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1 Services to be Provided

Services will be provided by culturally competent, compassionate staff committed to empowering each tenant to live their full potential. All services are flexible and responsive to the individual needs of the tenants and the community. Culturally specific and linguistically appropriate services are provided, beginning with pre-screening and the lease-up process. Services will be provided both on and off-site, depending on the nature of the service.

1.1  Case (Care) Management and Services Coordination

For each MHP participant, a comprehensive, client-driven case plan will be developed with both short- and long-term goals defined. A timeline and measures for each goal will be developed and weekly sessions with clients will be scheduled. Clients will be empowered and encouraged to become involved in their own planning and goal setting. Case plans will be evaluated and adjusted as needed. Written evaluations will be made of satisfactory progress in not being achieved by the MHP participant. Participants will be referred to appropriate resources to help them meet their goals.

Care management will work by collaborating and communicating with the member, doctors, specialists, family members and any necessary supportive and community services like transportation, legal aid, and any other support mechanism required to stabilize our residents’ medical conditions. This will be accomplished

We will provide the following direct services:

• If multiple health conditions exist, a care plan will be developed
• We will work with Clinicas del Camino Real to ensure that you understand the care you require, if multiple health conditions exist
• We will work with the resident to avoid emergency room visits
• We will ensure that you have access to Clinicas which is 2.6 miles from our property
• Work with the patient to review all medications, frequency, dosages, and any potential interactions
• Assist with navigating the health care system to ensure that our residents connect with their plan benefits and the local resources available to them

Additionally, in the event of a Mental Health Crisis, our residents will be able to access the Ventura County Behavioral Health Access & Crisis Team 24/7 at 1-866-998-2243.

For 24/7 Access to Substance Use services, our residents will be able to access the Ventura County Behavioral Health Substance Use Treatment Services Toll-free Access Line at 1-844-385-9200.

Lastly, Clinicas del Camino Real will partner with us in the provision of Telehealth Services by dialing 1-(866) 885-7900 when our residents are ready to schedule.

We will assist all our residents in navigating through these various programs to assist with any type of Care Management.

1.2 Medi-Cal Enrollment Assistance

The Case Manager will assist Participants in enrolling in Medi-Cal and other benefits for which they may be eligible. While it may appear to be an easy process, it can be extremely difficult for many to navigate through this system.  As a community partner in Ventura County, we are in the process of registering as a Community Based Organization in Ventura County, which will allow us to submit applications on behalf of a client.  This process can be a daunting task especially given the amount of information that is required proof of:  Social Security Number, California Residency, Age, Income, Citizenship or legal resident status, Number of people in your household and tax filing status evidence of other health coverage, if applicable. Households with a child and an absent parent, will be asked to cooperate with the Dept. of Child Support Services for Medical support, as needed.  In addition, we will work with the undocumented residents who are unable to provide proof of citizenship or legal resident status to qualify for restricted Medi-Cal to cover both pregnancy and/or emergency services. We are also aware of new changing legislation in the “Full-Scope Medi-Cal for All Children.” Under this new California law, that was implemented in May 2016, children under 19 years of age are eligible for full-scope Medi-Cal benefits regardless of immigration status, as long as they meet all other eligibility requirements.  Therefore, we will not only assist, but also inform, and provide training to our staff to access social and human services for our residents.

1.3 Peer Support Activities

CEDC Support Services staff will provide peer support group activities to MHP residents.  All staff providing such services will be trained in leading peer support groups.  Types of peer support groups will be established based upon residents’ needs.

Cabrillo believes strongly that Peer Support in the broadest of terms, is an evidence-based practice.  Peer Support is when two or more people that have similar experience of extreme states gather to learn, share, support and grow together. Peers do this through a combination of skills, knowledge, and personal experience.

Peer support workers are people who have been successful in the recovery process who help others experiencing similar situations. Through shared understanding, respect, and mutual empowerment, peer support workers help people become and stay engaged in the recovery process and reduce the likelihood of relapse. Peer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking a successful, sustained recovery process.

We have learned that peer support, especially for individuals with mental health conditions or challenges, utilize peer support lowers the overall cost of mental health services by reducing re-hospitalization rates and days spent in inpatient services, increasing the use of outpatient services. Peer support not only improves their quality of life, but increases and improves engagement with services, and increases whole health and self-management.

We will be working closely with the Ventura County Human Services Agency, Ventura County Behavioral Health, among others, to establish peer group training to cover the following:

• The Recovery Model
• Harm Reduction
• Motivational Interviewing
• Group Facilitation
• WRAP (Wellness Recovery Action Planning)
• Mental Health First Aid
• Effective Peer Support
• Trauma Informed Care
• Crisis Management
• Peer Support Guidelines
• Empathic Listening
• Employment Services
• Core Gift (the discovery and uncovering of one’s purpose).
• HOP (Being Honest, Open, Proud—The intentional, effective sharing of one’s lived experience)

1.4 Behavioral Health Care

The Case Manager will work to identify and advocate for the provision of mental health services by the County or other licensed care providers on behalf of the MHP Participant. To this end, we will be in partnership with the Ventura County Behavioral Health (VCBH) Department, which offers services for people looking for help for mental health and substance use issues.

At Cabrillo, taking care of one’s mental health is as important as taking care of your physical health. Mental illness can affect anyone, regardless of their cultural background, level of education, age, or income. Mental health problems can include a myriad of symptoms, many of which can debilitate and cause immobility; conditions include depression, anxiety, and other serious mental disorders. Having a mental illness is not a matter of personal choice or weakness, but usually caused by an imbalance of chemicals in the brain.  Science has also informed us that mental illness can be inherited, caused by emotional or physical stress, or a combination of these. Thankfully, mental health problems are diagnosable, treatable conditions.

VCBH provides a continuum of care for substance use disorder treatment services, offering individuals with services to help with the process of recovery from substance use disorders.

VCBH can provide services to include a mobile crisis response team, outpatient treatment services, substance use services, etc. Access to Primary Care

MHP Participants will receive support in linking to primary care services, including access to routine preventative health and dental care, medication management, and wellness services.

CEDC Staff will be a tremendous resource to our residents by providing guidance on the following topics:

• Resources to Help with Interpretation of Public Charge Rule
• Important Information about Preventative Care Services
• Doctors and Dentists Accepting Medi-Cal
• Vision Care Providers Accepting Medi-Cal
• Pharmacies Accepting Medi-Cal
• Long-Term Care Alternatives
• COBRA Information
• Prescription Discount Card
• Helpful Links & Information for Community Resources
• Covered California
• Timely Access to Care in English & Spanish

1.5 Benefits Counseling and Advocacy

MHP Participants will receive benefits counsel, advocacy, and support in obtaining primary physical and dental health care, including access to routine and preventative care, medication management, and wellness services. The Case Manager will work to obtain permission of the Participant to advocate for them to receive Medi-Cal health care services for local or regional providers of the resident’s choice. The Case Manager will help the Resident to schedule appointments and review follow-up instructions from the visit.

Staff will enroll in “My Benefits CalWIN” to assist residents with the be a tremendous resource to our residents by providing guidance on the following topics:

• Resources to Help with Interpretation of Public Charge Rule
• Important Information about Preventative Care Services
• Doctors and Dentists Accepting Medi-Cal
• Vision Care Providers Accepting Medi-Cal
• Pharmacies Accepting Medi-Cal
• Long-Term Care Alternatives
• COBRA Information
• Prescription Discount Card
• Helpful Links & Information for Community Resources
• Covered California
• Timely Access to Care in English & Spanish

1.6 Basic Housing Retention Skills Training

Training offered to residents will include such matters as unit maintenance, budgeting and paying bills, working with a landlord, having a good relationship with neighbors.  The training is intended to improve housing retention and quality of life for the residents and the community.

Cabrillo currently administers 11 VASH Vouchers at one of our properties.  We understand this program and recognize that it is the nation’s largest supported housing initiative.  Yet, 25% of HUD-VASH participants exit the program, often returning to homelessness.  We also understand the social skills are an important determinant of premature exists from permanent supportive housing.   What understand that our RCS (Resident and Community Services) Team and the Ventura County Behavioral Health must work in tandem to support our residents in the provision of training in communication, as well as instrumental activities of living (e.g., money management, budgeting, working with the property owner (Cabrillo), to improve and enhance their quality of life.  We provide personal well-checks and as needed, will enlist the help of their social work for illness self-management (e.g., medication adherence).  Since the inception of our property management line of business, we have worked with our residents to ensure housing stability and quality of life for all residents of the Cabrillo Communities.

The origins of our training modules date back to the beginning since many of our farmworker families came to live at our properties without knowledge or experience with running water, toilets, use of washing machines and dryers.  We had to provide instruction and education in a culturally and socially sensitive manner in Spanish so that they could familiarize themselves with budgeting, paying their bills, and building community with their neighbors. This is an area that Cabrillo is very familiar with and will utilize our vast experience to support and enhance our MHP residents.

1.7 Co-Occurring Disabilities and Disorders

MHP Participants with co-occurring mental and physical disabilities or co-occurring mental and substance use disorders will receive access to counseling and support, and aid with access to services.

For most mental health professionals, the term “dual diagnosis” is used to describe people who have a mental illness and a substance use disorder. However, we have recently encountered residents that can also exhibit co-occurring intellectual and developmental disabilities (IDD), and a mental illness, with or without a substance abuse disorder. As a result, we have found that few professionals are trained in this specialty or are aware of how frequently these conditions can coexist.

These individuals are often ostracized and have few, if any, social networks of support.  Sadly, an additional layer of complication (factor) may also exist, i.e., cultural or linguistic barriers.  We have enlisted the County Behavioral Health and found that this limitation makes it difficult or impossible for some residents to describe their own experiences accurately to the clinician.  Some may lack the words to express their feelings, or their perceptions.

To assist us with serving these populations, we have traditionally partnered with not only the County Behavioral Health but have also partnered with the following organization to assist us.

The Independent Living Resource Center (ILRC) is housed here in our Corporate Offices.  It is a private non-profit organization providing disability advocacy and independence increasing or maintaining services to Ventura, Santa Barbara, and San Luis Obispo Counties. They provide this support to individuals with all disabilities, all ages, and all income levels. Following the Independent Living Philosophy, their services are team-based; their consumers are active participants in achieving their goals toward independent living.  ILRC offers the following services:

• Housing
• Personal Assistant
• ASL Interpreting Services
• Peer Support
• Assistive Technology
• Youth Transition
• Older Individuals (over 55) who are Blind (OIB)

ILRC also has a partnership with a core partner, the Ventura County Area Agency on Aging (VCAAA) and countywide extended partners, ILRC is a California designated ADRC.  The goal of the ADRC’s is to bridge the gap between services for individuals with disabilities and older adults. Our partnerships provide increased services to assist in making informed decisions about short or long–term care needs, and to help our residents make a plan to be able to live as they wish in the community.

It should be noted that Cabrillo has an existing Agreement with Tri-Counties Regional Center (TCRC) to serve some of our residents at one of our senior properties.  TCRC’s mission is to provide person and family centered planning, services and supports for individuals with developmental disabilities to maximize opportunities and choices for living, working, learning, and recreating in the community.  Their vision is to support persons with developmental disabilities live fully and safely as active and independent members of their community.  They offer an array of services, counseling, and support to our residents at one of our properties and will do the same in Ojai.

1.8 Recreational and Social Activities

CEDC Supportive Services staff, working with the onsite property manager, will work to devise weekly programs and publish calendars of social and recreational activities for the MHP participants and other residents. The programs and activities will be offered on days of the week and at times that best suit the needs of the residents. Based upon feedback from the residents, staff will shape the programs and offer reading materials, tools, furnishing and equipment as appropriate to encourage active participation by all residents.

In addition to on-site activities, the Support Services staff will support residents accessing services off site. Staff will also support in finding and accessing community activities of interest, such as public events, faith communities and peer associations. Support will include aiding with arranging transportation.

1.9 Educational Services

Adult education classes will be offered free of charge to residents. Classes may include, but not limited to ESL, Budgeting and Money Matters, Fraud Prevention, Physical Stability Training for Seniors, Healthy Cooking, Emergency Preparedness, and other activities.

Cabrillo will assist its residents to work with the Adult Continuing Education Program in Ojai to complete coursework for ESL, GED Preparation, or Basic Computer and Technology Training. The Adult Diploma can be attained by students the majority of their work at home with teachers’ accessibility twice per week.  It’s a rolling open enrollment, and registration will be facilitated by Cabrillo staff.

Other classes for example in fraud prevention, and Healthy Cooking Classes are typically done by Cooperative Extension and other resources that we have identified in the community.  It is part of our “Speaker Forum.”

Lastly, Cabrillo is in partnership with the California State University of Chanell Islands, and they offer virtual learning for adults through their Osher Lifelong Learning Institute.  Their education is aimed at adults offering intellectually stimulating six-week college-level courses on a variety of topics without the burden of homework, tests, or grades. Right now, the classes that are being offered include: Rockin’ and a Rollin’ – The Earth is Shaking; The American Dream: The History and Future of an Idea; Seedy Secrets of Ancient Gardens: Culture and Horticulture in Rome, etc. Access to Other Needed Services

Assistance to other needed services that may arise will be provided. These could include civil legal services, translation services, food, clothing, or other basic needs.

Meeting the basic needs of our residents has been the hallmark of our property management company.  We offer a full array of services at many properties in our portfolio.  We will work with Help of Ojai, to establish an on-site Food Pantry.  We already partner with Food Share to distribute food at many of our properties in our portfolio.  In addition, the following Ojai and Ventura-based organizations also distribute food and clothing in Ojai:

• First Baptist Church
• St. Thomas Aquinas/St. Vincent de Paul
• Lighthouse-Oakview
• Iglesia Nueva Esperanza en Cristo/Springs of Life Baptist Church
• Temple Beth Torah
• Westpark Community Center
• Community
• Catholic Charities

In terms of pro-bono legal services, Cabrillo is committed to providing the resources listed below.  If accessibility is a problem, Cabrillo will make arrangements for either an on-site clinic in the evening, or will provide transportation to access these services, as needed.  The following entities offer specialized services, in the following:

• AIDS Care Legal Clinic (Bankruptcy, Civil Rights, Consumer and Estate Planning)
• Grey Law of Ventura County (Elder Abuse, Elder Matters)
• Ventura County Legal Aid, Inc. (Collections, Family, Immigration and Landlord Tenant)
• Self-Help Legal Access Center (Criminal, Divorce, Family and Juvenile