BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 1300             
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          |AUTHOR:        |Ridley-Thomas                                  |
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          |VERSION:       |June 21, 2016                                  |
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          |HEARING DATE:  |June 29, 2016  |               |               |
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          |CONSULTANT:    |Reyes Diaz                                     |
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           SUBJECT  :  Mental health: involuntary commitment

           SUMMARY  : Allows an emergency physician or psychiatric professional, who  
          is not a county-designated professional person, as specified, to  
          detain a person who is a danger to self or others, or is gravely  
          disabled, for up to 72 hours for evaluation and treatment, as  
          specified. 
          
          Existing law:
          1)Prohibits a facility not designated by a county, as defined,  
            and licensed professional staff of those facilities or any  
            physician and surgeon from being civilly or criminally liable  
            for detaining a person for more than eight hours but less than  
            24 hours if it is determined, as specified, that the person,  
            as a result of a mental disorder, is a danger to self or  
            others, or is "gravely disabled," as defined, or for the  
            release of a person and the actions of the person after the 24  
            hours, if certain criteria are met. Defines "gravely disabled"  
            to include a condition in which a person, as a result of a  
            mental health disorder, is unable to provide for his or her  
            basic personal needs for food, clothing, or shelter.

          2)Establishes the Lanterman-Petris-Short (LPS) Act and declares  
            the intent of the Legislature to end the inappropriate,  
            indefinite, and involuntary commitment of persons with mental  
            health disorders, developmental disabilities, and chronic  
            alcoholism, as well as to safeguard a person's rights, provide  
            prompt evaluation and treatment, and provide services in the  
            least restrictive setting appropriate to the needs of each  
            person.
             
          3)Authorizes a peace officer, member of the attending staff of a  
            facility designated by the county for evaluation and treatment  







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            ("designated facility"), member of the attending staff of a  
            designated facility, or other professional person designated  
            by the county, upon probable cause, to take a person with a  
            mental disorder who is a danger to self or others, or is  
            gravely disabled, into custody (a "5150" hold) and place him  
            or her in a designated facility. 

          4)Requires facilities, for the purposes of detaining a person  
            for up to 72-hour treatment and evaluation, to be designated  
            by a county and approved by the Department of Health Care  
            Services (DHCS).  

          5)Requires that a person who is taken into custody for up to  
            72-hour treatment and evaluation be provided an oral  
            advisement that informs the person of: 

                  a)        The name of the officer or mental health  
                    professional authorizing custody;
                  b)        The fact that the person is not under criminal  
                    arrest but under a mental health examination;
                  c)        Where the evaluation will take place;
                  d)        That he or she may take a few personal items;  
                    and,
                  e)        That he or she may make a phone call or leave  
                    a note to inform family and friends where he or she  
                    has been taken.

          6)Requires that a person who is admitted for up to 72 hours for  
            evaluation and treatment be provided with the following  
            information in writing:

                  a)        That he or she is being placed in a  
                    psychiatric unit because he or she may hurt him- or  
                    herself, or others, or be gravely disabled;
                  b)        A listing of the facts upon which the above  
                    allegation is based; 
                  c)        That he or she will be held for a period of up  
                    to 72 hours, and when that period will begin;
                  d)        That he or she may be held for a longer period  
                    of time; and,
                  e)        His or her right to a lawyer, as specified.

          7)Authorizes the county mental health director to develop  
            procedures for the county's designation and training of  
            professionals who perform LPS Act functions, including:








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                  a)        License types, practice disciplines, and  
                    clinical experience of professionals;
                  b)        Initial and ongoing training and testing  
                    requirements for professionals;
                  c)        The application and approval processes for  
                    professionals seeking to be designated by the county,  
                    including the timeframe for initial designation and  
                    procedures for renewal of the designation; and,
                  d)        The county's process for monitoring and  
                    reviewing these professionals to ensure appropriate  
                    compliance with state law, regulations, and county  
                    procedures. 
                     
          8)Provides immunity to public agencies (which includes public  
            hospitals) and their employees for the involuntary detention  
            of persons, including the enforcement and release of  
            detainment to the extent that the facility or employee acts in  
            accordance with requirements of the LPS Act in detaining a  
            person, and enforcing or releasing the detention.  
          
          This bill:
          1)Allows an "emergency physician" or a "psychiatric  
            professional," as defined, who is not a county-designated  
            professional person to take, or cause to be taken, a  
            person-who is a danger to self or others, or is gravely  
            disabled-into custody for up to 72 hours for the purpose of  
            obtaining evaluation and treatment from a professional person,  
            including members of a mobile crisis team, who is designated  
            by a county, or to arrange the transfer of the person to a  
            designated facility for evaluation and treatment.
                     
          2)Defines "emergency physician" as a physician and surgeon  
            during any scheduled period that he or she is on duty to  
            provide medical screening and treatment of patients in the  
            emergency department (ED). Defines "psychiatric professional"  
            as a physician and surgeon licensed by the Medical Board of  
            California who has completed an approved psychiatric residency  
            training program and who provides specialty services to EDs of  
            a hospital that is not a designated facility (non-designated  
            hospital [NDH]).

          3)Requires each designated facility to accept within its  
            clinical capability and capacity all categories of persons for  
            whom it is designated, without regard to insurance or  








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            financial status. Requires the facility to assist a person who  
            presents to the facility with a psychiatric emergency medical  
            condition in obtaining emergency services and care at an  
            appropriate facility.

          4)Allows specified individuals who participate in the  
            examination, consultation, treatment, placement, referral, or  
            transport of a detained person, or for whom there may be  
            probable cause for detainment, to engage in communication of  
            patient information among each other and with county  
            behavioral health professionals and staff, including when  
            examining a person at the scene of an emergency or in  
            transport to a hospital, and at a designated facility or other  
            agency, at which the person may be evaluated, treated, placed,  
            referred, or transported.

          5)Requires an application for detention for evaluation and  
            treatment to be valid in all counties in which there is a  
            designated facility to which a person who is being detained  
            may be taken. Requires an application for detention for  
            evaluation and treatment to be presented to a designated  
            facility or NDH, as specified, and retained for the period of  
            time required by the medical records retention policy of the  
            designated facility or the NDH.

           FISCAL  
          EFFECT  : This bill has not been analyzed by a fiscal committee. 

           PRIOR  
          VOTES  :  
          
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          |Assembly Floor:                     |Not relevant                |
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          |Assembly Appropriations Committee:  |Not relevant                |
          |Assembly Judiciary Committee:       |Not relevant                |
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          |Assembly Health Committee:          |Not relevant                |
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          COMMENTS  :
          1)Author's statement. According to the author, when the LPS Act  
            was enacted in 1967, it was envisioned that the evaluation and  
            treatment of people with mental illnesses would happen in  








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            designated facilities. Since its passage, there have been  
            significant changes that have adversely impacted the mental  
            health delivery system. As federal and state resources to  
            support psychiatric facilities have declined, peace officers,  
            individuals, and families in the middle of a mental health  
            crisis have turned to EDs for relief. Because the LPS Act did  
            not contemplate EDs serving as a necessary entry point into  
            the 5150 process, ED physicians often lack the authority to  
            place or sustain a 5150 hold. Instead of ignoring a growing  
            problem, ED physicians have asked to be part of the solution.  
            By granting ED physicians the authority to place 5150 holds in  
            a manner similar to peace officers, this bill will improve  
            public safety and outcomes for individuals during a mental  
            health crisis. While this bill takes an important step in the  
            right direction, we still must take significant steps to  
            improve the LPS Act and increase the capacity of our mental  
            health delivery system so we can provide better care for  
            people with mental illnesses.
            
          2)Background. The LPS Act was enacted in the 1960s to develop a  
            statutory process under which individuals could be  
            involuntarily held and treated in a county-designated facility  
            in a manner that safeguarded their constitutional rights. The  
            LPS Act was intended to balance the goals of maintaining the  
            constitutional right to personal liberty and choice in mental  
            health treatment. Since its passage in 1967, the field of  
            mental health has continued to evolve toward even greater  
            legal rights for mentally disordered persons. Welfare and  
            Institutions Code Section 5150 ("5150") of the LPS Act allows  
            peace officers, staff members of county-designated facilities,  
            or other county-designated professional persons to take an  
            individual into custody and place him or her in a facility for  
            72-hour treatment and evaluation to determine if, due to a  
            mental disorder, the individual is a danger to self or others,  
            or is gravely disabled. The LPS Act imposes strict conditions  
            relating to the detention, assessment and treatment of the  
            detainee. Provided that specified conditions are met, the  
            peace officer and the medical director of the facility, as  
            well as the professional staff responsible for the evaluation  
            and treatment of the person, are granted immunity from civil  
            and criminal liability for releasing the detainee at any time  
            prior to the end of the 72-hour hold or for any actions of the  
            person released before or after the 72-hour hold. 

               a)     Designated facilities vs. NDHs. Individual counties  








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                 are responsible for determining whether general acute  
                 care hospitals, psychiatric health facilities, acute  
                 psychiatric hospitals, and other licensed facilities  
                 qualify to be designated facilities. DHCS is responsible  
                 for the approval of designated facilities as determined  
                 by the counties. Counties generally have the discretion  
                 to implement how facilities are designated but facilities  
                 are required to uphold proper care of the patient and a  
                 patient's civil rights throughout the process of  
                 detention. As one example, Los Angeles County (LAC) has  
                 strict guidelines that designated facilities must meet.  
                 Every three years, facilities are re-evaluated for  
                 designation. If there are complaints about a designated  
                 facility, the county has the authority to inspect patient  
                 medical records and issue corrective action plans to the  
                 designated facilities. If designated facilities do not  
                 comply, LAC can revoke designation. While the intent of  
                 the LPS Act is for authorized individuals to take a  
                 person who has been placed on a 5150 hold to a designated  
                 facility, if one does not exist, or a person is suffering  
                 another condition that requires immediate emergency  
                 medical services, the person is transported to the  
                 nearest facility, which is often a NDH or other  
                 nondesignated facility, which is any facility  
                 participating in Medicare and is, therefore, required by  
                 federal Emergency Medical Treatment and Labor Act  
                 (EMTALA) laws to provide emergency medical services to  
                 any individual who presents and requires emergency  
                 medical attention.

               b)     EMTALA. Sometimes referred to as the "Patient  
                 Anti-Dumping Law," EMTALA was passed to address the  
                 problem of hospitals refusing to treat indigent,  
                 uninsured, or Medicaid patients, or dumping these  
                 patients by transferring them to county hospitals or  
                 other charity hospitals. According to the federal Centers  
                 for Medicare and Medicaid Services (CMS), in 1986,  
                 Congress enacted EMTALA to ensure public access to  
                 emergency services regardless of ability to pay. Section  
                 1867 of the Social Security Act imposes specific  
                 obligations on Medicare-participating hospitals that  
                 offer emergency services to provide a medical screening  
                 examination when a request is made for examination or  
                 treatment for an emergency medical condition, including  
                 active labor, regardless of an individual's ability to  








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                 pay. Hospitals are then required to provide stabilizing  
                 treatment for patients with an emergency medical  
                 condition. If a hospital is unable to stabilize a patient  
                 within its capability, or if the patient requests, then  
                 an appropriate transfer should be implemented. As an  
                 enforcement mechanism, EMTALA also established a private  
                 right of action.  

          3)Community-based treatment and inpatient psychiatric beds. 

               a)     Crisis Residential Programs. According to a 2010  
                 report by the California Mental Health Planning Council,  
                 crisis residential programs are a lower-cost,  
                 community-based treatment option in home-like settings  
                 that help reduce ED visits and divert hospitalization and  
                 incarcerations. According to the report, these programs  
                 include peer-run programs such as crisis respites that  
                 offer safer, trauma-informed alternatives to psychiatric  
                 emergency units or other locked facilities. The report  
                 indicates that crisis residential programs reduce  
                 unnecessary stays in psychiatric hospitals, reduce the  
                 number and expense of ED visits, and divert inappropriate  
                 incarcerations while producing the same or superior  
                 outcomes to those of institutionalized care. The report  
                 states that as the cost for inpatient treatment continues  
                 to rise the need to expand an appropriate array of acute  
                 treatment settings becomes more urgent, and state and  
                 county mental health systems should encourage and support  
                 alternatives to costly institutionalization and improve  
                 the continuum of care to better serve individuals  
                 experiencing an acute psychiatric episode.

               b)     Mobile Crisis Support Teams. Mobile crisis support  
                 teams can be utilized to provide crisis intervention,  
                 family support, and 5150 evaluations. These teams meet  
                 law enforcement in the field and, among other things,  
                 provide diversion into appropriate treatment  
                 arrangements.  These teams have been used in several  
                 areas across the state. A mobile crisis team typically  
                 consists of an interdisciplinary team of mental health  
                 professionals (nurses, social workers, psychiatrists,  
                 psychologists, mental health technicians, addiction  
                 specialists, or peer counselors) that respond to  
                 individuals in the community through home visits or  
                 responses to incidents at other locations.








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               c)     Crisis Stabilization. "Crisis stabilization (CS)" is  
                 defined in Title 9, California Code of Regulations (CCR),  
                 Division 1, Chapter 11, Section 1810.210 as a service  
                 lasting less than 24 hours, to or on behalf of a  
                 beneficiary for a condition that requires more timely  
                 response than a regularly scheduled visit. Service  
                 activities include, but are not limited to, one or more  
                 of the following: assessment, collateral, and therapy.  
                 Services are required to be provided on-site at a  
                 licensed 24-hour health care facility or hospital-based  
                 outpatient program or a provider site certified by DHCS  
                 or a Mental Health Plan. All beneficiaries receiving CS  
                 are required to receive an assessment of their physical  
                 and mental health. Physicians are required to be on-call  
                 at all times for the provision of CS services that only a  
                 physician can provide. At a minimum, CS staffing  
                 requirements include one registered nurse, psychiatric  
                 technician, or licensed vocational nurse on-site at all  
                 times beneficiaries are present. A ratio of one licensed  
                 mental health or waivered/registered professional on-site  
                 for each four beneficiaries or other patients receiving  
                 CS at any given time is required. The goal of CS is to  
                 stabilize a person and re-integrate him or her back into  
                 the community quickly. According to various reports,  
                 costs for providing care in a crisis stabilization unit  
                 are significantly lower than inpatient hospitalization. 

               d)     Inpatient psychiatric beds. The California Hospital  
                 Association (CHA), a sponsor of this bill, states that  
                 since 1995 the state has lost 43 facilities, either  
                 through the elimination of psychiatric inpatient care, or  
                 complete hospital closure, representing a nearly 24%  
                 drop. CHA states that while there has been an increase in  
                 psychiatric beds over the past several years, as of 2013  
                 data, California has lost nearly 30% of the psychiatric  
                 beds it had in 1995, a drop of almost 2,700 beds, making  
                 the state's psychiatric bed rate one bed for every 5,572  
                 people, compared to a national average of one bed for  
                 every 4,953 people. A County Behavioral Health Directors  
                 Association of California (CBHDAC) Governing Board Policy  
                 Brief from November 2015 cites specific challenges that  
                 contribute to the lack of crisis and inpatient care  
                 capacity, including:









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                       i)             The federal Medicaid Institution for  
                         Mental Disease exclusion (IMD exclusion), which  
                         prohibits states from receiving federal matching  
                         funds for inpatient services they provide to  
                         adult Medicaid enrollees aged 18-65 years in a  
                         hospital, nursing home, or other inpatient care  
                         setting with more than 16 beds; 
                       ii)            Stigma and discrimination, due to  
                         negative attitudes and myths about the  
                         dangerousness of people with mental illness.  
                         Counties and providers often face substantial  
                         community opposition when attempting to construct  
                         or repurpose a facility intended to be used for  
                         individuals in psychiatric crisis or in need of  
                         inpatient care; and, 
                       iii)           Divestment in acute psychiatric care  
                         and competing demands on hospitals, as, according  
                         to a report by the California Health Care  
                         Foundation, hospitals have focused more in the  
                         last decade on general acute care services (both  
                         adult and newborn intensive care capacity) over  
                         skilled nursing and acute psychiatric services.  
                         According to the American Hospital Association,  
                         hospitals have been closing psychiatric units  
                         because of low payments from public and private  
                         payers, uncompensated care for uninsured  
                         patients, and a dearth of psychiatrists willing  
                         to work in hospitals.

          1)Efforts to bolster the behavioral health services delivery  
            system.

               a)     Los Angeles County Department of Mental Health (LAC  
                 DMH) Pilot Project, which is currently being finalized,  
                 is a pilot project whereby the LAC DMH will enter into  
                 memoranda of understanding with NDHs, which through  
                 qualified staff (ED physicians, psychologists, social  
                 workers, and marriage and family therapists) will be  
                 allowed to place 5150 holds, be required to conform to  
                                                                 all applicable LPS designation requirements, and secure  
                 timely transport of persons to designated facilities for  
                 persons detained in EDs, among other requirements. LAC  
                 DMH will provide oversight to the eligible NDHs.

               b)     SB 364 (Steinberg, Chapter 567, Statues of 2014),  








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                 made several fundamental and needed changes to the LPS  
                 Act provisions regarding involuntary commitment.  
                 According to CBHDAC, these changes focused on ensuring  
                 clarity and consistency in the 5150 process to enable  
                 people with mental health disorder needs to obtain  
                 assessment, referral, and treatment as appropriate in the  
                 least restrictive setting as possible; broadened the  
                 types of facilities a county can designate for 5150  
                 purposes; and encourages counties to provide training of  
                 personnel authorized to write and release 5150 holds.  
                 Further, it restructured and recast several provisions of  
                 the 5150 process to more clearly articulate the  
                 sequencing of events. A reference to the Children's Civil  
                 Commitment and Mental Health Treatment Act of 1988 was  
                 also added since people detained under 5150 should also  
                 generally apply to children who are detained. 

               c)     SB 82 (Committee on Budget and Fiscal Review,  
                 Chapter 34, Statutes of 2013), made a one-time  
                 appropriation of $500,000 from the General Fund to the  
                 California Health Facilities Financing Authority to  
                 implement grant programs to support the development,  
                 capital, equipment acquisition, and applicable program  
                 startup or expansion costs to increase capacity for  
                 client assistance and services for individuals with  
                 mental health disorders, including services such as  
                 crisis intervention, crisis stabilization, crisis  
                 residential treatment, rehabilitative mental health  
                 services, and mobile crisis support teams, including  
                 personnel and the purchase or lease of equipment, such as  
                 vehicles. According to the CBHDAC policy brief, SB 82 has  
                 so far funded the addition of 796 crisis residential  
                 beds, 149 crisis stabilization beds, and 48 vehicles and  
                 58 staff members for mobile crisis teams. Additionally,  
                 by 2016-17, an estimated 490 triage personnel will be  
                 funded statewide by SB 82 funds. 

               d)     Medicaid Emergency Psychiatric Demonstration  
                 Program, was established in 2010 by Congress to test  
                 whether allowing federal Medicaid matching payments to  
                 freestanding psychiatric hospitals for emergency  
                 psychiatric cases (which are currently subject to the IMD  
                 exclusion) would improve the quality of, and access to,  
                 care and reduce Medicaid program costs. According to  
                 CBHDAC, the demonstration program, which ended December  








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                 2015, has provided up to $75 million over three years to  
                 enable current IMD-excluded facilities in 11 states,  
                 including California, and the District of Columbia to  
                 receive Medicaid reimbursement for treatment of patients  
                 aged 21 to 64 who require treatment for psychiatric  
                 emergencies. Preliminary data shows that allowing such  
                 reimbursement is reducing utilization and lowering costs.  
                 According to CMS's Web site, a final report to Congress  
                 about this demonstration program is due in September  
                 2016.

               e)     SB 743 (Committee on Health, Chapter 612, Statutes  
                 of 2009), extended the amount of time, up to 24 hours, a  
                 NDH can detain persons who meet criteria for a 5150  
                 detention and also extended civil and criminal liability  
                 protection to NDHs and specified staff. SB 743 also  
                 protects NDHs from being held liable for the release of a  
                 person, or for the actions of a person after release, as  
                 long as specified criteria is met, including documenting  
                 attempts to transfer a person to an appropriate,  
                 designated facility. Supporters of SB 743 argued at the  
                 time that the bill would provide clarity to and uniform  
                 application of the LPS Act when a person is taken to a  
                 NDH, which have no inpatient psychiatric services or  
                 county-designated staff. Supporters also argued that SB  
                 743 would help ensure that ED physicians would not be  
                 placed in a position to pursue mental health treatment at  
                 a separate facility before they know a patient is  
                 physically stable for transfer.

               f)     Assisted Outpatient Treatment (AOT) ("Laura's Law"),  
                 enacted pursuant to AB 1421 (Thompson, Chapter 1017,  
                 Statutes of 2002), established a court-ordered AOT  
                 demonstration program aimed at individuals with mental  
                 illness who meet specified criteria but who do not meet  
                 5150 criteria for involuntary commitment to an inpatient,  
                 designated facility. Laura's Law provides counties with  
                 the option to implement intensive programs for  
                 individuals who have difficulty maintaining their mental  
                 health stability in the community and have frequent  
                 hospitalizations and contact with law enforcement related  
                 to untreated or undertreated mental illness. Since  
                 implementation, Nevada County has found that Laura's Law  
                 has resulted in: 46% reduction in hospitalizations, 65%  
                 reduction in incarcerations, 61% reduction in  








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                 homelessness, 44% reduction in emergency contacts, and  
                 $1.81-$2.52 in savings for every dollar spent as a result  
                 of reducing incarceration, arrest, and hospitalization.  
                 According to DHCS, 15 counties have approved and/or  
                 implemented Laura's Law: Alameda, Contra Costa, El  
                 Dorado, Kern, Los Angeles, Mendocino, Nevada, Orange,  
                 Placer, San Diego, San Francisco, San Luis Obispo, San  
                 Mateo, Ventura, and Yolo.

          2)Related legislation. SB 1273 (Moorlach), would allow a county  
            to use its Mental Health Services Fund moneys for outpatient  
            crisis stabilization services to individuals who are  
            voluntarily receiving those services, even when facilities  
            co-locate services to individuals who are involuntarily  
            receiving services. SB 1273 is set to be heard in the Assembly  
            Health Committee on June 28, 2016.

            AB 59 (Waldron), would extend the repeal date of Laura's Law  
            by five years, to January 1, 2022, and delete and recast in  
            existing law DHCS's reporting requirement, as specified,  
            regarding the AOT services a county provides.  AB 59 is  
            pending in the Senate Appropriations Committee.

          3)Prior legislation. AB 1194 (Eggman, Chapter 570, Statutes of  
            2015), requires, for purposes of determining whether a person  
            is a danger to self or others, an individual making that  
            determination to consider available relevant information about  
            the historical course of the person's mental disorder if the  
            individual concludes that the information has a reasonable  
            bearing on the determination, and that the individual shall  
            not be limited to consideration of the danger of imminent  
            harm.
             
            SB 364 (Steinberg, Chapter 567, Statues of 2014).

            SB 585 (Steinberg, Chapter 288, Statutes of 2013), clarifies  
            that Mental Health Services Act funds and various County  
            Realignment accounts may be used to provide mental health  
            services under the Assisted Outpatient Treatment Demonstration  
            Project Act of 2002, or Laura's Law, and allows counties to  
            opt to implement Laura's Law through the county budget  
            process.
            
            SB 82 (Committee on Budget and Fiscal Review, Chapter 34,  
            Statutes of 2013).








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            AB 110 (Blumenfield, Chapter 20, Statutes of 2013), enacts the  
            2013-14 Budget Act, which includes, among its other  
            provisions, $206 million ($142 million General Fund one-time)  
            for a major investment in mental health services, including  
            additional residential treatment capacity, crisis treatment  
            teams, and triage personnel. 

            SB 1381 (Pavley, Chapter 457, Statutes of 2012), deletes in  
            state law references to "mental retardation" or a "mentally  
            retarded person" and instead replaces them with "intellectual  
            disability" or "a person with an intellectual disability."

            SB 743 (Committee on Health, Chapter 612, Statutes of 2009).

            SB 916 (Yee, Chapter 308, Statutes of 2007), extends to a  
            licensed acute psychiatric hospital or a licensed general  
            acute care hospital, that is not a designated facility, civil  
            and criminal immunity relating to the detention and release of  
            individuals who are a harm to themselves or others, or are  
            gravely disabled, and extends from eight to 24 hours the  
            period of time that patients can be detained in such  
            hospitals, providing the hospital has not been designated by a  
            county to conduct psychiatric evaluations under the LPS Act,  
            and specifies the criteria that must be met for the immunity  
            to be granted.

            AB 1421 (Thompson, Chapter 1017, Statutes of 2002).

            AB 1424 (Thomson, Chapter 506, Statutes of 2001), makes  
            various changes to the LPS Act to:  increase the involvement  
            of family members in commitment hearings for the mentally ill;  
            require more use of a patient's medical and psychiatric  
            records in these hearings; and prohibit health plans and  
            insurers from using the commitment status of a mentally ill  
            person to determine eligibility for claim reimbursement.

            SB 1111 (Costa, Chapter 547, Statutes of 1997), includes  
            specified clinical psychologists in the list of persons exempt  
            from civil or criminal liability for detaining a person, or  
            for the actions of the person following release from a  
            specified hospital, if certain conditions exist, including  
            that the detainment must not exceed eight hours.  SB 1111 also  
            requires that specified facility personnel make and document  
            repeated unsuccessful efforts to find appropriate mental  








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            health treatment for the person as an additional condition of  
            exemption from liability.

            SB 2003 (Costa, Chapter 716, Statutes of 1996), prohibits a  
            general acute care hospital, its licensed professional staff,  
            or any physician and surgeon providing emergency medical  
            services at the hospital from being civilly or criminally  
            liable for detaining a person, or for the actions of the  
            person following release from the hospital, if certain  
            conditions exist, including, that the detainment must not  
            exceed eight hours.

            SB 665 (Petris, Chapter 681, Statutes of 1991), establishes  
            the right, under the LPS Act, to refuse antipsychotic  
            medication and establishes hearing procedures to determine a  
            person's capacity to refuse treatment with antipsychotic  
            medication.

            AB 2541 (Bronzan and Mojonnier, Chapter 1286, Statutes of  
            1985), authorizes county mental health programs to initiate  
            services to various target populations, requires various  
            studies and planning activities, and prohibits mental health  
            personnel from instructing law enforcement personnel to take  
            individuals detained for mental health evaluations to jail  
            solely due to the unavailability of a mental health facility  
            bed.

            SB 677 (Lanterman, Petris, and Short, Chapter 1667, Statutes  
            of 1967), enacts the LPS Act, which governs involuntary civil  
            commitment for individuals with mental illness, with the  
            intent to end inappropriate, indefinite, and involuntary  
            commitment and provide for prompt evaluation and treatment.
            
          4)Support. The California Hospital Association (CHA), the  
            California Psychiatric Association (CPA), the California  
            Chapter of the American College of Emergency Physicians  
            (CalACEP), the San Gabriel Valley Medical Center, and Dignity  
            Health argue that since the passage of the LPS Act there have  
            been significant changes in the mental health delivery system  
            and fragmented application of due process across the state's  
            58 counties, which adversely impacts a patient's ability to  
            obtain prompt evaluation and treatment as required by current  
            law. CHA, CPA, CalACEP, and Dignity state that patients  
            currently languish in EDs for hours, days, and sometimes weeks  
            waiting for psychiatric assessment, referral, and treatment,  








          AB 1300 (Ridley-Thomas)                           Page 15 of ?
          
          
            and that this bill makes long overdue improvements to the LPS  
            Act by removing barriers to treatment and expediting the  
            ability of ED physicians and psychiatric professionals to  
            obtain services for patients with mental illness. Silicon  
            Valley Leadership Group states that standardizing the LPS Act  
            and easing the transfer of psychiatric patients from EDs to  
            psychiatric facilities will have an impact that reaches far  
            beyond mental health providers. 

          5)Support if amended. Tenet Health writes that its 13 acute care  
            hospitals, as many hospitals throughout the state, have  
            experienced a notable growth in the number of 5150 patients  
            dropped off by law enforcement in their EDs, and Tenet states  
            it is very important to recognize that these EDs [NDHs] are  
            not county-designated psychiatric facilities and therefore do  
            not have the specialized clinical staffing nor facility  
            designed to appropriately attend to patients in mental health  
            crisis. Tenet states that in an ideal environment, better  
            field tools also would be available to ensure that an  
            involuntary hold is only imposed when it is indisputably  
            indicated and a patient would be provided appropriate  
            treatment. Tenet argues that, notwithstanding incremental  
            improvements that might result from this bill, NDHs and their  
            EDs would remain ill-equipped to appropriately treat and  
            manage patients in mental health crisis. Tenet seeks  
            clarifying amendments to ensure that patient detainment occurs  
            at facilities with appropriate resources and by individuals  
            who have proper training.

          6)Oppose unless amended. The Union of American Physicians and  
            Dentists (UAPD)/AFSCME Local 206 argues that this bill  
            eliminates the need for psychiatrists to evaluate 72-hour/5150  
            holds and puts the public at risk if a patient with a mental  
            disorder is incorrectly diagnosed. UAPD argues that this bill  
            removes a psychiatrist's ability to perform medical duties in  
            psychiatric holds, which is detrimental for the patient as  
            they may need prompt assessment of a need for evaluation and  
            treatment from a physician who specializes in mental health.  
            UAPD supports the inclusion of psychiatric input in critical  
            mental health cases. Disability Rights California (DRC) argues  
            that while they support releasing people from involuntary  
            holds when they no longer meet the criteria to be held this  
            bill allows hospital EDs to detain people for longer than 24  
            hours, and allows the inappropriate exchange of confidential  
            information with people who do not need it. DRC expresses  








          AB 1300 (Ridley-Thomas)                           Page 16 of ?
          
          
            concern that this bill does not give a county oversight  
            authority over the 5150 process in NDHS. SEIU California  
            argues that this bill would bypass important patient rights  
            and protections put into place by the LPS Act by, in part,  
            placing no obligation on NDHs to care for a person's mental  
            health needs while on a detention for up to 72 hours. SEIU  
            California proposes amendments that require ED physicians and  
            psychiatrists who wish to place holds to meet minimum  
            compliance standards to align with the LPS Act, including, but  
            not limited to: training on laws governing 5150 holds; proper  
            staffing and provision of appropriate medical and mental  
            health services; conditions upon which a county could revoke  
            an nondesignated individual's ability to place holds should  
            any violations ever occur; that NDHs already have a memorandum  
            of understanding with a designated facility for transfer of a  
            person to ensure timely disposition of holds; and require any  
            detention by an NDH to be reported to a county and the state,  
            and to require ongoing public reporting that protects patient  
            confidentiality but allows policymakers to assess trends in  
            LPS holds over time.
          
          7)Opposition. NAMI California and its various affiliates, the  
            County Behavioral Health Directors Association of California  
            (CBHDAC), San Joaquin County, and the Santa Clara County Board  
            of Supervisors, and others argue that this bill does not  
            address the real cause of the issue that EDs currently face:  
            the current lack of mental health crisis services at a time  
            when the state has lost more than 3,000 psychiatric beds as  
            hospitals have chosen to reduce capacity within their hospital  
            systems for those services. The opponents argue that this bill  
            undermines counties' authority to regulate conditions of the  
            LPS Act and develop and implement systems of care for  
            residents. NAMI California states that this bill further  
            restricts psychiatric care by allowing ED physicians without  
            specific mental health knowledge or training to place LPS Act  
            detentions, which would significantly decrease the likelihood  
            that follow-up care in an appropriate outpatient setting would  
            be provided to a patient, as well as increase the occurrence  
            of costly future hospitalizations. NAMI California also states  
            that it is not clear if patient rights and protections  
            afforded under the LPS Act would apply when people are  
            detained in NDHs. CBHDAC argues that its member counties have  
            worked with state and local partners to build community  
            behavioral health services by sponsoring legislation and by  
            helping to enact recently approved legislation that provides  








          AB 1300 (Ridley-Thomas)                           Page 17 of ?
          
          
            added funding for crisis bed capacity. CBHDAC further argues  
            that this bill makes it easier for hospitals to skirt state  
            and federal laws that prevent the dumping of patients, and  
            would result in fewer avenues for emergency psychiatric care  
            for underserved communities. CBHDAC argues that counties  
            currently designate a number of ED physicians in NDHs, and the  
            process for being designated is not onerous. The various NAMI  
            affiliates argue that this bill fundamentally restructures  
            California's emergency psychiatric care and is likely to  
            increase the number of individuals requiring mental health  
            care who are inappropriately housed in county jails.

          8)Policy questions. 

               a)     Is current authority for NDHs insufficient? NDHs  
                 currently have authority to detain people for up to 24  
                 hours when there is probable cause to believe they meet  
                 5150 criteria. This authority was expanded to 24 hours  
                 (from eight hours) in 2009 to help address NDHs' concerns  
                 that they were being left with patients who should have  
                 been taken to designated facilities, with input from  
                 disability rights advocates. If 24 hours is no longer  
                 sufficient to meet the needs of NDHs, the author may wish  
                 to consider other options that could be vetted through a  
                 stakeholder process to ensure that a longer detention  
                 does not infringe upon a person's rights afforded under  
                 the LPS Act.    

               b)     What are the safeguards for patients? Counties have  
                 oversight authority for designated facilities, including  
                 inspecting patient medical records and revoking facility  
                 designation. The author may wish to consider whether  
                 counties should have the same authority over NDHs that  
                 detain people pursuant to the LPS Act to ensure proper  
                 care was provided to patients and that there is available  
                 recourse should a violation of LPS Act provisions ever  
                 occur.

               c)     Is this bill premature? LAC DMH is currently  
                 finalizing its pilot project to allow NDHs to perform the  
                 functions proposed in this bill, and the LAC DMH draft  
                 memorandum of understanding is more detailed in its  
                 requirements for NDHs. The author may wish to consider if  
                 this bill is premature and whether the LAC DMH pilot  
                 should be allowed to be fully implemented, which could  








          AB 1300 (Ridley-Thomas)                           Page 18 of ?
          
          
                 then serve as a guide for implementation statewide.  

           SUPPORT AND OPPOSITION  :
          Support:  California Chapter of the American College of  
                    Emergency Physicians (cosponsor)
                    California Hospital Association (cosponsor)
                    California Psychiatric Association (cosponsor)
                    San Gabriel Valley Medical Center (cosponsor)
                    Adventist Health (previous version)
                    Alliance of Catholic Health Care (previous version)
                    Association of California Healthcare Districts  
                    (previous version)
                    Bakersfield Behavioral Healthcare Hospital (previous  
                    version)
                    Dignity Health
                    Loma Linda University Health (previous version)
                    Our Health California (previous version)
                    Private Essential Access Community Hospitals (previous  
                    version)
                    Silicon Valley Leadership Group 
                    
          Oppose:   California Association of Social Rehabilitation  
                    Agencies
                    County Behavioral Health Directors Association of  
                    California
                    Disability Rights California (unless amended)
                    NAMI Amador
                    NAMI Butte County
                    NAMI California
                    NAMI Contra Costa County
                    NAMI Fresno
                    NAMI Humboldt
                    NAMI Kern County
                    NAMI Lassen
                    NAMI Los Angeles County Council
                    NAMI Mendocino County
                    NAMI San Bernardino Area
                    NAMI San Gabriel Valley
                    NAMI San Joaquin County
                          NAMI San Mateo County
                    NAMI Solano County
                    NAMI Sonoma County
                    NAMI South Bay
                    NAMI Southern Santa Barbara County
                    NAMI Urban Los Angeles








          AB 1300 (Ridley-Thomas)                           Page 19 of ?
          
          
                    NAMI Ventura County
                    NAMI Yolo County
                    San Joaquin County Health Care Services Agency
                    Santa Clara County Board of Supervisors
                    SEIU California (unless amended)
                    Solano County Health & Social Services Department
                    Union of American Physicians and Dentists/AFSCME Local  
                    206 (unless amended)                             


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