BILL ANALYSIS Ó
AB 59
Page 1
Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON JUDICIARY
Mark Stone, Chair
AB 59
(Waldron) - As Amended April 20, 2015
SUBJECT: MENTAL HEALTH SERVICES: ASSISTED OUTPATIENT TREATMENT
KEY ISSUES:
1)SHOULD THE JANUARY 1, 2017, DATE, WHEN THE INVOLUNTARY
ASSISTED OUTPATIENT MENTAL HEALTH TREATMENT PROGRAM
DEMONSTRATION PROJECT (AOT) IS SCHEDULED BY STATUTE TO EXPIRE,
BE DELETED SO THAT INVOLUNTARY OUTPATIENT MENTAL HEALTH
TREATMENT WOULD BE AUTHORIZED FOR AN INDEFINITE PERIOD IN ALL
COUNTIES OF THE STATE, DESPITE LACK OF EMPIRICAL OR SCIENTIFIC
EVIDENCE TO SUPPORT SUCH A CHANGE?
2)SHOULD THE REQUIREMENT FOR ANY COUNTY THAT ELECTS TO OFFER AOT
TO MAKE A FINDING, PRIOR TO AUTHORIZING AOT, THAT OTHER MENTAL
HEALTH PROGRAMS, INCLUDING BUT NOT LIMITED TO CHILDREN'S
MENTAL HEALTH PROGRAMS, WILL NOT BE REDUCED AS A RESULT OF THE
IMPLEMENTATION OF AOT BE ELIMINATED?
3)SHOULD THE PROFESSIONAL STAFF OF AN AGENCY OR FACILITY THAT
PROVIDES A PERSON WITH INVOLUNTARY INPATIENT TREATMENT BE
AUTHORIZED, AFTER THE PERSON HAS BEEN RELEASED FROM THAT
INPATIENT INVOLUNTARY TREATMENT FACILITY, TO REQUEST THE
AB 59
Page 2
COUNTY MENTAL HEALTH DIRECTOR TO FILE A PETITION FOR A COURT
ORDER, REQURING THE PERSON TO PARTICIPATE IN AOT?
SYNOPSIS
The Involuntary Assisted Outpatient Mental Health Treatment
Program (AOT), also known as "Laura's Law," was initially
adopted in 2001, reauthorized in 2006, and reauthorized again in
2012. The law allows any county that wishes to provide
"assisted outpatient treatment services," as defined, to do so.
In the past 12 years that AOT has been authorized, nine counties
- Nevada, Yolo, San Diego, Orange, Los Angeles, San Francisco,
Contra Costa, Placer, and Mendocino - have chosen to implement
it. In addition, according to the author, there are formal
processes in motion that may lead to adoption before the Board
of Supervisors in the following counties: El Dorado, Contra
Costa, San Mateo, Kern, Santa Barbara, and Ventura. Indeed,
studies of involuntary outpatient programs have shown that the
programs have impressive results. For example, a Duke
University/North Carolina State University study in the 1990s
showed that "subjects who underwent sustained periods of
outpatient commitment beyond that of the initial court order had
approximately 57% fewer readmissions and 20 fewer hospital days
than control subjects." And a 2013 study showed that New York
state's AOT law, "Kendra's Law," resulted in substantial cost
savings. Still, the program is controversial and a number of
groups still oppose it on philosophical grounds and argue that a
county's commitment to provide intensive services, not the
coercive nature of the services themselves, are what makes a
treatment program successful. This bill does three things.
First, it permanently deletes the January 1, 2017 sunset on the
law so it can be extended indefinitely, which may be premature.
Second, it eliminates the requirement for any county that elects
to offer AOT to make a finding, prior to authorizing the
program, that other mental health programs, including but not
limited to children's mental health services, will not be
reduced as a result of implementation of AOT, which undermines
AB 59
Page 3
the need to assess community needs. Finally, it permits, in any
county that has elected to implement the program, the
professional staff of the facility where a person has been
detained for involuntarily inpatient treatment to request that
the county mental health director file a petition for a court
order requiring that the person participate in AOT, which may be
unnecessary. This bill is supported by NAMI Contra Costa
County, but opposed by Disability Rights California and the
California Association of Mental Health Peer Run Organizations.
SUMMARY: Deletes the repeal date of January 1, 2017, of the AOT
program so that the program is authorized to continue for an
indefinite basis and makes other changes. Specifically, this
bill:
1)Deletes the January 1, 2017, repeal date for the Assisted
Outpatient Treatment Demonstration Project Act of 2002,
thereby extending the program indefinitely.
2)Eliminates the requirement for any county that elects to offer
AOT to make a finding, prior to authorizing the program, that
other mental health programs, including but not limited to
children's mental health services, will not be reduced as a
result of implementation of AOT.
3)Authorizes the professional staff of the agency or facility
which has provided a person with intensive inpatient treatment
to request that the county mental health director file a
petition in the superior court requiring the person to
participate in AOT.
EXISTING LAW:
1)Permits counties to provide AOT for people with serious mental
illnesses when a court determines that a person's recent
AB 59
Page 4
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. (Welfare and Institutions
Code Section 5346. All further statutory references are to
this Code, unless otherwise indicated.)
2)Requires the board of supervisors of a county, in order to
authorize an AOT program in the county to adopt the program by
resolution or through the county budget process and 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 its implementation. (Section 5349.)
3)Allows the following individuals to request that the county
mental health director file a motion for a court order
requiring a person to participate in AOT:
a) Any person 18 years of age or older with whom the person
who is the subject of the petition resides.
b) Any person who is the parent, spouse, or sibling or
child 18 years of age or older of the person who is the
subject of the petition.
c) The director of any public or private agency, treatment
facility, charitable organization, or licensed residential
care facility providing mental health services to the
person who is the subject of the petition in whose
institution the subject of the petition resides.
d) The director of a hospital in which the person who is
the subject of the petition is hospitalized.
e) A licensed mental health treatment provider who is
either supervising the treatment of, or treating for a
AB 59
Page 5
mental illness, the person who is the subject of the
petition.
f) A peace officer, parole officer, or probation officer
assigned to supervise the person who is the subject of the
petition. (5346(b)(2).)
1)Allows a court, upon petition of the county mental health
director and after finding that an individual meets the
criteria for assisted outpatient treatment and there is no
appropriate and feasible less restrictive level of care
necessary to ensure the person's recovery and stability in the
community, to order the individual to receive assisted
outpatient treatment 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. (Section 5346(d), (g).)
2)Sunsets this authorization on January 1, 2017. (Section
5349.5(a).)
3)Grants any person subject to a petition for an order of
assisted outpatient treatment the right to legal counsel at
all steps of the hearing process. (Section 5346(d)(4)(C).)
4)Requires the Department of Health Services to submit a report
and evaluation to the Governor and the Legislature of all
counties implementing an assisted outpatient treatment program
by July 1, 2015. (Section 5349.5(b).)
5)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
AB 59
Page 6
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. (Sections 5008 (h)(1)(A)
and 5150.)
6)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. (Section 5250, 5257, 5260.)
7)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. (Section 5300 et seq.)
FISCAL EFFECT: As currently in print this bill is keyed fiscal.
COMMENTS: 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 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
AB 59
Page 7
adults, and no children's mental health program, was reduced in
order to implement the law.
According to the author, "'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. 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.
AB 59 will authorize county participation in the Assisted
Outpatient Treatment Demonstration Project without requiring
counties to make findings that no existing mental health
programs will be reduced as a result of AOT implementation.
This bill streamlines the process for a county to opt into
Laura's law and removes a time consuming barrier to ensure more
counties have access to mental health treatment."
Indeed, studies of involuntary outpatient programs have shown
that the programs have impressive results. For example, a Duke
University/North Carolina State University study in the 1990s
showed that "subjects who underwent sustained periods of
outpatient commitment beyond that of the initial court order had
approximately 57% fewer readmissions and 20 fewer hospital days
than control subjects." That same study, however, showed that
"sustained outpatient commitment reduced hospital readmissions
only when combined with a higher intensity of outpatient
treatment" and concluded that "use of outpatient commitment is
not a substitute for intensive treatment; it requires a
substantial commitment of treatment resources to be effective."
Counties have a financial incentive to implement AOT programs,
according to other recent studies. For example, a 2013 study
showed that New York state's AOT law, "Kendra's Law," resulted
AB 59
Page 8
in substantial cost savings. "In the New York City sample, net
costs declined 43% in the first year after assisted outpatient
treatment began and an additional 13% in the second year. In
the five-county sample, costs declined 49% in the first year and
an additional 27% in the second year." (Swanson et al, Am J
Psychiatry 2013; 170:1423-1432.)
County Experience with implementation of AOT. The AOT
Demonstration Project was first implemented in Nevada County.
According to the treatment provider that provides AOT services
in Nevada County, 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 the person meets the 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
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
AB 59
Page 9
AOT commitments.
In the past ten years that AOT has been authorized, nine
counties - Nevada, Yolo, San Diego, Orange, San Francisco,
Contra Costa, Placer, and Mendocino -- have chosen to fully
implement it. (Los Angeles County has implemented AOT on a
limited basis). In addition, according to the author, there are
formal processes in motion that may lead to adoption before the
Board of Supervisors in the following counties: El Dorado,
Contra Costa, San Mateo, Kern, Santa Barbara, and Ventura.
Removal of the sunset provision. The AOT program was originally
scheduled to expire by law on January 1, 2008, but was
reauthorized in 2006, and reauthorized again in 2012. The 2012
legislation, Assembly Bill 1569 (Allen, Chapter 441, Statutes of
2102) was controversial. It was opposed by all of the groups
that oppose this bill, but also many others that do not oppose
this bill that removes the sunset in its entirety, including the
American Civil Liberties Union of California, California Council
of Community Mental Health Agencies, California Mental Health
Planning Council, Mental Health America of California, and the
National Association for Rights Protection and Advocacy. Based
upon the fact that fewer groups oppose this much more
far-reaching bill, it appears that the AOT program is more
widely accepted and less controversial that it was at one time,
but is not without critics.
Disability Rights California has "concerns about AOT programs
and we believe that voluntary services are more effective and
should be expanded, we believe that the sunset provision is
important to protect the rights of people with mental health
disabilities in California." Meanwhile, the California
Association of Mental Health Peer Run Organizations questions
whether AOT is as effective as less coercive alternative
treatments and writes:
AB 59
Page 10
Clearly it is the services that make the difference and
produce positive results. Through the MHSA (Prop 63),
California has put its money into a voluntary network of
community services that are person centered and holistic
and based on the recovery model. The results of a 2012
UCLA study of MHSA Full Service Partnerships found that
every dollar spent on mental health services in California
saved roughly $0.88 in costs to the criminal justice and
health and housing services by reducing the number of
arrests, incarcerations, ER visits, and hospitalizations.
These same kinds of results were found in the Petris Center
Evaluation, May 2010; a large reduction in homelessness, a
rise in the proportion of consumers living independently,
less use of mental health related emergency services, less
incarcerations, and a rise in employment. AB 34 and 2034,
the pilot programs that the full service partnerships are
modeled on, produced the same kind of positive results.
Given these concerns, the Committee may want to consider whether
this bill's proposal to delete the January 1, 2017 sunset date
and extend the program indefinitely is premature.
Importance of a finding by the board of supervisors that other
treatment programs will not be affected. Current law requires
the board of supervisors of a county, in order to authorize an
AOT program in the county, to adopt the program by resolution or
through the county budget process and make a finding that no
voluntary mental health program serving adults, and no
children's mental health program, will be reduced as a result of
its implementation. (Section 5349.) This bill would do away
with that requirement.
Disability Rights California writes, "Existing law requires the
board of supervisors when implementing an AOT program make a
AB 59
Page 11
finding that no voluntary mental health programs will be reduced
as a result of the AOT program. This bill would remove that
mandate, potentially threatening access and availability to
mental health services for individuals who seek them on a
voluntary basis." Given concerns among many consumers of health
services, including mental health services, at the local level,
the Committee may want to consider whether removal of this
requirement is warranted.
Parties who are authorized to request a petition to initiate AOT
process. Current law allows specific individuals to request
that the county mental health director file a motion for a court
order requiring a person to participate in AOT:
a) Any person 18 years of age or older with whom the person
who is the subject of the petition resides.
b) Any person who is the parent, spouse, or sibling or
child 18 years of age or older of the person who is the
subject of the petition.
c) The director of any public or private agency, treatment
facility, charitable organization, or licensed residential
care facility providing mental health services to the
person who is the subject of the petition in whose
institution the subject of the petition resides.
d) The director of a hospital in which the person who is
the subject of the petition is hospitalized.
e) A licensed mental health treatment provider who is
either supervising the treatment of, or treating for a
mental illness, the person who is the subject of the
petition.
AB 59
Page 12
f) A peace officer, parole officer, or probation officer
assigned to supervise the person who is the subject of the
petition. (5346(b)(2).)
Disability Rights California writes, "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, may 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 facility that provided involuntary treatment to an
individual to that list. It is unclear who would constitute
"professional staff" under this provision. To the extent this
category goes beyond the existing requirements, it increases the
possibility that the petitions may be filed without adequate
basis, therefore further limiting individual rights."
Related pending legislation. AB 1193 (Eggman) Mandates AOT in
all counties, unless they opt out of the program by proclamation
of the county board of supervisors, extends the sunset until
2022, and allows judges to recommend a petition for anyone
appearing in the judge's court.
AB 193 (Maienschein) - allows probate courts to recommend a
referral for an LPS conservatorship to the county officer
providing conservatorship investigations.
Previous legislation. AB 2266 (Waldron, 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 in the Assembly Judiciary Committee.
AB 59
Page 13
AB 1265 (Conway, 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 in the
Assembly Judiciary Committee.
AB 1569 (Allen), Chapter 441, Statutes of 2012, extended
authorization for "Laura's Law" to January 1, 2017 and required
DHCS to submit a report to the Legislature regarding the program
by July 1, 2015.
AB 1421 (Thomson), Chapter 1017, Statutes of 2002, authorized
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.
REGISTERED SUPPORT / OPPOSITION:
Support
NAMI - Contra Costa County
Opposition
California Association of Mental Health Peer Run Organizations
AB 59
Page 14
Disability Rights California
Analysis Prepared by:Alison Merrilees / JUD. / (916) 319-2334