AGENDA STAFF REPORT

Agenda Item AGENDA STAFF REPORT ASR Control 21-000948
MEETING DATE:	12/07/21
legal entity taking action:	Board of Supervisors
board of supervisors district(s):	All Districts
SUBMITTING Agency/Department:	Health Care Agency (Approved)
Department contact person(s):	Annette Mugrditchian (714) 834-5026
	Jeff Nagel (714) 834-7024

Subject: Contract for Telehealth and Digital Mental Health Support Services

ceo CONCUR

County Counsel Review

Clerk of the Board

Concur

Approved Agreement to Form

Discussion

3 Votes Board Majority

Budgeted: Yes

Current Year Cost: $1,800,000

Annual Cost: FY 2022-23 $2,700,000

Staffing Impact:

# of Positions:

Sole Source: Yes

Current Fiscal Year Revenue: N/A

Funding Source: State: 100% (Mental Health Services Act/Prop 63)	County Audit in last 3 years: No

Prior Board Action: 04/10/2018 #23

RECOMMENDED ACTION(S):

Approve the selection of and Contract with Mindstrong, Inc. for provision of telehealth and digital mental health support services for the term of January 1, 2022, through March 31, 2023, for an amount not to exceed $4,500,000.

Pursuant to Contract Policy Manual Section 3.3-114, authorize the County Procurement Officer or authorized Deputy to exercise a contingency contract cost increase, not to exceed a total of 10 percent of the Contract amount for the first year of the Contract, for the entire term of the Contract, including renewals, and within the scope of work set forth in the Contract. The use of this contingency contract cost increase is subject to approval requirements established by the County Procurement Officer.

Authorize the County Procurement Officer or authorized Deputy to execute the Contract with Mindstrong, Inc. as referenced in the Recommended Actions above.

SUMMARY:

Approval of the selection of and Contract with Mindstrong, Inc. for provision of telehealth and digital mental health support services will provide telehealth and 24-hour virtual crisis support for currently enrolled residents participating as part of the Help@Hand multi-county Innovation Project and expand services to the broader Orange County community.

BACKGROUND INFORMATION:

On April 10, 2018, your Honorable Board of Supervisors (Board) approved the use of $24 million in Mental Health Services Act (MHSA) Innovation (INN) funds and the Participation Agreement (PA) with California Mental Health Services Authority (CalMHSA) to act as the fiscal intermediary, contracting agent and project manager for the Mental Health Technology Solutions project (i.e., Help@Hand). The Health Care Agency (HCA) is requesting approval for the use of $4.5 million of the $24 million to continue and expand the use of secure telehealth services via phone, video or in-app texting, and access to 24-hour virtual crisis support to eligible residents living in Orange County.

Scope of Services:

In July 2018, CalMHSA, acting as the contracting agent on behalf of HCA, executed a contract with Mindstrong, Inc. (Mindstrong). Mindstrong is a digital mental health app through which licensed therapists, psychiatrists and/or care partners (i.e., Care Team) provide access to telehealth services via phone, video or in-app texting, and virtual 24-hour crisis support. The secure smartphone app also uses innovative and proprietary algorithms to anticipate when a person may benefit from additional support, prompting someone from the Care Team to reach out proactively and provide additional, unscheduled support before the person experiences a mental health emergency. Since October 2019, HCA and Mindstrong, engaged in extensive planning activities to implement this digital solution into the County behavioral health system. Activities included the development of an informational video, digital referral and consent processes, program and workflow integration, digital and printed outreach materials and data tracking methods. This Contract will continue services for existing Orange County consumers begun under the PA with CalMHSA and expand to additional populations, including but not limited to Orange County community college students and adults who have tested positive for COVID-19. Services will include: Mindstrong telehealth services, such as therapy, psychiatry and medication management; access to virtual urgent/crisis support 24 hours a day, seven days a week; secure in-app text messaging for on-demand support; and access to psychoeducation materials, including a personalized in-app dashboard graphing the participant's Mindstrong algorithm results. This array of services, funded by MHSA INN, are available to enrolled participants at a rate of $100 per member per month for up to 3,100 Mindstrong app licenses.

Outcomes:

In May 2020, HCA began piloting Mindstrong services at an Orange County outpatient psychiatry clinic. The initial pilot extended through December 2020 and focused on developing, troubleshooting and refining project implementation on an iterative basis to adjust the processes and requirements of multiple partners (i.e., HCA, Mindstrong, outpatient psychiatry clinic). Due to COVID-19, initial plans to engage and recruit participants on-site had to be modified to a digital approach. This resulted in the need to create additional workflows and referral processes, which further impacted the ability to increase enrollment. The table below includes referral and engagement outputs from May 26, 2020, through October 20, 2021.

Referrals and Engagement	Outputs
Total Referrals	294
Total Enrollments	223
Referral to Enrollment Conversion Rate	76%
Total Virtual Therapy Sessions	2,142
% who used virtual therapy sessions	81%
Total Virtual Urgent Sessions (i.e., crisis)	121
% after business hours and during weekends	58%
Average response time (in minutes) from request to connection	7 minutes
Number of unduplicated consumers who used urgent sessions	46
Number of urgent sessions resulting in a call to OC Crisis Assessment Team	1
Total In-App Text Messages (outside of scheduled sessions)	4,165
Average number of days/month consumers use the Mindstrong app (scheduled and urgent sessions, unscheduled/proactive outreach, review of in-app materials)	8 days/month
Proactive Clinician Outreach	~60 times/month

There is high utilization of digital mental health services accessed through the individual's smartphone as evidenced by the 223 enrolled consumers who are using Mindstrong services and the app an average of eight days per month. However, the case-by-case recruitment approach has limited the total number of referrals received and slowed overall enrollment. As such, HCA identified the need to shift to a wide-scale outreach and recruitment campaign, which will launch in December 2021. The earlier work on automating referrals and developing a digital consent process will allow the recruitment expansion to scale up quickly and increase the availability of Mindstrong mental health services to individuals at risk of developing a mental health condition, such as college students and adults who have tested positive for COVID-19.

In addition to monitoring engagement and use of Mindstrong services, an individual's level of functioning is assessed at intake and every 60 days using the Diagnostic and Statistical Manual (DSM)-5 Level 1 Symptom assessment, which assesses 13 symptom domains on a five-point scale ranging from 0 to 4, with a score of 3 or higher reflecting clinical elevation. While outcomes are typically analyzed after a consumer has been enrolled in services for six months, clinical progress among consumers who have been enrolled for at least two months (i.e., 60 or more days) are reported below as a preliminary evaluation of impact.

Of the 223 individuals enrolled, 73 (25 percent) have been enrolled for approximately two months or longer and completed a follow up DSM-5 assessment. Of these, 47 (64 percent) reported clinical elevation on one or more depression and/or anxiety symptoms. As shown in the table below, 43 percent to 58 percent of consumers who reported clinical elevation on a symptom at intake reported improvement on that symptom after enrolling in Mindstrong services, with 31 percent to 54 percent of consumers reporting clinically significant reductions and were no longer elevated at follow up. Another 25 percent to 50 percent maintained their level of functioning and did not report any worsening distress at follow up. Among those who reported worsening distress after enrolling (n=4% to 13%), Mindstrong proactively reached out to offer additional support. Notably, as reported in the table above, only one urgent session resulted in the Mindstrong Care Team calling the HCA Crisis Assessment Team, suggesting that frequent engagement with Mindstrong services, access to 24 hours a day, seven days per week virtual urgent care, and proactive outreach following a shift in clinical presentation may help prevent escalation into a psychiatric emergency necessitating an in-person intervention.

Clinical Progress Among Consumers Elevated at Intake and Enrolled for 2+ Months, by Symptom

Consumers Elevated at Intake, by Symptom	Significant Improvement at Follow up*	Some Improvement at Follow Up*	Maintaining at Follow Up*	Declining at Follow Up*
Depression Domain:
No interest/pleasure, n=30	13 (43%)	3 (10%)	10 (33%)	4 (13%)
Down/Hopeless, n=26	13 (50%)	2 (8%)	10 (38%)	1 (4%)
Anxiety Domain:
Situation /Avoidance, n=32	14 (44%)	5 (16%)	8 (25%)	5 (16%)
Nervous/Worried, n=32	10 (31%)	4 (12%)	16 (50%)	2 (6%)
Panic/Frightened, n=13	7 (54%)	0 (0%)	4 (31%)	2 (15%)

*Numbers within a row may not total to 100% due to rounding.

The Contract does not currently include subcontractors or pass through to other providers. See Attachment B for Contract Summary Form.

HCA has completed successful negotiations with Mindstrong, Inc. HCA staff have conducted due diligence on the vendor. Reference checks were satisfactory and completed with Humana, and Optum, regarding similar projects. The Orange County Preference Policy is not applicable to this Contract award.

The proposed Contract is a Sole Source Contract and a completed Sole Source Request Form is attached to this Agenda Staff Report, see Attachment C.

The contract between CalMHSA and Mindstrong, executed on behalf of HCA, will end on December 31, 2021. HCA and CalMHSA have since mutually agreed on an early termination of the PA with CalMHSA to allow for a more efficient use of project funds and to remain within the Mental Health Services Oversight and Accountability Commission (MHSOAC) approved funding amount. A sole source contract with Mindstrong will allow HCA to continue ongoing services and Help@Hand project activities. There are no other vendors with the required qualifications and historical knowledge to continue project services and facilitate plans for a large-scale expansion in the remaining time left in this time-limited INN project.

The Sole Source Contract with Mindstrong is being submitted to the Board less than 30 days prior to the start of the Contract to maintain continuity of clinical services for high need, high risk clients. Due to ongoing budget discussions between CalMHSA and HCA, the Sole Source Contract with Mindstrong was delayed until HCA was able to determine the remaining budget and identify the most efficient use of project funds. .

HCA requests that the Board approve the selection of and Contract with Mindstrong to continue telehealth services and digital mental health support, as referenced in the Recommended Actions.

FINANCIAL IMPACT:

Appropriations for this Contract are included in Budget Control 042 FY 2021-22 Budget and will be included in the budgeting process for future years.

Should services need to be reduced or terminated due to lack of funding, the Contract contains language that allows HCA to give a 30-day notice to either terminate or renegotiate the level of services to be provided. The notice will allow HCA adequate time to transition or terminate services to clients, if necessary.

STAFFING IMPACT:

N/A

ATTACHMENT(S):

Attachment A – Contract MA-042-22010649 Telehealth and Digital Mental Health Support Services
Attachment B - Contract Summary Form
Attachment C - Sole Source Form