BILL ANALYSIS                                                                                                                                                                                                    Ó




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          |SENATE RULES COMMITTEE            |                        AB 741|
          |Office of Senate Floor Analyses   |                              |
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                                   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.











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          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  








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             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.









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           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  








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                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.  









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            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  








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          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  








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          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  








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          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.










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          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  








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          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








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          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










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          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


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