HomeMy WebLinkAboutAgreement A-26-025 Amendment No 1. to Agreement No. 24-592.pdf Agreement No. 26-025
1 AMENDMENT NO. 1 TO SERVICE AGREEMENT
2 This Amendment No. 1 to Agreement No. A-24-592 is dated January 6, 2026
3 and is between each Contractor listed in Exhibit A "List of Contractor(s)" ("Contractor(s)"), and
4 the County of Fresno, a political subdivision of the State of California ("County").
5 Recitals
6 A. On November 5, 2024, the County and the Contractors entered into Master Agreement
7 for Wraparound and Super Wraparound services which is County agreement number A-24-592
8 ("Agreement"), to provide Senate Bill (SB) 163 wraparound services to eligible children and their
9 families involved in the Child Welfare Services (CWS) and Probation systems as well as Super
10 Wraparound services to high acuity foster youth who require intensive support through their
11 involvement in the County's Children's Well-Being Continuum; and
12 B. On July 8, 2025, the California Department of Social Services (CDSS) has issued All
13 County Letter (ACL) 25-47, which implements Part IV of the federal Family First Prevention
14 Services Act (FFPSA). ACL 25-47 requires counties to utilize California's High Fidelity
15 Wraparound (HFW) model when providing aftercare services for youth and families transitioning
16 from congregate care or other intensive service settings; and
17 C. In order to comply with this new mandate, the County must align the scope of services in
18 Agreement A-24-592 with the State's HFW model requirements for wraparound services. This
19 alignment ensures fidelity to the model's family-centered, team-based, and strengths-driven
20 approach, and supports improved outcomes for youth with complex needs; and
21 D. The County and the Contractors now desire to amend the Agreement to revise Exhibit B,
22 Scope of Services, so that the Agreement is consistent with ACL 25-47 and the FFPSA Part IV
23 requirements, and to ensure all services provided under this Agreement reflect the HFW model.
24 The parties therefore agree as follows:
25 1. Exhibit B-1, Scope of Services, is deleted in its entirety and replaced with a Revised
26 Exhibit B-1. All references to Exhibit B-1 shall be renamed to Revised Exhibit B-1.
27 2. Exhibit B-2, Scope of Services, is deleted in its entirety and replaced with a revised
28 Exhibit B-2. All references to Exhibit B-2 shall be renamed to Revised Exhibit B-2.
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1 3. Section 4, "Compensation, Invoices, and Payments", of the Agreement located at line
2 nineteen (19) on page eight (8) is amended to add the following after the end of the section:
3 "4.18 Fresno County Wraparound Flex Fund Policy. All expenditures of
4 flexible funds under this Agreement shall comply with the Flex Fund Policy
5 attached hereto and incorporated herein as Exhibit T, "Fresno County
6 Wraparound Flex Fund Policy."
7 4. Section 12, "Assurances", of the Agreement located at line eleven (11) on page twenty-
8 seven (27) is amended to add the following after the end of the section:
9 "12.2 Certification of Compliance with Wraparound Standards
10 (A) In entering into this Agreement, Contractor(s) certifies that it has
11 obtained, and shall maintain throughout the term of this Agreement, certification
12 by the State of California as an authorized Wraparound provider. Contractor(s)
13 further certifies that it will comply with all applicable High Fidelity Wraparound
14 (HFW) standards, fidelity requirements, practice guidelines, and quality
15 assurance protocols established by the State.
16 (B) Contractor(s) shall complete all re-certification processes required by the
17 State to maintain its Wraparound certification.
18 (C) Failure to obtain or maintain such certification, or failure to comply with
19 Wraparound standards, shall render the provisions of this Agreement null and
20 void and may result in the immediate suspension or termination of this
21 Agreement at the sole discretion of the County."
22 5. When both parties have signed this Amendment No. 1, the Agreement, and this
23 Amendment No. 1 together constitute the Agreement.
24 6. The Contractor represents and warrants to the County that:
25 a. The Contractor is duly authorized and empowered to sign and perform its obligations
26 under this Amendment.
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1 b. The individual signing this Amendment on behalf of the Contractor is duly authorized
2 to do so and his or her signature on this Amendment legally binds the Contractor to
3 the terms of this Amendment.
4 7. The parties agree that this Amendment may be executed by electronic signature as
5 provided in this section.
6 a. An "electronic signature" means any symbol or process intended by an individual
7 signing this Amendment to represent their signature, including but not limited to (1) a
8 digital signature; (2) a faxed version of an original handwritten signature; or (3) an
9 electronically scanned and transmitted (for example by PDF document) version of an
10 original handwritten signature.
11 b. Each electronic signature affixed or attached to this Amendment (1) is deemed
12 equivalent to a valid original handwritten signature of the person signing this
13 Amendment for all purposes, including but not limited to evidentiary proof in any
14 administrative or judicial proceeding, and (2) has the same force and effect as the
15 valid original handwritten signature of that person.
16 c. The provisions of this section satisfy the requirements of Civil Code section 1633.5,
17 subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3, Part
18 2, Title 2.5, beginning with section 1633.1).
19 d. Each party using a digital signature represents that it has undertaken and satisfied
20 the requirements of Government Code section 16.5, subdivision (a), paragraphs (1)
21 through (5), and agrees that each other party may rely upon that representation.
22 e. This Amendment is not conditioned upon the parties conducting the transactions
23 under it by electronic means and either party may sign this Amendment with an
24 original handwritten signature.
25 8. This Amendment may be signed in counterparts, each of which is an original, and all of
26 which together constitute this Amendment.
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1 9. The Agreement as amended by this Amendment No. 1 is ratified and continued. All
2 provisions of the Agreement and not amended by this Amendment No. 1 remain in full force and
3 effect.
4 [SIGNATURE PAGES FOLLOW)
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1 The parties are signing this Amendment No. 1 on the date stated in the introductory
2 clause.
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COUNTY OF FRESNO
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6 Garry BrWefeld, Chairman of the Board of
Supervisors of the County of Fresno
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Attest:
8 Bernice E. Seidel
Clerk of the Board of Supervisors
9 County of Fresno, State of California
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By:
11 Deputy
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13 For accounting use only:
14 Org No.: 56107480
Account No.: 7870
15 Fund No.: 0001
Subclass No.: 10000
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Please see additional
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Docusign Envelope ID:56BD5BB6-39A4-4D4C-BB35-9E27F9100AB7
1 Aspiranet, Inc.
2 DocuSigned by:
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Vernon Brown, CEO
4
90 W. Ashlan Ave, Suite 100
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Clovis, CA 93612
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Signed by:
8 E
4-0-
dQRF55QF54f'R4A4
9 Ann Domingo, CFO
10 90 W. Ashlan Ave, Suite 100
11 Clovis, CA 93612
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13 For accounting use only:
14 Org No.: 56107666
Account No.: 7870
15 Fund No.: 0001
Subclass No.: 10000
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signature page attached.
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I Central Star Behavioral Health
2 /dent DM4 -111a'°
Kent Dunlap(Dec 1,2025 1:39:21 PST)
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Kent Dunlap, CEO
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1501 Hughes Way, Suite 150
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Long Beach, CA 90810
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9 Olivia Aranda, Vice President/CFO
10 1501 Hughes Way, Suite 150
11 Long Beach, CA 90810
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13 For accounting use only:
14 Org No.: 56107665
Account No.: 7870
15 Fund No.: 0001
Subclass No.: 10000
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Revised Exhibit B-1
SCOPE OF SERVICES
ORGANIZATION: Aspiranet, Inc.
ADDRESS: 90 W. Ashlan Ave, Suite 100
Clovis, CA 93612
SERVICES: Senate Bill 163 Wraparound and Super Wraparound Services
TELEPHONE: 209-669-2577, ext. 2323
CONTACT: Sharon Lawicki, Division Director
EMAIL: slawicki@aspiranet.org
CONTRACT PERIOD: Upon execution - June 30, 2027 with two (2) optional one-year
extensions
Year 1: Upon execution —June 30, 2025
Year 2: July 1, 2025 —June 30, 2026
Year 3: July 1, 2026 —June 30, 2027
Year 4: July 1, 2027 —June 30, 2028
Year 5: July 1, 2028 —June 30, 2029
(. BACKGROUND
The California Department of Social Services (CDSS) describes Wraparound as a strengths-
based planning process that occurs in a team setting to engage with children, youth, and their
families. Wraparound shifts focus away from a traditional service-driven, problem-based
approach to care and instead follows a strengths-based, needs-driven approach. The intent is to
build on individual and family strengths to help families achieve positive goals and improve well-
being. Wraparound is also a team-driven process. From the start, a child and family team (CFT)
is formed and works directly with the family as they identify their own needs and strengths. The
team develops a service plan that describes specific strategies for meeting the needs identified
by the family. The service plan is individualized, with strategies that reflect the youth and
family's culture and preferences. California Wraparound is intended to allow youth to live and
grow up in a safe, stable, permanent family environment with access to formal and natural
supports, tribes when applicable, and services consistent with the High Fidelity Wraparound
(HFW) model.
The Fresno County Children's Wellbeing Continuum (CWBC) is designed to offer a seamless
service delivery model across multiple service levels and settings for Fresno youth with complex
behavioral and emotional needs. The Wraparound program will have a key role in ensuring
consistency as the youth moves through the continuum.
B-1-1
Revised Exhibit B-1
II. PROGRAM GOALS AND OUTCOMES
Wraparound services in Fresno County are designed to provide individualized and
comprehensive supports that reflect true partnership with families and full adherence to the
HFW values, principles, and fidelity indicators. Services aim to achieve permanent placement in
safe and stable family-based settings, decrease behaviors that may lead to out-of-home
placement, and support families in meeting their needs and vision for a better future.
The program also seeks to promote equitable access, cultural responsiveness, cost-effective,
successful outcomes across multiple life domains while increasing family social supports and
resources.
This Scope of Services is based on the current understanding of the needs of Fresno County
(County) youth and the initial conceptualization of program design to best meet the needs of
youth. The County and Aspiranet, Inc. (Contractor) acknowledge that circumstances may arise
that necessitate adjustments to the program design. In such cases, both parties agree to work
together in good faith to review and, if necessary, revise this Scope of Services provided that
any modifications remain consistent with HFW Standards, including fidelity indicators and State
and County requirements.
Any changes to this Scope of Services shall be documented in writing and agreed upon by both
parties. These changes may include additions, deletions, or modifications to the services
originally agreed upon, so long as they maintain alignment with HFW principles, phases, and
required fidelity monitoring processes. Any adjustments to this Scope of Services may have an
impact on the project timeline and deliverables, which will be discussed and agreed upon by
both parties before implementation.
III. TARGET POPULATION
Youth considered eligible for Wraparound will meet the following criteria:
1. Must be California Welfare and Institutions Code (WIC) 300, 601, 602; and
2. Currently placed in, at risk of being placed in, or recently discharged from a Qualified
Residential Treatment Program (QRTP), a licensed Short-Term Residential Therapeutic
Program (STRTP) or otherwise determined at risk of congregate care placement through
a CFT;
3. Must be approved for Wraparound through the Interagency Placement Committee (IPC)
and/or Enhanced Interagency Placement Committee (E-IPC) process.
4. Must be receiving services through Fresno County or be eligible to receive services in
Fresno County through presumptive transfer in accordance with Assembly Bill No. 1299
and Assembly Bill 1051. Presumptive transfer only transfers Medi-Cal benefits; selected
provider(s) will be expected to contract directly with the youth's county of origin.
5. Youth considered eligible for Super Wraparound will meet the following criteria:
1. Must be California Welfare and Institutions Code (WIC) 300, 601, 602; and
B-1-2
Revised Exhibit B-1
2. Currently placed, or at risk of being placed, in a licensed STRTP; and
3. Must be receiving services through Fresno County and/or be eligible for Fresno County
Medi-Cal; and
4. Must be identified as eligible to receive Super Wrap services through the Children's
Well-Being Continuum enrollment process, including approval by IPC and/or E-IPC, to
meet the following criteria, but not limited to:
a) Requires enhanced level of service, care coordination and support beyond
traditional Wrap due to more acute and urgent needs.
b) The child or family demonstrates a need for more robust support across multiple
areas, such as crisis stabilization or intensive mental health services.
IV. LOCATION OF SERVICES
Services will be provided at Contractor's clinic site, in the community, at home and education
locations, whichever is most comfortable for the youth and family. Services must be family-
driven, community-based, and culturally responsive.
Contractor must also be capable of offering services through telehealth-phone and telehealth-
video, when clinically appropriate or when access barriers (e.g., transportation, safety,
geography) prevent in-person participation. Telehealth services must meet all State and County
requirements for confidentiality, accessibility, and informed consent.
V. HOURS OF OPERATION
Contractors' office(s) shall be open Monday through Friday, 8:00 a.m. to 5:00 p.m., with
services available on evenings and weekends, if required to meet the unique needs of the youth
and family. Scheduling shall prioritize family convenience and accessibility, including
accommodations for cultural, linguistic, and disability-related needs. At least fifty percent (50%)
of services will be provided in the community and shall be scheduled on days and times that are
convenient for the families, including evenings and weekends, consistent with the HFW
requirement that services occur in the most natural and supportive environments.
Youth/families also have access to on-call crisis support twenty-four hours a day, seven days a
week (24/7). The Contractor's on-call worker, in consultation with a supervisor and Fresno
County CWS Supervisor if needed, will determine the level of support needed to address the
crisis. Support ranges from telephone support and coaching to an immediate in-person
response by staff.
For crisis services, the telephonic response time is 10 minutes or less and the in-person
response time for an emergency is 30 minutes or less; staff are required to respond in-person
when the Persons Served identify an urgent need. Crisis services must be trauma-informed,
culturally responsive, and coordinated with other County and State crisis systems (e.g., Family
Urgent Response Service (FURS), mobile crisis, 911, inpatient psychiatric services) as clinically
indicated.
VI. DESCRIPTION OF SERVICES - CONTRACTOR RESPONSIBILITIES
B-1-3
Revised Exhibit B-1
All services in this section shall be delivered in alignment with UC Davis HFW Standards,
including fidelity indicators and the four HFW phases (Engagement, Plan Development,
Implementation, Transition). Services must be family-driven, youth-guided, needs-driven,
culturally and linguistically responsive, and accessible to youth with disabilities. Contractor shall
provide a level of service and support that will reflect each youth's unique and individual needs.
A. Specialty Mental Health Services
1. Specialty Mental Health Services (SMHS) shall meet all MHP documentation, medical
necessity, and claiming standards. Contractor shall provide the following services to all
youth in the program. Services will include but are not limited to the following:
i. Provide support to the youth's family and other members of the youth's social
network to help them manage the symptoms and illness of the youth and reduce
the level of family and social stress associated with the illness;
ii. Make appropriate referrals and linkages to services that are beyond that of
Contractor's services under this Agreement, or as appropriate when
discharging/transitioning a youth from the program;
iii. Coordinate services with any other community mental health and non-mental
health providers as well as other medical professionals including behavioral health
programs for Indian children.
iv. Assist youth/family with accessing all entitlements or benefits for which they are
eligible (i.e., Medi-Cal, SSI, Section 8 vouchers, etc.);
v. Develop and Identify family support. Involvement whenever possible to engage
with natural support early
vi. Refer youth/family to supported education and employment opportunities, as
appropriate;
vii. Provide or link to transportation services when it is critical to initially access a
support service or gain entitlements or benefits;
viii. Provide peer support activities, as appropriate; and
ix. Ensure language access (interpreter/translation) and disability accommodations
for all contacts (in-person and telehealth), and obtain informed consent consistent
with State/County policy.
2. Contractor shall deliver a comprehensive Specialty Mental Health program. Behavioral
Health services include, but are not limited to:
i. Assessment;
ii. Treatment or care planning/goal setting;
iii. Pediatric Symptom Checklist (PSC) 35 and the clinically appropriate version of the
Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS)
assessment;
iv. Individual therapy;
B-1-4
Revised Exhibit B-1
v. Group therapy;
vi. Family therapy;
vii. Case management;
viii. Consultation;
ix. Medication support services;
x. Hospitalization/Post Hospitalization Support;
A. Certified Peer Support Services; and
xii. Intensive Home-Based Services (IHBS), as appropriate.
3. Contractor will ensure that all services:
i. Are determined in collaboration with youth and family and reflect the voice, choice,
and cultural practices;
ii. Be values-driven, strengths-based, individual-driven, trauma-informed and co-
occurring capable;
iii. Be culturally and linguistically competent;
iv. Be age, culture, gender, and language appropriate; and
v. Include accommodations for youth with physical disability(ies).
4. Methods for service coordination and communication between program and other service
providers shall be developed and implemented consistent with Fresno County Mental
Health Plan (MHP) confidentiality rules.
5. Contractor shall maintain up-to-date caseload records of all youth enrolled in services, and
provide individual, programmatic, and other demographic information to County as
requested.
6. Contractor shall ensure billable Specialty Mental Health Services meet any/all County,
State, Federal regulations including any utilization review and quality assurance standards
and provide all pertinent and appropriate information in a timely manner to Fresno County
Department of Behavioral Health (DBH) for the purpose of billing Medi-Cal for services
rendered.
7. Staffing should be appropriate for services needed by the youth and family, and shall
include a Wraparound trained clinician, Wraparound coach, Family Specialist, Facilitator,
Parent Partner, and Youth Peer Partner. Wraparound Role Descriptions (ca.gov)
B. SB 163 Wraparound (Wrap)
1. Contractor shall provide Wraparound services for up to fifty (50) youth at any given time,
with Wrap team caseload size of eight (8) to twelve (12) youth per team. Services shall be
family driven, youth-guided, highly coordinated, individualized, trauma-informed,
unconditional, and assist youth and families in addressing identified needs consistent with
the HFW Standards.
B-1-5
Revised Exhibit B-1
2. Contractor shall ensure that at least one staff person is available by phone and in person,
if needed, 24 hours per day, 7 days per week during the service period to provide support
and services to youth and their Caregivers on request.
3. Contractor shall provide services based on the ten (10) foundational principles of
Wraparound:
i. Family voice and choice
ii. Team-based
iii. Natural supports
iv. Collaborative
v. Community-based
vi. Culturally competent
vii. Individualized
viii. Strengths-based
ix. Persistence
x. Outcome-based
4. Ensure that each Wrap team provides four (4) phases of effective Wrap care coordination
and supportive services, including:
i. Engagement:
1. Within 24 hours of receiving the referral, Facilitator or Parent Partner
shall make voice-to-voice contact with the referral source and
Caregiver to clarify the reason for the referral, ascertain any
permanency plans for foster/probation youth, determine the referral
source's anticipated outcomes, and to explain the Wrap process.
2. At the start of Wrap and Super Wrap services, the HFW team shall
provide a comprehensive orientation to the youth and family, which
shall be documented in the case record and revisited as needed to
ensure continued clarity for the youth, family, and team members.
Orientation ensures that all participants understand the HFW process
and their role within it. At minimum, the orientation shall include:
a. Overview of the HFW principles and phases so that youth and
families understand the foundation of services and what to
expect over time.
b. Legal and ethical considerations, including confidentiality limits
and mandated reporter obligations.
c. Roles of all team members, including the youth and family
themselves, formal team members, natural supports, and
Tribes in the case of an Indian child.
d. Expectations for participation, including how the family's voice
and choice will guide service planning and implementation.
3. Within 72 hours of receiving the referral, Facilitator, Support
Counselor, and Family Partner, as needed, engage in a face-to-face
meeting with the Person Served and Caregiver to clarify expectations,
explain the role and principles of Wrap, discuss the overall timeline,
review family culture, values, and traditions, and begin to explore
B-1-6
Revised Exhibit B-1
strengths, needs, and vision for the future using UC Davis HFW
engagement tools and fidelity indicators.
4. Within 48 hours of the initial meeting, Facilitator, Support Counselor,
and Family Partner, as needed, meet with Person Served and
caregiver to briefly identify or re-state referral areas of concern,
explain the obligations of Wrap Team members as mandated
reporters, identify any safety concerns, and develop an Initial Safety
Plan as necessary. Engagement efforts shall also ensure that natural
supports, cultural representatives, and Tribes (when applicable) are
invited early into the process, in alignment with HFW practice
standards.
5. Youth referred to this program may have a current mental health
assessment with their primary treatment provider. If that assessment
was completed within the last six months and there have been no
significant changes in the youth's symptoms, the Contractor shall
obtain a copy of that assessment and use it to inform treatment
planning. If there is no current mental health assessment, the youth's
symptoms have changed significantly, and/or the previous
assessment was completed longer than six months ago, the
Contractor shall complete a mental health assessment within 14
calendar days or as soon as clinically appropriate.
6. Each youth in Wrap and Super Wrap shall have access to an
individual and/or family therapist utilizing evidence-based practices
(e.g., Motivational Interviewing, Cognitive Behavioral Therapy (CBT),
Dialectical Behavioral Therapy (DBT), and Internal Family Systems
(IFS)) to address relational and attachment trauma. Youth may
continue with an existing mental health provider, in which case the
Wrap/Super Wrap therapist will collaborate and provide consultation
to the team to ensure coordinated services. Service frequency shall
be at least one (1) contact per week for Wrap and two (2) contacts per
week for Super Wrap, as clinically appropriate. In addition, a
psychiatrist shall provide evaluation, assessment, and ongoing
support for psychotropic medication management, clinical
consultation, and linkage to psychiatric services, prioritizing continuity
of care.
7. Contractor will ensure staff are trained to timely engagement
strategies that include encouraging alternate strategies when contact
with the family is difficult.
ii. Initial plan development. (All timelines are determined by date of first contact,
which is to occur within 24 hours of receiving the referral.) The objective of the
Plan Development phase is to create a comprehensive, individualized plan of care
that addresses the prioritized needs and goals of the youth and family.
1. The Wrap team will review the current IP-CANS to identify the youth
and caregiver's needs and strengths, determine medical necessity for
Specialty Mental Health Services (SMHS), and drive the development
of the individualized plan of care. The completion of the IP-CANS, and
any subsequent updates, is generally the responsibility of the County
B-1-7
Revised Exhibit B-1
Social Worker (CSW) or Probation Social Worker (PSW) unless
otherwise directed by the County. The person identified as
responsible for completing the IP-CANS will also be responsible for
ensuring compliance with the timelines and parameters specified in
the All County Letter (ACL) 25-10. This includes reviewing and
updating, as needed, the IP-CANS at least every 90 days for youth
receiving certain Specialty Mental Health Services (SMHS) such as
ICC and IHBS, as well as updating the document within 30 days
following any triggering conditions such as a significant change in the
youth's behavior, placement, or service needs. Specific examples of
triggering conditions are provided in All County Letter (ACL) 25-10.
The Wrap team should be knowledgeable about what types of
triggering conditions prompt an IP-CANS update, and should notify
the CFT, including the person responsible for completing the IP-
CANS, within 24 hours of any event or condition that warrants an
update to the document.
2. Facilitator, in collaboration with the referring CSW or Deputy
Probation Officer (DPO), shall convene a CFT meeting within 30
calendar days of commencing Wrap services to engage all existing
and potential sources of support and connection for the Person
Served and Caregiver. By including them in the Wrap process from
the outset, the goal is to build and strengthen a team that can sustain
the Person Served and Caregiver after termination of Wrap services.
3. Facilitator, in collaboration with Person Served and Caregiver,
referring CWS or DPO, and representative(s) of the MHP, develops
individualized Plans that are in the language of the Person Served
and Caregiver, and that include goals that are specific, measurable,
achievable, relevant, and time-bound (i.e., SMART goals). The plan of
care shall be completed within 30 calendar days from the start of
services. The Wrap team will update the plan of care, distribute to all
team members, and document the updated plan in the child or youth's
file at least every 90 days and more often as needed.
4. Additionally, the Facilitator, in collaboration with the CFT, shall
develop a Wraparound Action Plan (WAP) within 30 calendar days of
commencing Wrap services that will be reviewed at each CFT
meeting, delineating SMART goals and the specific action steps that
each member of the CFT will take to put the plan into effect in order to
achieve the goals, including: what is going to be done, who is going to
do it, when it should be completed, and how the CFT will know the
action step is completed and whether it was effective.
5. Clinician shall collaborate with the Person Served and Caregiver to
complete an ecomap, genogram, PSC-35, and any other
documentation required by the County within 60 calendar days of
commencing Wrap services.
a. Ecomaps and genograms will be used to identify and
document known relatives, kin, and other lifelong supports as
part of family finding engagement and efforts.
B-1-8
Revised Exhibit B-1
6. The Wrap team shall collaborate with the assigned CSW, DSS Family
Finding Unit and/or DPO to support family finding, engagement, and
reunification efforts in alignment with HFW principles of family voice,
choice, and permanency. The Contractor shall actively participate in
coordinated planning and information-sharing to identify, engage, and
strengthen connections with birth family members and other natural
supports who can contribute to the youth's long-term stability. The
Wrap team shall document its engagement and support efforts and
incorporate the County's findings and direction into the individualized
plan of care and Wrap Action Plan, ensuring alignment with case plan
goals and permanency objectives. Progress toward family finding and
reunification shall be reviewed and updated during CFT meetings.
iii. Plan implementation: During the next three to four (3-4) months of Wrap services:
1. Facilitator and Support Counselor, in collaboration with the Person
Served and Caregiver, shall conduct a more thorough functional
analysis of particular target behavior.
2. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that a CFT meets no less frequently than every four (4) weeks
in order to monitor progress since the prior CFT meeting; support the
inclusion on the CFT of"natural supports," that is individuals in the
ecologies of Persons Served and Caregivers who provide care and
support; identify emerging skills and competencies, supports and
resources that can be utilized to achieve objectives and foundational
goals; develop hypotheses about how to achieve desired outcomes in
short windows of time; and develop action steps designed to address
larger foundational goals that can be accomplished weekly or
monthly, in order to maintain momentum by quickly demonstrating to
Person Served, Caregiver, and other CFT members that progress is
being made and there is hope for change.
3. Facilitator, and Family Partner as needed, shall meet at least once a
week with Person Served and Caregiver to ensure that the action
steps are taken, to troubleshoot difficulties they may have
encountered, and provide assistance navigating systems as needed.
4. Support Counselor shall meet at least once a week with Person
Served and Caregiver to review, coach, and support behavioral
interventions that may help shift behaviors, support insight building
around connection between emotions, thoughts, behaviors, and
support identity building and strengthening.
5. Contractor shall ensure that Wrap and Super Wrap services are
delivered with persistence and unconditional commitment throughout
the implementation phase. The Wrap Team shall continue
engagement and service delivery even in the face of barriers, limited
progress, or setbacks. Plans shall be revised, alternative strategies
developed, and natural supports engaged rather than discontinuing
services. When teams encounter barriers to implementation, they
shall seek assistance from County partners, including the assigned
CSW or DPO, the Wraparound County Coordinator, Court Connected
B-1-9
Revised Exhibit B-1
Care Justice Services (CCCJS) team, and/or other designated County
resources.
6. Facilitator, Support Counselor, and Peer Partner as appropriate, shall
monitor progress to identify when the Person Served and Caregiver
are ready to begin the transition out of formal Wrap services and
support. Wrap team members shall utilize the IP-CANS process,
monitoring verbal reports from CFT members, and personal
observation, completion of action steps and achievement of short-
term goals, proportionate increase in CFT composition of"natural
supports," increased involvement of"natural supports" in completing
action steps and managing the Wraparound process, engagement
efforts related to pursuing viable alternative permanency plans for
Persons Served in foster care, and decreased frequency, duration
and/or intensity of target behaviors or areas of concern to assess
transition readiness.
7. Implementation activities must clearly link service strategies back to
the family's identified strengths, culture, and vision, ensuring that
youth/family voice drives all CFT decisions.
8. Contractor shall ensure that data collected during implementation
(e.g., IP-CANS updates, Plan of Care and Wrap Action Plan progress,
family feedback) is used in real time to inform practice with the youth
and family, provide timely feedback to staff, and identify additional
staff training and coaching needs.
9. Contractor shall incorporate UC Davis HFW fidelity indicators by
documenting how engagement, plan development, and
implementation activities align with fidelity standards, and ensure this
documentation is reviewed within Continuous Quality Improvement
(CQI) processes.
iv. Transition: Approximately two (2) months prior to termination of Wrap services
and support:
1. Facilitator, Support Counselor, and Family Partner as appropriate,
shall ensure Persons Served and Caregivers have adequate support
systems, both formal and "natural," to sustain progress achieved
during Wrap, and that proper referrals have been made and no fewer
than three (3) "warm handoffs" to ongoing formal service providers
have been completed.
2. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that consensus exists among members of the CFT that
Persons Served and Caregivers have made sufficient progress, and
that adequate support systems, both formal and "natural," sufficient to
sustain progress are in place such that Wrap services and support are
no longer needed.
3. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that a plan is in place and agreed to by members of the CFT
regarding how the team will respond when problems arise in the
future.
B-1-10
Revised Exhibit B-1
4. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that the Person Served and Caregiver are provided an
opportunity to celebrate success with other members of the CFT and
say good-bye to members of the Wrap Team.
5. Transition planning shall begin early and be treated as an intentional
fourth phase of Wraparound, with clear benchmarks tied to family
readiness, natural supports, and permanency goals.
6. Contractor shall ensure transition plans document how the
youth/family vision, culture, and identified strengths are sustained
beyond Wrap services.
7. Transition activities shall include measurable goals for sustaining
gains (e.g., educational stability, permanency connections, symptom
reduction), and progress shall be reviewed at each CFT meeting
during the transition phase.
8. Contractor shall ensure that data from transition (e.g., permanency
outcomes, natural support involvement, family satisfaction surveys) is
reported back to the Community Leadership Team to identify and
address system barriers impacting HFW implementation.
5. For Indian Persons Served/families, the Contractor shall ensure that Tribes are engaged
at the earliest point of referral, and that Tribal representatives are included in CFT
meetings, plan development, and transition planning, in accordance with Indian Child
Welfare Act (ICWA) requirements and HFW practice standards.
6. Throughout the course of the four phases of wraparound, Contractor will elicit continuous
feedback from persons served/families and incorporate that feedback into service
planning, CFT decision-making, and CQI processes.
7. It is likely that some youth in the Wraparound program will be placed in a highly intensive
therapeutic placement setting such as Enhanced Intensive Services Foster Care (E-ISFC)
or an Enhanced STRTP (E-STRTP). For youth dually enrolled in Wraparound and an
intensive service setting, the Person-Served's CFT will determine which agency and which
person is assigned as lead for the following tasks based on existing therapeutic
relationships, treatment goals, and transition goals:
i. Advanced clinical services (example: therapy and psychiatry)
ii. Behavioral intervention/rehabilitation
iii. Case coordination such as CFT facilitation, case management, plan development
iv. Permanency work and family finding
8. Wraparound team members shall have the flexibility to adjust service levels based on the
needs of the youth and family. When the youth is in an intensive service setting, the
Wraparound team will remain engaged and responsible for care coordination and other
tasks as identified by the CFT and may need to decrease service intensity to avoid
duplication with the placement provider. Wraparound teams shall also be flexible to
increase service intensity when needed and as determined by the CFT.
9. Contractor shall ensure that staff and their supervisors are provided with feedback on their
ability to meet required service and reporting timelines. Such feedback shall be
incorporated into CQI processes, including but not limited to monthly reports, performance
monitoring meetings, and any County-requested CQI reports, to promote accountability,
improve service delivery, and support staff development.
B-1-11
Revised Exhibit B-1
10. Contractor shall ensure that all requests, approvals, and expenditures of Flexible Funds
are consistent with the County's Flex Fund Policy (Exhibit T). Contractors shall integrate
Flex Fund utilization into the service planning process, including documentation of team
recommendations, purpose of expenditure, and expected outcomes.
11. Length of Stay:
i. The approximate length of stay for the traditional Wrap service line is nine (9) to
twelve (12) months. While stated length of stay reflects general parameters, a
youth and family's ongoing participation in the Wrap program is driven by their
demonstrated need.
C. Super Wrap
1. In addition to the above-mentioned Wraparound services, the Contractor shall provide
higher intensity Wrap services referred to as "Super Wrap" to four (4) youth, at any given
time, who have been pre-authorized for these services by the County. Super Wrap team
caseload size shall be one (1) youth per team. Contractor has discretion regarding team
make-up.
2. Contractor shall ensure that the Super Wrap Team provides up to twenty-five (25) hours
per week of care coordination and/or support services to the Person Served, on behalf of
the Person Served, or to the Caregiver.
3. Contractor shall ensure that at least one staff person is available by phone and in person,
if needed, 24 hours per day, 7 days per week during the service period to provide support
and services to youth and their Caregivers on request.
4. Contractor shall ensure that each Super Wrap Team provides four (4) phases of effective
Wrap care coordination and supportive services as outlined in Wraparound section 3 with
these frequency modifications for Super Wrap participants:
i. Initial plan development. (All timelines are determined by date of first contact,
which is to occur within 24 hours of receiving the referral.)
1. Facilitator, in collaboration with the CFT shall develop a WAP within
14 calendar days of commencing Wrap services that will be reviewed
at each CFT meeting, delineating SMART goals and the specific
action steps that each member of the CFT will take to put the plan into
effect in order to achieve the goals, including: what is going to be
done, who is going to do it, when it should be completed, and how the
CFT will know the action step is completed and whether it was
effective.
2. Clinician shall collaborate with the Person Served and their Caregiver
to complete an ecomap, genogram, PSC-35, and any other
documentation required by the County within 14 calendar days of
commencing Super Wrap services, unless otherwise noted.
ii. Plan implementation: During the next three (3) months of Super Wrap services:
B-1-12
Revised Exhibit B-1
1. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that the CFT meets no less frequently than every two (2)
weeks in order to monitor progress since the prior CFT meeting;
support the inclusion on the CFT of"natural supports," that is
individuals in the ecologies of Person Served and their Caregiver who
provide care and support; identify emerging skills and competencies,
supports and resources that can be utilized to achieve objectives and
foundational goals; develop hypotheses about how to achieve desired
outcomes in short windows of time; and develop action steps
designed to address larger foundational goals that can be
accomplished weekly or monthly in order to maintain momentum by
quickly demonstrating to Persons Served, their Caregiver(s), and
other CFT members that progress is being made and there is hope for
change.
2. Facilitator, and Family Partner as needed, shall meet at least two (2)
times per week with the Person Served and their Caregiver to ensure
that the action steps are taken, to troubleshoot difficulties they may
have encountered, and provide assistance navigating systems as
needed.
3. Support Counselor shall meet at least two (2) times per week with the
Person served and their Caregiver to review, coach and support
behavioral interventions that my help shift behaviors, support insight
building around connection between emotions, thoughts, and
behaviors, and support identity building and strengthening.
4. Therapist shall meet at least two (2) times per week with each Person
Served and/or their Caregiver to provide individual or family therapy
as indicated and, utilizing evidence-based practices (e.g., Motivational
Interviewing, CBT, DBT, and IFS Therapy), to address the individual
Person Served's experience of relational and attachment trauma.
5. Family Partner shall meet at least one (1) time every week with the
Caregiver to provide support navigating the numerous systems of
care and service provision impacting their lives.
iii. Transition: Approximately 45 calendar days prior to termination of Super Wrap
services and support:
1. Facilitator, Support Counselor, and Family Partner as appropriate,
shall ensure the Person Served and their Caregiver have adequate
support systems, both formal and "natural," to sustain progress
achieved during Super Wrap, and that proper referrals have been
made and no fewer than six (6) "warm handoffs" to ongoing formal
service providers have been completed.
5. Length of Stay:
i. The approximate length of stay for the Super Wrap service line is 90-days. While
stated service timeline reflects general parameters, a youth and family's length of
stay in the Super Wrap program is driven by their demonstrated need.
B-1-13
Revised Exhibit B-1
ii. All extension requests for Super Wrap services would need to be presented to the
County for approval. These presentations shall include the start date for Super
Wrap services, the average frequency and duration of scheduled services,
description of the youth's level of engagement and progress or lack of progress in
treatment and any other relevant treatment information that would explain why this
youth needs to remain at the Super Wrap level of service. The contractor shall
also present a projected transition date for when the youth can return to traditional
Wrap services.
D. Crisis Services
1. Contractor shall develop, document, and implement individualized crisis and safety plans
for each youth and family in accordance with HFW standards. Contractor shall provide
supports designed to reduce the need for professional crisis interventions by strengthening
the family's and natural supports' capacity to manage crises.
i. At the time of Engagement, the Wrap team shall discuss any immediate crisis or
safety concerns raised by the youth or family. If pressing concerns are identified,
the team will develop an immediate written crisis response plan, provide a copy of
the plan to the family, and document it in the youth's chart.
ii. The immediate crisis plan shall inform, but not replace, the formal HFW Safety
Plan developed during the Plan Development phase.
iii. All families shall be provided with clear information on how to access 24/7 crisis
response when needed, including the on-call contact process.
iv. Contractor shall ensure Wrap staff are trained to implement safety and preventive
measures when responding to any self- harming and/or other behaviors that pose
risk to the youth or others. Wrap staff shall be prepared to initiate mobile
response services by contacting the treating provider, FURS, or 911, as clinically
indicated. Should the youth require an emergency evaluation for acute psychiatric
hospitalization, Wrap staff shall take the necessary steps to ensure the youth
receives the appropriate intervention to address the mental health crisis.
2. Contractor shall ensure that Wrap staff or Wrap administrator notify the CWS hotline, the
CSW, DPO and appropriate CWS Division Chief/Assistant Deputy Chief(ADC), or
designee for all incidents that indicate a sign of threat or continued risk to the physical or
mental health status of the Wrap youth including all such incidents that require a Critical
Incident Report, as outlined in this agreement.
i. The Contractor shall then follow up with the SW by phone within one business day
of the incident.
3. Contractor shall comply with the following when youth are referred for psychiatric
hospitalization:
i. Notify the CWS hotline, the SW, DPO and appropriate CWS Division Chief/ADC,
or designee as soon as it is reasonably safe to do so, but no later than the end of
the day and complete a critical incident report.
1. The Contractor shall then follow up with the SW by phone within one
business day.
ii. Participate in case conferences, hospital discharge conference and/or the CFT
meetings for youth referred for psychiatric hospitalization.
B-1-14
Revised Exhibit B-1
iii. Continue to provide Wrap services, to the extent possible, during the youth's
hospitalization.
iv. Initiate a CFT meeting within 24 hours of youth's return to the community.
4. Contractor shall track and report all crisis incidents, including those averted through
natural supports and those requiring professional intervention (e.g., mobile crisis,
emergency department, psychiatric hospitalization, law enforcement involvement). A
quarterly report summarizing crisis incidents, responses, and outcomes shall be submitted
to the County.
E. Additional Responsibilities
1. Maintain responsibility for necessary testimony and/or providing County with information
needed to generate court reports, as outlined below:
i. Court Reports - Documented reports of assessment and evaluation findings,
progress in treatment, recommendations for treatment and service plans
regarding reunification, maintenance and termination of parental rights, and
justification for recommendations.
ii. Court Testimony - Provide care plan updates when a court is considering
reunification, maintenance, and/or termination of parental rights.
2. Upon notification of a pending court hearing, Contractor agrees to complete and submit to
the County a "Periodic Review Report" twenty-one (21) calendar days prior to the court
date or seven (7) calendar days after notification.
3. Maintain electronic health records and supply their own personal computers, Internet
access, printers, signature pads and other network devices to meet statistical reporting
requirements, report Person-Served and program outcomes and any State or County data
requirements of the Katie A. Implementation Plan. Contractor shall also maintain capability
to enter electronic billing data into County's electronic health record system. A computer
with Internet access is required for both office and field-based staff.
4. Cooperate and participate with the County MHP in Quality Assurance/Improvement and
Utilization Review Programs and grievance procedures and comply with all final
determinations rendered by County's Quality Assurance/Improvement and Utilization
Review Programs, unless the decision is reversed on appeal as set forth in the County
MHP Provider Manual, incorporated herein by this reference. County's adverse decisions
regarding Contractor's services to Persons-Served may result in the disallowance of
payment for services rendered; or may result in additional controls to the delivery of
services; or may result in the termination of this Agreement. County shall have sole
discretion in the determination of Quality Assurance/Improvement and Utilization Review
outcomes, decisions and actions.
5. Obtain signatures, as required, regarding consent:
i. Care provider can sign for day trips and other minor miscellaneous items.
ii. Court Order should suffice for most other items.
6. Work collaboratively with other CWBC providers to develop and enter into Memorandum
of Understanding or other business agreements between themselves that defines the
processes and procedures for provision of services to foster youth, including, but not
limited to the:
i. Case Planning
ii. Care Coordination
B-1-15
Revised Exhibit B-1
iii. Intensive Transition Planning
iv. Assessment
v. Transportation between service settings
vi. Information sharing
vii. Data collection and dissemination
7. Work with DPO on criminogenic risk factors for probation youth as addressed through
contracted services as applicable.
F. Admission, Transition and Discharge
1. Entry Criteria
All youth referred to the Wrap and Super Wrap services will have pre-approval from
the County. This includes STRTP aftercare and re-referrals. Equal access is
required. Services shall not be denied or delayed based on the youth's placement,
geographic location (including out-of-county placements under presumptive transfer),
disability, or cultural needs.
Family First Prevention Services Act (FFPSA) Part IV mandates six months family-
based aftercare services for children discharged from qualified residential treatment
programs to family-based settings, including high-fidelity Wrap ( ACL 21-116).
Fresno County will be leveraging existing Wraparound services to meet this
requirement.
2. Intake and Initial Assessment
Contractor shall respond to all Wrap and Super Wrap referrals within 24 hours of
receipt. Youth referred to this program may have a current mental health assessment
with their primary treatment provider. If that assessment was completed within the
last six months and there have been no significant changes in the youth's symptoms,
the Contractor shall obtain a copy of that assessment and use it to inform treatment
planning. If there is no current mental health assessment, the youth's symptoms
have changed significantly and/or the previous assessment was completed longer
than six months ago, the Contractor shall complete a mental health assessment
within 14 calendar days or as soon as clinically appropriate.
In instances where a youth is currently enrolled in Wraparound services and is
subsequently identified as potentially eligible for Super Wraparound services,
Contractor shall, in coordination with the County, evaluate the youth's eligibility for
Super Wraparound within thirty (30) calendar days of identification. If deemed
appropriate, Contractor shall implement Super Wraparound services within this
timeframe. Ongoing communication with the County regarding the youth's status,
eligibility determination, and service transition shall be maintained throughout this
process.
3. Transition and Discharge
Youth referred to the Wrap/Super Wrap program may be denied services if the youth
does not meet medical necessity for specialty mental health services and/or the
B-1-16
Revised Exhibit B-1
necessary criteria to be eligible for Wrap/Super Wrap services. Youth who are
determined to be ineligible for these services will be linked to other appropriate
services and resources.
Discharge is determined on a case-by-case basis depending on the youth's progress
toward individualized treatment goals. Wraparound services operate with an
unconditional care approach; services are not ended solely due to challenges in
engagement, crisis events, or lack of progress. Instead, the team adapts strategies
and persists in supporting the youth and family until transition readiness is achieved.
Reasons for discharge include the youth or caregiver refuses or terminates services;
the youth is transferred to another program mutually agreed upon by the youth,
parent/caregiver, and Wrap; and/or mutual agreement that the treatment goals have
been met. For youth and families who decline or terminate services, reasonable and
documented efforts must reflect the team's attempts to engage and re-engage the
family in alignment with HFW standards.
All transitions and discharges shall be discussed in a CFT to ensure all members of
the youths' support system are aware of the recommendation being made by the
Contractor.
Contractor shall administer a survey to youth and families at discharge, collect and
track responses, and report data to the County. Surveys shall capture satisfaction
with services, family voice and choice, and perceived readiness for transition in
alignment with HFW standards. Aggregate results shall be incorporated into the
Contractor's CQI process and reported to the County as required.
VI. STAFFING
A. Each Contractor shall provide the following staffing components, at minimum:
1. Staffing shall be appropriate and aligned with the HFW model, which would include
the following roles: facilitator, family specialist, parent partner, youth partner, fidelity
coach, HFW Supervisor/Manager, and clinical supervisor.
2. Each Wrap and Super Wrap Team shall be comprised of:
a. One (1) Facilitator with a Mental Health Rehabilitation Specialist (MHRS)
qualification or above who meets with the youth, their Caregiver, and other
team members to complete assessments, individualized plans, and
Wraparound Action Plans; organize and facilitate Family Team meetings;
and ensure successful linkage of Persons Served and their Caregiver(s) to
ongoing resources and support. The Facilitator shall also serve as a support
and mentor to other members of the team, as needed.
A. Frequency of service for Wrap: at least one (1) contact per week
B. Frequency of service for Super Wrap: at least two (2) contacts per
week
b. A minimum of two (2) Support Counselors who are a bachelor's level
paraprofessional who shall meet with the Person Served to provide one-on-
one support for the Person Served, focusing on increasing the frequency of
B-1-17
Revised Exhibit B-1
desired behaviors, gaining access to pro-social activities and resources
within the community, and developing effective relationship-building skills.
A. Frequency of service for Wrap: at least one (1) contact per week
B. Frequency of service for Super Wrap: at least two (2) contacts per
week
c. One (1) Family/Parent Partner and One (1) Youth Partner, who has lived
experience, to provide support to the Person Served and their Caregiver in
navigating the numerous systems of care and service provision impacting
their lives as needed.
A. Frequency of service for Wrap: at least one (1) contact every 2
weeks
B. Frequency of service for Super Wrap: at least one (1) contact per
week
d. Fidelity coaching is to be provided to ensure services are delivered in
accordance with High Fidelity Wraparound principles and standards. The
position fulfilling this role will support staff through regular observation,
coaching sessions, and review of fidelity tools, promotes continuous quality
improvement, and ensures that facilitators, family partners, and youth
partners are implementing the model with fidelity.
3. Ensure each Wrap and Super Wrap team has access to:
a. One (1) Individual or Family Therapist to meet with the youth and their
Caregiver to provide individual or family therapy and utilizing evidence-
based practices (e.g., Motivational Interviewing, Cognitive Behavioral
Therapy, Dialectical Behavioral Therapy, Internal Family Systems Therapy)
to address youth's experience of relational and attachment trauma as
needed. If the youth choose to continue therapy with their current mental
health provider, the Wrap/Super Wrap therapist shall continue to provide
consultation to the other members of the WRAP/Super Wrap team and will
work in collaboration with the existing therapist to ensure joint services are
provided appropriately.
A. Frequency of service for Wrap: at least one (1) contact per week
as clinically appropriate
B. Frequency of service for Super Wrap: at least two (2) contacts per
week as clinically appropriate
b. One (1) Psychiatrist to meet with the Person Served to provide evaluation
and assessment for psychotropic medication, clinical consultation, and
assistance linking the Person Served and their Caregiver to ongoing
psychiatric services and support as needed and prioritizing continuity of care
where possible.
A. The frequency of psychiatry services will be at least one (1) time
per month for Wrap and Super Wrap participants.
4. Workforce development, including recruitment, hiring, training, and coaching, shall
be consistent with the California High Fidelity Wraparound (HFW) Standards and
Toolkit (Staffing Wraparound).
5. Ensure there is no change to a youth's primary Wraparound team members when
the youth transitions between the Wrap level of service and the Super Wrap level of
service to preserve the therapeutic relationship and provide continuity of care.
B-1-18
Revised Exhibit B-1
6. Ensure that direct service staff reimbursed through this contract shall spend at least
65% of their paid work time providing and documenting direct service to clients or
on behalf of clients. Administrative staff meetings, supervision meetings, and staff
trainings shall not be included in the 65%.
VII. TRAINING:
A. The California Wrap Standards require providers to have a HFW training plan that incorporates
initial, ongoing, and annual booster training to all staff as well as role specific training.
Contractor shall ensure that all Wrap and Super Wrap staff receive comprehensive initial
training and ongoing coaching consistent with the California HFW Standards (HFW Traininq)
and Fresno County expectations.
1. Foundational Training (Wraparound 101: Foundations for Fidelity)
a. All staff shall receive orientation and training in the Ten Principles of
Wraparound, the Four Phases of HFW (Engagement, Plan Development,
Implementation, Transition), and the use of High Fidelity Wraparound fidelity
indicators.
b. Staff shall be trained in trauma-informed, culturally respectful, and
linguistically competent practices.
c. Staff are trained in timely engagement strategies, including alternate
strategies when contact with families is difficult.
d. Supervisors and staff receive training on meeting timelines and CQI
processes tied to engagement, plan development, plan updates, and
reporting.
2. Needs-Driven, Strengths-Based and Solution-Focused Practices
a. Staff are trained to identify underlying needs, develop needs statements that
go beyond behaviors, and ensure plans are needs-focused rather than
deficit-focused.
b. Staff shall receive ongoing training and coaching in identifying functional
strengths of youth, caregivers, families, and community supports, and in
applying strengths to drive planning and service strategies.
c. Staff shall receive training in solution-focused and evidence-based practices
including, but not limited to, Motivational Interviewing, CBT, DBT, and IFS.
3. IP-CANS and Assessment Tools
a. Staff shall be trained to complete, interpret, and utilize the IP-CANS, PSC-
35, and other County-required assessments to guide planning and CQI.
b. Training includes requirements for timely completion (within 14 days of
engagement, updated every 90 days or within 30 days of a triggering event)
and integration into CFT decision-making.
4. Facilitation and Teaming
a. Facilitators shall be trained and coached in leading CFT meetings that are
inclusive of family, natural supports, and Tribes in the case of an Indian
child, and in ensuring family voice and choice are central to planning.
b. Training shall include engagement strategies, team-building activities, and
consensus-based decision-making.
5. Individualized Services
B-1-19
Revised Exhibit B-1
a. Facilitators and staff are trained to develop highly individualized plans of
care, using flexible strategies tailored to youth and family strengths, needs,
values, and culture.
6. Culturally Respectful and Relevant Services
a. Staff receive ongoing training in eliciting, honoring, and incorporating family
culture, traditions, and values into planning and service delivery.
b. Contractor shall provide training for staff on ICWA requirements, Tribal
sovereignty, and culturally responsive service delivery for Native American
youth and families.
7. Crisis and Safety Planning
a. Staff shall be trained in development and implementation of crisis and safety
plans, including proactive and reactive strategies, safety interventions, and
maximizing natural supports.
b. Training includes immediate crisis response procedures, 24/7 access, and
escalation protocols (FURS, mobile crisis, 911).
8. CQI and Fidelity Monitoring
a. Staff and supervisors shall receive training on the use of fidelity and quality
monitoring tools which may include but not limited to Wraparound Fidelity
Index [WFI], Team Observation Measure [TOM 2.0]), Document Assessment
Review Tool (DART), satisfaction surveys, and feedback loops to improve
practice.
b. Supervisors and coaches shall observe team meetings, review
documentation, and provide feedback to staff for ongoing skill-building and
adherence to HFW fidelity standards.
c. All staff are trained on how family feedback and fidelity measures inform CQI
processes.
9. Ongoing and Annual Requirements
a. All staff must complete at least an annual refresher training on Wraparound
principles, fidelity indicators, trauma-informed care, cultural competency,
and County-specific requirements.
b. Staff must attend County-offered trainings, which may include Quality
Parenting Initiative (QPI), Neurosequential Model of Therapeutics (NMT),
cultural competency, Civil Rights, and other System of Care initiatives.
c. Contractor shall maintain training logs, curricula, and attendance records,
and shall provide documentation of training completion to the County upon
request.
10. Youth, families and peer partners with current or prior Wraparound experience are
meaningfully incorporated into the delivery of required Wraparound trainings.
11. Community partners are invited to attend Wraparound trainings or are offered
trainings on Wraparound to strengthen their participation on HFW teams or to
strengthen their role in supporting HFW within the System of Care.
12. Develop training curriculum as County identifies a need.
13. Assist with training County staff and the community in Wraparound Service
processes and service options.
VIII. COUNTY RESPONSIBILITIES:
B-1-20
Revised Exhibit B-1
COUNTY shall:
A. Assist Contractors' efforts to evaluate the needs of each enrolled youth on an ongoing
basis to ensure each youth is receiving clinically appropriate services.
B. Provide oversight and collaborate with contractors, other County Departments, and
community agencies to help achieve State program goals and outcomes. Oversight
includes, but is not limited to, contract monitoring and coordination with the State
Department of Health Care Services (DHCS) and California Department of Social
Services (CDSS) in regard to program administration and outcomes.
C. Assist Contractors in making linkages with the total mental health system of care. This
will be accomplished through regularly scheduled meetings as well as formal and
informal consultation.
D. Participate in evaluating overall program progress and efficiency and remain
available to contractors for ongoing consultation.
E. Gather outcome information from target Person Served groups and Contractors
throughout each term of this Agreement. County shall notify Contractors when their
participation is required. The performance outcome measurement process will not be
limited to survey instruments but will also include, as appropriate, Person Served and
staff interviews, chart reviews, and other methods of obtaining required information.
F. Assist Contractors' efforts toward cultural and linguistic competency by providing the
following to contractors:
B. Technical assistance and training regarding cultural competency requirements at
no cost to contractors.
C. Mandatory cultural competency training for contractors' personnel, on an
annual basis, at minimum.
D. Technical assistance for translating information into County's threshold languages
(Spanish and Hmong). Translation services and costs associated will be the
responsibility of contractors.
VIII. REPORTS
Contractor shall track data and provide reporting on the following items and send all applicable
information and reports to the following distribution list for County staff: DSS Staff Analyst, DSS
Division Chief, DSS Social Work Supervisor, DBH Contract Analyst, Probation Assistant Deputy
Chief, and Probation Contract Analyst.
1) Contractors shall be expected to comply with all contract monitoring and compliance
protocols, procedures, data collection methods, and reporting requirements conducted
by County.
2) Contractors will be responsible for meeting with DBH and DSS on a monthly basis, or
more often as agreed upon between DBH, DSS, and Contractors, for contract and
performance monitoring.
B-1-21
Revised Exhibit B-1
3) Contractors will be required to submit monthly reports on performance measures to the
County. Report formats will be established through County/Contractor collaboration.
Outcome measures may change, based on information or measures needed. Required
monthly reports include:
a) DSS Monthly Activity Report (MAR); and
b) Other reports as established by the County.
4) All reports will be due to the County by the 10t" business day of each month and will be
reviewed for accuracy. (If the 101" lands on a weekend or Holiday, reports will be due
the next business day). Reimbursement for monthly expenses may be delayed in the
event inaccurate reports are submitted.
5) Provide county with various reports through the length of the youth's enrollment in the
program; a few of which are standardized and include: "Monthly Progress Report",
"Discharge Presentation", "Individual Child and Family Plan Presentation Outline", and
"Individual Child and Family Plan (ICFP)".
6) Contractor will report and document all major and/or sensitive incidents ("critical
incidents") to the County pursuant to the procedures and timing outlined in Exhibit J
"Fresno County Mental Health Plan Incident Report." The County, at its sole discretion,
may require the Contractor to conduct all necessary follow-up activities after reporting
critical incidents. If there is any doubt about whether an incident should be reported, the
default shall be for the Contractor to report the incident to the County.
7) Contractors shall use collected data not only for compliance reporting but also in real
time to improve practice with youth and families, including providing staff with timely
feedback from data or reports relevant to their service provision.
8) Data shall be reviewed and analyzed at multiple levels (youth/family, program, and
system) to identify staff training needs, address program effectiveness, and inform CQI
processes.
9) Contractor shall ensure that data is collected, analyzed, and utilized to identify and
communicate both outcomes of HFW implementation and system barriers that impact
service delivery, including those that impact Tribal youth. Outcomes and barriers shall be
elevated to the Community Leadership Team (CLT) for review, discussion, and
resolution.
10)Contractor shall ensure all data collection and reporting is culturally responsive, ensuring
outcomes are interpreted in the context of family culture, values, and vision.
11)Contractor shall participate in collaborative local CQI evaluation plans with County,
Providers, and System of Care participant organizations, as required by UC Davis HFW
fidelity indicators.
12)Additional reports and outcome information may be requested by County at a later date,
as needed.
IX. GOALS/OUTCOMES
Contractor is required to submit measurable outcomes on a semi-annual, as identified in the
DBH's Policy and Procedure Guide (PPG) 1.2.7 Performance Outcomes Measures.
Performance outcome measures must be approved by DBH and DSS and satisfy all State and
local mandates. County will provide technical assistance and support in defining measurable
B-1-22
Revised Exhibit B-1
outcomes. The outcome measures and indicators provided below represent County DBH and
DSS program goals to be achieved by the Contractor in addition to Contractor's developed
outcomes and the HFW Expected Outcomes. Outcomes for youth center on the following core
areas: permanency, behavioral stability, symptom reduction, living situation stability, strengths
development, and educational stability. Outcomes for Persons-Served vary based on their
individual needs and challenges faced by the specific youth and their plans of care; however,
common quantifiable outcomes at the program level include:
Fresno County Wraparound Contract Performance Expectations
Metric Definition Performance Indicator
Service Minimum service levels by the Wraparound: Ensure that the Wrap
utilization required staffing level in order to Team provides between 24 to 32 hours
earn full payment per month (about 6-8 per week) of care
coordination and/or support services to
Persons Served or to Person's Served
Caregiver.
Super Wrap: Ensure that the Super Wrap
Team provides approximately 100 hours
a month (about 25 hours a week) of
care coordination and/or support services
to the Person Served.
In no case should the hours of service
performed be less than the minimum
above.
Service Wrap 90% compliance with service timeliness
timeliness . Make contact with referral as documented in Monthly Activity
source within 24 hours Reports (MARs)
Initial face to face
engagement meeting within 72
hours of referral
Follow-up meeting within 48
hours
• IP-CANS completion within
14 calendar days of initial
meeting
Wrap Action Plan developed
within 30 calendar days of
initial meeting
CFT meeting within 30
calendar days of initial meeting
(and w/n 24 hours of discharge
form inpatient admission)-
B-1-23
Revised Exhibit B-1
Ecomap, genogram, PSC-35
created within 60 calendar
days of initial meeting
CFT meetings no less than
monthly-
• Weekly activity with
facilitator, family partner, youth
and caregiver
• Support counselor meets at
least 1 x per week
• Transition planning occurs 1-
2 months prior to end of Wrap
Super Wrap
Make contact with referral
source within 24 hours
• Initial face to face
engagement meeting within 72
hours of referral
• Follow-up meeting within 48
hours
• IP-CANS completion within
14 calendar days of initial
meeting
• Wrap Action Plan developed
within 15 calendar days of
initial meeting
• CFT meeting within 15
calendar days of initial meeting
(and w/n 24 hours of discharge
form inpatient admission)-
• Ecomap, genogram, PSC-35
created within 15 calendar
days of initial meeting
• CFT meetings no less than
every 2 weeks-
• Activity with facilitator, youth
and caregiver at least 2 x per
week
• Activity with family partner at
least 1 x per week
• Support counselor meets at
least 2 x per week
• Transition planning occurs 45
calendar days prior to end of
Wrap
B-1-24
Revised Exhibit B-1
Fresno County Wraparound Contract Outcomes
Metric Definition Performance Indicator
Improved Youth shall have a reduction in 90% of youth shall see a reduction in
behavioral/ action items in the action items on IP-CANS over time
emotional Behavioral/Emotional Needs
needs Domain, Risk Behaviors
Domain
Improved Youth will have improved 80% of youth shall show improvement on
Strengths scores in the Strengths domain IP-CANS over time
of the IP-CANS
School Youth will demonstrate 80% of youth shall show improvement on
Improvement improved educational IP-CANS over time
functioning from intake to
discharge as measured by IP-
CANS Life Functioning items
related to school functioning
including school behavior,
school achievement, and
school attendance.
Increase Natural Supports are actively At least one natural support attends 50%
Natural involved across all phases of of all CFTs.
Supports Wrap/Super Wrap.
Permanency Youth will have improved 90% of youth shall show improvement on
Planning scores in the Living Situation IP-CANS over time
and Family Functioning items in
the Life Functioning Domain
Transition to Youth experience stability in 80% of youth accepted to the program
less their community-based living will be transitioned to less restrictive
restrictive situation and do not experience placements including but not limited to
placements a new placement in an legal or emotional/relational permanency
institution (such as detention, or with their family for stabilization and
psychiatric hospitalization, preservation of their family placement.
treatment center, or STRTP)
upon discharge.
Reduction in Youth experience stability with At least 80% of youth enrolled in
Inpatient, regard to their behavioral Wraparound will experience no more than
Emergency health, necessitating fewer or one behavioral health-related inpatient or
Department no visits to the hospital. emergency department admission during
Admission for the course of enrollment.
B-1-25
Revised Exhibit B-1
Behavioral
Health Visits
Improved Youth experience improved At least 75% of youth will show improved
Functioning functioning in the community as scores on IP-CANS items related to
in the well as improved interpersonal Community and School Functioning over
Community functioning. time.
Client Youth and families are satisfied At least 75% of youth and caregivers
satisfaction with their HFW experience and shall report a positive experience of
progress, including caregiver services, perceived improvement in
confidence in their ability to functioning, and increased caregiver
manage the youth's needs and confidence, as measured through post-
access support. service surveys
In addition to the outcomes above being tracked on the MAR and other County-designated
reporting mechanisms (e.g., DOMO dashboards), Contractors shall utilize a computerized
tracking system with which performance and outcome measures and other relevant Person
Served data, such as demographics, will be maintained. The data tracking system may be
incorporated into the Contractors' electronic health records (EHR) systems or in stand-alone
databases (e.g., Access or Excel spreadsheets). County must be afforded read-only access to
the data tracking system.
County may adjust the performance and outcome measures periodically throughout the duration
of the Agreement, as needed, to best measure the program as determined by County and/or
CDSS/DHCS.
B-1-26
Revised Exhibit B-2
SCOPE OF SERVICES
ORGANIZATION: Central Star Behavioral Health, Inc.
ADDRESS: 1501 Hughes Way, Suite 150
Long Beach, CA 90810
SERVICE ADDRESS: 3433 W. Shaw Ave, Suite 107
Fresno CA, 93711
SERVICES: Senate Bill 163 Wraparound and Super Wraparound Services
TELEPHONE: 310-221-6336, Ext. 125
CONTACT: Kent Dunlap, CEO
EMAIL: kdunlap@starsinc.com
CONTRACT PERIOD: Upon execution - June 30, 2027 with two (2) optional one-year
extensions
Year 1: Upon execution —June 30, 2025
Year 2: July 1, 2025 —June 30, 2026
Year 3: July 1, 2026 —June 30, 2027
Year 4: July 1, 2027 —June 30, 2028
Year 5: July 1, 2028 —June 30, 2029
(. BACKGROUND
The California Department of Social Services (CDSS) describes Wraparound as a strengths-
based planning process that occurs in a team setting to engage with children, youth, and their
families. Wraparound shifts focus away from a traditional service-driven, problem-based
approach to care and instead follows a strengths-based, needs-driven approach. The intent is to
build on individual and family strengths to help families achieve positive goals and improve well-
being. Wraparound is also a team-driven process. From the start, a child and family team (CFT)
is formed and works directly with the family as they identify their own needs and strengths. The
team develops a service plan that describes specific strategies for meeting the needs identified
by the family. The service plan is individualized, with strategies that reflect the youth and
family's culture and preferences. California Wraparound is intended to allow youth to live and
grow up in a safe, stable, permanent family environment with access to formal and natural
supports, tribes when applicable, and services consistent with the High Fidelity Wraparound
(HFW) model.
The Fresno County Children's Wellbeing Continuum (CWBC) is designed to offer a seamless
service delivery model across multiple service levels and settings for Fresno youth with complex
B-2-1
Revised Exhibit B-2
behavioral and emotional needs. The Wraparound program will have a key role in ensuring
consistency as the youth moves through the continuum.
II. PROGRAM GOALS AND OUTCOMES
Wraparound services in Fresno County are designed to provide individualized and
comprehensive supports that reflect true partnership with families and full adherence to the
HFW values, principles, and fidelity indicators. Services aim to achieve permanent placement in
safe and stable family-based settings, decrease behaviors that may lead to out-of-home
placement, and support families in meeting their needs and vision for a better future.
The program also seeks to promote equitable access, cultural responsiveness, cost-effective,
successful outcomes across multiple life domains while increasing family social supports and
resources.
This Scope of Services is based on the current understanding of the needs of Fresno County
(County) youth and the initial conceptualization of program design to best meet the needs of
youth. The County and Central Star Behavioral Health, Inc. (Contractor) acknowledge that
circumstances may arise that necessitate adjustments to the program design. In such cases,
both parties agree to work together in good faith to review and, if necessary, revise this Scope
of Services provided that any modifications remain consistent with HFW Standards, including
fidelity indicators and State and County requirements .
Any changes to this Scope of Services shall be documented in writing and agreed upon by both
parties. These changes may include additions, deletions, or modifications to the services
originally agreed upon, so long as they maintain alignment with HFW principles, phases, and
required fidelity monitoring processes. Any adjustments to this Scope of Services may have an
impact on the project timeline and deliverables, which will be discussed and agreed upon by
both parties before implementation.
III. TARGET POPULATION
Youth considered eligible for Wraparound will meet the following criteria:
1. Must be California Welfare and Institutions Code (WIC) 300, 601, 602; and
2. Currently placed in, at risk of being placed in, or recently discharged from a Qualified
Residential Treatment Program (QRTP), a licensed Short-Term Residential Therapeutic
Program (STRTP) or otherwise determined at risk of congregate care placement through
a CFT;
3. Must be approved for Wraparound through the Interagency Placement Committee (IPC)
and/or Enhanced Interagency Placement Committee (E-IPC) process.
4. Must be receiving services through Fresno County or be eligible to receive services in
Fresno County through presumptive transfer in accordance with Assembly Bill No. 1299
and Assembly Bill 1051. Presumptive transfer only transfers Medi-Cal benefits; selected
provider(s) will be expected to contract directly with the youth's county of origin.
5. Youth considered eligible for Super Wraparound will meet the following criteria:
B-2-2
Revised Exhibit B-2
1. Must be California Welfare and Institutions Code (WIC) 300, 601, 602; and
2. Currently placed, or at risk of being placed, in a licensed Short-Term Residential
Therapeutic Program (STRTP); and
3. Must be receiving services through Fresno County and/or be eligible for Fresno County
Medi-Cal; and
4. Must be identified as eligible to receive Super Wrap services through the Children's
Well-Being Continuum enrollment process, including approval by IPC and/or E-IPC, to
meet the following criteria, but not limited to:
a) Requires enhanced level of service, care coordination and support beyond
traditional Wrap due to more acute and urgent needs.
b) The child or family demonstrates a need for more robust support across multiple
areas, such as crisis stabilization or intensive mental health services.
IV. LOCATION OF SERVICES
Services will be provided at Contractor's clinic site, in the community, at home and education
locations, whichever is most comfortable for the youth and family. Services must be family-
driven, community-based, and culturally responsive.
Contractor must also be capable of offering services through telehealth-phone and telehealth-
video, when clinically appropriate or when access barriers (e.g., transportation, safety,
geography) prevent in-person participation. Telehealth services must meet all State and County
requirements for confidentiality, accessibility, and informed consent.
V. HOURS OF OPERATION
Contractors' office(s) shall be open Monday through Friday, 8:00 a.m. to 5:00 p.m., with
services available on evenings and weekends, if required to meet the unique needs of the youth
and family. Scheduling shall prioritize family convenience and accessibility, including
accommodations for cultural, linguistic, and disability-related needs. At least fifty percent (50%)
of services will be provided in the community and shall be scheduled on days and times that are
convenient for the families, including evenings and weekends. consistent with the (HFW)
requirement that services occur in the most natural and supportive environments.
Youth/families also have access to on-call crisis support twenty-four hours a day, seven days a
week (24/7). The Contractor's on-call worker, in consultation with a supervisor and Fresno
County CWS Supervisor if needed, will determine the level of support needed to address the
crisis. Support ranges from telephone support and coaching to an immediate in-person
response by staff.
For crisis services, the telephonic response time is 10 minutes or less and the in-person
response time for an emergency is 30 minutes or less; staff are required to respond in-person
when the Persons Served identify an urgent need. Crisis services must be trauma-informed,
culturally responsive, and coordinated with other County and State crisis systems (e.g., Family
Urgent Response Service (FURS), mobile crisis, 911, inpatient psychiatric services) as clinically
indicated.
B-2-3
Revised Exhibit B-2
VI. DESCRIPTION OF SERVICES - CONTRACTOR RESPONSIBILITIES
All services in this section shall be delivered in alignment with UC Davis HFW Standards,
including fidelity indicators and the four HFW phases (Engagement, Plan Development,
Implementation, Transition). Services must be family-driven, youth-guided, needs-driven,
culturally and linguistically responsive, and accessible to youth with disabilities. Contractor shall
provide a level of service and support that will reflect each youth's unique and individual needs.
A. Specialty Mental Health Services
1. Specialty Mental Health Services (SMHS) shall meet all MHP documentation, medical
necessity, and claiming standards. Contractor shall provide the following services to all
youth in the program. Services will include but are not limited to the following:
i. Provide support to the youth's family and other members of the youth's social
network to help them manage the symptoms and illness of the youth and reduce
the level of family and social stress associated with the illness;
ii. Make appropriate referrals and linkages to services that are beyond that of
Contractor's services under this Agreement, or as appropriate when
discharging/transitioning a youth from the program;
iii. Coordinate services with any other community mental health and non-mental
health providers as well as other medical professionals including behavioral health
programs for Indian children.
iv. Assist youth/family with accessing all entitlements or benefits for which they are
eligible (i.e., Medi-Cal, SSI, Section 8 vouchers, etc.);
v. Develop and Identify family support. Involvement whenever possible to engage
with natural support early
vi. Refer youth/family to supported education and employment opportunities, as
appropriate;
vii. Provide or link to transportation services when it is critical to initially access a
support service or gain entitlements or benefits;
viii. Provide peer support activities, as appropriate; and
ix. Ensure language access (interpreter/translation) and disability accommodations
for all contacts (in-person and telehealth), and obtain informed consent consistent
with State/County policy.
2. Contractor shall deliver a comprehensive Specialty Mental Health program. Behavioral
Health services include, but are not limited to:
i. Assessment;
ii. Treatment or care planning/goal setting;
iii. Pediatric Symptom Checklist (PSC) 35 and the clinically appropriate version of the
Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS)
assessment;
B-2-4
Revised Exhibit B-2
iv. Individual therapy;
v. Group therapy;
vi. Family therapy;
vii. Case management;
viii. Consultation;
ix. Medication support services;
x. Hospitalization/Post Hospitalization Support;
A. Certified Peer Support Services; and
xii. Intensive Home-Based Services (IHBS), as appropriate.
3. Contractor will ensure that all services:
i. Are determined in collaboration with youth and family and reflect the voice, choice,
and cultural practices;
ii. Be values-driven, strengths-based, individual-driven, trauma-informed and co-
occurring capable;
iii. Be culturally and linguistically competent;
iv. Be age, culture, gender, and language appropriate; and
v. Include accommodations for youth with physical disability(ies).
4. Methods for service coordination and communication between program and other service
providers shall be developed and implemented consistent with Fresno County Mental
Health Plan (MHP) confidentiality rules.
5. Contractor shall maintain up-to-date caseload records of all youth enrolled in services, and
provide individual, programmatic, and other demographic information to County as
requested.
6. Contractor shall ensure billable Specialty Mental Health Services meet any/all County,
State, Federal regulations including any utilization review and quality assurance standards
and provide all pertinent and appropriate information in a timely manner to Fresno County
Department of Behavioral Health (DBH) for the purpose of billing Medi-Cal for services
rendered.
7. Staffing should be appropriate for services needed by the youth and family, and shall
include a Wraparound trained clinician, Wraparound coach, Family Specialist, Facilitator,
Parent Partner, and Youth Peer Partner. Wraparound Role Descriptions (ca.gov)
B. SIB 163 Wraparound (Wrap)
1. Contractor shall provide Wraparound services for up to fifty (50) youth at any given time,
with Wrap team caseload size of eight (8) to twelve (12) youth per team. Services shall be
B-2-5
Revised Exhibit B-2
family driven, youth-guided, highly coordinated, individualized, trauma-informed,
unconditional, and assist youth and families in addressing identified needs consistent with
the HFW Standards.
2. Contractor shall ensure that at least one staff person is available by phone and in person,
if needed, 24 hours per day, 7 days per week during the service period to provide support
and services to youth and their Caregivers on request.
3. Contractor shall provide services based on the ten (10) foundational principles of
Wraparound:
i. Family voice and choice
ii. Team-based
iii. Natural supports
iv. Collaborative
v. Community-based
vi. Culturally competent
vii. Individualized
viii. Strengths-based
ix. Persistence
x. Outcome-based
4. Ensure that each Wrap team provides four (4) phases of effective Wrap care coordination
and supportive services, including:
i. Engagement:
1. Within 24 hours of receiving the referral, Facilitator or Parent Partner
shall make voice-to-voice contact with the referral source and
Caregiver to clarify the reason for the referral, ascertain any
permanency plans for foster/probation youth, determine the referral
source's anticipated outcomes, and to explain the Wrap process.
2. At the start of Wrap and Super Wrap services, the HFW team shall
provide a comprehensive orientation to the youth and family, which
shall be documented in the case record and revisited as needed to
ensure continued clarity for the youth, family, and team members.
Orientation ensures that all participants understand the HFW process
and their role within it. At minimum, the orientation shall include:
a. Overview of the HFW principles and phases so that youth and
families understand the foundation of services and what to
expect over time.
b. Legal and ethical considerations, including confidentiality limits
and mandated reporter obligations.
c. Roles of all team members, including the youth and family
themselves, formal team members, natural supports, and
Tribes in the case of an Indian child.
d. Expectations for participation, including how the family's voice
and choice will guide service planning and implementation.
3. Within 72 hours of receiving the referral, Facilitator, Support
Counselor, and Family Partner, as needed, engage in a face-to-face
B-2-6
Revised Exhibit B-2
meeting with the Person Served and Caregiver to clarify expectations,
explain the role and principles of Wrap, discuss the overall timeline,
review family culture, values, and traditions, and begin to explore
strengths, needs, and vision for the future using UC Davis HFW
engagement tools and fidelity indicators.
4. Within 48 hours of the initial meeting, Facilitator, Support Counselor,
and Family Partner, as needed, meet with Person Served and
caregiver to briefly identify or re-state referral areas of concern,
explain the obligations of Wrap Team members as mandated
reporters, identify any safety concerns, and develop an Initial Safety
Plan as necessary. Engagement efforts shall also ensure that natural
supports, cultural representatives, and Tribes (when applicable) are
invited early into the process, in alignment with HFW practice
standards.
5. Youth referred to this program may have a current mental health
assessment with their primary treatment provider. If that assessment
was completed within the last six months and there have been no
significant changes in the youth's symptoms, the Contractor shall
obtain a copy of that assessment and use it to inform treatment
planning. If there is no current mental health assessment, the youth's
symptoms have changed significantly, and/or the previous
assessment was completed longer than six months ago, the
Contractor shall complete a mental health assessment within 14
calendar days or as soon as clinically appropriate.
6. Each youth in Wrap and Super Wrap shall have access to an
individual and/or family therapist utilizing evidence-based practices
(e.g., Motivational Interviewing, Cognitive Behavioral Therapy (CBT),
Dialectical Behavioral Therapy (DBT), and Internal Family Systems
(IFS)) to address relational and attachment trauma. Youth may
continue with an existing mental health provider, in which case the
Wrap/Super Wrap therapist will collaborate and provide consultation
to the team to ensure coordinated services. Service frequency shall
be at least one (1) contact per week for Wrap and two (2) contacts per
week for Super Wrap, as clinically appropriate. In addition, a
psychiatrist shall provide evaluation, assessment, and ongoing
support for psychotropic medication management, clinical
consultation, and linkage to psychiatric services, prioritizing continuity
of care.
7. Contractor will ensure staff are trained to timely engagement
strategies that include encouraging alternate strategies when contact
with the family is difficult.
ii. Initial plan development. (All timelines are determined by date of first contact,
which is to occur within 24 hours of receiving the referral.) The objective of the
Plan Development phase is to create a comprehensive, individualized plan of care
that addresses the prioritized needs and goals of the youth and family.
1. The Wrap team will review the current IP-CANS to identify the youth
and caregiver's needs and strengths, determine medical necessity for
B-2-7
Revised Exhibit B-2
Specialty Mental Health Services (SMHS), and drive the development
of the individualized plan of care. The completion of the IP-CANS, and
any subsequent updates, is generally the responsibility of the County
Social Worker (CSW) or Probation Social Worker (PSW) unless
otherwise directed by the County. The person identified as
responsible for completing the IP-CANS will also be responsible for
ensuring compliance with the timelines and parameters specified in
the All County Letter (ACL) 25-10. This includes reviewing and
updating, as needed, the IP-CANS at least every 90 days for youth
receiving certain Specialty Mental Health Services (SMHS) such as
ICC and IHBS, as well as updating the document within 30 days
following any triggering conditions such as a significant change in the
youth's behavior, placement, or service needs. Specific examples of
triggering conditions are provided in All County Letter (ACL) 25-10.
The Wrap team should be knowledgeable about what types of
triggering conditions prompt an IP-CANS update, and should notify
the CFT, including the person responsible for completing the IP-
CANS, within 24 hours of any event or condition that warrants an
update to the document.
2. Facilitator, in collaboration with the referring CSW or Deputy
Probation Officer (DPO), shall convene a CFT meeting within 30
calendar days of commencing Wrap services to engage all existing
and potential sources of support and connection for the Person
Served and Caregiver. By including them in the Wrap process from
the outset, the goal is to build and strengthen a team that can sustain
the Person Served and Caregiver after termination of Wrap services.
3. Facilitator, in collaboration with Person Served and Caregiver,
referring CWS or DPO, and representative(s) of the MHP, develops
individualized Plans that are in the language of the Person Served
and Caregiver, and that include goals that are specific, measurable,
achievable, relevant, and time-bound (i.e., SMART goals). The plan of
care shall be completed within 30 calendar days from the start of
services. The Wrap team will update the plan of care, distribute to all
team members, and document the updated plan in the child or youth's
file at least every 90 days and more often as needed.
4. Additionally, the Facilitator, in collaboration with the CFT, shall
develop a Wraparound Action Plan (WAP) within 30 calendar days of
commencing Wrap services that will be reviewed at each CFT
meeting, delineating SMART goals and the specific action steps that
each member of the CFT will take to put the plan into effect in order to
achieve the goals, including: what is going to be done, who is going to
do it, when it should be completed, and how the CFT will know the
action step is completed and whether it was effective.
5. Clinician shall collaborate with the Person Served and Caregiver to
complete an ecomap, genogram, PSC-35, and any other
documentation required by the County within 60 calendar days of
commencing Wrap services.
B-2-8
Revised Exhibit B-2
a. Ecomaps and genograms will be used to identify and
document known relatives, kin, and other lifelong supports as
part of family finding engagement and efforts.
6. The Wrap team shall collaborate with the assigned CSW, DSS Family
Finding Unit and/or DPO to support family finding, engagement, and
reunification efforts in alignment with HFW principles of family voice,
choice, and permanency. The Contractor shall actively participate in
coordinated planning and information-sharing to identify, engage, and
strengthen connections with birth family members and other natural
supports who can contribute to the youth's long-term stability. The
Wrap team shall document its engagement and support efforts and
incorporate the County's findings and direction into the individualized
plan of care and Wrap Action Plan, ensuring alignment with case plan
goals and permanency objectives. Progress toward family finding and
reunification shall be reviewed and updated during CFT meetings.
iii. Plan implementation: During the next three to four (3-4) months of Wrap services:
1. Facilitator and Support Counselor, in collaboration with the Person
Served and Caregiver, shall conduct a more thorough functional
analysis of particular target behavior.
2. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that a CFT meets no less frequently than every four (4) weeks
in order to monitor progress since the prior CFT meeting; support the
inclusion on the CFT of"natural supports," that is individuals in the
ecologies of Persons Served and Caregivers who provide care and
support; identify emerging skills and competencies, supports and
resources that can be utilized to achieve objectives and foundational
goals; develop hypotheses about how to achieve desired outcomes in
short windows of time; and develop action steps designed to address
larger foundational goals that can be accomplished weekly or
monthly, in order to maintain momentum by quickly demonstrating to
Person Served, Caregiver, and other CFT members that progress is
being made and there is hope for change.
3. Facilitator, and Family Partner as needed, shall meet at least once a
week with Person Served and Caregiver to ensure that the action
steps are taken, to troubleshoot difficulties they may have
encountered, and provide assistance navigating systems as needed.
4. Support Counselor shall meet at least once a week with Person
Served and Caregiver to review, coach and support behavioral
interventions that may help shift behaviors, support insight building
around connection between emotions, thoughts, behaviors, and
support identity building and strengthening.
5. Contractor shall ensure that Wrap and Super Wrap services are
delivered with persistence and unconditional commitment throughout
the implementation phase. The Wrap Team shall continue
engagement and service delivery even in the face of barriers, limited
progress, or setbacks. Plans shall be revised, alternative strategies
B-2-9
Revised Exhibit B-2
developed, and natural supports engaged rather than discontinuing
services. When teams encounter barriers to implementation, they
shall seek assistance from County partners, including the assigned
CSW or DPO, the Wraparound County Coordinator, Court Connected
Care Justice Services (CCCJS) team, and/or other designated County
resources.
6. Facilitator, Support Counselor, and Peer Partner as appropriate, shall
monitor progress to identify when the Person Served and Caregiver
are ready to begin the transition out of formal Wrap services and
support. Wrap team members shall utilize the IP-CANS process,
monitoring verbal reports from CFT members, and personal
observation, completion of action steps and achievement of short-
term goals, proportionate increase in CFT composition of"natural
supports," increased involvement of"natural supports" in completing
action steps and managing the Wraparound process, engagement
efforts related to pursuing viable alternative permanency plans for
Persons Served in foster care, and decreased frequency, duration
and/or intensity of target behaviors or areas of concern to assess
transition readiness.
7. Implementation activities must clearly link service strategies back to
the family's identified strengths, culture, and vision, ensuring that
youth/family voice drives all CFT decisions.
8. Contractor shall ensure that data collected during implementation
(e.g., IP-CANS updates, Plan of Care and Wrap Action Plan progress,
family feedback) is used in real time to inform practice with the youth
and family, provide timely feedback to staff, and identify additional
staff training and coaching needs.
9. Contractor shall incorporate UC Davis HFW fidelity indicators by
documenting how engagement, plan development, and
implementation activities align with fidelity standards, and ensure this
documentation is reviewed within Continuous Quality Improvement
(CQI) processes.
iv. Transition: Approximately two (2) months prior to termination of Wrap services
and support:
1. Facilitator, Support Counselor, and Family Partner as appropriate,
shall ensure Persons Served and Caregivers have adequate support
systems, both formal and "natural," to sustain progress achieved
during Wrap, and that proper referrals have been made and no fewer
than three (3) "warm handoffs" to ongoing formal service providers
have been completed.
2. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that consensus exists among members of the CFT that
Persons Served and Caregivers have made sufficient progress, and
that adequate support systems, both formal and "natural," sufficient to
sustain progress are in place such that Wrap services and support are
no longer needed.
B-2-10
Revised Exhibit B-2
3. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that a plan is in place and agreed to by members of the CFT
regarding how the team will respond when problems arise in the
future.
4. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that the Person Served and Caregiver are provided an
opportunity to celebrate success with other members of the CFT and
say good-bye to members of the Wrap Team
5. Transition planning shall begin early and be treated as an intentional
fourth phase of Wraparound, with clear benchmarks tied to family
readiness, natural supports, and permanency goals.
6. Contractor shall ensure transition plans document how the
youth/family vision, culture, and identified strengths are sustained
beyond Wrap services.
7. Transition activities shall include measurable goals for sustaining
gains (e.g., educational stability, permanency connections, symptom
reduction), and progress shall be reviewed at each CFT meeting
during the transition phase.
8. Contractor shall ensure that data from transition (e.g., permanency
outcomes, natural support involvement, family satisfaction surveys) is
reported back to the Community Leadership Team to identify and
address system barriers impacting HFW implementation.
5. For Indian Persons Served/families, the Contractor shall ensure that Tribes are engaged
at the earliest point of referral, and that Tribal representatives are included in CFT
meetings, plan development, and transition planning, in accordance with Indian Child
Welfare Act (ICWA) requirements and HFW practice standards.
6. Throughout the course of the four phases of wraparound, Contractor will elicit continuous
feedback from persons served/families and incorporate that feedback into service
planning, CFT decision-making, and CQI processes.
7. It is likely that some youth in the Wraparound program will be placed in a highly intensive
therapeutic placement setting such as Enhanced Intensive Services Foster Care (E-ISFC)
or an Enhanced STRTP (E-STRTP). For youth dually enrolled in Wraparound and an
intensive service setting, the Person-Served's CFT will determine which agency and which
person is assigned as lead for the following tasks based on existing therapeutic
relationships, treatment goals, and transition goals:
i. Advanced clinical services (example: therapy and psychiatry)
ii. Behavioral intervention/rehabilitation
iii. Case coordination such as CFT facilitation, case management, plan development
iv. Permanency work and family finding
8. Wraparound team members shall have the flexibility to adjust service levels based on the
needs of the youth and family. When the youth is in an intensive service setting, the
Wraparound team will remain engaged and responsible for care coordination and other
tasks as identified by the CFT and may need to decrease service intensity to avoid
duplication with the placement provider. Wraparound teams shall also be flexible to
increase service intensity when needed and as determined by the CFT.
9. Contractor shall ensure that staff and their supervisors are provided with feedback on their
ability to meet required service and reporting timelines. Such feedback shall be
B-2-11
Revised Exhibit B-2
incorporated into CQI processes, including but not limited to monthly reports, performance
monitoring meetings, and any County-requested CQI reports, to promote accountability,
improve service delivery, and support staff development.
10. Contractor shall ensure that all requests, approvals, and expenditures of Flexible Funds
are consistent with the County's Flex Fund Policy (Exhibit T). Contractors shall integrate
Flex Fund utilization into the service planning process, including documentation of team
recommendations, purpose of expenditure, and expected outcomes.
11. Length of Stay:
i. The approximate length of stay for the traditional Wrap service line is nine (9) to
twelve (12) months. While stated length of stay reflects general parameters, a
youth and family's ongoing participation in the Wrap program is driven by their
demonstrated need.
C. Super Wrap
1. In addition to the above-mentioned Wraparound services, the Contractor shall provide
higher intensity Wrap services referred to as "Super Wrap" to four (4) youth, at any given
time, who have been pre-authorized for these services by the County. Super Wrap team
caseload size shall be one (1) youth per team. Contractor has discretion regarding team
make-up.
2. Contractor shall ensure that the Super Wrap Team provides up to twenty-five (25) hours
per week of care coordination and/or support services to the Person Served, on behalf of
the Person Served, or to the Caregiver.
3. Contractor shall ensure that at least one staff person is available by phone and in person,
if needed, 24 hours per day, 7 days per week during the service period to provide support
and services to youth and their Caregivers on request.
4. Contractor shall ensure that each Super Wrap Team provides four (4) phases of effective
Wrap care coordination and supportive services as outlined in Wraparound section 3 with
these frequency modifications for Super Wrap participants:
i. Initial plan development. (All timelines are determined by date of first contact,
which is to occur within 24 hours of receiving the referral.)
1. Facilitator, in collaboration with the CFT shall develop a WAP within
14 calendar days of commencing Wrap services that will be reviewed
at each CFT meeting, delineating SMART goals and the specific
action steps that each member of the CFT will take to put the plan into
effect in order to achieve the goals, including: what is going to be
done, who is going to do it, when it should be completed, and how the
CFT will know the action step is completed and whether it was
effective.
2. Clinician shall collaborate with the Person Served and their Caregiver
to complete an ecomap, genogram, PSC-35, and any other
B-2-12
Revised Exhibit B-2
documentation required by the County within 14 calendar days of
commencing Super Wrap services, unless otherwise noted.
ii. Plan implementation: During the next three (3) months of Super Wrap services:
1. Facilitator, in collaboration with the referring CSW or DPO, shall
ensure that the CFT meets no less frequently than every two (2)
weeks in order to monitor progress since the prior CFT meeting;
support the inclusion on the CFT of"natural supports," that is
individuals in the ecologies of Person Served and their Caregiver who
provide care and support; identify emerging skills and competencies,
supports and resources that can be utilized to achieve objectives and
foundational goals; develop hypotheses about how to achieve desired
outcomes in short windows of time; and develop action steps
designed to address larger foundational goals that can be
accomplished weekly or monthly in order to maintain momentum by
quickly demonstrating to Persons Served, their Caregiver(s), and
other CFT members that progress is being made and there is hope for
change.
2. Facilitator, and Family Partner as needed, shall meet at least two (2)
times per week with the Person Served and their Caregiver to ensure
that the action steps are taken, to troubleshoot difficulties they may
have encountered, and provide assistance navigating systems as
needed.
3. Support Counselor shall meet at least two (2) times per week with the
Person served and their Caregiver to review, coach and support
behavioral interventions that my help shift behaviors, support insight
building around connection between emotions, thoughts, and
behaviors, and support identity building and strengthening.
4. Therapist shall meet at least two (2) times per week with each Person
Served and/or their Caregiver to provide individual or family therapy
as indicated and, utilizing evidence-based practices (e.g., Motivational
Interviewing, CBT, DBT, IFS Therapy), to address the individual
Person Served's experience of relational and attachment trauma.
5. Family Partner shall meet at least one (1) time every week with the
Caregiver to provide support navigating the numerous systems of
care and service provision impacting their lives.
iii. Transition: Approximately 45 calendar days prior to termination of Super Wrap
services and support:
1. Facilitator, Support Counselor, and Family Partner as appropriate,
shall ensure the Person Served and their Caregiver have adequate
support systems, both formal and "natural," to sustain progress
achieved during Super Wrap, and that proper referrals have been
made and no fewer than six (6) "warm handoffs" to ongoing formal
service providers have been completed.
5. Length of Stay:
B-2-13
Revised Exhibit B-2
i. The approximate length of stay for the Super Wrap service line is 90-days. While
stated service timeline reflects general parameters, a youth and family's length of
stay in the Super Wrap program is driven by their demonstrated need.
ii. All extension requests for Super Wrap services would need to be presented to the
County for approval. These presentations shall include the start date for Super
Wrap services, the average frequency and duration of scheduled services,
description of the youth's level of engagement and progress or lack of progress in
treatment and any other relevant treatment information that would explain why this
youth needs to remain at the Super Wrap level of service. The contractor shall
also present a projected transition date for when the youth can return to traditional
Wrap services.
D. Crisis Services
1. Contractor shall develop, document, and implement individualized crisis and safety plans
for each youth and family in accordance with HFW standards. Contractor shall provide
supports designed to reduce the need for professional crisis interventions by strengthening
the family's and natural supports' capacity to manage crises.
i. At the time of Engagement, the Wrap team shall discuss any immediate crisis or
safety concerns raised by the youth or family. If pressing concerns are identified,
the team will develop an immediate written crisis response plan, provide a copy of
the plan to the family, and document it in the youth's chart.
ii. The immediate crisis plan shall inform, but not replace, the formal HFW Safety
Plan developed during the Plan Development phase.
iii. All families shall be provided with clear information on how to access 24/7 crisis
response when needed, including the on-call contact process.
iv. Contractor shall ensure Wrap staff are trained to implement safety and preventive
measures when responding to any self- harming and/or other behaviors that pose
risk to the youth or others. Wrap staff shall be prepared to initiate mobile
response services by contacting the treating provider, FURS, or 911, as clinically
indicated. Should the youth require an emergency evaluation for acute psychiatric
hospitalization, Wrap staff shall take the necessary steps to ensure the youth
receives the appropriate intervention to address the mental health crisis.
2. Contractor shall ensure that Wrap staff or Wrap administrator notify the CWS hotline, the
CSW), DPO and appropriate CWS Division Chief/Assistant Deputy Chief(ADC), or
designee for all incidents that indicate a sign of threat or continued risk to the physical or
mental health status of the Wrap youth including all such incidents that require a Critical
Incident Report, as outlined in this agreement.
i. The Contractor shall then follow up with the SW by phone within one business day
of the incident.
3. Contractor shall comply with the following when youth are referred for psychiatric
hospitalization:
i. Notify the CWS hotline, the SW, DPO and appropriate CWS Division Chief/ADC,
or designee as soon as it is reasonably safe to do so, but no later than the end of
the day and complete a critical incident report.
1. The Contractor shall then follow up with the SW by phone within one
business day.
B-2-14
Revised Exhibit B-2
ii. Participate in case conferences, hospital discharge conference and/or the CFT
meetings for youth referred for psychiatric hospitalization.
iii. Continue to provide Wrap services, to the extent possible, during the youth's
hospitalization.
iv. Initiate a CFT meeting within 24 hours of youth's return to the community.
4. Contractor shall track and report all crisis incidents, including those averted through
natural supports and those requiring professional intervention (e.g., mobile crisis,
emergency department, psychiatric hospitalization, law enforcement involvement). A
quarterly report summarizing crisis incidents, responses, and outcomes shall be submitted
to the County.
E. Additional Responsibilities
1. Maintain responsibility for necessary testimony and/or providing County with information
needed to generate court reports, as outlined below:
i. Court Reports - Documented reports of assessment and evaluation findings,
progress in treatment, recommendations for treatment and service plans
regarding reunification, maintenance and termination of parental rights, and
justification for recommendations.
ii. Court Testimony - Provide care plan updates when a court is considering
reunification, maintenance, and/or termination of parental rights.
2. Upon notification of a pending court hearing, Contractor agrees to complete and submit to
the County a "Periodic Review Report" twenty-one (21) calendar days prior to the court
date or seven (7) calendar days after notification.
3. Maintain electronic health records and supply their own personal computers, Internet
access, printers, signature pads and other network devices to meet statistical reporting
requirements, report Person-Served and program outcomes and any State or County data
requirements of the Katie A. Implementation Plan. Contractor shall also maintain capability
to enter electronic billing data into County's electronic health record system. A computer
with Internet access is required for both office and field-based staff.
4. Cooperate and participate with the County MHP in Quality Assurance/Improvement and
Utilization Review Programs and grievance procedures and comply with all final
determinations rendered by County's Quality Assurance/Improvement and Utilization
Review Programs, unless the decision is reversed on appeal as set forth in the County
MHP Provider Manual, incorporated herein by this reference. County's adverse decisions
regarding Contractor's services to Persons-Served may result in the disallowance of
payment for services rendered; or may result in additional controls to the delivery of
services; or may result in the termination of this Agreement. County shall have sole
discretion in the determination of Quality Assurance/Improvement and Utilization Review
outcomes, decisions and actions.
5. Obtain signatures, as required, regarding consent:
i. Care provider can sign for day trips and other minor miscellaneous items.
ii. Court Order should suffice for most other items.
6. Work collaboratively with other CWBC providers to develop and enter into Memorandum
of Understanding or other business agreements between themselves that defines the
processes and procedures for provision of services to foster youth, including, but not
limited to the:
B-2-15
Revised Exhibit B-2
i. Case Planning
ii. Care Coordination
iii. Intensive Transition Planning
iv. Assessment
v. Transportation between service settings
vi. Information sharing
vii. Data collection and dissemination
7. Work with DPO on criminogenic risk factors for probation youth as addressed through
contracted services as applicable.
F. Admission, Transition and Discharge
1. Entry Criteria
All youth referred to the Wrap and Super Wrap services will have pre-approval from
the County. This includes STRTP aftercare and re-referrals. Equal access is
required. Services shall not be denied or delayed based on the youth's placement,
geographic location (including out-of-county placements under presumptive transfer),
disability, or cultural needs.
Family First Prevention Services Act (FFPSA) Part IV mandates six months family-
based aftercare services for children discharged from qualified residential treatment
programs to family-based settings, including high-fidelity Wrap ( ACL 21-116).
Fresno County will be leveraging existing Wraparound services to meet this
requirement.
2. Intake and Initial Assessment
Contractor shall respond to all Wrap and Super Wrap referrals within 24 hours of
receipt. Youth referred to this program may have a current mental health assessment
with their primary treatment provider. If that assessment was completed within the
last six months and there have been no significant changes in the youth's symptoms,
the Contractor shall obtain a copy of that assessment and use it to inform treatment
planning. If there is no current mental health assessment, the youth's symptoms
have changed significantly and/or the previous assessment was completed longer
than six months ago, the Contractor shall complete a mental health assessment
within 14 calendar days or as soon as clinically appropriate.
In instances where a youth is currently enrolled in Wraparound services and is
subsequently identified as potentially eligible for Super Wraparound services,
Contractor shall, in coordination with the County, evaluate the youth's eligibility for
Super Wraparound within thirty (30) calendar days of identification. If deemed
appropriate, Contractor shall implement Super Wraparound services within this
timeframe. Ongoing communication with the County regarding the youth's status,
eligibility determination, and service transition shall be maintained throughout this
process.
3. Transition and Discharge
B-2-16
Revised Exhibit B-2
Youth referred to the Wrap/Super Wrap program may be denied services if the youth
does not meet medical necessity for specialty mental health services and/or the
necessary criteria to be eligible for Wrap/Super Wrap services. Youth who are
determined to be ineligible for these services will be linked to other appropriate
services and resources.
Discharge is determined on a case-by-case basis depending on the youth's progress
toward individualized treatment goals. Wraparound services operate with an
unconditional care approach; services are not ended solely due to challenges in
engagement, crisis events, or lack of progress. Instead, the team adapts strategies
and persists in supporting the youth and family until transition readiness is achieved.
Reasons for discharge include the youth or caregiver refuses or terminates services;
the youth is transferred to another program mutually agreed upon by the youth,
parent/caregiver, and Wrap; and/or mutual agreement that the treatment goals have
been met. For youth and families who decline or terminate services, reasonable and
documented efforts must reflect the team's attempts to engage and re-engage the
family in alignment with HFW standards.
All transitions and discharges shall be discussed in a CFT to ensure all members of
the youths' support system are aware of the recommendation being made by the
Contractor.
Contractor shall administer a survey to youth and families at discharge, collect and
track responses, and report data to the County. Surveys shall capture satisfaction
with services, family voice and choice, and perceived readiness for transition in
alignment with HFW standards. Aggregate results shall be incorporated into the
Contractor's CQI process and reported to the County as required.
VI. STAFFING
A. Each Contractor shall provide the following staffing components, at minimum:
1. Staffing shall be appropriate and aligned with the HFW model, which would include
the following roles: facilitator, family specialist, parent partner, youth partner, fidelity
coach, HFW Supervisor/Manager, and clinical supervisor.
2. Each Wrap and Super Wrap Team shall be comprised of:
a. One (1) Facilitator with a Mental Health Rehabilitation Specialist (MHRS)
qualification or above who meets with the youth, their Caregiver, and other
team members to complete assessments, individualized plans, and
Wraparound Action Plans; organize and facilitate Family Team meetings;
and ensure successful linkage of Persons Served and their Caregiver(s) to
ongoing resources and support. The Facilitator shall also serve as a support
and mentor to other members of the team, as needed.
A. Frequency of service for Wrap: at least one (1) contact per week
B. Frequency of service for Super Wrap: at least two (2) contacts per
week
b. A minimum of two (2) Support Counselors who are a bachelor's level
paraprofessional who shall meet with the Person Served to provide one-on-
B-2-17
Revised Exhibit B-2
one support for the Person Served, focusing on increasing the frequency of
desired behaviors, gaining access to pro-social activities and resources
within the community, and developing effective relationship-building skills.
A. Frequency of service for Wrap: at least one (1) contact per week
B. Frequency of service for Super Wrap: at least two (2) contacts per
week
c. One (1) Family/Parent Partner and One (1) Youth Partner, who has lived
experience, to provide support to the Person Served and their Caregiver in
navigating the numerous systems of care and service provision impacting
their lives as needed.
A. Frequency of service for Wrap: at least one (1) contact every 2
weeks
B. Frequency of service for Super Wrap: at least one (1) contact per
week
d. Fidelity coaching is to be provided to ensure services are delivered in
accordance with High Fidelity Wraparound principles and standards. The
position fulfilling this role will support staff through regular observation,
coaching sessions, and review of fidelity tools, promotes continuous quality
improvement, and ensures that facilitators, family partners, and youth
partners are implementing the model with fidelity.
3. Ensure each Wrap and Super Wrap team has access to:
a. One (1) Individual or Family Therapist to meet with the youth and their
Caregiver to provide individual or family therapy and utilizing evidence-
based practices (e.g., Motivational Interviewing, Cognitive Behavioral
Therapy, Dialectical Behavioral Therapy, Internal Family Systems Therapy)
to address youth's experience of relational and attachment trauma as
needed. If the youth choose to continue therapy with their current mental
health provider, the Wrap/Super Wrap therapist shall continue to provide
consultation to the other members of the WRAP/Super Wrap team and will
work in collaboration with the existing therapist to ensure joint services are
provided appropriately.
A. Frequency of service for Wrap: at least one (1) contact per week
as clinically appropriate
B. Frequency of service for Super Wrap: at least two (2) contacts per
week as clinically appropriate
b. One (1) Psychiatrist to meet with the Person Served to provide evaluation
and assessment for psychotropic medication, clinical consultation, and
assistance linking the Person Served and their Caregiver to ongoing
psychiatric services and support as needed and prioritizing continuity of care
where possible.
A. The frequency of psychiatry services will be at least one (1) time
per month for Wrap and Super Wrap participants.
4. Workforce development, including recruitment, hiring, training, and coaching, shall
be consistent with the California High Fidelity Wraparound (HFW) Standards and
Toolkit (Staffing Wraparound).
B-2-18
Revised Exhibit B-2
5. Ensure there is no change to a youth's primary Wraparound team members when
the youth transitions between the Wrap level of service and the Super Wrap level of
service to preserve the therapeutic relationship and provide continuity of care.
6. Ensure that direct service staff reimbursed through this contract shall spend at least
65% of their paid work time providing and documenting direct service to clients or
on behalf of clients. Administrative staff meetings, supervision meetings, and staff
trainings shall not be included in the 65%.
VII. TRAINING:
A. The California Wrap Standards require providers to have a HFW training plan that incorporates
initial, ongoing, and annual booster training to all staff as well as role specific training.
Contractor shall ensure that all Wrap and Super Wrap staff receive comprehensive initial
training and ongoing coaching consistent with the California HFW Standards (HFW Training)
and Fresno County expectations.
1. Foundational Training (Wraparound 101: Foundations for Fidelity)
a. All staff shall receive orientation and training in the Ten Principles of
Wraparound, the Four Phases of HFW (Engagement, Plan Development,
Implementation, Transition), and the use of High Fidelity Wraparound fidelity
indicators.
b. Staff shall be trained in trauma-informed, culturally respectful, and
linguistically competent practices.
c. Staff are trained in timely engagement strategies, including alternate
strategies when contact with families is difficult.
d. Supervisors and staff receive training on meeting timelines and CQI
processes tied to engagement, plan development, plan updates, and
reporting.
2. Needs-Driven, Strengths-Based and Solution-Focused Practices
a. Staff are trained to identify underlying needs, develop needs statements that
go beyond behaviors, and ensure plans are needs-focused rather than
deficit-focused.
b. Staff shall receive ongoing training and coaching in identifying functional
strengths of youth, caregivers, families, and community supports, and in
applying strengths to drive planning and service strategies.
c. Staff shall receive training in solution-focused and evidence-based practices
including, but not limited to, Motivational Interviewing, CBT, DBT, and IFS.
3. IP-CANS and Assessment Tools
a. Staff shall be trained to complete, interpret, and utilize the IP-CANS, PSC-
35, and other County-required assessments to guide planning and CQI.
b. Training includes requirements for timely completion (within 14 days of
engagement, updated every 90 days or within 30 days of a triggering event)
and integration into CFT decision-making.
4. Facilitation and Teaming
a. Facilitators shall be trained and coached in leading CFT meetings that are
inclusive of family, natural supports, and Tribes in the case of an Indian
child, and in ensuring family voice and choice are central to planning.
B-2-19
Revised Exhibit B-2
b. Training shall include engagement strategies, team-building activities, and
consensus-based decision-making.
5. Individualized Services
a. Facilitators and staff are trained to develop highly individualized plans of
care, using flexible strategies tailored to youth and family strengths, needs,
values, and culture.
6. Culturally Respectful and Relevant Services
a. Staff receive ongoing training in eliciting, honoring, and incorporating family
culture, traditions, and values into planning and service delivery.
b. Contractor shall provide training for staff on ICWA requirements, Tribal
sovereignty, and culturally responsive service delivery for Native American
youth and families.
7. Crisis and Safety Planning
a. Staff shall be trained in development and implementation of crisis and safety
plans, including proactive and reactive strategies, safety interventions, and
maximizing natural supports.
b. Training includes immediate crisis response procedures, 24/7 access, and
escalation protocols (FURS, mobile crisis, 911).
8. CQI and Fidelity Monitoring
a. Staff and supervisors shall receive training on the use of fidelity and quality
monitoring tools which may include but not limited to Wraparound Fidelity
Index [WFI], Team Observation Measure [TOM 2.0]), Document Assessment
Review Tool (DART), satisfaction surveys, and feedback loops to improve
practice.
b. Supervisors and coaches shall observe team meetings, review
documentation, and provide feedback to staff for ongoing skill-building and
adherence to HFW fidelity standards.
c. All staff are trained on how family feedback and fidelity measures inform CQI
processes.
9. Ongoing and Annual Requirements
a. All staff must complete at least an annual refresher training on Wraparound
principles, fidelity indicators, trauma-informed care, cultural competency,
and County-specific requirements.
b. Staff must attend County-offered trainings, which may include Quality
Parenting Initiative (QPI), Neurosequential Model of Therapeutics (NMT),
cultural competency, Civil Rights, and other System of Care initiatives.
c. Contractor shall maintain training logs, curricula, and attendance records,
and shall provide documentation of training completion to the County upon
request.
10. Youth, families and peer partners with current or prior Wraparound experience are
meaningfully incorporated into the delivery of required Wraparound trainings.
11. Community partners are invited to attend Wraparound trainings or are offered
trainings on Wraparound to strengthen their participation on HFW teams or to
strengthen their role in supporting HFW within the System of Care.
12. Develop training curriculum as County identifies a need.
13. Assist with training County staff and the community in Wraparound Service
processes and service options.
B-2-20
Revised Exhibit B-2
VIII. COUNTY RESPONSIBILITIES:
COUNTY shall:
A. Assist Contractors' efforts to evaluate the needs of each enrolled youth on an ongoing
basis to ensure each youth is receiving clinically appropriate services.
B. Provide oversight and collaborate with contractors, other County Departments, and
community agencies to help achieve State program goals and outcomes. Oversight
includes, but is not limited to, contract monitoring and coordination with the State
Department of Health Care Services (DHCS) and California Department of Social
Services (CDSS) in regard to program administration and outcomes.
C. Assist Contractors in making linkages with the total mental health system of care. This
will be accomplished through regularly scheduled meetings as well as formal and
informal consultation.
D. Participate in evaluating overall program progress and efficiency and remain
available to contractors for ongoing consultation.
E. Gather outcome information from target Person Served groups and Contractors
throughout each term of this Agreement. County shall notify Contractors when their
participation is required. The performance outcome measurement process will not be
limited to survey instruments but will also include, as appropriate, Person Served and
staff interviews, chart reviews, and other methods of obtaining required information.
F. Assist Contractors' efforts toward cultural and linguistic competency by providing the
following to contractors:
B. Technical assistance and training regarding cultural competency requirements at
no cost to contractors.
C. Mandatory cultural competency training for contractors' personnel, on an
annual basis, at minimum.
D. Technical assistance for translating information into County's threshold languages
(Spanish and Hmong). Translation services and costs associated will be the
responsibility of contractors.
VIII. REPORTS
Contractor shall track data and provide reporting on the following items and send all applicable
information and reports to the following distribution list for County staff: DSS Staff Analyst, DSS
Division Chief, DSS Social Work Supervisor, DBH Contract Analyst, Probation Assistant Deputy
Chief, and Probation Contract Analyst.
1) Contractors shall be expected to comply with all contract monitoring and compliance
protocols, procedures, data collection methods, and reporting requirements conducted
by County.
B-2-21
Revised Exhibit B-2
2) Contractors will be responsible for meeting with DBH and DSS on a monthly basis, or
more often as agreed upon between DBH, DSS, and Contractors, for contract and
performance monitoring.
3) Contractors will be required to submit monthly reports on performance measures to the
County. Report formats will be established through County/Contractor collaboration.
Outcome measures may change, based on information or measures needed. Required
monthly reports include:
a) DSS Monthly Activity Report (MAR); and
b) Other reports as established by the County.
4) All reports will be due to the County by the 101" business day of each month and will be
reviewed for accuracy. (If the 10t" lands on a weekend or Holiday, reports will be due
the next business day). Reimbursement for monthly expenses may be delayed in the
event inaccurate reports are submitted.
5) Provide county with various reports through the length of the youth's enrollment in the
program; a few of which are standardized and include: "Monthly Progress Report",
"Discharge Presentation", "Individual Child and Family Plan Presentation Outline", and
"Individual Child and Family Plan (ICFP)".
6) Contractor will report and document all major and/or sensitive incidents ("critical
incidents") to the County pursuant to the procedures and timing outlined in Exhibit J
"Fresno County Mental Health Plan Incident Report." The County, at its sole discretion,
may require the Contractor to conduct all necessary follow-up activities after reporting
critical incidents. If there is any doubt about whether an incident should be reported, the
default shall be for the Contractor to report the incident to the County.
7) Contractors shall use collected data not only for compliance reporting but also in real
time to improve practice with youth and families, including providing staff with timely
feedback from data or reports relevant to their service provision.
8) Data shall be reviewed and analyzed at multiple levels (youth/family, program, and
system) to identify staff training needs, address program effectiveness, and inform CQI
processes.
9) Contractor shall ensure that data is collected, analyzed, and utilized to identify and
communicate both outcomes of HFW implementation and system barriers that impact
service delivery, including those that impact Tribal youth. Outcomes and barriers shall be
elevated to the Community Leadership Team (CLT) for review, discussion, and
resolution.
10)Contractor shall ensure all data collection and reporting is culturally responsive, ensuring
outcomes are interpreted in the context of family culture, values, and vision.
11)Contractor shall participate in collaborative local CQI evaluation plans with County,
Providers, and System of Care participant organizations, as required by UC Davis HFW
fidelity indicators.
12)Additional reports and outcome information may be requested by County at a later date,
as needed.
IX. GOALS/OUTCOMES
Contractor is required to submit measurable outcomes on a semi-annual, as identified in the
DBH's Policy and Procedure Guide (PPG) 1.2.7 Performance Outcomes Measures.
Performance outcome measures must be approved by DBH and DSS and satisfy all State and
B-2-22
Revised Exhibit B-2
local mandates. County will provide technical assistance and support in defining measurable
outcomes. The outcome measures and indicators provided below represent County DBH and
DSS program goals to be achieved by the Contractor in addition to Contractor's developed
outcomes and the HFW Expected Outcomes. Outcomes for youth center on the following core
areas: permanency, behavioral stability, symptom reduction, living situation stability, strengths
development, and educational stability. Outcomes for Persons-Served vary based on their
individual needs and challenges faced by the specific youth and their plans of care; however,
common quantifiable outcomes at the program level include:
Fresno County Wraparound Contract Performance Expectations
Metric Definition Performance Indicator
Service Minimum service levels by the Wraparound: Ensure that the Wrap
utilization required staffing level in order to Team provides between 24 to 32 hours
earn full payment per month (about 6-8 per week) of care
coordination and/or support services to
Persons Served or to Person's Served
Caregiver.
Super Wrap: Ensure that the Super Wrap
Team provides approximately 100 hours
a month (about 25 hours a week) of
care coordination and/or support services
to the Person Served.
In no case should the hours of service
performed be less than the minimum
above.
Service Wrap 90% compliance with service timeliness
timeliness . Make contact with referral as documented in Monthly Activity
source within 24 hours Reports (MARs)
Initial face to face
engagement meeting within 72
hours of referral
• Follow-up meeting within 48
hours
IP-CANS completion within
14 calendar days of initial
meeting
Wrap Action Plan developed
within 30 calendar days of
initial meeting
• CFT meeting within 30
calendar days of initial meeting
B-2-23
Revised Exhibit B-2
(and w/n 24 hours of discharge
form inpatient admission)-
• Ecomap, genogram, PSC-35
created within 60 calendar
days of initial meeting
CFT meetings no less than
monthly-
• Weekly activity with
facilitator, family partner, youth
and caregiver
Support counselor meets at
least 1 x per week
Transition planning occurs 1-
2 months prior to end of Wrap
Super Wrap
• Make contact with referral
source within 24 hours
• Initial face to face
engagement meeting within 72
hours of referral
Follow-up meeting within 48
hours
• IP-CANS completion within
14 calendar days of initial
meeting
Wrap Action Plan developed
within 15 calendar days of
initial meeting
CFT meeting within 15
calendar days of initial meeting
(and w/n 24 hours of discharge
form inpatient admission)-
Ecomap, genogram, PSC-35
created within 15 calendar
days of initial meeting
CFT meetings no less than
every 2 weeks-
• Activity with facilitator, youth
and caregiver at least 2 x per
week
• Activity with family partner at
least 1 x per week
Support counselor meets at
least 2 x per week
B-2-24
Revised Exhibit B-2
Transition planning occurs 45
calendar days prior to end of
Wrap
Fresno County Wraparound Contract Outcomes
Metric Definition Performance Indicator
Improved Youth shall have a reduction in 90% of youth shall see a reduction in
behavioral/ action items in the action items on IP-CANS overtime
emotional Behavioral/Emotional Needs
needs Domain, Risk Behaviors Domain
Improved Youth will have improved scores 80% of youth shall show improvement on
Strengths in the Strengths domain of the IP-CANS overtime
IP-CANS
School Youth will demonstrate 80% of youth shall show improvement on
Improvement improved educational IP-CANS overtime
functioning from intake to
discharge as measured by IP-
CANS Life Functioning items
related to school functioning
including school behavior,
school achievement, and school
attendance.
Increase Natural Supports are actively At least one natural support attends 50%
Natural involved across all phases of of all CFTs.
Supports Wrap/Super Wrap.
Permanency Youth will have improved scores 90% of youth shall show improvement on
Planning in the Living Situation and IP-CANS overtime
B-2-25
Revised Exhibit B-2
Family Functioning items in the
Life Functioning Domain
Transition to Youth experience stability in 80% of youth accepted to the program
less their community-based living will be transitioned to less restrictive
restrictive situation and do not experience placements including but not limited to
placements a new placement in an legal or emotional/relational permanency
institution (such as detention, or with their family for stabilization and
psychiatric hospitalization, preservation of their family placement.
treatment center, or STRTP)
upon discharge.
Reduction in Youth experience stability with At least 80% of youth enrolled in
Inpatient, regard to their behavioral health, Wraparound will experience no more than
Emergency necessitating fewer or no visits one behavioral health-related inpatient or
Department to the hospital. emergency department admission during
Admission the course of enrollment.
for
Behavioral
Health Visits
Improved Youth experience improved At least 75% of youth will show improved
Functioning functioning in the community as scores on IP-CANS items related to
in the well as improved interpersonal Community and School Functioning over
Community functioning. time.
Client Youth and families are satisfied At least 75% of youth and caregivers
satisfaction with their HFW experience and shall report a positive experience of
progress, including caregiver services, perceived improvement in
confidence in their ability to functioning, and increased caregiver
manage the youth's needs and confidence, as measured through post-
access support. service surveys
In addition to the outcomes above being tracked on the MAR and other County-designated
reporting mechanisms (e.g., DOMO dashboards), Contractors shall utilize a computerized
tracking system with which performance and outcome measures and other relevant Person
Served data, such as demographics, will be maintained. The data tracking system may be
incorporated into the Contractors' electronic health records (EHR) systems or in stand-alone
databases (e.g., Access or Excel spreadsheets). County must be afforded read-only access to
the data tracking system.
County may adjust the performance and outcome measures periodically throughout the duration
of the Agreement, as needed, to best measure the program as determined by County and/or
CDSS/DHCS.
B-2-26
Exhibit T
Fresno County Wraparound
Flex Fund Policy
Preamble
This policy establishes guidance for the use of flexible funds within the High Fidelity
Wraparound (HFW) program. Flex funds are included in the program's funding plan and are
intended to support children, youth, and families in overcoming barriers, achieving stability, and
building on strengths. They are not supplemental money for general use, but a resource to
creatively and responsibly meet individualized needs when no other funding or resource is
available.
Policy
Flexible fund expenditures must be tied to the Wraparound Plan of Care and evaluated based
on the recommendation of the HFW team. Expenditures should add value to the team mission
and the individualized care plan, build on family strengths, meet identified youth and family
needs, be culturally relevant, build on natural supports and/or community capacity, represent a
good deal for the investment, and include a plan for sustainability. Requests should be discussed
and identified in the Child and Family Team (CFT) process and documented in the CFT summary.
In emergency situations where waiting for a CFT would create a barrier to timely access,
requests may be approved at the program level but must be presented to the CFT at the next
meeting. If the CFT denies the expenditure, the cost will be unallowable and cannot be included
in monthly invoices.
Allowable Uses
Examples include basic needs (food, clothing, utilities, housing-related costs), wellness or
enrichment activities (sports fees, music lessons, family outings), milestone or cultural
celebrations (birthdays, graduations), and tribal activities identified as important by the youth,
family, or Tribe. Flex funds may also be used for short-term crisis prevention and stabilization to
prevent placement disruption, hospitalization, or entry into higher levels of care.
Non-Allowable Uses
Flex funds may not be used to provide cash directly to families or youth. They may not be
applied toward services or expenses already covered by Medi-Cal, insurance, or separate line
items within approved budget, nor for luxury or entertainment items that are not tied to the
Wraparound Plan of Care.
Fiscal Cap
Flex fund requests should remain modest, with expenditures limited to an average amount of
$35 per youth, per month, not to exceed $420 per youth annually, unless prior Department of
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Exhibit T
Social Services (DSS) approval and justification are obtained. This annualized cap allows
flexibility in utilization, recognizing that some youth may require less support in certain months
and more in others. Providers must ensure that funds are used equitably across all youth and
that expenditures remain within their approved line-item budget amounts.
Providers are responsible for monitoring their flex fund line item to ensure sufficient funds
remain available for the duration of the contract period. If it becomes evident that the approved
budget line item is insufficient to meet projected needs, providers must submit a timely budget
modification request to DSS for review and approval.
As part of documentation, each vendor must maintain individual cost tracking of flex funds
spent per youth to ensure expenditures are transparent, equitable, and aligned with this policy.
Timely Access
Providers must maintain processes that allow for urgent family needs to be addressed promptly,
even outside of regular CFT meetings.
Approval Process
All requests must be reviewed through the provider's established approval process, using the
evaluation criteria outlined in this policy. Providers are expected to maintain their own internal
policies and procedures that ensure timely access to flex funds and a clear approval process that
aligns with this policy. Requests may be approved at the program level as long as expenditures
remain within the fiscal cap described above. Any request that would exceed those limits, or
that raises questions of appropriateness, requires prior DSS approval with documented
justification.
Appeals Process
If a request is denied, the provider must document the reason, communicate the denial to the
youth, family, and team, and inform them of an appeal process. Appeals include review by
program management and consultation with the DSS.
Monitoring
DSS will review flex fund expenditures during contract monitoring. Providers must maintain
documentation of all requests, approvals, denials, receipts, and outcomes. Unallowable or
undocumented costs may not be reimbursed by DSS.
County Authority
DSS reserves the right to adjust the monthly cap, allowable ranges, or other policy elements
based on available funding and program needs.
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