BILL ANALYSIS Ó
SB 364
Page 1
Date of Hearing: July 2, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 364 (Steinberg) - As Amended: June 26, 2013
SENATE VOTE : 39-0
SUBJECT : Mental health.
SUMMARY : Revises the law related to 72-hour treatment and
evaluation for individuals with a mental health disorder
(referred to as 5150 in reference to Welfare and Institutions
Code section 5150) by adding to the types of facilities that a
county is allowed to designate to provide services and allowing
county mental health directors to develop procedures for the
designation and training of professionals who can perform 5150
functions. Specifically, this bill :
1)Allows a county mental health director to develop procedures
for the designation and training of professionals who perform
5150 functions, including, but not limited to:
a) License types, practice disciplines, and clinical
experience of professionals eligible to be designated by
the county;
b) Training and testing requirements for professionals
eligible to be designated by the county;
c) Application and approval processes; and,
d) Processes for monitoring and reviewing professionals
designated by the county to ensure appropriate compliance
with state law, regulations, and county procedures.
2)Requires 5150-designated facilities to be licensed or
certified as mental health treatment facilities or hospitals,
as defined, by the Department of Health Care Services or the
Department of Public Health. Specifies that 5150-designated
facilities, may include, but are not limited to, licensed
psychiatric hospitals, licensed psychiatric health facilities,
and certified crisis stabilization units.
3)Removes a requirement for the Department of Social Services
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(DSS) to approve facilities for 72-hour treatment and
evaluation.
4)Modifies the legislative intent language in the
Lanterman-Petris-Short (LPS) Act to:
a) Update terminology: replaces "mentally disordered
persons" with "persons with mental health disorders,"
replaces "gravely disabled persons" with "persons who are
gravely disabled," and replaces "developmentally disabled
persons" with "persons with developmental disabilities;
b) Declare intent to provide consistent standards for
individuals receiving services under the LPS Act and those
receiving services under the Children's Civil Commitment
and Mental Health Treatment Act of 1988;
c) Declare intent to provide services in the least
restrictive setting appropriate to the needs of each person
receiving services under the LPS Act and the Children's
Civil Commitment and Mental Health Treatment Act; and,
d) Make other minor and technical changes.
5)Clarifies that telehealth may be used for evaluation under the
LPS Act.
6)Clarifies that the referral process includes each agency or
facility providing assessment, evaluation, crisis
intervention, or treatment services, and allows these services
to be provided through county or city mental health
departments, state hospitals, regional centers, or other
public or private entities.
7)Clarifies that crisis intervention interviews may include
family members, significant support persons, providers, or
other entities or individuals, as appropriate and as
authorized by law.
8)States legislative intent that referrals between facilities,
providers, and other organizations be facilitated by the
sharing of information and records, in accordance with current
state and federal laws, as specified.
9)Encourages each city or county mental health department to
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include on its Website a current list, updated annually, of
local ambulatory services and other resources for persons with
mental health disorders and substance use disorders.
10)Authorizes a professional person in charge of a facility
designated by the county for evaluation and treatment, a
member of the attending staff, or a professional person
designated by the county to provide 5150 assessment,
evaluation, and crisis intervention, as defined.
11)Allows a person who is a danger to self or others or gravely
disabled to be taken into custody for assessment, evaluation,
and crisis intervention.
12)Requires the professional person in charge of the facility,
member of the attending staff, or professional person
designated by the county to assess the person to determine
whether he or she can be properly served without being
detained. If so, requires that the person be provided
evaluation, crisis intervention, or other inpatient or
outpatient services on a voluntary basis.
13)Requires that, when a person is found to be in need of mental
health services, but is not admitted, all available
alternative services provided pursuant to 11) above be
offered, as determined by the county mental health director.
14)Requires a person, at the time he or she takes another person
into custody under the 5150 process, to provide currently
required oral advisements in a language or modality accessible
to the person and record documentation of that language or
modality. If the person is taken into custody at his or her
own residence, adds to that oral advisement an offer to help
turn off any appliance or water. Eliminates the option to
provide the currently required information at the facility.
15)Requires information given at the time of admission to a
facility under the 5150 process, in addition to being provided
in an individual's language, to provide accommodations for
other disabilities that may affect communication.
16)Requires the information given upon 72-hour admission to
include the following statement: "During the 72 hours you may
also be transferred to another facility. You may request to
be evaluated or treated at a facility of your choice. You may
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request to be evaluated or treated by a mental health
professional of your choice. We cannot guarantee the facility
or mental health professional you choose will be available,
but we will honor your choice if we can."
17)Requires the information given upon 72-hour admission to
inform the person that they can contact the county's Patients'
Rights Advocate if they have questions about their legal
rights.
18)Requires patients to be notified at admission if weekends and
holidays will be excluded from the 72-hour period.
19)Requires documentation of the language or modality used to
provide information given upon admission.
20)Requires the professional person in charge of a facility
designated by the county for evaluation and treatment, member
of the attending staff, or professional person designated by
the county to assess the person to determine whether he or she
can be properly served without being detained.
21)Makes numerous minor, technical, and terminological changes.
EXISTING LAW :
1)Provides, under the LPS Act, for the involuntary commitment
and treatment of individuals with specified mental disorders
and for the protection of committed individuals.
2)States legislative intent regarding the LPS Act, which
includes ending inappropriate, indefinite, and involuntary
commitment of mentally disordered persons, developmentally
disabled persons, and persons impaired by chronic alcoholism,
and eliminating legal disabilities and protecting mentally
disordered persons and developmentally disabled persons.
3)Authorizes, under section 5150 of the LPS Act, a peace
officer, member of the attending staff of an evaluation
facility designated by the county, or other professional
person designated by the county, upon probable cause, to take
a person with a mental disorder who is a danger to himself or
herself, a danger to others, or who is gravely disabled, into
custody and place him or her in a facility designated by the
county and approved as a facility for 72-hour treatment and
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evaluation.
4)Requires a person who is taken into custody for a 72-hour
treatment and evaluation to be provided specified information
orally, and requires a person who is admitted for a 72-hour
evaluation and treatment to be provided specified information.
5)Defines "evaluation" as multidisciplinary professional
analyses of a person's medical, psychological, educational,
social, financial, and legal conditions as may appear to
constitute a problem.
6)Defines "crisis intervention" as an interview or series of
interviews within a brief period of time, conducted by
qualified professionals, and designed to alleviate personal or
family situations which present a serious and imminent threat
to the health or stability of the person or the family.
Provides that crisis intervention may, as appropriate, include
suicide prevention, psychiatric, welfare, psychological,
legal, or other social services.
7)Defines "assessment" as the determination of whether a person
shall be evaluated and treated pursuant to section 5150.
FISCAL EFFECT : According to the Senate Appropriations
Committee, this bill would have minor local costs, not likely to
be reimbursed (local funds/General Fund), and minor cost savings
to the DSS, which will no longer be required to approve county
facilities for use as a 72-hour evaluation and treatment
facility (General Fund).
COMMENTS :
1)PURPOSE OF THIS BILL . The author writes that, unfortunately,
section 5150 has become part of a modern day vernacular that
implies an individual is being locked up and put away. This
bill is intended to change this construct by making focused
changes to this section of the landmark LPS Act, which was,
and remains to this day, a civil rights act for persons with
mental health disorders to ensure their personal rights.
The author writes that this bill broadens the types of
facilities a county can designate for 5150 purposes to include
licensed facilities (e.g., psychiatric hospital facilities,
free-standing acute psychiatric hospitals, psychiatric units
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in general hospitals, and certified facilities such as crisis
stabilization units). The author writes that this is intended
to provide counties with more options for assisting
individuals, help alleviate emergency room wait times for this
population, and, most importantly, offer a less restrictive
environment for a client to receive necessary assistance.
The author writes that this bill also authorizes county mental
health directors to develop procedures for the county
designation of LPS facilities and the training of
professionals who perform the functions of section 5150. This
is intended to improve consistency across counties for the
application of 5150 protocols and to serve as a quality
improvement tool for training of professionals in the 5150
process. The author writes that this will also offer more
transparency of county processes and help ensure humane and
equitable treatment of clients with mental health disorders
who are gravely ill.
In addition, the author writes that this bill restructures and
recasts several provisions to more clearly articulate the
sequencing of events in the 5150 process. Further, this bill
clarifies that if a person can be treated without being
detained, they can be transitioned for evaluation, crisis
intervention or other inpatient or outpatient services on a
voluntary basis. This change is intended to emphasize that
voluntary services are a viable option and that mental health
treatment services can be provided in county mental health
systems.
Finally, the author writes that this bill modernizes the law by
adding legislative intent language to facilitate the sharing
of information and records in accordance with current law,
updates terminology and the use of "people first" language,
and emphasizes that services need to be provided in the least
restrictive settings, as appropriate.
2)BACKGROUND . Section 5150 of the LPS Act allows peace
officers, staff-members of county-designated evaluation
facilities, or other county-designated professional persons,
to take an individual into custody and place him in a facility
for 72-hour treatment and evaluation if they believe that, due
to a mental disorder, the individual is a danger to himself,
herself, or others, or is gravely disabled-i.e., unable to
provide for basic personal needs for food, clothing, or
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shelter due to a mental disability. The LPS Act, enacted in
the 1960s, was intended to balance the goals of maintaining
the constitutional right to personal liberty and choice in
mental health treatment, with the goal of safety when an
individual may be a danger to oneself or others or is gravely
disabled. At the time of its enactment, the LPS Act was
considered progressive because it afforded the mentally
disordered more legal rights than most other states. Since its
passage in 1967, the law in the field of mental health has
continued to evolve toward greater legal rights for mentally
disordered persons.
3)COMMUNITY-BASED TREATMENT OPTIONS .
a) Crisis Residential Programs . According to a 2010 report
by the California Mental Health Planning Council, crisis
residential programs are a lower-cost, community-based
treatment option in home-like settings that help reduce
emergency department visits and divert hospitalization and
incarcerations. According to the report, these programs
include peer-run programs such as crisis respites that
offer safer, trauma-informed alternatives to psychiatric
emergency units or other locked facilities. The report
indicates that crisis residential programs reduce
unnecessary stays in psychiatric hospitals, reduce the
number and expense of emergency room visits, and divert
inappropriate incarcerations while producing the same or
superior outcomes to those of institutionalized care. The
report states that, as the costs for inpatient treatment
continue to rise, the need to expand an appropriate array
of acute treatment settings becomes more urgent, and state
and county mental health systems should encourage and
support alternatives to costly institutionalization and
improve the continuum of care to better serve individuals
experiencing an acute psychiatric episode.
b) Mobile Crisis Support Teams . Mobile crisis support
teams can be utilized to provide crisis intervention,
family support, and section 5150 evaluations. These teams
meet law enforcement in the field and, among other things,
provide diversion into appropriate treatment arrangements.
These teams have been used in several areas across the
state (for example, Sonoma County's Mobile Support Team and
the City of Berkeley's Mobile Crisis Team). A mobile
crisis team typically consists of an interdisciplinary team
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of mental health professionals (e.g., nurses, social
workers, psychiatrists, psychologists, mental health
technicians, addiction specialists, or peer counselors)
that respond to individuals in the community through home
visits or responses to incidents at other locations.
c) Crisis Stabilization . Crisis stabilization services are
those lasting less than 24 hours for individuals who are in
psychiatric crisis whose needs cannot be accommodated
safely in a residential service setting. Crisis
stabilization must be provided onsite at a 24-hour health
facility or hospital-based outpatient program or at other
certified provider sites. The goal of the crisis
stabilization is to stabilize the consumer and re-integrate
him or her back into the community quickly. According to
various reports, costs for providing care in a crisis
stabilization unit are significantly lower than inpatient
hospitalization.
4)SUPPORT . In support, the California Mental Health Directors
Association (CMHDA) writes that this bill provides helpful
clarifications to the LPS Act while upholding the original
intent of these landmark civil rights statutes. CMHDA writes
that this bill will remove the unnecessary and burdensome
process of requiring county-designated facilities to also be
approved by the state and make changes to better reflect the
sequence of events that may occur under the LPS Act.
Disability Rights California, also in support, writes that
this bill will help ensure people with mental health
disabilities are treated appropriately and in the least
restrictive environments.
5)CONCERNS . The California Psychiatric Association (CPA) has
expressed concerns that the language in this bill could be
variously interpreted to add to the current confusion in roles
with regard to 5150 holds. CPA offers a number of amendments
to impose more uniform standards upon all the counties: a) to
state that the purpose of the LPS Act is to provide consistent
standards for statewide education and training as a way to
ensure equal protection for all persons experiencing a
psychiatric crisis and subject to involuntary detention; b)
require the Department of Health Care Services (DHCS) to
develop guidelines for county designation and training
procedures, which would be subject to DHCS approval; c)
require counties to specify whether emergency room physicians
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may be eligible for 5150 designation; d) specify that
county-designated facilities for 72-hour detention may include
licensed acute psychiatric hospitals, licensed general acute
care hospitals with designated acute psychiatric beds, and
psychiatric health facilities, as defined; and e) specify that
county-designated facilities for assessment, evaluation, and
crisis intervention include short-term crisis residential
alternatives to hospitalization, crisis intervention services
lasting less than 24 hours, and crisis stabilization services.
6)OPPOSITION . The Citizens Commission on Human Rights writes
that, by changing the intent language of the LPS Act to state
that it applies to individuals with "mental health disorders,"
rather than "serious mental disorders," this bill will open
the door to many more people being ordered to forced treatment
for trivial reasons. Numerous individuals submitted letters
in opposition to various provisions of this bill. These
letters generally support the intent of this bill but object
to various details of implementation. Leaving the
determination of who can place a 72-hour hold to the counties,
these individuals argue, is counterproductive, as it would
exacerbate the current balkanization of the treatment system
for people with mental illness. Individual opponents also
argue that this bill's language could be interpreted to allow
individuals who are not admitted to a 72-hour facility to be
taken into custody in any facility. Several individuals have
submitted letters in opposition that object to involuntary
treatment generally and contend that this bill will expand
authority to impose involuntary treatment.
7)OPPOSITION TO PRIOR VERSION . Numerous individuals submitted
letters in opposition to a prior version of this bill that
contained a provision that required individuals subject to the
5150 process to receive a copy of the application, including
the name of any person whose statement provided probable cause
for establishing 5150 criteria. These individuals wrote that
this provision could result in retaliatory violence,
endangering the safety of friends and family members and make
them less likely to seek intervention on behalf of individuals
with severe mental illness. The provision in question has
been removed from the current version of this bill.
8)RELATED LEGISLATION .
a) AB 110 (Blumenfield), Chapter 20, Statutes of 2013,
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enacts the 2013-14 Budget Act, which includes, among its
other provisions, $206 million ($142 million General Fund
one-time) for a major investment in mental health services,
including additional residential treatment capacity, crisis
treatment teams, and triage personnel.
b) SB 585 (Steinberg) clarifies that Mental Health Services
Act funds and various County Realignment accounts may be
used to provide mental health services under the Assisted
Outpatient Treatment Demonstration Project Act of 2002, or
Laura's Law, and allows counties to opt to implement
Laura's Law through the county budget process. SB 585 is
pending in the Assembly Appropriations Committee.
9)PREVIOUS LEGISLATION .
a) SB 1381 (Pavley), Chapter 457, Statutes of 2012, deletes
in state law references to "mental retardation" or a
"mentally retarded person" and instead replaces them with
"intellectual disability" or "a person with an intellectual
disability."
b) AB 2370 (Mansoor), Chapter 448, Statutes of 2012, is
substantially similar to SB 1381.
c) SB 665 (Petris), Chapter 681, Statutes of 1991,
establishes the right, under the LPS Act, to refuse
antipsychotic medication and establishes hearing procedures
to determine a person's capacity to refuse treatment with
antipsychotic medication.
d) AB 2541 (Bronzan and Mojonnier), Chapter 1286, Statutes
of 1985, authorizes county mental health programs to
initiate services to various target populations, requires
various studies and planning activities, and prohibits
mental health personnel from instructing law enforcement
personnel to take individuals detained for mental health
evaluations to jail solely due to the unavailability of a
mental health facility bed.
e) AB 1424 (Thomson), Chapter 506, Statutes of 2001, makes
various changes to the LPS Act to: increase the
involvement of family members in commitment hearings for
the mentally ill; require more use of a patient's medical
and psychiatric records in these hearings; and prohibit
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health plans and insurers from using the commitment status
of a mentally ill person to determine eligibility for claim
reimbursement.
f) SB 677 (Lanterman, Petris, and Short), Chapter 1667,
Statutes of 1967, enacts the LPS Act, which governs
involuntary civil commitment for individuals with mental
illness, with the intent to end inappropriate, indefinite,
and involuntary commitment and provide for prompt
evaluation and treatment.
10)TECHNICAL POLICY COMMENTS .
a) Under current law, a professional person in charge of a
facility or his or her designee is required to conduct an
assessment to determine whether a person shall be evaluated
and treated under section 5150 prior to admission. This
bill creates a new assessment requirement for a
professional person in charge of a facility, member of the
attending staff, or professional person designated by the
county to assess a person to determine whether he or she
can be properly served without being detained. The
committee may wish to amend this bill to clarify the
chronology of assessment, evaluation, crisis intervention,
treatment, and admission, as applicable.
b) Current law requires peace officers to document probable
cause that an individual requires psychiatric evaluation
pursuant to section 5150. However, under current law and
under this bill a peace officer does not make a
determination whether an individual requires psychiatric
evaluation. The committee may wish to amend this bill to
remove reference to "psychiatric evaluation" and instead
require documentation of probable cause that an individual
meets the criteria of section 5150.
c) This bill requires facilities designated for 72-hour
evaluation and treatment to be licensed or certified as
mental health treatment facilities or hospitals, as
specified, by DHCS or the Department of Public Health
(DPH). The committee may wish to amend this bill to
clarify which facilities must be certified by DHCS and
which facilities must be licensed by DPH.
REGISTERED SUPPORT / OPPOSITION :
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Support
California Mental Health Directors Association
Disability Rights California
Hillview Mental Health Center, Inc.
National Alliance on Mental Illness, California
The Arc and United Cerebral Palsy California Collaboration
Opposition
Citizens Commission on Human Rights
Mental Health Collaborative of Kern County (prior version)
Numerous individuals (prior version)
Analysis Prepared by : Ben Russell / HEALTH / (916) 319-2097