Program Overview
Program Information
Service Team (Adult Dual Diagnosis Service Team — RU 01113)
Program Name
Service Team
Contracted Services
- Outreach & Engagement
- Mental Health Services
- Case Management / Brokerage
- Crisis Intervention
- Medication Support
- ACBHD Substitute Payee Program (Section VI requirement)
- Individual Placement Support (IPS) Supported Employment
- Client Support Expenditures (“Flex Funds”)
- Medi-Cal documentation & claiming requirements apply
Program Goals
The Service Team aims to:
- Help clients achieve autonomy within their chosen community.
- Reduce the impact of mental health symptoms on daily functioning.
- Support development of meaningful activity, education, volunteerism, or employment.
- Increase connection to natural supports and the broader community.
- Promote stability in finances and benefits.
- Assist clients in meeting basic living needs (housing, food, utilities, transportation).
- Improve overall quality of life with a recovery-oriented approach.
Target Population
Who the Program Serves
Adults (18+) with:
- Severe mental illness (SMI)
- Co-occurring substance use
- Histories of homelessness, institutionalization, or high-utilization of crisis settings
- Significant functional impairment
- Threatened loss of housing or community tenure
- Difficulty accessing or engaging in services
- Limited natural supports
Referral Sources
- ACCESS
- Mobile Crisis Teams
- ACBH contracted providers
- Hospitals & PES
- Community partners
- Family members
- Self-referral
Eligibility
Clients must:
- Be 18 or older
- Live in Alameda County
- Have serious mental illness
- Require intensive case management services
- Be unable to benefit from lower-intensity outpatient care
- Need support with community functioning, symptoms, and housing stability
Program Description
Core Service Model
The Service Team provides intensive, field-based, recovery-oriented, multidisciplinary services for adults with SMI. Services focus on:
- Symptom management
- Housing stability
- Community integration
- Skill development
- Relapse prevention
- Meaningful daily activity
- Benefits, finances & payee support
- Independent living skills
- Crisis prevention & early intervention
Services are delivered in office, home, field, and community settings.
Key Activities
- Intensive case management
- Clinical assessment & treatment planning
- Individual therapy
- Peer support
- Medication support / coordination
- Housing stabilization services
- Budgeting, benefits support & payeeship
- Substance use counseling
- Transportation assistance
- Linkage to medical, dental, and social services
- Court, APS, CPS, and landlord collaboration
- Crisis intervention
- Supported employment (IPS model)
- Collaboration with family & natural supports
Service Expectations
- Field-based contact
- Collaboration with hospitals, PES, shelters, SNFs, and community systems
- Client-centered care plans with measurable objectives
- Use of evidence-based models (MI, Harm Reduction, etc.)
- Warm handoffs & coordination across systems
Hours of Operation
Monday–Friday, 9:00 AM – 5:00 PM
(After-hours by phone as clinically needed)
Service Location
Primary Office:
- 1909 University Ave., Berkeley, CA 94704
- Field-based services across Alameda County
Staffing Requirements
Minimum staffing includes:
- Program Manager
- Clinicians (LMFT, LCSW, ASW, AMFT)
- Peer Specialists
- Case Managers
- RN or medical coordination support
- IPS Employment Specialist
- Administrative / Payee Support Staff
Must maintain appropriate supervision and licensure coverage.
Contract Deliverables
Annual Process Objectives
- Provide intensive case management to the contracted caseload
- Provide IPS-model supported employment
- Support payeeship cases as required
- Complete all documentation to Medi-Cal standards
- Maintain contact standards (field-based, office-based, collateral)
- Participate in ACBH quality improvement and outcomes reporting
Quality Objectives
| Measure | Objective |
|---|---|
| % of clients who agree “I like the services I received here” | ≥ 85% |
| % of clients with improved functioning in daily life | ≥ 50% |
Reporting & Evaluation Requirements
Monthly
- Service logs & Medi-Cal documentation
- Housing status updates
- Payeeship reports
- IPS employment data
Quarterly
- Outcomes reports
- Caseload summaries
- Client progress indicators
Annual
- CSS MHSA Annual Report
- Evaluation metrics
- Staffing & fidelity documentation (IPS)
Additional Requirements
Payeeship Duties
Program must:
- Administer benefits according to ACBHD guidelines
- Maintain documented budgets
- Issue client funds safely and consistently
- Protect assets and meet federal representative payee requirements
IPS Supported Employment
Contractor must:
- Maintain fidelity to IPS model
- Offer rapid job search
- Provide individualized employment planning
- Coordinate with employers and vocational partners
Coordination
Must collaborate with:
- ACBH
- City and County agencies
- Healthcare providers
- PES, hospitals, shelters
- Courts, APS, CPS
- Landlords and housing entities
Discharge Criteria
Client may be discharged when:
- They are stable enough for lower-intensity services
- They move out of county
- They request transfer/referral
- They discontinue participation
- They require a higher level of care