BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                     AB 741


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          CONCURRENCE IN SENATE AMENDMENTS


          AB  
          741 (Williams)


          As Amended  August 19, 2016


          Majority vote


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          |ASSEMBLY:  |77-0  |(June 2, 2015) |SENATE: |38-0  |(August 24,      |
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          Original Committee Reference:  HEALTH


          SUMMARY:  Allows a short-term residential treatment center  
          (STRTC) to be operated as a children's crisis residential center  
          (CCRC) as defined, which would be operated specifically to  
          divert children experiencing a mental health crisis from  
          psychiatric hospitalization.  Requires the Department of Social  
          Services (DSS) to establish regulations for STRTCs that are  
          operated as CCRCs, and requires the regulations to include  
          specified minimum components.  Requires the Department of Health  
          Care Services (DHCS) to establish Medi-Cal rates as needed that  
          are sufficient to reimburse the costs for children's crisis  
          residential services in excess of any specialty mental health  
          services that would have been otherwise authorized, provided,  
          and invoiced for each eligible Medi-Cal beneficiary receiving  
          children's crisis residential services.


          The Senate amendments 









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          1)Establish legislative findings and declarations.
          2)Define a CCRC as a STRTC operated specifically to divert  
            children experiencing a mental health crisis from psychiatric  
            hospitalization.


          3)Require DSS to establish regulations for STRTCs that are  
            operated as CCRC.  Requires, at a minimum, the regulations to  
            include all of the following:


             a)   Require the CCRC to be used only for diversion from  
               admittance to a psychiatric hospitalization; 


             b)   Require the length of stay for a single admission to a  
               CCRC to be limited to 10 consecutive days, permit a length  
               of stay to be extended once for no more than two  
               consecutive 10-day lengths of stay, and prohibit a child  
               from being admitted to a CCRC for more than a 20-day period  
               in 6 months;


             c)   Require therapeutic programming to 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; 


             d)   Require the program to be staffed with sufficient  
               personnel to accept children 24 hours per day, seven days a  
               week and to admit children, at a minimum, from 7 a.m. to 11  
               p.m., seven days a week, 365 days per year; 


             e)   Require the program to be sufficiently staffed to  
               discharge children, as appropriate, seven days a week, 365  
               days per year;










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             f)   Require facilities to be limited to fewer than 16 beds,  
               with at least 50% of those beds in single-occupancy rooms; 


             g)   Require facilities to include ample physical space for  
               accommodating individuals who provide natural supports to  
               each child and for integrating family members into the  
               day-to-day care of the youth; and, 


             h)   Require the CCRC to collaborate with each child's mental  
               health team, child and family team, and other formal and  
               natural supports within 24 hours of intake and throughout  
               the course of care and treatment as appropriate.


          4)Require CCRCs to annually provide DSS with the age and gender  
            of the clients served, the duration of stay, the professional  
            classification of staff and contracted staff, and the type of  
            placement the client was discharged to.


          5)Require DHCS to establish Medi-Cal rates as needed that are  
            sufficient to reimburse the costs for CCRC in excess of any  
            specialty mental health services that would have been  
            otherwise authorized, provided, and invoiced for each eligible  
            Medi-Cal beneficiary receiving children's crisis residential  
            services.  Requires DHCS to consult with subject matter  
            experts from the California Behavioral Health Directors  
            Association and provider associations to obtain information  
            necessary to ensure sufficiency of the rate.


          6)Require, for foster children admitted for CCRC, programs to  
            receive payment for board and care equivalent to the rate paid  
            for STRTCs.


          7)Prohibit the Medi-Cal rate provisions from preventing a county  
            from providing payment in excess of the STRTC rate in order to  
            meet the needs of individual children.









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          8)Permit a STRTC that is operating as a CCRC to accept for  
            admission or placement 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 hospital, or admission into a  
            psychiatric hospital or the psychiatric inpatient unit of a  
            hospital.


          9)Make CCRCs eligible for grant funding authorized in the 2016  
            Budget Act.


          10)Add language to avoid chaptering conflicts with AB 1997  
            (Stone) and SB 524 (Lara) of the current legislative session.


          EXISTING LAW:  


          1)Establishes in federal law the Medicaid program to provide  
            comprehensive health benefits to low income persons.


          2)Establishes the Medi-Cal program as California's Medicaid  
            program.


          3)Establishes specified Medi-Cal benefits, some required by  
            federal law, and other benefits which are optional under  
            federal law.


          4)Defines "social rehabilitation facility" as any residential  
            facility that provides social rehabilitation services in a  
            group setting up to 18 months to adults recovering from mental  








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            illness who temporarily need assistance, guidance, or  
            counseling.


          FISCAL EFFECT:  According to the Senate Appropriations  
          Committee:


          1)One-time costs of about $550,000 for the development of  
            regulations by DSS (General Fund).  This bill requires DSS to  
            adopt regulations to specify the requirements for operating a  
            short-term residential treatment center as a children's crisis  
            residential center. 


          2)Unknown information technology costs, likely in the low  
            hundreds of thousands, for the DSS to modify its internal  
            systems for licensing and regulating children's crisis  
            residential treatment centers (General Fund).


          3)Ongoing costs of about $125,000 per year for DSS to license  
            and regulate children's crisis residential center (General  
            Fund).  Although DSS does collect licensing fees from  
            regulated entities, those fees are not set at a level that is  
            sufficient to fund DSS's licensing and enforcement program.


          4)No significant administrative costs are anticipated by DHCS.   
            This bill requires DHCS to establish Medi-Cal rates to pay for  
            the costs of providing children's crisis residential services.  
             However, DHCS indicates that the Medi-Cal State Plan already  
            includes children's crisis residential services and includes a  
            methodology to pay for those services.  DHCS indicates that  
            the reimbursement rate will be the same as that provided for  
            adult crisis residential services.


          5)Unknown increase in Medi-Cal costs due to increased  
            utilization of children's crisis residential services (General  
            Fund, local funds, and federal funds).  The intention of the  
            bill is to provide services to children in children's crisis  








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            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.  The size of  
            this impact is unknown.


          COMMENTS:  According to the author, the objective for mental  
          health services, guided by the federal Olmstead Act, is to  
          provide treatment in the least restrictive setting possible.   
          The overarching goal of existing programs is to keep youth  
          experiencing a mental health crisis in calm, familiar  
          environments where their mental health needs can be met.   
          Currently, an estimated three out of every four children in the  
          United States that need mental health services, do not receive  
          them.  Nearly 20% of high school students in California consider  
          suicide at some point in their lives and more than 10% actually  
          attempt it.  With 47 out of 58 counties lacking any  
          child/adolescent psychiatric hospital inpatient beds for  
          children under 12 (and fewer than 70 beds statewide), the need  
          for children's crisis residential services could not be more  
          acute.  Among the benefits already included in the State Mental  
          Health Plan are: crisis intervention; crisis stabilization;  
          crisis residential treatment services; and the Early and  
          Periodic Screening, Diagnostic and Treatment (EPSDT)  
          supplemental Specialty Mental Health Services (SMHS).  Without a  
          licensing category specific to children's crisis residential  
          programs, however, this critically needed service - both in lieu  
          of inpatient care and as a step down from inpatient care - is  
          missing from the continuum of care.


          According to the California Alliance of Child and Family  
          Services, cosponsors of this bill, and other supporters, this  








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          bill is aimed at addressing a critical component missing in the  
          continuum of specialty mental health services for children and  
          youth in California - children's crisis residential services.   
          This bill creates the needed licensing category to ensure that  
          counties and their community-based providers have the ability to  
          develop crisis residential programs with an appropriate  
          licensing category, to ensure children and youth have access to  
          mental health services that are responsive to their individual  
          needs and strengths in a timely manner, and consistent with the  
          requirements of the Medi-Cal EPSDT and SMHS program standards  
          and requirements.  There is no question that a full continuum of  
          care for children and youth with critical mental health needs is  
          both essential and required by law.  The lack of a licensing  
          component for crisis residential services, however, is  
          preventing the development of this much needed program which  
          would provide a residentially-based acute care option in a less  
          restrictive environment than inpatient hospitalization and would  
          offer a more appropriate alternative for children that do not  
          require a hospital level of care.


          This bill has no known opposition.


          Analysis Prepared by:                                             
                          Paula Villescaz / HEALTH / (916) 319-2097  FN:   
          0004752