BILL ANALYSIS                                                                                                                                                                                                    Ó



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          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. 









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          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  








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            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  








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                 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,








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                 (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  








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               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. 









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          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  








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               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  








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            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










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          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










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          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