BILL NUMBER: AB 334 CHAPTERED 10/03/01 CHAPTER 454 FILED WITH SECRETARY OF STATE OCTOBER 3, 2001 APPROVED BY GOVERNOR OCTOBER 2, 2001 PASSED THE ASSEMBLY SEPTEMBER 12, 2001 PASSED THE SENATE SEPTEMBER 10, 2001 AMENDED IN SENATE AUGUST 27, 2001 AMENDED IN SENATE JUNE 25, 2001 AMENDED IN ASSEMBLY MAY 31, 2001 INTRODUCED BY Assembly Member Steinberg (Principal coauthor: Assembly Member Cox) (Coauthors: Assembly Members Aroner, Chan, Keeley, Koretz, Liu, and Strom-Martin) (Coauthors: Senators Chesbro, Kuehl, Machado, Scott, and Soto) FEBRUARY 16, 2001 An act to amend Sections 5806, 5811, 5814, and 5814.5 of the Welfare and Institutions Code, relating to mental health. LEGISLATIVE COUNSEL'S DIGEST AB 334, Steinberg. Mental health funding: local grants. Existing law provides for the allocation of state funds to counties for mental health programs. Existing law requires the State Department of Mental Health to establish service standards relating to mental health services. These standards are required to include, among other things, plans for services, evaluation strategies, coordination, and access to related medications, substance abuse services, housing assistance, vocational rehabilitation, and veterans' services. Existing law requires the department to select up to 3 counties or portions of counties for eligibility for demonstration grants to be used to provide comprehensive services to certain adults who are severely mentally ill. Existing law also requires the director to establish a methodology for awarding these grants and to establish a designated advisory committee. This bill would make various statements of legislative findings and intent regarding the need to provide sufficient funds to counties for adult mental health and related services. This bill would define the outreach services that are part of the service planning and delivery process under the bill. This bill would provide that the outreach to adults required as part of the service standards may include adults voluntarily or involuntarily hospitalized as a result of a severe mental illness. This bill would also require that the service standards include provision for persons who have been suffering from an untreated severe mental illness for less than one year, and who do not require the full range of services but are at risk of becoming homeless unless a comprehensive individual and family support services plan is implemented. The bill would require that these persons be served in a manner that is designed to meet their needs. This bill would also make various changes in and additions to reporting requirements. This bill would also add certain training, consultation, and technical assistance requirements to existing law. This bill would also provide for services for persons who have been suffering from an untreated severe mental illness for less than one year. This bill would also provide for training for various professionals likely to come into contact with persons who may be suffering from an untreated severe mental illness. This bill would also require that proposals to be submitted to the state by a city or county be reviewed by a local advisory committee, including clients, family members, private providers of services, and other relevant stakeholders. This bill would require the advisory committee to provide to the director written comment on each of the county programs. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. The Legislature finds and declares all of the following: (a) In 1999, the Legislature recognized the longstanding problem of the underfunded community mental health care system and the consequences of severely mentally ill adults not getting treatment resulting in these adults being homeless, incarcerated in jails and prisons, and hospitalized. (b) The Legislature began to address this problem by funding three pilot programs in Los Angeles, Sacramento, and Stanislaus Counties to provide extended community mental health services and outreach to mentally ill adults who are homeless or at risk of homelessness. (c) Chapter 617 of the Statutes of 1999 (AB 34), required the State Department of Mental Health to evaluate these programs and determine if they were effective in reducing the risk of continued homelessness, incarceration, or hospitalization. (d) A May 2000 report showed that the legislation has been a great success, and the programs are having excellent results. Days of hospitalization were reduced by 60 percent, days of homelessness were reduced by 65 percent, and days in jail were reduced by 80 percent. (e) The State Budget for the 2000-01 fiscal year added 26 additional counties and cities to participate in the program. These counties have developed new programs in efforts to replicate the success of the three pilot programs in order to take this program statewide. (f) While the program has been successful in helping those that it has served, there is still the need to expand the program to service a sufficient number of people so as to make a difference noticeable to law enforcement officers and the public as to the number of homeless and mentally ill people on our streets; a difference noticeable to sheriffs as to the population in their jails of people who are suffering from mental illnesses; and a noticeable difference in the number of hospitalizations of people with mental illness who did not receive timely assistance. (g) The counties receiving funding for this program should continue to be required to demonstrate the effectiveness of the program, including those who will have received funds on a countywide basis for at least three years. Those counties should be required to quantify the benefits and the impact the program is making on the streets, in the jails, and in hospitals. (h) One of the greatest values of integrated treatment services is that it can lead to recovery by dealing with all of the aspects of a person's mental illness. For those counties that were funded both in the 1999-2000 and 2000-01 fiscal years, there are now nearly 1,000 individuals who will have received services for more than a year. Those programs are evaluated on the extent to which they are succeeding in enabling the individual served to significantly recover and reduce their overall public dependence due to their mental illness. (i) The outreach services of the AB 34 program provide opportunities for earlier intervention so that a person's mental illness can be treated before it is as severe as it might otherwise become if left untreated for a considerable period of time. Chapter 617 of the Statutes of 1999 specifically expanded outreach to serve individuals who were not homeless and were living with their family members. Many of these individuals are likely to be experiencing the early phases of severe mental illness. Studies from pilot programs in Australia, Canada, and Norway show that when outreach is expanded to include families, primary care physicians, and the general community, treatment is sought and received within six months of the onset of a severe mental illness as compared to more than two years of untreated mental illness without this special outreach effort. These same studies also show that when treatment is provided within the first six months of the onset of symptoms of mental illness, the majority of individuals are back in full-time work or education within one year of treatment. Less than 20 percent of individuals with untreated illnesses of more than two years achieve such full recovery even following several years of treatment. (j) Outreach efforts should include outreach to family members of persons with mental illness, employment centers, and other places where young adults are likely to be found in order to enhance the likelihood that symptoms will be more readily recognized and treatment sought before the illness has progressed to a level that results in homelessness. SEC. 2. Section 5806 of the Welfare and Institutions Code is amended to read: 5806. The State Department of Mental Health shall establish service standards that ensure that members of the target population are identified, and services provided to assist them to live independently, work, and reach their potential as productive citizens. The department shall provide annual oversight of grants issued pursuant to this part for compliance with these standards. These standards shall include, but are not limited to, all of the following: (a) A service planning and delivery process that is target population based and includes the following: (1) Determination of the numbers of clients to be served and the programs and services that will be provided to meet their needs. The local director of mental health shall consult with the sheriff, the police chief, the probation officer, the mental health board, contract agencies, and family, client, ethnic and citizen constituency groups as determined by the director. (2) Plans for services, including outreach to families whose severely mentally ill adult is living with them, design of mental health services, coordination and access to medications, psychiatric and psychological services, substance abuse services, supportive housing or other housing assistance, vocational rehabilitation, and veterans' services. Plans shall also contain evaluation strategies, that shall consider cultural, linguistic, gender, age, and special needs of minorities in the target populations. Provision shall be made for staff with the cultural background and linguistic skills necessary to remove barriers to mental health services due to limited-English-speaking ability and cultural differences. Recipients of outreach services may include families, the public, primary care physicians, and others who are likely to come into contact with individuals who may be suffering from an untreated severe mental illness who would be likely to become homeless if the illness continued to be untreated for a substantial period of time. Outreach to adults may include adults voluntarily or involuntarily hospitalized as a result of a severe mental illness. (3) Provisions for services to meet the needs of target population clients who are physically disabled. (4) Provision for services to meet the special needs of older adults. (5) Provision for family support and consultation services, parenting support and consultation services, and peer support or self-help group support, where appropriate. (6) Provision for services to be client-directed and that employ psychosocial rehabilitation and recovery principles. (7) Provision for psychiatric and psychological services that are integrated with other services and for psychiatric and psychological collaboration in overall service planning. (8) Provision for services specifically directed to seriously mentally ill young adults 25 years of age or younger who are homeless or at significant risk of becoming homeless. These provisions may include continuation of services that would still be received through other funds had eligibility not been terminated due to age. (9) Services reflecting special needs of women from diverse cultural backgrounds, including supportive housing that accepts children, personal services coordinator therapeutic treatment, and substance treatment programs that address gender specific trauma and abuse in the lives of persons with mental illness, and vocational rehabilitation programs that offer job training programs free of gender bias and sensitive to the needs of women. (10) Provision for housing for clients that is immediate, transitional, permanent, or all of these. (11) Provision for clients who have been suffering from an untreated severe mental illness for less than one year, and who do not require the full range of services but are at risk of becoming homeless unless a comprehensive individual and family support services plan is implemented. These clients shall be served in a manner that is designed to meet their needs. (b) Each client shall have a clearly designated mental health personal services coordinator who may be part of a multidisciplinary treatment team who is responsible for providing or assuring needed services. Responsibilities include complete assessment of the client' s needs, development of the client's personal services plan, linkage with all appropriate community services, monitoring of the quality and follow through of services, and necessary advocacy to ensure each client receives those services which are agreed to in the personal services plan. Each client shall participate in the development of his or her personal services plan, and responsible staff shall consult with the designated conservator, if one has been appointed, and, with the consent of the client, consult with the family and other significant persons as appropriate. (c) The individual personal services plan shall ensure that members of the target population involved in the system of care receive age, gender, and culturally appropriate services, to the extent feasible, that are designed to enable recipients to: (1) Live in the most independent, least restrictive housing feasible in the local community, and for clients with children, to live in a supportive housing environment that strives for reunification with their children or assists clients in maintaining custody of their children as is appropriate. (2) Engage in the highest level of work or productive activity appropriate to their abilities and experience. (3) Create and maintain a support system consisting of friends, family, and participation in community activities. (4) Access an appropriate level of academic education or vocational training. (5) Obtain an adequate income. (6) Self-manage their illness and exert as much control as possible over both the day-to-day and long-term decisions which affect their lives. (7) Access necessary physical health care and maintain the best possible physical health. (8) Reduce or eliminate serious antisocial or criminal behavior and thereby reduce or eliminate their contact with the criminal justice system. (9) Reduce or eliminate the distress caused by the symptoms of mental illness. (10) Have freedom from dangerous addictive substances. (d) The individual personal services plan shall describe the service array that meets the requirements of subdivision (c), and to the extent applicable to the individual, the requirements of subdivision (a). SEC. 3. Section 5811 of the Welfare and Institutions Code is amended to read: 5811. The State Department of Mental Health shall provide participating counties all of the following: (a) Request for proposals, application guidelines, and format, and coordination and oversight of the selection process as described in Article 2 (commencing with Section 5803). (b) Contracts with each state funded county stipulating the approved budget, performance outcomes, and scope of work. (c) Training, consultation, and technical assistance for county applicants. This training, consultation, and technical assistance shall include: (1) Efforts to ensure that all of the different programs are operating as well as they can. (2) Information on which programs are having particular success in particular areas so that they can be replicated in other counties. (3) Technical assistance to counties in their first two years of participation to ensure quality and cost-effective service. SEC. 4. Section 5814 of the Welfare and Institutions Code is amended to read: 5814. (a) (1) This part shall be implemented only to the extent that funds are appropriated for purposes of this part. To the extent that funds are made available, the first priority shall go to maintain funding for the existing programs that meet adult system of care contract goals. The next priority for funding shall be given to counties with a high incidence of persons who are severely mentally ill and homeless or at risk of homelessness, and meet the criteria developed pursuant to paragraphs (3) and (4). (2) The director shall establish a methodology for awarding grants under this part consistent with the legislative intent expressed in Section 5802, and in consultation with the advisory committee established in this subdivision. (3) (A) The director shall establish an advisory committee for the purpose of providing advice regarding the development of criteria for the award of grants, and the identification of specific performance measures for evaluating the effectiveness of grants. The committee shall review evaluation reports and make findings on evidence-based best practices and recommendations for grant conditions. At not less than one meeting annually, the advisory committee shall provide to the director written comments on the performance of each of the county programs. Upon request by the department, each participating county that is the subject of a comment shall provide a written response to the comment. The department shall comment on each of these responses at a subsequent meeting. (B) The committee shall include, but not be limited to, representatives from state, county, and community veterans' services and disabled veterans outreach programs, supportive housing and other housing assistance programs, law enforcement, county mental health and private providers of local mental health services and mental health outreach services, the Board of Corrections, the State Department of Alcohol and Drug Programs, local substance abuse services providers, the Department of Rehabilitation, providers of local employment services, the State Department of Social Services, the Department of Housing and Community Development, a service provider to transition youth, the United Advocates for Children of California, the California Mental Health Advocates for Children and Youth, the Mental Health Association of California, the California Alliance for the Mentally Ill, the California Network of Mental Health Clients, the Mental Health Planning Council, and other appropriate entities. (4) The criteria for the award of grants shall include, but not be limited to, all of the following: (A) A description of a comprehensive strategic plan for providing outreach, prevention, intervention, and evaluation in a cost appropriate manner corresponding to the criteria specified in subdivision (c). (B) A description of the local population to be served, ability to administer an effective service program, and the degree to which local agencies and advocates will support and collaborate with program efforts. (C) A description of efforts to maximize the use of other state, federal, and local funds or services that can support and enhance the effectiveness of these programs. (b) In each year in which additional funding is provided by the State Budget the department shall establish programs that offer individual counties sufficient funds to comprehensively serve severely mentally ill adults who are homeless, recently released from a county jail or the state prison, or others who are untreated, unstable, and at significant risk of incarceration or homelessness unless treatment is provided to them and who are severely mentally ill adults. For purposes of this subdivision, "severely mentally ill adults" are those individuals described in subdivision (b) of Section 5600.3. In consultation with the advisory committee established pursuant to paragraph (3) of subdivision (a), the department shall report to the Legislature on or before May 1 of each year in which additional funding is provided, and shall evaluate, at a minimum, the effectiveness of the strategies in providing successful outreach and reducing homelessness, involvement with local law enforcement, and other measures identified by the department. The evaluation shall include for each program funded in the current fiscal year as much of the following as available information permits: (1) The number of persons served, and of those, the number who are able to maintain housing, and the number who receive extensive community mental health services. (2) The number of persons with contacts with local law enforcement and the extent to which local and state incarceration has been reduced or avoided. (3) The number of persons participating in employment service programs including competitive employment. (4) The number of persons contacted in outreach efforts who appear to be severely mentally ill, as described in Section 5600.3, who have refused treatment after completion of all applicable outreach measures. (5) The amount of hospitalization that has been reduced or avoided. (6) The extent to which veterans identified through these programs' outreach are receiving federally funded veterans' services for which they are eligible. (7) The extent to which programs funded for three or more years are making a measurable and significant difference on the street, in hospitals, and in jails, as compared to other counties or as compared to those counties in previous years. (c) Each project shall include outreach and service grants in accordance with a contract between the state and approved counties that reflects the number of anticipated contacts with people who are homeless or at risk of homelessness, and the number of those who are severely mentally ill and who are likely to be successfully referred for treatment and will remain in treatment as necessary. (d) All counties that receive funding shall be subject to specific terms and conditions of oversight and training which shall be developed by the department, in consultation with the advisory committee. (e) (1) As used in this part, "receiving extensive mental health services" means having a personal services coordinator, as described in subdivision (b) of Section 5806, and having an individual personal service plan, as described in subdivision (c) of Section 5806. (2) The funding provided pursuant to this part shall be sufficient to provide mental health services, medically necessary medications to treat severe mental illnesses, alcohol and drug services, transportation, supportive housing and other housing assistance, vocational rehabilitation and supported employment services, money management assistance for accessing other health care and obtaining federal income and housing support, accessing veterans' services, stipends, and other incentives to attract and retain sufficient numbers of qualified professionals as necessary to provide the necessary levels of these services. These grants shall, however, pay for only that portion of the costs of those services not otherwise provided by federal funds or other state funds. (3) Methods used by counties to contract for services pursuant to paragraph (2) shall promote prompt and flexible use of funds, consistent with the scope of services for which the county has contracted with each provider. (f) Contracts awarded pursuant to this part shall be exempt from the Public Contract Code and the state administrative manual and shall not be subject to the approval of the Department of General Services. (g) Notwithstanding any other provision of law, funds awarded to counties pursuant to this part and Part 4 (commencing with Section 5850) shall not require a local match in funds. SEC. 5. Section 5814.5 of the Welfare and Institutions Code is amended to read: 5814.5. (a) (1) In any year in which funds are appropriated for this purpose through the annual Budget Act, counties funded under this part in the 1999-2000 fiscal year are eligible for funding to continue their programs if they have successfully demonstrated the effectiveness of their grants received in that year and to expand their programs if they also demonstrate significant continued unmet need and capacity for expansion without compromising quality or effectiveness of care. (2) In any year in which funds are appropriated for this purpose through the annual Budget Act, other counties or portions of counties, or cities that operate independent public mental health programs pursuant to Section 5615 of the Welfare and Institutions Code, are eligible for funding to establish programs if a county or eligible city demonstrates that it can provide comprehensive services, as set forth in this part, to a substantial number of adults who are severely mentally ill, as defined in Section 5600.3, and are homeless or recently released from the county jail or who are untreated, unstable, and at significant risk of incarceration or homelessness unless treatment is provided. (b) (1) Counties eligible for funding pursuant to subdivision (a) shall be those that have or can develop integrated adult service programs that meet the criteria for an adult system of care, as set forth in Section 5806, and that have, or can develop, integrated forensic programs with similar characteristics for parolees and those recently released from county jail who meet the target population requirements of Section 5600.3 and are at risk of incarceration unless the services are provided. Before a city or county submits a proposal to the state to establish or expand a program, the proposal shall be reviewed by a local advisory committee or mental health board, which may be an existing body, that includes clients, family members, private providers of services, and other relevant stakeholders. Local enrollment for integrated adult service programs and for integrated forensic programs funded pursuant to subdivision (a) shall adhere to all conditions set forth by the department, including the total number of clients to be enrolled, the providers to which clients are enrolled and the maximum cost for each provider, the maximum number of clients to be served at any one time, the outreach and screening process used to identify enrollees, and the total cost of the program. Local enrollment of each individual for integrated forensic programs shall be subject to the approval of the county mental health director or his or her designee. (2) Each county shall ensure that funds provided by these grants are used to expand existing integrated service programs that meet the criteria of the adult system of care to provide new services in accordance with the purpose for which they were appropriated and allocated, and that none of these funds shall be used to supplant existing services to severely mentally ill adults. In order to ensure that this requirement is met, the department shall develop methods and contractual requirements, as it determines necessary. At a minimum, these assurances shall include that state and federal requirements regarding tracking of funds are met and that patient records are maintained in a manner that protects privacy and confidentiality, as required under federal and state law. (c) Each county selected to receive a grant pursuant to this section shall provide data as the department may require, that demonstrates the outcomes of the adult system of care programs, shall specify the additional numbers of severely mentally ill adults to whom they will provide comprehensive services for each million dollars of additional funding that may be awarded through either an integrated adult service grant or an integrated forensic grant, and shall agree to provide services in accordance with Section 5806. Each county's plan shall identify and include sufficient funding to provide housing for the individuals to be served, and shall ensure that any hospitalization of individuals participating in the program are coordinated with the provision of other mental health services provided under the program.