BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 1300 --------------------------------------------------------------- |AUTHOR: |Ridley-Thomas | |---------------+-----------------------------------------------| |VERSION: |June 21, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |June 29, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Reyes Diaz | --------------------------------------------------------------- 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 AB 1300 (Ridley-Thomas) Page 2 of ? ("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: AB 1300 (Ridley-Thomas) Page 3 of ? 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 AB 1300 (Ridley-Thomas) Page 4 of ? 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 : ----------------------------------------------------------------- |Assembly Floor: |Not relevant | |------------------------------------+----------------------------| |Assembly Appropriations Committee: |Not relevant | |Assembly Judiciary Committee: |Not relevant | |------------------------------------+----------------------------| |Assembly Health Committee: |Not relevant | | | | ----------------------------------------------------------------- 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 AB 1300 (Ridley-Thomas) Page 5 of ? 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 AB 1300 (Ridley-Thomas) Page 6 of ? 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 AB 1300 (Ridley-Thomas) Page 7 of ? 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. AB 1300 (Ridley-Thomas) Page 8 of ? 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: AB 1300 (Ridley-Thomas) Page 9 of ? 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), AB 1300 (Ridley-Thomas) Page 10 of ? 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 AB 1300 (Ridley-Thomas) Page 11 of ? 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 AB 1300 (Ridley-Thomas) Page 12 of ? 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). AB 1300 (Ridley-Thomas) Page 13 of ? 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 AB 1300 (Ridley-Thomas) Page 14 of ? 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) -- END --