BILL ANALYSIS Ó
SB 585
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Date of Hearing: June 18, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 585 (Steinberg and Correa) - As Amended: May 13, 2013
SENATE VOTE : 36-0
SUBJECT : Mental health: Mental Health Services Fund.
SUMMARY : Clarifies that Mental Health Services Act (MHSA) funds
and various County Realignment accounts may be used to provide
mental health services under the Assisted Outpatient Treatment
(AOT) Demonstration Project Act of 2002, or Laura's Law, and
allows counties to opt to implement Laura's Law through the
county budget process. Specifically, this bill :
1)Allows counties to implement Laura's Law through the county
budget process, rather than a resolution of the board of
supervisors.
2)Clarifies that counties that elect to implement Laura's Law
are permitted to pay for the provision of AOT services using
funds distributed to the counties from the Mental Health
Subaccount, the Mental Health Equity Subaccount, and the
Vehicle License Collection Account of the Local Revenue Fund,
funds from the Mental Health Account and the Behavioral Health
Subaccount within the Support Services Account of the Local
Revenue Fund 2011, funds from the Mental Health Services Fund,
as specified, and any other funds from which the Controller
makes distributions to the counties for those purposes.
EXISTING LAW :
1)Establishes MHSA, which imposes a 1% income tax on personal
income in excess of $1 million to provide for local mental
health services.
2)Establishes the Mental Health Services Fund in the state
Treasury, continuously appropriated to and administered by the
Department of Health Care Services (DHCS), to fund MHSA
programs.
3)Under MHSA, requires counties' plans for services funded under
the MHSA to promote concepts key to recovery for individuals
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who have mental illness: hope, personal empowerment, respect,
social connections, self-responsibility, and
self-determination.
4)Establishes the Local Revenue Fund and the Local Revenue Fund
2011, which contain various accounts and subaccounts used to
fund county mental health services.
5)Establishes Laura's Law, which allows county boards of
supervisors, by resolution, to authorize court-ordered AOT
services, whereby a county mental health director can petition
for a court to order a person over age 18 with a mental
illness to receive AOT, as specified.
6)Requires counties implementing Laura's Law to make a finding
that no voluntary mental health program serving adults and no
children's mental health program may be reduced as a result of
the implementation.
7)Requires a county that provides court-ordered AOT services to
also offer the same services on a voluntary basis.
8)Requires a court that orders AOT to find that the individual
meets specified criteria, including: a clinical determination
that the person is unlikely to survive safely in the community
without supervision; the person has a history of noncompliance
with treatment for his or her mental illness; the person's
condition is substantially deteriorating; and participation in
AOT would be the least restrictive placement necessary to
ensure the person's recovery.
9)Requires DHCS to submit a report and evaluation of all
counties implementing any component of Laura's Law to the
Governor and the Legislature by July 1, 2015.
10)Sunsets Laura's Law on January 1, 2017.
11)Establishes the Lanterman-Petris-Short Act (LPS Act), which
authorizes a person to be involuntarily detained for inpatient
mental health treatment when, as a result of a mental
disorder, the person is a danger to him or herself or to
others, or is gravely disabled. Defines "gravely disabled" to
mean a condition in which a person, as a result of a mental
disorder, is unable to provide for his or her basic personal
needs for food, clothing, or shelter.
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12)Authorizes a peace officer, member of the attending staff of
an evaluation facility designated by the county, designated
members of a mobile crisis team, 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 by Department of Social Services as a
facility for 72-hour treatment and evaluation (referred to as
a 72-hour hold).
FISCAL EFFECT : This bill, as amended, has not been analyzed by
a fiscal committee.
COMMENTS :
1)PURPOSE OF THIS BILL . Approved by voters through Proposition
63 of 2004, MHSA provides over $1 billion annually for local
mental health services. The MHSA has served as a catalyst for
transforming California's mental health system by emphasizing
the philosophy, principles, and practices of recovery for
mental health clients, including personal empowerment,
self-responsibility, and self-determination.
According to the author, there is presently a lack of clarity as
to whether MHSA funds can be used for mental health services
provided under Laura's Law. This bill will clarify that
Mental Health Services Funds, in addition to other funding
sources as specified, may be expended to support mental health
treatment services provided under Laura's Law when a county
has acted to participate in the demonstration and it has been
included in a county's MHSA plan. This proposed change will
serve to mitigate potential misconceptions that only certain
funding sources can be used for implementation of a Laura's
Law demonstration project by a county.
In addition, this bill provides counties with the option to
implement Laura's Law either through a separate resolution
process or to make the declaration through their county budget
process. The author states that it provides flexibility for
counties that elect to implement Laura's Law but does not take
away the requirement that no voluntary services lose ground as
the result of a county choosing to implement Laura's Law.
2)BACKGROUND . In 2002, the Legislature passed AB 1421
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(Thomson), Chapter 1017, Statutes of 2002, also known as
Laura's Law, in memory of Laura Wilcox, a 19-year-old college
student who was killed by a severely mentally ill man who was
not adhering to prescribed mental health treatment. Laura's
Law gives counties the option to implement intensive AOT
programs for individuals who have difficulty maintaining their
mental health stability in the community and have frequent
hospitalizations and contact with law enforcement related to
untreated or undertreated mental illness. Laura's Law
requires a county board of supervisors to authorize
implementation by resolution and to make a finding that access
to voluntary mental health programs would not be reduced as a
result of implementation.
Under Laura's Law, a person subject to AOT must have a history
of not complying with needed mental health treatment and be
unlikely to survive safely in the community without
supervision. To qualify for AOT, a person's mental illness
must have twice led to psychiatric hospitalizations or
incarcerations within the prior 36 months or resulted in
violence toward self or others within the prior 48 months. If
these criteria are satisfied, the county mental health
director or designee may file a petition with the court
indicating that AOT is needed to help prevent relapse or
deterioration that would likely result in grave disability or
serious harm to self or others. Such a petition must
establish that the person has been offered an opportunity to
voluntarily participate in a treatment plan but continues not
to engage in treatment.
Under Laura's Law, an adult living with the person, the parent,
spouse, sibling, or adult child of that person, or specified
mental health and law enforcement personnel, may request a
petition for an AOT order for the person. Upon receiving the
request, the county mental health director or designee is
required to conduct an investigation. The director or
designee is permitted to file a petition only if he or she
determines that it is likely that all the necessary elements
described above for an AOT petition can be proven by clear and
convincing evidence.
Implementation of a Laura's Law AOT program is currently a
local option. In 2003, the Department of Mental Health (DMH)
required counties that choose to implement an AOT program to
submit specified documentation to DMH prior to implementation,
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including a copy of the board of supervisor's resolution
verifying that voluntary services will not be reduced as a
result of implementation; documentation of the local mental
health board's review of the county's implementation plan; a
detailed AOT program narrative; a proposed budget and budget
narrative for AOT program expenditures; a description of
methods for data collection; and a plan for development of an
AOT training and education program.
3)AOT IMPLEMENTATION AND RESULTS . In 2005, DMH sent a letter to
counties outlining requirements for their three-year plans for
community services and supports provided under the MHSA. This
plan specified that "Individuals accessing services funded by
the Mental Health Services Act may have voluntary or
involuntary legal status which shall not affect their ability
to access the expanded services under this Act. Programs
funded under the Mental Health Services Act must be voluntary
in nature." In a May 2007 letter to the Director of the
Nevada County Behavioral Health Department, the Director of
DMH clarified that this meant that an AOT program could be
implemented for voluntary and involuntary enrollees; i.e.,
that MHSA funds could be used to fund Laura's Law programs.
In 2008, the Board of Supervisors of Nevada County passed a
resolution implementing AOT. In a 2011 report, DMH found that
Nevada County's AOT program had served a total of four
court-ordered individuals over two years, with two individuals
served each year. The report indicated that the program had
succeeded primarily in assisting clients to significantly
reduce hospitalization days, with total hospitalization days
for all participants decreased from 239 to 97, a 59%
reduction. The report noted that, as of 2011, Nevada County's
AOT was the only county in the state that had fully
implemented Laura's Law.
In April 2010, the Los Angeles County Department of Mental
Health instituted a voluntary pilot AOT program for up to 50
individuals with mental illness involved in the criminal
justice system or transitioning from certain county
psychiatric facilities who would be able to live safely in the
community if they participated in the recommended AOT program.
Los Angeles County reported outcomes information to DMH for
the period covering April 2010 through October 2010, during
which 10 individuals were served. Los Angeles reported that
80% of individuals served were compliant with treatment. The
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data in the report indicated that there was a 78% reduction in
incarcerations for the program participants during the six
months following their enrollment in AOT and a 77% reduction
in hospitalization days after they were discharged from the
program.
Despite the positive results reported by Nevada County, rigorous
studies of AOT have found small or negligible effects in favor
of involuntary AOT. A 2005 Cochrane review, "Compulsory
community and involuntary outpatient treatment for people with
severe mental disorders," examined two randomized controlled
trials comparing AOT with voluntary treatment and found little
evidence to indicate that compulsory community treatment was
effective with respect to various outcomes, including hospital
readmission, arrests, homelessness, and perception of
coercion. The study estimated that, in terms of numbers
needed to treat, it would take 85 outpatient commitment orders
to prevent one hospital readmission, 27 to prevent one episode
of homelessness, and 238 to prevent one arrest. A 2013 study
of AOT in the United Kingdom, published in the Lancet and
entitled, "Community treatment orders for patients with
psychosis (OCTET): a randomised controlled trial," found that
the number of patients readmitted to the hospital did not
differ between two groups that, based on random assignment,
received either six months of compulsory outpatient treatment
or, on average, eight days of supervised leave prior to
release.
4)MHSA . As a funding source for mental health programs, MHSA
imposes a 1% income tax on personal income in excess of $1
million to expand mental health services for individuals with
severe mental health disorders. Under MHSA, counties that
receive funds must have a three-year plan developed with
significant local stakeholder input and involvement. The MHSA
requires each plan to cover the following five components: a)
Community Services and Supports for Adults and Children's
System of Care; b) Prevention and Early Intervention; c)
Innovation; d) Workforce Education and Training; and, e)
Capital Facilities and Technological Needs.
MHSA emphasizes the philosophy, principles, and practices of
recovery for mental health clients, including personal
empowerment, self-responsibility, and self-determination.
Despite DMH's 2007 approval of the use of MHSA funds to
provide services under Laura's Law, there has historically
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been some confusion about whether the involuntary nature of
AOT under Laura's Law is incompatible with the guiding
principles of MHSA. The author maintains that this bill will
serve to mitigate these misconceptions and that support for
Laura's Law through MHSA funding, in fact, ensures that the
full continuum of needs for mental health client recovery and
wellness is supported.
5)SUPPORT IF AMENDED . The National Alliance on Mental Illness,
California (NAMI California), writes in support of the bill's
provisions that clarify which funds may be used for Laura's
Law. However, NAMI California is concerned that the bill's
provision that allows for county implementation through the
budget process will lead to a lack of transparency and
community involvement, since attendance and media coverage of
county budget hearings are typically low. Similarly, the
California Mental Health Directors Association (CMHDA) writes
that this bill will reduce the opportunity for community
partners, such as the courts and public defenders, as well as
community members and stakeholders, to have a voice in Laura's
Law implementation. CMHDA writes that it is also unclear how
counties would make the required finding that no voluntary
mental health program would be reduced if a board of
supervisors decided to make Laura's Law operative through the
county budget process, rather than through a resolution that
would document this finding. CMHDA and NAMI California both
request that the bill be amended to delete the county budget
process provision.
6)SUPPORT . The Urban Counties Caucus (UCC), in support, writes
that, since the enactment of Laura's Law, many counties have
considered implementation, but funding has been a major
barrier. UCC writes that, by making it clear that counties
may use MHSA and other funding provided under the Public
Safety Realignment of 2011, this bill will enable counties to
implement Laura's Law without incurring major cost impacts to
the county's general fund. The California Treatment Advocacy
Coalition (CTAC), in support, writes that studies have shown
that, when AOT is implemented, vicinities experience both cost
avoidance and social consequence reduction by reducing
violence, suicide, homelessness, and incarceration. CTAC
states that this bill will increase the likelihood that more
counties will implement and benefit from Laura's Law.
7)OPPOSITION . The California Psychological Association (CPA)
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opposes the provision of this bill that allows counties to
implement Laura's Law through county budget process, rather
than through a Board of Supervisors resolution, which will
prevent counties from having proper discussion and
deliberation surrounding Laura's Law implementation. CPA
believes that coercive treatment does not add to the
effectiveness of community mental health services; rather, it
could interfere with recovery by compromising the nature of
trust between the practitioner and client. The Citizens
Commission on Human Rights, also in opposition, believes that
providing drug-based treatments for mental health disorders
leads individuals to carry out violent acts, and that making
more money available for counties to provide these treatments
"will increase the number of rights violations exponentially."
8)RELATED LEGISLATION .
a) SB 664 (Yee), pending in the Senate Appropriations
Committee, deletes the requirement under Laura's Law that
county boards of supervisors must pass a resolution
authorizing Laura's Law services and make a finding that no
voluntary mental health programs may be reduced as a result
of Laura's Law implementation.
b) AB 1265 (Conway), which failed passage in the Assembly
Judiciary Committee and was granted reconsideration,
increases the maximum period of imposed AOT under Laura's
Law from six months to one year.
c) AB 1367 (Mansoor), pending in the Assembly Health
Committee, clarifies that AOT provided under Laura's Law
may be provided pursuant to the MHSA and allows funding of
local educational agencies for training to identify
students with mental health issues that may result in a
threat to themselves or others.
9)PREVIOUS LEGISLATION .
a) AB 1569 (Allen), Chapter 441, Statutes of 2012, delays
the sunset on Laura's Law from January 1, 2013, to January
1, 2017.
b) AB 2134 (Chesbro) of 2012 would have required counties,
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when they opt to implement Laura's Law, to develop and
implement best practices for mental health crisis response.
AB 2134 failed passage in the Senate Health Committee.
c) SB 1606 (Yee) of 2008 would have required DMH to conduct
a study of individuals who fail to meet the eligibility
criteria for specified court-ordered mental health
treatment available pursuant to AB 1421. SB 1606 was held
on the Suspense File in the Assembly Appropriations
Committee.
d) AB 2357 (Karnette), Chapter 774, Statutes of 2006,
delays the sunset of Laura's Law from January 1, 2008, to
January 1, 2013, and requires DMH to submit an evaluation
to the Governor and Legislature by July 31, 2011.
e) AB 1421 enacts Laura's Law, which permits counties to
provide court-ordered outpatient treatment services for
people with serious mental illnesses when a court finds
that a person's recent history of hospitalizations or
violent behavior, coupled with noncompliance with voluntary
treatment, indicate the person is likely to become
dangerous or gravely disabled without the court-ordered
outpatient treatment.
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.
REGISTERED SUPPORT / OPPOSITION :
Support
California Council of Community Mental Health Agencies
California Treatment Advocacy Coalition
National Alliance on Mental Illness, Orange County
Urban Counties Caucus
Treatment Advocacy Center
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18 individuals
Opposition
California Psychological Association
Citizens Commission on Human Rights
Two individuals
Analysis Prepared by : Ben Russell / HEALTH / (916) 319-2097