BILL ANALYSIS �
AB 1569
Page 1
Date of Hearing: March 27, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1569 (Allen) - As Introduced: January 31, 2012
SUBJECT : Community mental health services: assisted outpatient
treatment.
SUMMARY : Extends the sunset date in current law providing
counties with the option to implement court-ordered assisted
outpatient treatment (AOT) programs for mentally ill persons
from January 1, 2013, to January 1, 2019, and deletes an
obsolete reporting requirement.
EXISTING LAW :
1)Establishes, pursuant to AB 1421 (Thomson), Chapter 1017,
Statutes of 2002, the AOT Demonstration Project Act of 2002
(Act) to permit counties to provide AOT services for people
with serious mental illnesses when a court finds that a
person's recent history of hospitalizations or violent
behavior, and noncompliance with voluntary treatment,
indicates the person is likely to become dangerous or gravely
disabled without the court-ordered outpatient treatment.
2)Sunsets the Act on January 1, 2013, and requires the
Department of Mental Health (DMH) to submit a report and
evaluation to the Legislature of all counties implementing an
AOT program by July 31, 2011.
3)Establishes the Lanterman-Petris Short Act (LPS Act), which
authorizes a person to be involuntarily detained for inpatient
mental health treatment 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)Specifies the conditions of involuntary detention as follows:
a) Initial 72-hour hold. Initial evaluation and treatment
of persons who, as a result of a mental disorder, are
AB 1569
Page 2
dangerous to themselves or others, or are gravely disabled.
b) Additional 14-day hold. A person detained for a 72-hour
hold may be certified for an additional 14 days of
involuntary detention and treatment if: i) the person has
been advised of the need for, but has failed to accept,
voluntary treatment; and, ii) the medical staff finds that
the person continues to be a danger to self or others, or
is gravely disabled.
c) Renewed 14-day hold if suicidal. A person detained as
dangerous to self may be certified for an additional 14
days of involuntary detention and treatment, for a total of
31 days, if the person continues to be suicidal.
d) Additional, renewable six months hold if "dangerous to
others." After the initial 72-hour and 14-day holds, an
additional 180-day detention may be imposed on a person who
is imminently dangerous to others, based on recent threats,
or attempted or actual infliction of harm. The person may
be placed on an undefined "outpatient status" if the
director of the inpatient facility determines the person no
longer will be a threat to others and will benefit from
outpatient status.
e) Additional 30-day to one-year conservatorship if still
"gravely disabled," but not dangerous to self or others.
After the initial 72-hour and 14-day holds, an individual
who continues to be gravely disabled and fails to accept
voluntary treatment may be placed under a 30-day
conservatorship and then a renewable, one-year
conservatorship.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The author states that scientific
research demonstrates that sustained AOT services can be
highly successful for individuals with the most severe and
persistent mental illnesses. The author points to numerous
studies of New York's AOT law, also known as Kendra's Law,
that have found that, in the first five years of the program,
the estimated 3,900 individuals who received treatment orders
experienced a 21% increase in engagement of services, a 34%
increase in adherence to prescribed medications, a 75%
reduction in hospitalizations, a 14% decrease in homelessness,
a 25% reduction in arrests, and, an 18% decrease in
AB 1569
Page 3
incarcerations. The author notes that, while only Nevada
County has opted to implement an AOT program in California,
this bill is needed to ensure that counties continue to have
another tool available for providing the legal and clinical
treatment structure necessary to give severely mentally ill
individuals who chronically refuse voluntary treatment the
support they need to achieve stability and meaningful recovery
in their communities.
2)AB 1421 . AB 1421 is also known as Laura's Law, in memory of
Laura Wilcox, a 19-year-old college student who was killed by
a severely mentally ill man who was not adhering to prescribed
mental health treatment. Laura's Law provides counties with
the option to implement intensive AOT 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. AB 1421 requires a county board
of supervisors to authorize implementation by resolution and
to make a finding that access to voluntary mental health
programs serving adults and children would not be reduced as a
result of implementation.
Under AB 1421, a person subject to AOT must live in the county
operating the AOT program, have a history of not complying
with needed mental health treatment, and be unlikely to
survive safely in the community without supervision. A person
qualifying for AOT must meet the following threshold criteria:
the person's mental illness has twice been a factor leading to
psychiatric hospitalizations or incarcerations within the
prior 36 months or it has resulted in one or more actual or
attempted serious acts of violence toward self or others
within the prior 48 months. If these criteria are satisfied,
the county mental health director or designee may file a
petition with the court indicating that AOT is needed to help
prevent relapse or deterioration that would likely result in
grave disability or serious harm to self or others. Such a
petition must establish that the person has been offered an
opportunity to voluntarily participate in a treatment plan but
continues not to engage in treatment and is deteriorating.
AB 1421 allows an adult living with the person, the parent,
spouse, sibling, or adult child of that person, or specified
mental health and law enforcement personnel, to request a
petition for an AOT order for the person. Upon receiving the
AB 1569
Page 4
request, the county mental health director or designee is
required to conduct an investigation. The director or designee
is permitted to file a petition only if he or she determines
that it is likely that all the necessary elements described
above for an AOT petition can be proven by clear and
convincing evidence.
Although implementation of an AOT program is a local option,
counties that choose to implement one are required to submit
specified documentation to DMH prior to implementation that
includes a copy of the Board of Supervisor's resolution
verifying that voluntary services will not be reduced as a
result of implementation; documentation of the local mental
health board's review of the county's implementation plan; a
detailed AOT program narrative; a proposed budget and budget
narrative for AOT program expenditures; a description of
methods for data collection; and, a plan for development of an
AOT training and education program.
3)IMPLEMENTATION OF AB 1421 . In a December 2011 report that DMH
submitted to the Legislature as required by AB 2357
(Karnette), Chapter 774, Statutes of 2006, which extended the
sunset date of Laura's Law from 2008 to 2013, the only fully
implemented AOT program is in Nevada County where it has been
operational since 2008. The program is recovery-oriented and
supportive for individuals by helping them to reduce or avoid
hospitalizations and contact with local law enforcement
related to their mental illness and focuses on promoting
consumer-driven decision making in treatment planning to the
extent possible. The program provides community-based care by
a multidisciplinary team of highly trained mental health
professionals with a staff-to-client ratio of not more than
one to 10. Services include 24/7 crisis contact and/or
intervention, rehabilitation, counseling, medication
adherence, and daily living skills assistance.
For fiscal years (FY) 2008-09 and 2009-10, data show that the
AOT program served a total of four court-ordered individuals
over two years. However, DMH notes that recent data suggest
an additional six individuals were served by Nevada County
through FY 2010-11. This report only addresses those
individuals in Nevada County who went to a court hearing and
AOT was, in fact, court-ordered. DMH notes that 75% of
referrals to Nevada County's AOT program result in a
"voluntary" agreement by the individual to accept mental
AB 1569
Page 5
health treatment assistance.
Of the four individuals served by Nevada County's program, DMH
reports that each year of data shows significant reductions in
the number of days of hospitalization by individuals involved
in services, due primarily to intensive contact with the
treatment team. The total hospitalization days for all
individuals in the 12 months prior to AOT were 239, compared
to 97 days during their participation in the program.
4)PARTIAL IMPLEMENTATION IN LOS ANGELES COUNTY . As a result of
a settlement agreement reached after the California Network of
Mental Health Clients filed a lawsuit against Los Angeles
County in September 2005, the L.A. County Department of Mental
Health instituted a voluntary pilot AOT program in April 2010
for up to 50 individuals with mental illness involved in the
criminal justice system or transitioning from certain county
psychiatric facilities who would be able to live safely in the
community if they participated in the recommended AOT program.
According to outcomes information that L.A. County reported
to DMH for the period covering April 2010 through October
2010, 10 individuals have been served since the program's
inception. The data showed a 78% reduction in incarcerations
for most of the program participants during the six months
following their enrollment in AOT and a 77% reduction in
hospitalization days after they were discharged from the
program.
5)LPS REFORM TASK FORCE REPORT . A March 2012 report entitled
"The Case for Updating California's Mental Health Treatment
Law" by the LPS Reform Task Force includes several consensus
recommendations to address what can be done legally and
procedurally for people with mental illness who are badly in
need of treatment, likely to suffer harm without treatment,
and, unlikely to accept and stay in treatment. The Task Force
consisted of members with first-hand experience and knowledge
of the state's mental health system including judges,
physicians, psychiatrists, nurses, law enforcement personnel,
and representatives of the California Psychiatric Association,
the California Hospital Association, and the National Alliance
on Mental Illness (NAMI).
One of the Task Force's recommendations in the report is to more
fully implement Laura's Law statewide by removing the
requirement for a Board of Supervisors resolution, reviewing
AB 1569
Page 6
and developing expansion strategies, and, extending or
removing the current January 1, 2013, sunset date, as proposed
in this bill. According to the Task Force, lack of
implementation of Laura's Law deprives communities of an
effective early intervention tool that can prevent costly,
potentially dangerous deterioration when an individual with a
history of repeat hospitalization or arrest due to threat of
violence is refusing treatment. The Task Force notes that
statewide implementation of Laura's Law would ensure that the
small but significant number of individuals with a severe and
persistent mental illness receive needed treatment before a
public tragedy occurs and provide clear benefits for courts,
law enforcement, emergency responders, and hospital emergency
departments.
6)PROPOSITION 63 . In 2004, California voters approved
Proposition 63, the Mental Health Services Act (MHSA).
Proposition 63 enacted a surcharge on incomes over $1 million
annually, and dedicated the resulting revenue to expanding
community mental health programs. The MHSA addresses a broad
continuum of prevention, early intervention and service needs
and the necessary infrastructure, technology, and training
elements that will effectively support this system, with the
purpose of promoting recovery for individuals with serious
mental illness. Subsequent regulations adopted by DMH require
programs and/or services provided with MHSA funds to offer
mental health services and supports to individuals with severe
mental illness; to be designed for voluntary participation;
and, to comply with specified non-supplantation requirements.
It is unclear whether or not it is permissible for a county to
use MHSA funds to support an AB 1421 program.
7)SUPPORT . The sponsor of this bill, California Psychiatric
Association, states that AB 1421 needs to be extended because
it is a valuable early intervention alternative to revolving
door hospitalization and incarceration for a small group of
individuals who meet certain stringent criteria and occupies a
unique niche in counties' continuum of care that supports
recovery from severe and persistent mental illness. The
California Treatment Advocacy Coalition notes in support that,
in Nevada County, AOT saved $1.81 in hospitalization and
incarceration costs for every $1.00 invested and it has had a
positive fiscal impact on decreasing costs to other county
systems, such as emergency departments, ambulance, law
enforcement, and the courts. L.A. County supports this bill
AB 1569
Page 7
and suggests an amendment to include State implementation
funds as more funding is needed to increase program capacity
and serve more county residents with severe mental illnesses
who may be a risk to themselves or others. The California
Association of Psychiatric Technicians adds in support that,
as trained, licensed, and regulated mental health and
developmental services nursing professionals, they are
strongly compelled to support AOT services, which could save
lives, families, and funds if AB 1421 is allowed to continue
and encouraged to be implemented.
8)OPPOSITION . Disability Rights California (DRC) objects to
this bill, arguing that AOT is unnecessary as there are good
alternatives to ensure access to needed mental health
services; AOT has not been widely implemented and does not
work; and, current LPS Act law allows for involuntary mental
health treatment under statutorily defined criteria. DRC
contends that some counties already have in place proven
voluntary treatment programs that have comparable results to
AOT without the expense and coercion of court-ordered
treatment, citing Orange County's Full Service Partnerships
funded by MHSA that have reduced hospitalizations by 50%,
incarcerations by 88%, and homelessness by 70%. Other
opponents, including the California Association of Mental
Health Patients' Rights Advocates and the California Network
of Mental Health Clients, maintain that forced treatment is
inconsistent with mental health recovery principles of
self-determination and empowerment and drives people away from
the mental health system altogether. The American Civil
Liberties Union of California (ACLU) writes in opposition that
California should increase the availability of a full array of
voluntary mental health services for the mentally disabled and
expand programs that have demonstrated success in saving lives
and money.
9)DOUBLE-REFERRAL . This bill is double-referred. Should it
pass out of this committee, it will be referred to the
Assembly Judiciary Committee.
10)POLICY COMMENT . While the option to implement an AOT program
is considered to be an important tool for providing care to
the small minority of individuals whose mental illness is so
severe that it poses a danger to the public and to themselves,
it is unclear how counties can best utilize it given the
state's ongoing fiscal crisis that is requiring counties to do
AB 1569
Page 8
more with less and the lack of an identified funding source in
the original statute for implementation.
REGISTERED SUPPORT / OPPOSITION :
Support
California Psychiatric Association (sponsor)
American Federation of State, County and Municipal Employees,
AFL-CIO
California Association of Psychiatric Technicians
California Hospital Association
California State Sheriffs' Association
California Treatment Advocacy Coalition
County of Los Angeles
Friends Committee on Legislation of California
NAMI Orange County
Nevada County Suicide Prevention Task Force
Treatment Advocacy Center
Several individuals
Opposition
ACLU
Bazelon Center for Mental Health Law
California Association of Mental Health Patients' Rights
Advocates
California Association of Social Rehabilitation Agencies
California Network of Mental Health Clients
Disability Rights California
MindFreedom International
National Association for Rights Protection and Advocacy
San Diego Disability Action Coalition
United States Psychiatric Rehabilitation Association
Voices of the Heart, Inc.
Several individuals
Analysis Prepared by : Cassie Royce / HEALTH / (916) 319-2097