BILL ANALYSIS Ó
AB 59
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Date of Hearing: April 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 59
Waldron - As Amended April 6, 2015
SUBJECT: Mental health services: assisted outpatient
treatment.
SUMMARY: Changes requirements for county participation in the
Assisted Outpatient Treatment (AOT) Demonstration Project and
increases the maximum period of imposed outpatient treatment
under the AOT Demonstration Project from six months to one year.
Specifically this bill:
1)Authorizes county participation in the AOT Demonstration
Project without requiring counties to make findings that no
existing mental health programs will be reduced as a result of
AOT implementation.
2)Deletes the January 1, 2017 repeal date of Laura's Law and
extends the program indefinitely.
3)Authorizes a court to order a person to obtain AOT for an
initial period not to exceed 12 months.
4)Authorizes a person who has been released from an intensive
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treatment or postcertification treatment program to be
evaluated to determine whether they meet the criteria for AOT.
5)Authorizes the professional staff of the agency or facility to
request the county mental health director to file a petition
in the superior court for AOT if that person meets certain
criteria.
EXISTING LAW:
1)Permits counties to provide AOT services for people with
serious mental illnesses when a court determines that a
person's recent history of hospitalizations or violent
behavior, and noncompliance with voluntary treatment,
indicates the person is likely to become dangerous or gravely
disabled without the court-ordered outpatient treatment.
2)Allows a court, after finding that an individual meets the
criteria for AOT, and there is no appropriate and feasible
less restrictive alternative, to order the individual to
receive AOT for an initial period not to exceed six months.
If the director of the assisted outpatient program determines
that the individual requires further assisted outpatient
services, requires that director, prior to expiration of the
time period of the treatment, to apply to the court for an
extension of the services, not to exceed 180 days.
3)Permits a petition for a court order authorizing AOT to be
filed by the county mental health director, or his or her
designee, in the superior court in the county where the person
requiring treatment is present.
4)Authorizes the following individuals to make a request to the
county mental health department for the filing of a petition:
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a) An adult whom the person lives with;
b) Family members that include adult children, parents,
siblings or spouse;
c) Law enforcement, parole, or probation officer;
d) Director of a public or private agency providing mental
health services to that person;
e) Hospital director who is providing psychiatric care to
that person; or,
f) Licensed mental health provider who is treating or
supervising the person.
5)Grants any person subject to a petition for an order of AOT
the right to legal counsel at all steps of the hearing
process.
6)Requires the Department of Health Care Services (DHCS) to
submit a report and evaluation to the Governor and the
Legislature of all counties implementing an AOT program by
July 1, 2015.
7)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
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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.
8)Allows, under the LPS Act, a person who is gravely disabled to
be involuntarily detained for further inpatient mental health
treatment for an additional 14 days, as provided, which can be
extended for 14 days if the person presents an imminent threat
of taking his or her own life or 30 days if the county has
authorized the program and the person remains gravely
disabled.
9)Allows, under the LPS Act, a court to order an imminently
dangerous person to be confined for further inpatient
intensive health treatment for an additional 180 days, as
provided.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1) PURPOSE OF THIS BILL. According to the author, AOT or
"Laura's Law" provides family members with important tools
for initiating outpatient treatment for severely mentally ill
adults who are incapable of seeking help on their own. The
author states that it helps to identify when a patient's
condition is significantly worsening and to intervene before
the patient becomes too ill and is subject to involuntary
civil confinement. The author further states that based on
previous evidence, the first six months in the program
demonstrate significant improvements in self-care and
community living, social functioning, task performance, and
incidents of harmful behaviors in patients. According to the
author, studies also show that improvement takes time
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therefore, to insure full stability of patients once the
initial period is complete, this bill will require counties
with available funding to implement this program and extend
it from six months to one year.
2) BACKGROUND. The AOT Demonstration Project allows courts in
participating counties to order a person into an AOT program
if the court finds that the individual either meets existing
involuntary commitment requirements pursuant to Welfare and
Institutions Code Section 5150 (is gravely disabled or is a
danger to self or others), or the person meets non-5150
criteria including that the person has refused treatment,
their mental health condition is substantially deteriorating,
and AOT would be the least restrictive level of care
necessary to ensure the person's recovery and stability in
the community. The law is only operative in those counties
in which the county board of supervisors, by resolution,
authorizes its application and makes a finding that no
voluntary mental health program serving adults, and no
children's mental health program, was reduced in order to
implement the law.
a) County Implementation. Currently, Nevada, Orange, Yolo,
and the City and County of San Francisco have approved full
implementation of Laura's Law; Los Angeles County
implemented the law on a limited basis. According to the
treatment provider that Nevada County contracts with for
services, Turning Point Community Programs, Initiating the
AOT process begins with a referral submitted by family
members, relatives, cohabitants, treatment providers or
their supervisors, or peace officers. If individuals meet
AOT eligibility requirements, a preliminary care plan is
developed. If the individual voluntarily engages with the
treatment after initial contact, a petition is no longer
necessary and the patient no longer meets the criteria for
AOT referral. However if the client declines the
preliminary care plan, the AOT team proceeds with a
petition and a public defender is assigned to the client.
The court must be notified within 10 days of the
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intervention, and a hearing must be set within five days of
the filing of the petition and the judge either grants or
rejects the AOT petition. If ordered, AOT is valid for up
to 180 days.
According to Nevada County, in the seven years the county has
implemented Laura's Law, 37 AOT commitments have been
ordered by the court, and six individuals have failed to
complete their orders due to hospitalization,
incarceration, or death. Nevada County indicates that the
number of hospitalization days for program participants has
been cut in half, and no patient has encountered problems
with law enforcement since their commitment. In Orange
County, two individuals have been ordered to fulfill an AOT
commitment. The other county programs have been recently
implemented and do not yet have any court ordered AOT
commitments.
b) Increased Treatment and Outcomes. This bill seeks to
extend, from six months to one year, the time period for
which an individual can be ordered to participate in AOT.
New York made a similar change in 2012, extending its
mandatory outpatient treatment time from six months to one
year in its version of Laura's Law. Supporters have
provided research papers that argue that six months is the
bare minimum time period necessary to achieve positive
outcomes and that those outcomes improve when treatment
times are extended to one year or longer. However, it is
important to note that during the time of the study in New
York, the maximum initial period of imposed treatment was
six months. Patients who received treatment longer than
six months received extensions beyond the initial six-month
treatment period, which is currently permissible by
California Law
3) SUPPORT. The California Medical Association (CMA) states in
support of the bill that Laura's Law provides for
community-based, AOT services to a small population of
individuals who meet specific criteria and as a result of
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their mental illness are unable to voluntarily access
community mental health services. AOT has been consistently
demonstrated to be effective in stabilizing individuals which
increases the likelihood of stable housing, medical
adherence, and social skill building. Laura's Law provides
necessary mental health treatment to individuals, while at
the same time making our communities safer. The CMA notes
that Nevada County, which has fully implemented the law, has
seen increased access to mental health treatment and a
reduction of cost to the county in the amount of $500,000
through avoidance of hospitalizations and incarcerations.
Failure to implement Laura's Law results in individuals
suffering from severe mental illness failing to receive
needed mental health treatment and counties incurring costs
that could have been circumvented. The CMA concludes that
this bill is an integral step in the statewide implementation
of Laura's Law.
4) OPPOSITION. Disability Rights California (DRC) writes in
opposition that this bill removes many provisions in current
law that protect the rights of individuals subject to AOT.
This bill removes the requirement that a county board of
supervisors approve an AOT program and the county prohibition
to reduce voluntary mental health services when implementing
AOT programs. This bill increases the maximum duration of an
AOT order from six to 12 months; broadens the group of people
who can request an AOT petition; and removes the program's
sunset provision. DRC states that to the extent it continues
to be authorized in California, counties should retain local
control and AOT should be at their election and not imposed
on them by the state. DRC also notes that existing law
provides that certain people who are involved in providing
mental health treatment to an individual, including a
licensed mental health treatment provider and the director of
a hospital, public or private agency, treatment facility,
charitable organization or licensed residential care
facility, any request that the county mental health
department file an AOT petition on behalf of that individual.
This bill would add the professional staff of an agency or
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facility that provided involuntary treatment to an individual
to that list. DRC argues that this increases the possibility
that the petitions may be filed without adequate basis,
therefore further limiting individual rights.
The California State Association of Counties (CSAC), and the
County Behavioral Health Directors Association (CBHDA) write
in opposition to the bill, stating that it is critical that
county Boards of Supervisors retain the authority and
flexibility to determine whether implementing Laura's Law AOT
services in their community is appropriate. CSAC states that
they believe that counties should be able to use funds to best
meet the needs within their county. County Boards of
supervisors, as one of the levels of government that is
closest to the people, are experts at grappling with
significant local decisions while also remaining responsive to
local needs and perspectives.
The California Association of Social Rehabilitation Agencies
(CASRA), and the California Psychological Association (CPA)
state in opposition that outpatient commitment has not been
shown to be the most effective in reducing hospitalization or
other adverse outcomes and that involuntary treatment is
inconsistent with current evidence-based best practice in
behavioral health care. CPA further states that the White
House Conference on Mental Health Fact Sheet (1999) showed
that when persons with even the most serious mental illnesses
are provided with appropriate and comprehensive community
mental health services, they succeed. CASRA argues that
research to date does not support the use of involuntary
commitment to treat difficult to engage individuals and that
much of the existing research is flawed by confounding
variables and poor research design.
5) RELATED LEGISLATION. AB 1193 (Eggman) Mandates an increase
in the maximum period of imposed outpatient treatment under
the AOT Demonstration Project from six months to one year.
6) PREVIOUS LEGISLATION.
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a) AB 2266 (Waldron) of 2014 would have increased the
maximum period of imposed outpatient treatment under the
AOT Demonstration Project from six months to one year. AB
2266 failed passage in the Assembly Judiciary Committee.
b) AB 1265 (Conway) of 2013 would have increased the
maximum period of imposed outpatient treatment under the
AOT Demonstration Project from six months to one year. AB
1265 also failed passage in the Assembly Judiciary
Committee.
c) AB 1569 (Allen), Chapter 441, Statutes of 2012, extends
authorization for "Laura's Law" to January 1, 2017, and
would have required DHCS to submit the report by July 1,
2015.
d) SB 1606 (Yee) of 2008 would have required the Department
of Mental Health (now called the Department of State
Hospitals) to conduct a study of individuals whose mental
health needs are not currently being met, because they do
not meet existing eligibility criteria for AOT, but have
mental health needs that may not be met through voluntary
services. SB 1606 passed out of the Senate, but was held
on the Assembly Appropriations Committee suspense file.
e) AB 1421 (Thomson), Chapter 1017, Statutes of 2002,
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.
7) DOUBLE REFERRAL. This bill is double referred, upon passage
of this Committee, it will be referred to the Assembly
Committee on Judiciary.
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8) COMMITTEE COMMENTS. The previous version of this bill
mandated county implementation of Laura's Law, where counties
had available funding to implement the AOT program. This was
a significant source of contention for opposition. Author's
amendments of April 6, 2015 removed those provisions and
maintain the provisions that permit counties to opt-in that
are currently in statute. Additional author's amendments
delete the requirement that counties make findings that no
other existing mental health program serving adults or
children may be reduced as a result of the implementation of
this article before a county board of supervisors can vote to
adopt Laura's Law. County boards of supervisors are still
required to pass a resolution to implement Laura's Law.
9) COMMITTEE AMENDMENTS. This bill permits an initial AOT
commitment of one year instead of six months as currently
permitted by law. In the limited available data regarding
AOT programs, there is no evidence that an increase in the
initial commitment treatment period improves health care
outcomes for program participants. For this reason, the
Committee may wish to remove that provision from this bill
and maintain the currently allowable six month initial
treatment time period for AOT participants.
REGISTERED SUPPORT / OPPOSITION:
Support
California Medical Association
Opposition
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California Association of Social Rehabilitation Agencies
California State Association of Counties
California Psychological Association
County Behavioral Health Directors Association
Disability Rights California
Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097