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Program Overview

Program Information

Program Name

In-Home Outreach Team (IHOT)

Contracted Services

  • Outreach & Engagement
  • Client & Program Support
  • Medi-Cal Administrative Activities (MAA) – MAA requirements apply
  • Bridges to Recovery (BTR) services under RU 01EE7

Program Goals

IHOT aims to:

  1. Increase access to care through strategic outreach and engagement with high-need adults.
  2. Help clients and family members identify goals and connect to education, supports, and community resources.
  3. Increase understanding of mental health disorders and reduce the effects of untreated illness.
  4. Support clients in accessing and transitioning to appropriate behavioral health services.
  5. Improve family satisfaction with the mental health care system.
  6. Reduce hospitalizations and emergency service utilization.
  7. Support clients in transitioning to the least intensive and most appropriate level of care.

Target Population

Clients Served

Adults who may be:

  • Experiencing serious mental illness (SMI)
  • Unserved or underserved by behavioral health systems
  • Unwilling or unable to seek services on their own
  • At risk of homelessness or currently homeless
  • High utilizers of emergency or crisis services
  • In need of linkage to the Specialty Mental Health Services (SMHS) system

Family & Caregiver Support

IHOT also works with families who:

  • Struggle to engage a loved one in treatment
  • Need assistance coordinating services
  • Need psychoeducation or support around behavioral health conditions

Referral Process

Referrals may come from:

  • ACBH departments
  • Mobile crisis teams
  • Hospitals
  • Community-based organizations
  • Law enforcement partners
  • Family members
  • Self-referrals (where appropriate)

Program Description

Core Service Model

IHOT provides short-term, field-based, intensive outreach and engagement to help individuals enter and stay connected to behavioral health services. The model emphasizes:

  • Building trust and rapport
  • Culturally responsive engagement
  • Strength-based and trauma-informed practices
  • Collaboration with family and natural supports
  • Multi-disciplinary teamwork
  • Warm handoffs and supported transitions

Program Activities

Activities may include:

  • Outreach in community settings
  • Field-based engagement and assessment
  • Psychoeducation for clients and families
  • Motivational interviewing
  • Linkage to behavioral health services
  • Assistance navigating benefits and resources
  • Crisis prevention and short-term stabilization
  • Transportation support for behavioral health appointments
  • Collaboration with outpatient programs, hospitals, and crisis teams

Coordination of Care

IHOT works closely with:

  • ACCESS
  • Specialized outpatient programs
  • Mobile crisis teams
  • Primary care and physical health providers
  • Housing and social services agencies

Discharge & Transition

Clients transition out of IHOT when they:

  • Link successfully to ongoing services, or
  • No longer require short-term outreach and engagement support

Discharge plans include warm handoffs and coordination with receiving programs.

Hours of Operation

  • Monday–Friday, 9:00 AM – 5:00 PM
  • Limited early evening/field coverage as needed for engagement

Service Locations

  • Field-based services throughout Alameda County
  • Office/home visits and community outreach

Staffing Requirements

Minimum staffing:

  • 3.00 FTE Mental Health Rehabilitation Specialists
  • Staff trained in:
    • Motivational Interviewing
    • Trauma-informed care
    • Crisis prevention and engagement
    • Culturally responsive outreach

Contract Deliverables

Process Objectives (Annual)

  • 3,000 hours of total service delivery
  • Serve 60 clients
  • Complete standard documentation for all encounters
  • Maintain MAA logs for all eligible activities

Quality Objectives

MeasureObjective
Client satisfaction survey: “I feel supported by IHOT staff”≥ 85%

Impact Objectives

MeasureObjective
Clients linked successfully to ongoing services≥ 70%

Reporting & Evaluation Requirements

Monthly

  • MAA logs sorted by staff and date, submitted by the 15th of each month

Quarterly Reports

QuarterDatesDue
1stJul 1 – Sept 30Oct 31
2ndOct 1 – Dec 31Jan 31
3rdJan 1 – Mar 31Apr 30
4th/AnnualJul 1 – Jun 30Jul 31

Annual Reports

  • CSS Annual Report submitted within 30 days of fiscal year end.

Additional Requirements

  • Maintain a MAA claim plan and maximize MAA revenue.
  • Provide culturally responsive, field-based outreach with a focus on engagement and stabilization.