DATE: March 11, 2025
TO: Board of Supervisors
SUBMITTED BY: Sanja Bugay, Director, Department of Social Services
Susan Holt, Director, Department of Behavioral Health
Kirk Haynes, Chief Probation Officer, Probation Department
SUBJECT: Retroactive Amendment I to Master Agreement for Enhanced Intensive Services Foster Care and Emergency Enhanced Intensive Services Foster Care
RECOMMENDED ACTION(S):
TITLE
Approve and authorize the Chairman to execute retroactive Amendment I to Master Agreement No. 24-500 with Aspiranet, Inc. and Promesa Behavioral Health to provide greater clarity, flexibility, and specificity in the reimbursement process, addressing challenges related to home capacity and recruitment efforts, effective December 1, 2024 with no change to the term of September 10, 2024 through June 30, 2028, or compensation maximum of $39,364,924.
REPORT
There is no additional Net County Cost associated with approval of the recommended action, which will allow providers under this agreement to be reimbursed adequately to remain operational during ongoing recruitment efforts for Specialized Resource Parents to participate in the Enhanced Intensive Services Foster Care (E-ISFC) and Emergency Enhanced Intensive Services Foster Care (E-E-ISFC) program. Initial contract design utilized the standard three-month start-up period. However, due to the additional training, commitments, and responsibilities required of participating Specialized Resource Parents, recruitment has proven challenging. This item is Countywide.
ALTERNATIVE ACTION(S):
Should your Board not approve the recommended action, the existing compensation methodology will significantly limit allowable reimbursements, potentially putting financial strain on the providers to such an extent that the success and continuity of the pilot is jeopardized.
RETROACTIVE AGREEMENT:
The recommended Amendment is retroactive to December 1, 2024, due to the length of time to prepare the Amendment and have it approved by Aspiranet, Inc. and Promesa Behavioral Health. In late November 2024, the providers expressed concerns regarding recruitment challenges and emphasized the need to adopt additional strategies and maintain ongoing flexibility beyond the startup period, which concluded on November 30, 2024. In December 2024, after several discussions with the providers, the California Department of Social Services (CDSS), and other pilot counties, the Department of Social Services (DSS) reevaluated the approach to this new program, ultimately shifting course on the Amendment to ensure providers have sufficient flexibility while also maintaining accountability for service provision. The recommended Amendment was finalized on January 23, 2025.
FISCAL IMPACT:
There is no increase in Net County Cost associated with the recommended action. Total expenditures will be based on actual costs incurred, total not to exceed the maximum amount, $39,364,924.
The maximum amount of the agreement ($39,364,924) will be offset with Medi-Cal Federal Financial Participation (FFP) revenue ($10,141,275), Early and Periodic Screening, Diagnostic, & Treatment (EPSDT) funds ($8,113,020), Children’s Crisis Continuum Pilot Program (CCCPP) Grant ($5,015,318), Complex Care Capacity Building (CCCB) Allocation ($699,992), Title IV-E funds ($4,685,535), and SB 163 Trust Funds ($10,709,784). Sufficient appropriations and estimated revenues are included in DSS Org 5610 FY 2024-25 Adopted Budget and will be included in subsequent budget requests.
DISCUSSION:
In 2021, Assembly Bill (AB) 153 (2021) established the Children’s Crisis Continuum Pilot Program (CCCPP), implemented by the CDSS and the Department of Health Care Services (DHCS). The purpose of the pilot program is to allow counties to develop a highly integrated continuum of services designed to serve foster youth with high acuity needs. It emphasizes stabilization and treatment within the least restrictive environments, enabling seamless transitions across service settings, and empowering providers to manage the full continuum of care from intensive settings to family-based homes.
In 2022, the Department of Social Services (DSS), in collaboration with Department of Behavioral Health (DBH) and Probation Department, identified several gaps within the County’s existing continuum of care that too often resulted in a lack of consistently responsive, trauma-informed services for foster youth and their families. Youth in crisis have often had to remain in hospital emergency departments or other temporary, non-therapeutic settings due to the lack of available and appropriate crisis services. DSS is currently using several strategies to alleviate these issues including the implementation and licensure of the Transitional Shelter Care Facility (TrSCF), introduction of the trauma-informed Neurosequential Model of Therapeutics (NMT), as well as child-specific strategies that utilize both a child’s local team partners through CDSS technical assistance efforts.
In an effort to address the identified gaps within the continuum, DSS, in partnership with DBH and Probation, responded to a Request for Proposal (RFP) released by the California Department of Social Services (CDSS) for the CCCPP grant on December 1, 2022. Fresno County was one of eight counties to be awarded the grant.
On August 6, 2024, the Board approved the retroactive submission of the Children’s Crisis Continuum Pilot Program (CCCPP) grant Application and Standard Agreement with CDSS to support the expansion and implementation of the Children’s Well-Being Continuum (CWBC) in Fresno County.
Two of the components of the crisis continuum, CWBC, are Enhance Intensive Services Foster Care (E-ISFC) and Emergency Enhanced Intensive Services Foster Care (E-E-ISFC). These programs provide intensive, individualized supports for young people who do not require treatment in locked, inpatient facilities but who are not yet ready to step-down into lower levels of care, such as Intensive Services Foster Care (ISFC) homes or Short-Term Residential Treatment Programs (STRTPs).
On September 10, 2024, the Board approved Master Agreement No. 24-500 with Aspiranet, Inc. and Promesa Behavioral Health for E-ISFC and E-E-ISFC services. Through this agreement the Department aims to increase and enhance the ISFC level of care through the implementation of E-ISFC and E-E-ISFC homes, equally divided between Aspiranet, Inc. and Promesa Behavioral Health for supporting youth with intensive needs for anywhere between 30 days and one year of stabilizing placement. Youth eligible for these services will be supported by E-ISFC/E-E-ISFC Specialized Resource Parent(s), who differ from traditional ISFC Resource Parents in several critical ways, including capacity for 24/7 availability to respond to youth needs, by ensuring the presence of at least one parent with no competing responsibilities outside the home, commitment to providing care for the youth regardless of any behavioral challenges that emerge, and successful completion of rigorous supplemental training and continuing education. The E-ISFC and E-E-ISFC programs provide a structured and safe home-based setting promoting stabilization and the development of therapeutic relationships with both Specialized Resource Parents and staff, allowing the in-home, multidisciplinary team to complete an accurate assessment of the youth’s needs, engage the youth in intensive treatment services, and recommend next steps toward permanency and healing. The difference between the two is the length of stay: E-E-ISFC provides placement and services for up to 30 days and E-ISFC provides placement and services up to 12 months.
Both contracted providers have faced challenges in soliciting qualified resource parents who are willing to undertake the additional training, commitments, and responsibilities required to become Specialized Resource Parents for the target population. The County has consulted with the State and the other pilot participants regarding recruitment and have discovered that soliciting interest and recruiting qualified individuals has been difficult for all participants. The County continues to consult with the State, other counties both in and out of the pilot program, and multiple consultants to better assist the providers with recruitment efforts.
Exhibit C (“Compensation”) of Master Agreement No. 24-500, utilizes a proration methodology based on “actual home capacity” to calculate all costs that are to be reimbursed as of December 1, 2024. This methodology divides total allowable costs incurred, by the number of existing or available placements for each provider. As it is currently written, if there are no available placements for any reason, including inability to recruit any Specialized Resource Parents, providers will not be reimbursed for any costs incurred after the startup period, which ended on November 30, 2024. By aligning compensation with performance and service readiness, the intent of the methodology language was to encourage efficiency and ensure that funds were allocated appropriately to support services directly benefiting the program’s goals. However, while well-intentioned, this structure did not account for challenges such as recruitment difficulties, which has constrained the providers' ability to meet capacity targets, ultimately limiting their access to necessary funding to sustain operations and recruitment efforts.
Approval of the recommended action will retroactively adjust the compensation methodology to December 1, 2024, to provide greater clarity, flexibility, and specificity in the reimbursement process, particularly addressing challenges related to home capacity and recruitment efforts. It allows providers to receive proportional reimbursement for maintaining service readiness even if full capacity is not met, while explicitly defining allowable expenses for direct services, facilities, and recruitment efforts. The updated language also supports providers by reimbursing recruitment and training costs for Specialized Resource Parents, ensuring essential staffing and capacity-building. Additionally, appropriate staffing for Medi-Cal site certification is required prior to commencing services. The recommended amendment allows for providers to maintain the appropriate level of staffing in order to obtain site certification and ensure readiness to provide Specialty Mental Health Services. By aligning reimbursement with recruitment efforts and budget constraints and flexibility, the new methodology improves financial stability for the providers, while maintaining accountability and program continuity. Without the adjustment to the language, providers may face significant financial strain, jeopardizing their ability to remain operational and, ultimately, threatening the success and continuity of the program.
REFERENCE MATERIAL:
BAI #62, September 10, 2024
BAI #55, August 6, 2024
ATTACHMENTS INCLUDED AND/OR ON FILE:
On file with Clerk - Amendment I to Master Agreement No. 24-500
CAO ANALYST:
Ronald Alexander