BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 741| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: AB 741 Author: Williams (D) Amended: 8/16/16 in Senate Vote: 21 SENATE HUMAN SERVICES COMMITTEE: 4-0, 6/14/16 AYES: McGuire, Hancock, Liu, Nguyen NO VOTE RECORDED: Berryhill SENATE HEALTH COMMITTEE: 8-0, 6/29/16 AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth NO VOTE RECORDED: Wolk SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16 AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen ASSEMBLY FLOOR: 77-0, 6/2/15 - See last page for vote SUBJECT: Mental health: community care facilities SOURCE: California Alliance of Child and Family Services California Council of Community Mental Health Agencies DIGEST: This bill expands the definition of a short-term residential treatment center to include a children's crisis residential center to be used as a diversion from psychiatric hospitalization, and limits the stay to 10 consecutive days and no more than 20 total days within a six-month period. AB 741 Page 2 ANALYSIS: Existing law: 1) Establishes a system of juvenile dependency for children who are or are at risk of being physically, sexually or emotionally abused, being neglected or being exploited to ensure their safety, protection and physical and emotional well-being. (WIC 300, et seq.) 2) Requires the state, through the California Department of Social Services (CDSS) and county welfare departments, to establish and support a public system of child welfare services to protect and promote the welfare of children. (WIC 10600 and 16500) 3) Establishes California's Medicaid program, Medi-Cal, through which eligible low-income individuals receive health care and mental health services, including foster youth. Under Medi-Cal, establishes the federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program to provide comprehensive and preventive health services including specialty mental health services to Medi-Cal beneficiaries under the age of 21. (WIC 14000 et seq., 42 USC Section 1396 et seq and 42 CFR 435.145.) 4) Requires county mental health departments to provide children served by county social services and probation departments, with mental health screening, assessment, participation in multidisciplinary placement teams and AB 741 Page 3 specialty mental health treatment, as specified. (WIC 5867.5) 5) Establishes a system of licensure and oversight for community care facilities, including short term residential treatment centers, to provide rehabilitation and therapy for youth in foster care or other systems, as specified, and defines a "short-term residential treatment center" to mean a CDSS-licensed residential facility to provide short-term, specialized, and intensive treatment, and 24-hour care and supervision to children. (HSC 1502 (a)(18)) 6) Requires a short term residential treatment center to have all of the following, as of January 1, 2017: (a) national accreditation from an entity identified by CDSS, as specified; (b) a mental health certification, as defined, which shall be in good standing; (c) a current written plan of operation, as specified, which must include a statement of purposes and goals, plan for supervision, evaluation and training of staff; and (d) a qualified administrator, as specified, and staff training on specific topics of information relevant to the population of children served. (HSC 1562.01) This bill: 1) Makes a series of legislative findings and declarations, including that there is an urgent need to provide more crisis care alternatives to hospitals for children and youth experiencing mental health crises and that it is imperative that California identify a licensing category specifically for mental health crisis residential care that can be utilized for children and youth who are beneficiaries of both public and private health care plans. AB 741 Page 4 2) Adds to the definition of "short-term residential treatment center" that it includes a children's crisis residential center, defined as a short-term residential treatment center operated specifically to divert children experiencing a mental health crisis from psychiatric hospitalization. 3) Adds a new section, WIC 1502.1, which requires CDSS to establish regulations for short-term residential treatment centers that are designated as children's crisis residential centers, and requires, at a minimum, the regulations include: a) Crisis residential centers be used only for diversion from admittance to a psychiatric hospitalization. b) The length of stay for a single admission will be limited to 10 consecutive days. c) The length of stay may be extended once for no more than two consecutive 10-day lengths of stay, however before extending the length of stay for a Medi-Cal beneficiary beyond 10 consecutive days, an organization providing children's crisis residential services shall obtain prior approval from the county mental health plan authorizing those services. d) Prohibits a child from being admitted to a children's crisis residential center for more than 20 total days in any six-month period. e) Therapeutic programming shall be provided seven days a week, including weekends and holidays, with sufficient professional and paraprofessional staff to maintain an appropriate treatment setting and services, based on individual children's needs. f) The program shall be staffed with sufficient personnel to accept and admit children, at a minimum, from 7 a.m. to 11 p.m., seven days a week, 365 days per year. The program AB 741 Page 5 shall be sufficiently staffed to discharge children, as appropriate, seven days a week, 365 days per year. g) Requires facilities to be limited to fewer than 16 beds, with at least 50 percent of those beds in single-occupancy rooms, and requires that facilities include ample physical space for working with individuals who provide natural supports to each child and for integrating family members into the day-to-day care of the youth. h) Requires the center collaborate with each child's mental health team, child and family team, and other paid and natural supports within 24 hours of intake and throughout the course of care and treatment as appropriate. 4) Requires each center to annually provide CDSS with all of the following data as it pertains to children in foster care and children not in foster care in conjunction with its application for licensure renewal: (a) age and gender of clients served; (b) duration of stay; (c) professional classification of staff and contracted staff; and (d) type of placement the client was discharged to. 5) Requires the Department of Health Care Services (DHCS) to set interim Med-Cal rates for care within a crisis residential home, requires and to consult with subject matter experts from the County Behavioral Health Directors Association of California and provider associations to obtain data and background information necessary to ensure sufficiency of the rate. 6) Requires that the board and care rate for foster children admitted to a crisis residential center be the same as for a short term residential treatment center (STRTC) and establishes that nothing prevents a county from paying a higher rate for crisis residential care. AB 741 Page 6 7) Adds crisis residential centers to the list of services eligible for grant awards under the Investment in Mental Health Wellness Act of 2013 for startup costs to increase capacity for crisis services to children and youth 21 years of age and under, as specified. 8) Permits a children's crisis residential center to admit or accept any child, referred by a parent or guardian, or by the representative of a public or private entity, including, but not limited to, the county probation agency or child welfare services agency with responsibility for the placement of a child in foster care, that has the right to make these decisions on behalf of a child who is in mental health crisis and, absent admission to a children's crisis residential center, would otherwise require acceptance by the emergency department of a general hospital, or admission into a psychiatric hospital or the psychiatric inpatient unit of a general hospital. 9) Permits emergency placement be made into a crisis residential center but requires a mental health professional determine within 24 hours of placement that the child is in need of that level of care. 10) Makes various technical and conforming changes. Background California's child welfare system was designed to protect children at risk of child abuse and neglect or exploitation by AB 741 Page 7 providing intensive services to families to allow children to remain in their homes, or by arranging temporary or permanent placement of the child in the safest and least restrictive environment possible. Approximately 62,000 children were in the custody of the child welfare system as of October 2015, according to the state's child welfare case management system. About 45,000 children were placed in out-of-home situations in 2016, according to data released by CDSS with the Governor's Budget. Continuum of Care Reform Efforts. After a three-year stakeholder effort, CDSS last year unveiled a reform effort intended to reduce the reliance on group care, so that children in foster care are raised primarily in family-like environments. A cornerstone of this effort is the elimination of the category of foster care group homes, effective January 1, 2017, and the creation of a category of STRTCs which provide brief, intensive, mental health interventions to youth and adolescents who qualify for that level of care. This bill expands that category of treatment facilities to include short term crisis residential care for adolescents who can be treated effectively in a 10-day stay, in order to divert teens and youth from inpatient psychiatric facilities. Mental Illness Approximately 20 percent of youth between the ages of 13 and 18, and 13 percent of younger youth experience severe mental disorders in a given year, according to statistics compiled by the National Alliance on Mental Illness (NAMI). About 7 in 10 youth in juvenile justice systems have at least one mental health condition and 20 percent are living with serious mental illness. NAMI reports that almost half of children aged 8 to 15 AB 741 Page 8 who were diagnosed with a mental illness received no mental health services in the previous year. Foster youth experience a heightened rate of mental illness, compared to peers, according to various studies. Specifically, an American Psychological Association report noted that nearly half of youth in foster care had clinically significant emotional or behavioral problems, and more than half of children entering foster care exhibited behavioral or social competency problems that warranted mental health services. The report also found that children under age seven who enter foster care show high rates of developmental problems. Capacity issues. California has few crisis diversion programs for adolescents and few options in a mental health crisis aside from emergency hospitalization. According to a 2015 paper published by six mental health advocacy organizations, the lack of crisis options for children and teens results in untreated mental health issues which worsen over time. "Kids in Crisis: California's Failure to Provide Appropriate services for Youth Experiencing a Mental Health Crisis," described California's system as inconsistent statewide with many families turning to local hospital emergency rooms for help. The report advocated for the creation of community-based crisis facilities for children and youth. "The emergency room should be the last resort for a child in crisis, yet in our current system, this is where children are first being identified," the report noted. It cited a statewide decrease in the availability of inpatient psychiatric hospital beds for children and adolescents and a lack of comprehensive community-based solutions to meet the mental health needs of children. It also noted that while there are existing crisis service programs in AB 741 Page 9 California, the availability of these programs are limited in the type of services that are available and vary significantly from one county to another county. For example, a handful of counties may operate children's mobile crisis teams, but there are no crisis stabilization units or beds within that same region. Therefore, inpatient hospitalization is the only option for a youth experiencing a crisis in many areas of the state, which often is "the least effective measure," according to the report. A 2012 study of California hospital emergency rooms, published by the California Hospital Association, indicated children and adolescents with a primary psychiatric diagnosis waited an average 12.97 hours for psychiatric evaluation and placement - nearly three hours longer than adults in the same situation. Total length of stay for children and teens in crisis was estimated to be more than 19 hours. Related/Prior Legislation AB 1997 (Stone, 2016) is the clean-up bill to AB 403 (Stone, 2015), and will include modifications to the licensure and certification of STRTCs. AB 403 (Stone, Chapter 773, Statutes of 2015) codified the continuum of care reform effort by eliminating group homes and creating short term residential treatment centers, home-based therapeutic efforts and other reforms. AB 741 Page 10 SB 82 (Committee on Budget and Fiscal Review, Chapter 34, Statutes of 2013) established the Investment in Mental Health Wellness Act of 2013, which authorized the California Health Facilities Financing Authority to administer a local grant program to increase capacity for crisis support programs. FISCAL EFFECT: Appropriation: No Fiscal Com.:YesLocal: Yes An analysis by the Senate Appropriations Committee identified one-time costs of about $550,000 for the development of regulations by CDSS (General Fund). The bill requires the Department to adopt regulations to specify the requirements for operating a short-term residential treatment center as a children's crisis residential center. It also identified unknown information technology costs, likely in the low hundreds of thousands, for CDSS to modify its internal systems for licensing and regulating children's crisis residential treatment centers (GF) and ongoing costs of about $125,000 per year for CDSS to license and regulate children's crisis residential center (GF). Licensing fees are not set at a level that is sufficient to fund the Department's licensing and enforcement program. The analysis identified no significant administrative costs anticipated by DHCS, which is required by this bill to establish Medi-Cal rates to pay for the costs of providing children's crisis residential services. DHCS indicates that the Medi-Cal State Plan already includes children's crisis residential services and includes a methodology to pay for those services. The Department indicates that the reimbursement rate will be the same as that provided for adult crisis residential services. Additionally, the analysis identified an unknown increase in Medi-Cal costs due to increased utilization of children's crisis AB 741 Page 11 residential services (General Fund, local funds, and federal funds). The intention of the bill is to provide services to children in children's crisis residential centers, rather than in psychiatric hospitals or general acute care hospitals. In those cases, there would likely be cost savings to Medi-Cal, since the reimbursement rates for crisis residential services will be lower than inpatient hospital rates. However, there is a consensus that there is a significant shortage in available psychiatric beds for children in the state. There is likely to be a significant unmet need for psychiatric inpatient services. Therefore, some of the utilization of children's crisis residential care will be in addition to those services currently being provided in hospitals, rather than a substitution for services already being provided. SUPPORT: (Verified 8/15/16) California Alliance of Child and Family Services (co-source) California Council of Community Mental Health Agencies (co-source) Anka Behavioral Health, Inc. Aviva Family and Children's Services Bill Wilson Center California Chapter of the American College of Emergency Physicians California Coalition for Youth California Mental Health Advocates for Children and Youth California Primary Care Association California State PTA California State University Channel Islands Casa Pacifica Centers for Children and Families Child Abuse Listening Mediation Common Sense Kids Action County of Santa Barbara Crittenton Services for Children and Families David & Margaret Youth and Family Services Disability Rights California Family Care Network, Inc. Foster Care Task Force Hathaway-Sycamores Child and Family Services AB 741 Page 12 Hillsides Junior Blind of America La Clinica de la Raza Lincoln Child Center Mental Health America of Los Angeles NAMI California National Association of Social Workers, California Chapter National Council for Behavioral Health Oxnard Police Department Pacific Clinics Redwood Community Services Redwood Quality Management Company Remi Vista, Inc. San Diego Center for Children Santa Barbara County Board of Supervisors Santa Barbara County Sheriff Bill Brown Seneca Family of Agencies Sierra Sacramento Valley Medical Society Stanford Youth Solutions Stars Behavioral Health Group Steinberg Institute The Guidance Center The Village Family Services Transitions-Mental Health Association Trinity Youth Services United Advocates for Children and Families United Parents Uplift Family Services Ventura County Board of Supervisors Ventura County Sheriff Geoff Dean West Coast Children's Clinic Young Minds Advocacy Project Youth Homes, Inc. Youth In Mind OPPOSITION: (Verified8/15/16) California Department of Finance AB 741 Page 13 ARGUMENTS IN SUPPORT: The California Alliance of Children and Family Services, sponsor, writes that this bill creates the needed licensing category to ensure that counties and their community based providers have the ability to develop crisis residential programs to ensure children and youth have access to mental health services. ARGUMENTS IN OPPOSITION: The California Department of Finance writes that it is opposed to this bill, in addition to cost factors, because the implementation of the Continuum of Care Reform is still underway and discussions continue regarding certification of the STRTCs. "Therefore, it is premature to include this additional STRTC category before implementation of that effort," according to DOF. ASSEMBLY FLOOR: 77-0, 6/2/15 AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins NO VOTE RECORDED: Brough, Chávez, Grove Prepared by:Mareva Brown / HUMAN S. / (916) 651-1524 8/16/16 17:55:10 **** END **** AB 741 Page 14