BILL ANALYSIS Ó SB 1273 Page 1 Date of Hearing: June 28, 2016 ASSEMBLY COMMITTEE ON HEALTH Jim Wood, Chair SB 1273 (Moorlach) - As Amended April 19, 2016 SENATE VOTE: 38-0 SUBJECT: Crisis stabilization units: funding. SUMMARY: Clarifies that Mental Health Services Act (MHSA) funds may be used for the provision of outpatient crisis stabilization services (CSS) to individuals who are voluntarily receiving those services, even when facilities colocate services to individuals who are receiving services involuntarily. EXISTING LAW: 1)Establishes the MHSA (through Proposition 63), enacted in in 2004 to provide counties with funds to expand services, develop innovative programs, and develop integrated service plans for mentally ill children, adults, and seniors through a 1% income tax on personal income above $1 million. 2)Establishes the Mental Health Oversight and Accountability Commission (Commission) to oversee the implementation of MHSA, made up of 16 members appointed by the Governor, President pro Tempore of the Senate, Speaker of the Assembly, and others, as specified. SB 1273 Page 2 3)Specifies that the MHSA can only be amended by a two-thirds vote of both houses of the Legislature and only as long as the amendment is consistent with and furthers the intent of the MHSA. Permits provisions clarifying the procedures and terms of the MHSA to be added by a majority vote of the Legislature. 4)Requires the Department of Health Care Services (DHCS) to develop and implement mental health plans for Medi-Cal beneficiaries. 5)Requires mental health plans, whether administered by public or private entities, to be governed by specified guidelines, including the provision of culturally competent and age-appropriate services, to the extent feasible. 6)Requires a mental health plan to assess the cultural competency needs of the program and to include a process to accommodate the significant needs with reasonable timeliness. FISCAL EFFECT: None. COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, this bill clarifies that counties can direct local MHSA funds to outpatient CSS that colocate voluntary and involuntary patients. The author argues that California is facing a mental health crisis and lacks enough infrastructure dedicated for the rapid assessment and stabilization of individuals in psychiatric crisis. As a result, individuals in mental health crisis are often transported to local emergency rooms (ERs) that are high stress, chaotic environments designed for split-second lifesaving decision-making, rather than thoughtful therapeutic treatment. The author states that patients are often boarded in the ERs against their will while waiting for assessment or transfer to a psychiatric bed. The boarding of psychiatric patients in the ERs also results in lost access to beds for patients with medical emergencies. When the ERs are full, ambulances are diverted and patients SB 1273 Page 3 leave the waiting rooms without being seen by a physician. Because law enforcement officers are often the first responders, the hours spent in the ER represents "out of service" time from the field. These issues are significant public health and safety issues in California. The author concludes that additional outpatient resources will support rapid patient stabilization, while preserving ER access for medical emergencies and minimizing out of service time for law enforcement. 2)BACKGROUND. a) Proposition 63. Proposition 63 was passed by voters in November 2004. The MHSA imposes a 1% income tax on personal income in excess of $1 million and creates the 16 member Commission charged with overseeing the implementation of MHSA. The 2015-16 Governor's Budget projected that $1.776 billion would be deposited into the Mental Health Services Fund (MHSF) in fiscal year 2015-16. The MHSA addresses a broad continuum of prevention, early intervention, and service needs as well as providing funding for infrastructure, technology, and training needs for the community mental health system. In addition to local programs, the MHSA authorizes up to 5% of revenues for state administration. These include administrative functions performed by a variety of state entities such as the DHCS and Office of Statewide Health Planning and Development. It also funds evaluation of the MHSA by the Commission. i) Commission. MHSA requires each county mental health department to prepare and submit a three-year plan to DHCS that must be updated each year and approved by DHCS after review and comment by the Commission. In their three-year plans, counties are required to include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. Counties must submit their plans for approval to the Commission before the counties SB 1273 Page 4 may spend certain categories of funding. ii) Funding. The MHSA provides funding for programs within five components: (1) Community Services and Supports: Provides direct mental health services to the severely and seriously mentally ill, such as mental health treatment, cost of health care treatment, and housing supports. Regulations require counties to direct the majority of its Community Services and Supports funds to Full-Service Partnerships (FSPs). FSPs are county coordinated plans, in collaboration with the client and the family to provide a full spectrum of community services. These services consist of mental health services and supports, such as peer support; crisis intervention services; and, non-mental health services and supports, such as food, clothing, housing, and the cost of medical treatment. Currently the County of Stanislaus, and the City/County of San Francisco provide CSS as part of their FSP; (2) Prevention and Early Intervention: Provides services to mental health clients in order to help prevent mental illness from becoming severe and disabling; (3) Innovation: Provides services and approaches that are creative in an effort to address mental health clients' persistent issues, such as improving services for underserved or unserved populations within the community; (4) Capital Facilities and Technological Needs: Creates additional county infrastructure such as additional clinics and facilities and/or development of a technological infrastructure for the mental health system, such as electronic health records for mental health services; and, SB 1273 Page 5 (5) Workforce Education and Training: Provides training for existing county mental health employees, outreach and recruitment to increase employment in the mental health system, and financial incentives to recruit or retain employees within the public mental health system. b) 2016 "No Place Like Home" Initiative. On January 4, 2016, the California State Senate announced a proposed legislative package intended to use $2 billion of Proposition 63 bond funds and leverage additional dollars from other local, state, and federal funding for purposes of providing housing for chronically homeless persons with mental illness. The initiative includes proposals to construct permanent supportive housing for chronically homeless persons with mental illness, provide $200 million over four years in shorter-term, rent subsidies while the permanent housing is constructed or rehabilitated, and support for special housing programs that will assist families that are part of the child welfare system or are enrolled in California Work Opportunity and Responsibility to Kids Housing Support Program. c) Crisis stabilization (CS). California Code of Regulations (regulations) defines CS 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. 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 the 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 SB 1273 Page 6 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. If CS services are colocated with other specialty mental health services, persons providing CS must be separate and distinct from persons providing other services. d) Voluntary vs. Involuntary. Regulations regarding the implementation of MHSA state that programs and/or services provided with MHSA funds shall be designed for voluntary participation and that no person shall be denied access based solely on his/her previous voluntary or involuntary legal status. However, state laws amending MHSA have permitted funds to be used for services related to Assisted Outpatient Treatment (AOT), which is an involuntary program. 3)SUPPORT. The California State Association of Counties, the County Behavioral Health Directors Association of California, the Urban Counties of California, and the Rural Counties Representatives of California state that this bill would provide counties additional flexibility in the use of MHSA funds for outpatient CSS by clarifying that counties may use MHSA funds for outpatient CSS which are often in high demand. The California State Sheriffs' Association (CSSA) states that statutory clarification will allow existing funds to be utilized to address outpatient mental health care, thereby easing pressure on hospital ERs. CSSA states that the frequency with which law enforcement deals with the effects of mental illness grows by the day. Jail inmates suffer from mental health issues at alarming rates and there are a limited number of tools available to first responders and practitioners to address mental illness encountered in the community. Proposition 63 expanded county mental health programs but problems still exist. One glaring deficiency is the lack of treatment and placement options for persons who could be a danger to themselves or others. SB 1273 Page 7 4)OPPOSITION. Disability Rights California (DRC) states that this bill could allow MHSA funds to pay for involuntary hold facilities. Any use of MHSA funds for crisis programs must be voluntary, further the purpose of MHSA, be used to expand mental health services and not used to supplant funding from other sources. DRC argues that a change in the statute may not be necessary to fund voluntary crisis intervention programs. 5)OPPOSE UNLESS AMENDED. The California Labor Federation (CLF) states that this bill may result in a negative impact on counties' long-term services by opening up MHSA resources to private providers rather than by providing much needed resources to expand and enhance existing CSS currently performed by highly skilled county professionals. CLF further states that introducing private providers to perform these critical services would result in potential lower quality of care or private providers cherry picking patients with less severe conditions while, leaving only the more challenging, more costly patients to county staff. 6)RELATED LEGISLATION. a) AB 2017 (McCarty) establishes the College Mental Health Services Trust Account, and appropriates an unspecified amount annually to that account from the MHSF to create a grant program for public community colleges, colleges, and universities to improve access to mental health services on campus. Requires campuses that have been awarded grants annually to report on the use of grant funds. AB 2017 is pending in the Senate. b) AB 1644 (Bonta) reestablishes the 1991 School-Based Early Mental Health Intervention and Prevention Services for Children Act, rename it the Healing from Early Adversity to Level the Impact of Trauma in Schools Act, to provide outreach, free regional training, and technical assistance for local educational agencies in providing mental health services at school sites. AB 1644 is pending SB 1273 Page 8 in the Senate. c) AB 2279 (Cooley) requires DHCS to annually compile county revenue and expenditure information related to the MHSA based on the existing Annual MHSA Revenue and Expenditure Report. AB 2279 is pending in the Senate. d) SB 1466 (Mitchell) requires screening services provided by Early and Periodic Screening, Diagnosis, and Treatment Program to include screening for trauma and would require any victim of child abuse and neglect or a child removed from a parent or legal guardian by a child welfare agency to be screened for trauma. SB 1644 is pending in the Assembly. 7)PREVIOUS LEGISLATION. a) AB 847 (Mullin), Chapter 6, Statutes of 2016, requires DHCS to develop a proposal to participate in demonstration programs administered by the federal Secretary of Health and Human Services to improve mental health services furnished by certified community behavioral health clinics to Medi-Cal beneficiaries and would appropriate $1 million from the MHSF for the purpose of developing a competitive proposal. b) SB 585 (Steinberg), Chapter 288, Statutes of 2013, allows counties, when included in their plans, to use MHSF monies for AOT, known as "Laura's Law," if a county elects to participate in and implement Laura's Law. 8)SUGGESTED AMENDMENT. The Committee may wish to consider an amendment clarifying that if CS services are provided at a location where involuntary and voluntary services are colocated and are currently being provided by collectively bargained employees, then those services must continue to be SB 1273 Page 9 provided as such. REGISTERED SUPPORT / OPPOSITION: Support American Academy of Pediatrics, California California Chapter of the American College of Emergency Physicians California Hospital Association California Psychiatric Association California State Association of Counties California State Sheriffs' Association City of Newport Beach County Behavioral Health Directors Association of California Emergency Nurses Association Kaiser Permanente SB 1273 Page 10 KPC Health Orange County Board of Supervisors Orange County Chiefs of Police & Sheriff's Association Orange County Department of Education Orange County Division of the League of California Cities Orange County Medical Association Orange County Sheriff's Department Rural County Representatives of California St. Joseph Hoag Health St. Joseph Hospital in Orange St. Jude Medical Center in Fullerton Steinberg Institute Tenet Health SB 1273 Page 11 University of California Urban Counties of California Opposition California Labor Federation Disability Rights California Orange County Employees Association Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097