BILL ANALYSIS Ó
AB 59
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Date of Hearing: January 12, 2016
ASSEMBLY COMMITTEE ON JUDICIARY
Mark Stone, Chair
AB 59
(Waldron) - As Amended January 6, 2016
FOR VOTE ONLY
SUBJECT: MENTAL HEALTH SERVICES: ASSISTED OUTPATIENT TREATMENT
KEY ISSUE: 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 EXTENDED BY FIVE YEARS SO THAT INVOLUNTARY OUTPATIENT MENTAL
HEALTH TREATMENT IS AUTHORIZED IN ALL COUNTIES OF THE STATE
UNTIL JANUARY 1, 2022?
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
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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 oppose it, pointing out that a county's commitment to
provide intensive services, not the coercive nature of the
services themselves, determines whether the county's treatment
program is successful. When first heard by the Committee, this
bill was far more ambitious, eliminating 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,
would not be reduced as a result of implementation of AOT. It
also, in its original form, removed the sunset provision from
the law (thus making it permanent) and permitted, in any county
that elects 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. As recently amended, the bill only
extends the January 1, 2017 sunset on the law by five years, so
that the law would be repealed as of January 1, 2022. The other
more controversial provisions have been removed from the bill.
As amended on January 6, 2016, this bill is supported by NAMI
Contra Costa County, Nevada County Health and Human Services
Agency, California State Association of Counties, and California
Chapter of the American College of Emergency Physicians, but
opposed by Disability Rights California. Regarding prior
versions of the bill, other organizations have supported (San
Diego Regional Chamber of Commerce) or opposed (Mental Health
America, California Council of Community Mental Health Agencies,
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California Association of Mental Health Peer-Run Organizations)
the bill in the past but have not submitted new position letters
to the Committee. Therefore, it is unclear whether and how the
most recent amendments affect the positions of those
organizations.
SUMMARY: Extends the sunset provision on the repeal date of
January 1, 2017 for the AOT program so that the program is
authorized to continue for an additional five years.
Specifically, this bill:
1)Extends the January 1, 2017 repeal date for the Assisted
Outpatient Treatment Demonstration Project Act of 2002 until
January 1, 2022, thereby extending the program by five years.
2)Repeals a duplicative section of the law, requiring the
Department of Health Care Services to submit a report and
evaluation of all counties implementing AOT to the Governor
and the Legislature, which is required by another section of
the Welfare and Institutions Code. (All further statutory
references are to this Code, unless otherwise indicated.)
EXISTING LAW:
1)Permits counties to provide AOT 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. (Section 5346.)
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
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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
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. (Section 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
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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)Requires counties that implement AOT to provide data to the
Department of Health Care Services (DHCS) and, based upon that
information, requires DHCS to submit a report and evaluation
to the Legislature by May 1st of each year. (Section 5348
(d).)
3)Sunsets this authorization on January 1, 2017. (Section
5349.5(a).)
4)Requires DHCS to submit to the Governor and the Legislature a
report and evaluation of all counties implementing any
component of the 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
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
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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. (Sections 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
adults, and no children's mental health program, may be 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
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becomes too ill and is subject to involuntary civil
confinement."
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
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.) In fact, as explained in more
detail below, counties in California that have implemented AOT
say that they have already realized substantial savings.
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
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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. Nevada County reports that the AOT program has
resulted "in a 45% net savings ($503, 621) for Nevada County
over the first 30 months of the program" and that "[e]very
dollar spent on the Assisted Outpatient Treatment program has
prevented acute psychiatric hospitalizations and jail days [and]
saved $1.81."
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). A number of county programs have been recently
implemented and either have no court ordered AOT commitments, or
very few. The most recent data available to the Committee from
Orange County indicates that only two individuals have been
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ordered to fulfill an AOT commitment in that county.
Contra-Costa County is implementing AOT this month. According
to the author, there are formal processes in motion that may
lead to adoption before the Board of Supervisors in several
other counties: El Dorado, San Mateo, Kern, Santa Barbara, and
Ventura.
Extension 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 many
organizations that do not oppose this bill, 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 bill, it appears
that the AOT program is more widely accepted and has become less
controversial as time has gone on.
But AOT 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." Similarly,
writing in opposition to this bill's original provisions, the
California Association of Mental Health Peer Run Organizations
questions whether AOT is as effective as less coercive
alternative treatments, a concern that is obviously still
relevant to this version of the bill, writing as follows:
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
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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.
Removal of Duplicative DHCS Reporting Requirements. Current law
has two separate, virtually identical requirements for DHCS to
report data about counties that implement AOT to the Legislature
and the Governor. One provision requires DHCS to submit a
report and evaluation of all counties implementing any component
of the assisted outpatient treatment program to the Legislature
by May 1st of each year. (Section 5348 (d).) Another section
requires DHCS to submit to the Governor and the Legislature a
report and evaluation of all counties implementing any component
of the assisted outpatient treatment program by July 1, 2015.
(Section 5349.5(b).) This bill's most recent amendments remove
the latter reporting requirement and require the former report
to be provided to both the Governor and the Legislature. This
change, for all practical purposes, is non-substantive because
it removes a duplicative reporting requirement from existing
law.
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. Status: Assembly Appropriations
Committee.
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Previous legislation. AB 193 (Maienschein, 2015) would have
allowed probate courts to recommend a referral for an LPS
conservatorship to the county officer providing conservatorship
investigations. AB 193 was vetoed.
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 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 - January 6th Version
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California Chapter of the American College of Emergency
Physicians
California State Association of Counties
NAMI - Contra Costa County
Nevada County Health and Human Services Agency
Support - Prior Versions
San Diego Regional Chamber of Commerce
Opposition - January 6th Version
Disability Rights California
Opposition - Prior Versions
California Association of Mental Health Peer Run Organizations
California Council of Community Mental Health Agencies
Mental Health America
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Analysis Prepared by:Alison Merrilees / JUD. / (916) 319-2334