BILL ANALYSIS Ó
AB 2743
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Date of Hearing: April 12, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2743
(Eggman) - As Introduced February 19, 2016
SUBJECT: Psychiatric bed registry.
SUMMARY: Requires the Department of Public Health (DPH) to
establish an Internet web-based electronic acute psychiatric bed
registry (hereafter registry) to collect, aggregate, and display
information regarding the availability of acute psychiatric beds
in psychiatric health facilities. Specifically, this bill:
1)Defines "designated employee" as an employee designated by a
health facility to submit information for inclusion in the
registry and serve as the contact person to respond to
requests for information related to data reported to the
registry.
2)Requires, prior to July 1, 2017, DPH to establish and operate
a registry to collect, aggregate, and display information
regarding the availability of acute psychiatric beds in health
facilities.
3)Specifies that the purpose of the registry is to facilitate
the identification and designation of available beds in
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psychiatric health facilities for the temporary detention and
treatment of individuals who meet the criteria for temporary
detention under Section 5150 of the Welfare and Institutions
Code (WIC).
4)Requires DPH to notify each health facility when the registry
is operational and, on and after the date that the registry is
operational, the health facility to submit notification that
an acute psychiatric bed has become available.
5)Requires, prior to July 1, 2017, a health facility to
designate an employee to submit information for inclusion in
the registry and serve as the contact person to respond to
requests for information related to data reported to the
registry.
EXISTING LAW:
1)Defines "designated facility" or "facility designated by the
county for evaluation and treatment" as a facility that is
licensed or certified as a mental health treatment facility or
a hospital, as defined by DPH regulations, and may include,
but is not limited to, a licensed psychiatric hospital, a
licensed psychiatric health facility, and a certified crisis
stabilization unit.
2)Provides for the involuntary commitment and treatment of
individuals with specified mental disorders and for the
protection of committed individuals, with the declared goal of
ending inappropriate, indefinite, and involuntary commitment
of mentally disordered persons, developmentally disabled
persons, and persons impaired by chronic alcoholism.
3)Establishes the Lanterman-Petris Short Act (LPS Act), which
authorizes a person to be involuntarily detained for a period
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of up to 72 hours for assessment, evaluation, and crisis
intervention, when, as a result of a mental disorder, the
person is a danger to him or herself or to others, or is
"gravely disabled."
4)Defines "gravely disabled" to mean a condition in which a
person, as a result of a mental disorder, is unable to provide
for his or her basic personal needs for food, clothing, or
shelter.
5)Allows, under the LPS Act, a person who is gravely disabled to
be involuntarily detained for further inpatient mental health
treatment for an additional 14 days, as provided, which can be
extended for 14 days if the person presents an imminent threat
of taking his or her own life.
6)Allows, under the LPS Act, a court to order an imminently
dangerous person to be confined for further inpatient
intensive health treatment for an additional 180 days, as
provided.
7)Requires, when determining if probable cause exists to take a
person into custody, or cause a person to be taken into
custody, pursuant to WIC Section 5150, any person who is
authorized to take that person into custody to consider
available relevant information about the historical course of
the person's mental disorder if the authorized person
determines that the information has a reasonable bearing on
the determination as to whether the person is a danger to
others, or to himself or herself, or is gravely disabled as a
result of the mental disorder.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, mental
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illness, like many other health conditions, when treated early
and with appropriate supports and services can resolve in
recovery. Although 16% of California adults live with a
mental illness, more than 60% do not receive treatment. From
2004 to 2013, the number of hospital beds in the state
remained largely unchanged, while the number of acute
psychiatric beds decreased by 22%. A web-based psychiatric
bed registry would improve mental health service access by
getting patients dealing with mental health crises to the
appropriate professionals more quickly and streamlining
communication and reduce patient waiting time.
2)BACKGROUND.
a) LPS Act. The LPS Act, enacted in the 1960s, was
intended to balance the goals of maintaining the
constitutional right to personal liberty and choice in
mental health treatment, with the goal of safety when an
individual may be a danger to oneself or others or is
gravely disabled. At the time of its enactment, the LPS
Act was considered progressive because it afforded the
mentally disordered more legal rights than most other
states. Since its passage in 1967, the law in the field of
mental health has accorded greater legal rights for
mentally disordered persons. WIC Section 5150 of the LPS
Act allows peace officers, staff-members of
county-designated evaluation facilities, or other
county-designated professional persons to take an
individual into custody and place that person in a facility
for 72-hour treatment and evaluation if they believe that,
due to a mental disorder, the individual is a danger to
himself, herself, or others, or is gravely disabled and
unable to provide for basic personal needs for food,
clothing, or shelter due to a mental disability.
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b) Designated vs. Non Designated Facilities. Individual
counties are responsible for determining whether general
acute care hospitals, psychiatric health facilities, acute
psychiatric hospitals and other licensed facilities qualify
to be designated facilities. Designated facilities are
health facilities that have been designated by a local
emergency medical services agency (LEMSA) to perform
specified emergency medical services systems functions
pursuant to guidelines established by the LEMSA. The
Department of Health Care Services is responsible for the
approval of designated facilities as determined by the
counties. While peace officers and other authorized
individuals are required to take an individual first to a
designated facility, if one does not exist individuals are
transported to a non-designated facility, which is also any
facility participating in Medicare that is therefore
required by federal Emergency Medical Treatment and Active
Labor Act (EMTALA) laws to provide medical services to any
individual who shows up requiring medical attention.
c) 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. Congress enacted EMTALA in 1986 which requires
anyone coming to an emergency department to be stabilized
and treated, regardless of their insurance status or
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 pay. Hospitals are then required
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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, an appropriate transfer should be
implemented. As an enforcement mechanism, EMTALA also
established a private right of action.
d) Office of Statewide Health Planning and Development
(OSHPD) reporting requirements. Under existing law, OSHPD
is the single state agency that collects specified health
facility or clinic data for use by all state agencies. All
licensed acute care hospitals, including psychiatric health
facilities, are required to file with OSHPD certain
reports, including a Hospital Discharge Abstract Data
Record that includes 19 specified patient-based data
elements for each admission, including date of birth, sex,
admission date, discharge date, principal diagnosis, other
diagnoses, principal procedures, and disposition of the
patient. In addition to this discharge report, hospitals
are required to file an Emergency Care Data Record for each
patient encounter in a hospital emergency department, and
hospitals and freestanding ambulatory surgery clinics are
required to file an Ambulatory Surgery Data Record for each
patient encounter during which at least one ambulatory
surgery procedure is performed. For all three reports,
OSHPD is permitted to make additions or deletions to the
data elements required in these reports, as long as OSHPD
adds no more than a net of 15 elements to each data set
over any five-year period, and as long as OSHPD considers
the costs and benefits of data collection and other factors
prior to adding or deleting any data element.
e) Psychiatric Bed Shortages. According to a 2011 OSHPD
data analyzed by the California Hospital Association (CHA),
California has lost 44 psychiatric facilities from
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1995-2011, either through the elimination of psychiatric
inpatient care, or complete hospital closure, representing
a 24% drop. This represents a loss of almost 32%, or
nearly 3000 beds compared to 1995. California's bed rate is
one bed for every 5,975 people, as of 2011, compared to the
nation's average of one bed for every 4,758 people.
Additionally, 26 of California's 58 counties have no
inpatient psychiatric services.
f) Virginia Registry. A large number of states have some
sort of computerized tracking database in place for acute
psychiatric beds, with wide variation on the type of bed
tracked. Alabama, Connecticut, and Texas track available
beds only in their state hospitals or state-run funded beds
while some states, like Massachusetts, track private acute
care beds. However, all states that have comprehensive
databases rely on voluntary participation. The exception
to this is the state of Virginia, which launched the
Virginia Acute Psychiatric and Community Services Board Bed
Registry, a mandatory web-based registry in March of 2014.
A January 2016 report published by the Virginia Office of
the State Inspector General (OSIG report) examined the
utility of the registry as a tool for emergency services
staff to facilitate the identification and designation of
facilities for the temporary detention and treatment of
individuals including the registry's successes, challenges,
and efficiencies, and the impact of the current
registry-related operations on various health facilities
and stakeholders. While the OSIG report found full
compliance with the mandates in statute, a survey of
registry users indicated that for 55% of respondents it was
taking more time to locate a willing facility than prior to
the implementation of the registry. Respondents attributed
this in part to a lack of uniformity in updating the
registry whenever there was a change in bed availability
requiring emergency services staff to make additional calls
to facilities or programs to confirm bed availability.
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Additionally, 36% of respondents indicated that the
registry did not improve the time that it took to identify
an available bed, and only 9% reported that the amount of
time it took to identify an available bed decreased. The
OSIG report states that the lack of regular updating of the
registry, in addition to requiring duplicative efforts by
staff, resulted in diverting limited staff time and
resources, preventing individuals from placement in an
appropriate bed in the most efficient manner, and
preventing emergency services staff from proceeding to
other emergencies. The OSIG report also noted the following
strengths of the registry:
i) The registry is a 24-hour centralized resource for
emergency services staff to identify potential available
beds for individuals in crisis who are in need of a bed;
ii) Registry queries can be tailored by region, security
level, age, and gender;
iii) The majority of survey participants indicated that
the registry was user friendly;
iv) Private acute psychiatric facilities reported that
the bed registry is a valuable tool for obtaining a
broader view of admitting facilities and that the bed
registry enables them to actively conduct outreach with
regional facilities when their census is low;
v) Residential crisis stabilization units reported that
the bed registry is helpful when an individual receiving
services in their programs needs a higher level of care;
and,
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vi) State facilities reported that the registry has
provided a greater understanding of the available private
and state operated facilities both within their area and
other regions.
3)SUPPORT. The California Psychiatric Association (CPA), a
cosponsor of this bill, state that California is one of 24
states that lack a statewide computerized tracking database,
or other electronic system for the tracking of available
psychiatric beds in community based hospitals. CPA argues
that the need is critical because the loss of about 3,000
California psychiatric beds in the last two decades has made
open beds more difficult to find. CPA states that the sooner
patients can get into inpatient care, the sooner they can
start being treated. A bed registry is one tool that would
help identify open beds not otherwise readily identifiable.
Finding an available bed can be laborious and a hit and miss
proposition which may take an inordinate amount of time. CPA
concludes that an online web interface would give contact
information for the facility admissions coordinator to ensure
that the right person is available to discuss bed availability
and an online, statewide bed registry would streamline the
process of identification and would serve to more timely
provide access to beds appropriate for individual patients.
The Steinberg Institute, also a cosponsor of the bill, and the
California Chapter of the American College of Emergency
Physicians (Cal/ACEP) write in support of the measure that
individuals often receive their first assessment for a
psychiatric crisis in the emergency department. However, once
that individual is assessed and found to need a more
specialized level of psychiatric crisis care, the problem of
access arises. Reports of individuals languishing in an
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emergency department for hours and even days have increased
across the state, all because there isn't a known available
crisis bed that meets their needs. The Steinberg Institute
and Cal/ACEP note that this is especially concerning
considering that the number of hospital's acute psychiatric
beds decreased 22% from 2004 to 2013, while all other hospital
beds remained largely unchanged. Additionally, there are
reports that open beds are not being accessed, because their
availability is not known to the emergency department.
The California State Sheriffs' Association (CSSA) write in
support of the bill that law enforcement officers often
encounter persons in the community who present a danger to
themselves or others because of mental health disorders.
Unfortunately, appropriate bed space for such persons is not
always readily available, and finding that bed space can be
difficult. CSSA states that with this measure, mental health
patients will be more likely to be placed in an appropriate
environment, while law enforcement and medical professionals
will not have to take unnecessary steps to search for
available beds.
The California Council of Community Behavioral Health Agencies
and Association of Regional Center Agencies states in support
of the measure that the shortage of psychiatric beds and
crisis care facilities is far too great to allow any spaces to
remain empty and that this registry should help psychiatric
patients find care more quickly and efficiently, when time is
of the essence.
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4)OPPOSITION. CHA, states that an electronic bed registry would
do little to improve the availability or access to inpatient
beds for individuals in need of emergency inpatient
psychiatric care and would redirect critical staff within the
hospitals to administrative functions and away from patient
care. CHA argues that "real-time" bed registries have been
tried in other states (both on a voluntary and mandated basis)
and they have proven to be very difficult to implement and
have not shown significantly improved efficiencies. CHA
argues that the vast majority (70%) of individuals with
behavioral health conditions in emergency departments can
receive treatment and be referred for follow-up care in
outpatient, community-based treatment settings. The remaining
30% require a higher level of care and may be referred to a
variety of specialized behavioral health treatment settings in
both inpatient and outpatient crisis settings. CHA concludes
that an electronic registry would not remove the necessity for
professionals to call facilities with available beds to
ascertain appropriateness for the patient, the capability and
capacity of the facility, nor the need to work with the
individual and family to make treatment decisions.
The Hospital Corporation of America, Redlands Community
Hospital, St. Joseph Hospital, and dozens of other individual
hospitals write in opposition to the measure, stating that
gaining admission to a hospital psychiatric bed is a dynamic
and patient-centric process and every hospital must make
individual patient admission decisions based on a number of
factors including: patient capacity and the therapeutic
milieu; treatment capabilities; staffing; physical plant
layout; a patient's legal status; and, a hospital's licensure
and physician availability. They also argue that a bed
registry cannot provide truly meaningful information to
providers, patients, or their families and that logistical
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complexities far outweigh the value of such a registry and
hospitals will be forced to divert resources away from patient
care and towards maintaining a registry that provides
meaningless information.
5)RELATED LEGISLATION. AB 1300 (Ridley-Thomas) makes numerous
changes to the provisions regarding evaluation procedures,
terms and lengths of detention, and criteria for release and
transfer protocol related to the involuntary detention of
individuals. AB 1300 is pending in the Senate Health
Committee.
6)PREVIOUS LEGISLATION. AB 1194 (Eggman), Chapter 570, Statutes
of 2015, requires, when an individual is determining if a
person is a danger as a result of a mental health disorder,
the individual 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 specifies danger
is not limited to danger of imminent harm.
7)POLICY COMMENTS
a) Registry operation. The measure requires, after the
registry is operational, a facility to immediately notify
the registry when a bed becomes available at a health
facility. While immediate notification would be necessary
for the registry to be up-to-date and therefore to be most
useful to health care professionals, requiring an immediate
entry by the sole employee designated to do so may be
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impractical. The author may want to consider an amendment
allowing an initial grace period for entering data into the
registry. Additionally the author may wish to consider an
amendment permitting more than one individual at any given
health facility to enter information into the database.
b) Reporting requirements. As discussed above, health care
facilities, including acute psychiatric facilities, already
have extensive patient-level reporting requirements as
required by OSHPD, which cannot add more than a net of 15
elements to each data set over any five-year period, and
must consider the costs and benefits of data collection and
other factors prior to adding or deleting any data element.
The author may wish to consider requiring a more thorough
evaluation of the costs and benefits of data collection and
necessary data elements prior to implementing a mandatory
web-based registry.
c) Training requirements. As the Virginia Study indicates,
a lack of uniformity in updating and use of the registry
may result duplicative efforts by staff, diverting
limited staff time and resources, preventing individuals
from placement in an appropriate bed in the most
efficient manner, and preventing emergency services
staff from proceeding to other emergencies. For these
reasons, the author may wish to consider training
requirements for both the designated employee entering the
data and any health care professionals permitted access to
search the database.
d) Database access. As currently drafted the measure does
not indicate who can utilize the electronic registry to
identify available beds. The author may wish to consider
an amendment clarifying which health care professionals
have access to search the database.
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e) Voluntary implementation. While mandatory participation
in the registry for health facilities would be an essential
component to ensuring the most up-to-date information is
available in the registry, immediate statewide
implementation may not be practical. The author may wish to
consider creating a voluntary or pilot registry system.
8)COMMITTEE AMENDMENTS.
a) Technical amendments:
Facility definition. The Committee recommends an
amendment clarifying the type of facility expected to
utilize the registry.
(b) "Psychiatric health facility" means an acute
psychiatric hospital as defined by subdivision (b) of
Section 1250 and a licensed health facility that
provides a program certified by the State Department
of Health Care Services pursuant to Section 5909 of
the Welfare and Institutions Code.
b) Type of beds. Psychiatric facilities and beds vary
widely in order to treat different patient needs. The
Committee recommends amendments that add fields to the
registry that provide information differentiating the type
of bed, and the facility in which it is available,
including the following: the license type of the facility,
what type of treatment the facility provides, whether an
available bed is secure, and the type of diagnosis for
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which an available bed is appropriate.
The department shall include at least the
following fields in the registry to enable each
psychiatric health facility to report and update the
following information:
(1) The contact information for the
psychiatric health facility's designated employee
(2) The license type of the facility
(3) Whether the facility provides substance
abuse treatment.
(4) Whether the facility provides medical
treatment.
(5) Whether the available bed is secure
(6) The types of diagnoses for which the
available bed is appropriate.
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REGISTERED SUPPORT / OPPOSITION:
Support
The Steinberg Institute (cosponsor)
California Psychiatric Association (cosponsor)
Association of Regional Center Agencies
California Chapter of the American College of Emergency
Physicians
California State Sheriff's Association
The California Council of Community Behavioral Health Agencies
Opposition
Adventist Health
Alameda Health System and John George Psychiatric Hospital
Alvarado Parkway Institute
Antelope Valley Hospital
Association of California Healthcare Districts
Aurora San Diego Behavioral Health Care LLC.
Bakersfield Behavioral Healthcare Hospital
Banner Lassen Medical Center
BHC Alhambra Hospital
California Hospital Association
Canyon Ridge Hospital
Chinese Hospital
College Hospital Costa Mesa
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Community Medical Centers
Corona Regional Medical Center
Cottage Health of Goleta Valley, Santa Barbara, and Santa Ynez
Valley
Delano Regional Medical Center
Desert Valley Hospital
Dignity Health
El Camino Hospital
El Centro Regional Medical Center
Fairchild Medical Center
Feather River Hospital
Fremont Hospital
Gateways Hospital and Mental Health Center
Glendale Adventist Medical Center
Hemet Valley Medical Center
Hoag Hospital in Newport Beach
Hoag Hospital Irvine
Jerold Phelps Community Hospital
John Muir Health
Kindred Hospitals
KPC Health
Lodi Memorial Hospital
Loma Linda University Behavioral Medicine Center
Loma Linda University Health
Loma Linda University Medical Center
Madera Community Hospital
Mayers Memorial Hospital District
Methodist Hospital of Southern California
Mission Hospital and Mission Hospital Laguna Beach
Monterey Park Hospital
Motion Picture and Television Fund Hospital
NorthBay Healthcare
Oak Valley Hospital District
Orchard Hospital
Palmdale Regional Medical Center
Palomar Health
Petaluma Valley Hospital
Pioneers Memorial Healthcare District
Plumas District Hospital
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Providence Health & Services - Southern California
Redlands Community Hospital
Redwood Memorial Hospital Fortuna
Ridgecrest Regional Hospital
Riverside Community Hospital
San Antonio Regional Hospital
San Bernardino Mountains Community Hospital
San Gorgonio Memorial Hospital
San Jose Behavioral Health
Santa Rosa memorial Hospital
Scripps Health
Seneca Healthcare District
Sharp HealthCare
Sierra View Medical Center
Sonoma Valley Hospital
Southern Mono Healthcare District dba Mammoth Hospital
Southwest Healthcare System
Southwest Healthcare System - Rancho Springs & Inland Valley
Medical Centers
St. Helena Hospital
St. Joseph Hospital
St. Joseph Hospital Eureka
St. Jude Medical Center in Fullerton
St. Mary Medical Center in Apple Valley
St. Rose Hospital
Temecula Valley Hospital
The Hospital Corporation of America
Ukiah Valley Medical Center
United Hospital Association
Watsonville Community Hospital
Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097
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