Court Judges, County Office of Education, & others admission processes.
In all, there were more than 500 County "stakeholders" who collaborated in the design and implementation of Starlight
Adolescent Center.

In October 2000, Starlight began admitting clients establishing the first CTF in the state, which effectively launched the
County of Santa Clara as a leader in children's mental health service delivery and design.
rONSEOTJENCES OF NFGATrVE ACTION

Failure to approve this action would prevent the County from submitting this entry to the CSAC Challenge Awards
Program for 2002.
ATTACHMENTS

.(Transmittal submitted on May 21, 2002 5:56:05 PM - PDF Version)
• Entry Form (Resolution)
• Resolution (Resolution)

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jirn Beall, Liz Kniss
Count)'’ Executive: Richard Wittenberg

3

Il

II

i!

Hiiiiniiii

i

Mf

Report on the First Two Years
(October 2000 - October 2002)

starlight: A Report on the First Two Years
(November 2002)

Contents

Introduction

Page 1

Background: The Need for CTFs

Page 1

Starlight; A Collaborative Creation

Page 2

Starlight: A Special Program for Youth with Special Needs

Page 3

Population of Starlight(Age, Sex, Ethnicity)

Page 4

Placing Agencies Counties, Legal Status, Prior Histories

Page 5

Client Diagnoses and Functional Levels

. Page 6

Outcomes

Page 7

Client Satisfaction

Page 8

Clinical Quality Indicators Data

Page 8

Issues and Accomplishments

Page 10

starlight: A Report on the First Two Years
(November 2002)
Introduction

This report summarizes Starlight Adolescent Center’s first two years of operation. The
role of the Community Treatment Facility(CTF) in the continuum of care for emotionally
disturbed youth is outlined in the first part of the report. Subsequently, data are
presented on the 67 youngsters who have been admitted to Starlight between October
16, 2000 and October 16, 2002.

Background: The Need for Community Treatment Facilities
Community Treatment Facilities (CTF) were created to fill a unique role in the
California’s mental health system of care, allowing for the most intensive and secure
treatment of the most seriously emotionally disturbed youth. Special regulations
(summarized in the box below) permit CTFs to provide high levels of supervision and
security while facilitating intensive mental health and psychopharmaceutical treatment.
What is a CTF?

“A Community Treatment Facility (CTF) is a secure facility for seriously emotionally
disturbed children who have tried other less restrictive mental health interventions

and who may require periods of containment.

Why was the CTF created as
part of the system of care?
■

To provide for a level of
care in between the RCL-

■

14(Group Home) and the
acute psychiatric hospital;
To provide special
regulations that facilitate
the management of serious
psychiatric symptoms such
as assaultive behaviors,
noncompliance, and
AWOLs.

•

T0 allow for extended

periods of secure
residential care, while still
allowing for “graduations”
to community living
settings.

(DSS - CCL Licensing)

What are some of the unique regulatory
provisions for the CTF?
Certification by DM FI
Capacity for being locked
Use of seclusion and restraint permitted
LOS > 90 days allowed through review by
external case manager
Specific patient rights defined (as for a
mental health patient, i.e., possibility of
denial of rights, right to hearing; Title 9 and
WIC)
Specific admission policies (i.e.,
certification of SED status by LMFIP and
previous participation in less restrictive
mental health interventions and consent to

treatment on behalf of child (6552/ Tcon/
Conservatorship/ Roger S)

Specific staffing requirements: more staff,
higher staff qualifications, more staff
orientation and training required

Starlight Two Year Report (November 2002)

Page #1

starlight: A Collaborative Creation
In 1999, Santa Clara County was selected as a host county to develop California’s first
CTF for SED youth. This county’s Department of Mental Health serves more than 6,000
wards and dependents and another 500 AB3632 Special Education students, many of
whom are in out of home placements. Services for the most seriously ill of these youth
are coordinated through an Interagency Team of placement, administrative, and
program staff representing the Mental Health Department, the Social Services Agency,
and the Probation Department. In addition, since 1998, the Board of Supervisors has
committed significant resources to ensure that children placed out of home receive
needed and appropriate services. In all, there were more than 500 County
stakeholders” who collaborated with Stars Behavioral Health Group principals in the
design and implementation of Starlight Adolescent Center.
The County implementation process is illustrated in the diagram below. Three
workgroups (Legal, Program & Facilities/Contracts) were established to facilitate the
implementation process. These groups met weekly for almost 6 months to prioritize and
expedite the start-up tasks. Mental Health Department staff and legal stakeholders
resolved and formalized legal issues regarding admission and medication consents.
Staff from the Mental Health Department, Social Service Agency, Juvenile Probation
Department, and County Counsel developed training materials and held trainings for 75
placement workers & others to educate front-line staff about program and admission
processes.

IMPLEMENTATION

Facilities/Contract Workgroup
GSA Building Operations, Property Management S
Purctiasing: MH Admin, Systems Office & Quality
Improvement; OBA ; SCO Fire Marshall; County ISO;
SCVHHS Environmental Health & Telecom Services;

COE; County Counsel; County Exec's Office; MJG

Legal Workgroup
o

County Counsel. Juvenile Dependency Court, District
Attorney; Public Guardian's Office; MHD Family &
Children’s Division; County Office of Education;
Mental Health Advocacy Project MJG & Associates.
PROCESS
• Initiate Collaboration

Program Workgroup
Mental Health Family & Children's Division; DFCS;

Social Services Agency; County Office of Education: MJG;
Juvenile Probation; SCVMC Admin; Family Partners;

o
3

• Mutual Respect
• Parent Involvement

• Cultural Competency
• Group Cohesion
• Accomplishment

O
fi
)

3

Alliance for the Mentally III (AMI); Alameda County
Behavioral Health

Starlight Two Year Report (November 2002)

Page #2

starlight: A Special Program for Youth with Special Needs
The Starlight model, philosophy, services, and goals and the most common client
symptoms are summarized in the boxes below.

THE STARLIGHT MODEL
Case

Management

Mental

Therapeutic
Behavior

36 - Bed

Services

Locked

Health
Services

intensive MH
NonPublic

Treatment

School

Program

STARLIGHT SERVICES

MOST COMMON

STARLIGHT PHILOSOPHY

CLIENT PROBLEMS

• Comprehensive evaluations
• Psychotherapy
• Psychoeducational skills
development
'Recreational activities

•

Social

services

&

case

management
Medication

• Suicide attempts
» Runaway attempts
• Sexual acting out
• Explosive tantrums
•Hallucinations and

• Dietetic services

•

• Assaultive

&

delusions

medication

• Paranoia

monitoring
• Educational services

• Safety and supervision
• Positive youth development
• Expectation of success
• Enhancing quality of life
• Achieving of independence
• Interagency collaboration
• Family participation
• Results orientation

• Cultural competence
• Comprehensiveness
• Transitional services

STARLIGHT GOALS

To provide an intensive treatment program to SED adolescents which maintains them in their
community setting and assists them and their family/caregiver to return as soon as possible to
their family environment.
Starlight Two Year Report (November 2002)

Page #3

Population of Starlight (Age, Sex, and Ethnicity)
Between October 15. 2000 and October 15. 2002 April 1. 2002. a total of 65 youngsters
were admitted to Starlight. Slightly more than half of the clients (52%) were girls and
slightly less than half were boys.
The ethnic distribution of the Starlight clients is shown in the table below. Because
Starlight includes youth from various counties in Northern California, this table includes
comparison data of children in out-of-home placements in both Santa Clara County and
in California as a whole.

DATA ON ETHNICITY OF CHILDREN IN OUT-OF- HOME PLACEMENTS

Starlight

Santa Clara County

California

Black

18%

15%

36%

White

45%

27%

30%

Hispanic

34%

51%

32%

Asian

1%

6%

2%

Native American

1%

<1%

<1%

The clients ranged in age from 12 to 17 years at admission, and their average age at
admission was 15.1 years (± 1.4). As illustrated in the graph below, the most common
age at admission was 16 years.

Age of Clients at Admission
30%

£7%

I

22%

25%

19%

20%

16%

15%

12%

10%
5%

3%

0%

12yrs

13yrs

14 yrs

Starlight Two Year Report (November 2002)

15yrs

16yrs

17 yrs

Page #4

Placing Agencies, Counties, Legal Status, Prior Histories
Starlight’s clients were referred by the Departments of Social Services, Mental Health,
and Probation from various counties in Northern California,

information about the

placing counties, placing agencies, legal status of the clients, and prior histories of the
clients is summarized below.

Placing Counties
1%

Placing Agencies

1%

4%
26%

1%
5%

62%
■ Alameda
■ San Mateo
0Solano
0Tulare

□ Butte
□ Santa Clara
□ Sonoma

Prior Histories

Prior to admission, most of the clients

were residing: in Juvenile Hall (47%), in a
psychiatric hospital (18%), or with family
(15%).
Previous Psychiatric Hospitalizations:

84% of the clients had previous psychiatric
hospitalizations, and 43% had 4 or more
such hospitalizations. Several clients had
had 12 psychiatric hospitalizations.
Previous
Placements:

Failed

Group

Home

87% of the clients had a

history of at least one failed group home
placement, and more than a quarter of the
clients (28%) had 5 or more failed group
home placements.

Starlight Two Year Report (November 2002)

Page #5

Client Diagnoses and Functional Levels
All Starlight’s clients have serious psychiatric diagnoses (according to DSM-IV
diagnostic criteria), and most(78%) have more than one such diagnosis. The table and
charts belo\A/ illustrate the number and types of psychiatric diagnoses found at Starlight.
Global Assessment Scores

The average “GAF” scores for the clients
at admission was 37.9 (±11.3).

Almost half of the clients (48%) had
scores in the 31-40 range, indicating
major impairments in several areas (e.g.,
persistent aggression without instigation,
markedly withdrawn and isolated, or
suicidal attempts with clear lethal intent,
affecting behaviors at home, school, with
peers, or in society at large). Another
26% of the clients had scores below this

range, reflecting even more serious
difficulties (e.g., inability to function in
almost all areas or need for supervision
to prevent hurting self or others).

Emotional disorders (e.g., depressions, bipolar disorder, obsessive-compulsive disorder
and PTSD) affected 81% of Starlight’s clients. Behavioral disorders (e.g., oppositionaldefiant disorder, conduct disorder, and ADHD) were present in 61% of the clients.
Psychotic disorders (e.g., psychosis not otherwise specified, schizophrenia, and
schizoaffective disorder) were present in 16% of the clients.

Types of Psychiatric Disorders in the
Starlight Population
100%
81%
80%
61%

Diagnosis
Depression NOS
Major Depression
Dysthymia
Bipolar
Obsessive compulsive
PTSD

0%

6%
18%
1%

4%

Mood NOS

20%

24%

1%

Gen. Anxiety
16%

21%

25%

60%

40%

%

25%

Oppositional-defiant
Conduct

25%

ADHD

27%

Emotional

Behavioral

Psychotic

Intermittent Explosive

6%

disorders

disorders

disorders

PNOS

9%

Schizoaffective Disorder

4%

Schizophrenia

3%

Starlight Two Year Report (November 2002)

Page #6

Outcomes
As of October 15, 2002, 36 clients have been

permanently discharged from Starlight. Twentythree of these (64%) were discharged to lower
levels of care and 13 (36%) had other types of
discharges.
The specific discharge locations for these clients are
illustrated in the bar graph below. The most
common type of discharge was family reunification
(occurring with 15 clients or 42% of the discharges).
For the most part, these youth had been alienated
from their families for long periods of time, so this is
a significant accomplishment.

The next largest group of discharges were to group
home settings.
Seven clients (19% of those
discharged) were successfully placed in community group homes and one other client
was placed in another group living situation.
“Unsuccessful" discharges included three clients who AWOLed (8% of the discharges),
four clients who were psychiatrically hospitalized, and six clients sent to Juvenile Hall.
Those who were sent to Juvenile Hall had received many services and much support at
Starlight; however, they were not amenable to mental health treatment.

Specific Discharge Locations
45%

40%
35%

30%
25%
19%
20%

17%

15%

11%

10%
5%

0%
Home/

Family

I
Group
home

8%
3%

Other group
living

Starlight Two Year Report (November 2002)

AWOL

Psych.

Juvenile

Hospital

Hall

Page #7

Client Satisfaction

The chart below summarizes the results of the most recent Client Satisfaction Survey
(done in June 2002). The areas rated included: school services, nursing services,
counseling, groups and rehab activities, social services/case management, food, family
services, rooms/the facility, and the treatment philosophy. When all of these areas were
averaged, 64% of clients were found to be “satisfied” or “very satisfied” overall.
Another client satisfaction survey will be done during November 2002.

CLIENT SATISFACTION AT STARLIGHT (JUNE 2002)
80%
Q
LU

70%

68%

70%

68%
65%

64%

63%

64%

64%

PHIL.

AVG.

59%
h-

60%

56%

<
CO
CO

LU

50%

40%

O
Ll_

O

LU

30%

20%

O
QC
LU
CL

10%
0%
SCHL

NGS

CNS

GRPS

S SERV

FOOD

FAMILY ROOMS

AREAS OF SERVICE RATED

Clinical Quality Indicators
Starlight has a The Quality Improvement System which focuses on critical aspects of
treatment and care. It continuously collects data; identifies problems; recommends
corrective actions; and monitors and evaluates functioning. Two recent concerns at
Starlight have been high rates of assaults and high rates of restraints.

The two charts on the following page illustrate how assault episodes have been reduced
by approximately half between May and September 2002 and the use of restraints has
Starlight Two Year Report (November 2002)

Page #8

been reduced by approximately 75% between June 2002 and September 2002.

ASSAULTS AT STARLIGHT

RESTRAINTS AT
STARLIGHT

60
50

40
30
20

10
0

May- Jun- Jul- Aug- Sep02

02

02

02

02

—•—Client to client assaults

-

- Client to staff assaults

Another recent quality improvement project was to improve attendance levels at
Starlight High School.
A Quality Improvement Team formulated a set of
recommendations in early September and since then, school attendance has steadily
increased. As illustrated in the chart below, in September alone, average attendance
(for all students and all classes) went from 70% in the first week to 85% by the end of
the month. By the end of October, rates had gone to 89%.

Attendance at Starlight High School
95%
90%

-♦

85%

♦

♦

80%
75%

70%

♦

65%
60%
55%

50%

Aug Aug Aug

Sep Sep

Sep Sep Sep

Oct

Oct

Oct

02,

02,

02,

02,

02,

02,

02,

02,

02,

02,

02,

02,

1st

2nd

3rd

1st

2nd

3rd

4th

5th

1st

2nd

3rd

4rd

wk

wk

wk

wk

wk

wk

wk

wk

wk

wk

wk

wk

starlight Two Year Report (November 2002)

Oct

Page #9

Issues and /Accomplishments
Opening the first CTF in California was a complex undertaking even with the full support
of the State and County Departments of Mental Health and other State and County
agencies including Community Care Licensing. For those areas which have represented
special challenges to the program, the current progress and/or upcoming plans or goals
are summarized below.

.

Staff recruitment and retention; In

last 6-9 months, the staff recruitment and

retention situation in the San Jose area has significantly changed due to the
economic factors in the South Bay. All positions including both Nursing and Social
Work are now being filled at Starlight without difficulty.
®

Client acuity and appropriateness: As the data presented earlier in this report
illustrate, the youth being referred to Starlight have high acuity levels and multiple,
very serious psychiatric disorders including psychoses, major mood disorders, and
serious acting-out or behavioral disorders. Many came from acute psychiatric
hospitals where they had received intensive psychiatric interventions including
multiple psychotropic medications. Others came from Juvenile Hall, and brought
with them a mindset of treatment noncompliance.
Starlight has worked hard to develop a “Clinical Pathways” program that includes
tailored combinations of medications, counseling, rehabilitation groups, and other
treatments specifically designed for different clinical profiles. Nonetheless, there are
some youth who are not amenable to mental health treatment. A goal for the
upcoming year is to refine the patient referral process so that all referrals are
appropriate for Starlight’s services and meet the SED criteria.

• Family issues: The majority of the youth referred to Starlight have been placed
away from families and have lacked close consistent role-models for long periods of
time. Families have been an increasing focus at Starlight, with special emphasis on
our “Multifamily Group” and a new “Parent Partner” program. Starlight is finding that
even the most troubled families are showing signs of reengaging with their youth and
working as part of the treatment team in a renewed effort to improve their relations
with their youngsters. Starlight is very proud of having achieved family reunifications
for 42% of its youth. It is our hope that, through our “transition aftercare program”
the youth who are “graduating" from residential treatment in Starlight will have the
guidance and support necessary to ensure continuing success in the community
and with their reunified families.

. Community Day Treatment: During the last few months, considerable progress
has been made in developing our community based aftercare program which is
composed of a NonPublic School and Intensive Day Treatment. Currently ten
youngsters attend school, day treatment, or both. The youngsters enrolled include
STARLIGHT CTF graduates as well as Community youth.
. TBS Services: Therapeutic Behavioral Services at Starlight have expanded to
include youngsters in the Community Program as well as those in the County
Children's Shelter.

Starlight Two Year Report (November 2002)

Page #10