BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1569
AUTHOR: Allen
AMENDED: April 16, 2012
HEARING DATE: June 13, 2012
CONSULTANT: Bain
SUBJECT : Community mental health services: assisted outpatient
treatment (AOT).
SUMMARY : Extends the sunset date of the Assisted Outpatient
Treatment Demonstration Project Act of 2002 (AOT Act, which is
also known as "Laura's Law") from January 1, 2013 until January
1, 2017. The AOT Act allows a county that has adopted a
resolution to petition for a court order that a person with a
mental illness obtain AOT if that person meets specified
criteria. Requires the Department of Mental Health (DMH) to
submit a report and evaluation of all counties implementing any
component of the AOT Act to the Governor and the Legislature by
July 31, 2015.
Existing law:
1.Allows county boards of supervisors, by resolution, to
authorize AOT whereby a county mental health director can
petition for a court to order a person over age 18 with a
mental illness to receive AOT if the court finds the
individual meets specified criteria, including a clinical
determination that the person is unlikely to survive safely in
the community without supervision; the person has a history of
noncompliance with treatment for his or her mental illness;
and the person's condition is substantially deteriorating and
participation in the AOT program would be the least
restrictive placement necessary to ensure the person's
recovery.
2.Requires counties implementing the AOT Act to make a finding
that no voluntary mental health program serving adults, and no
children's mental health program, may be reduced as a result
of the implementation. DMH is required to monitor compliance
with this requirement as part of its review and approval of
county mental health plans.
3.Requires a county that provides court-ordered AOT services to
also offer the same services on a voluntary basis.
Continued---
AB 1569 | Page 2
4.Required DMH to submit a report and evaluation of all counties
implementing any component of the AOT Act to the Governor and
the Legislature by July 31, 2011, as specified.
5.Sunsets the AOT Act on January 1, 2013.
6.Authorizes a peace officer, member of the attending staff of
an evaluation facility designated by the county, designated
members of a mobile crisis team, or other professional person
designated by the county, upon probable cause, to take a
person with a mental disorder who is a danger to himself or
herself, a danger to others, or who is gravely disabled, into
custody and place him or her in a facility designated by the
county and approved by DMH as a facility for 72-hour treatment
and evaluation (referred to as a 72-hour hold).
This bill:
1.Extends the sunset date authorizing the AOT Act, from January
1, 2013, until January 1, 2017.
2.Requires DMH to submit a report and evaluation of all counties
implementing any component of the AOT Act to the Governor and
to the Legislature by July 1, 2015, and requires the report to
include specified information.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1.Based on experience to date, likely minor state trial court
costs.
2.Minor, absorbable one-time costs to DMH to collect data from
counties and prepare an evaluation report.
3.To the extent the involuntary AOT program is implemented more
widely throughout the state and is successful in helping
treated individuals avoid hospitalizations or interaction with
the criminal justice system, there could be minor avoided
costs in local law enforcement or health care programs. To
date, only one county has implemented an AOT program.
PRIOR VOTES :
Assembly Health: 15- 3
Assembly Judiciary: 10- 0
Assembly Appropriations:16- 0
Assembly Floor: 68- 4
AB 1569 | Page
3
COMMENTS :
1.Author's statement. AB 1569 would extend the sunset date of
Laura's Law which authorizes counties to implement AOT
services to severely mentally disabled individuals who have
chronically refused mental health treatment. Enacted in 2002,
Laura's Law was named for Laura Wilcox, a 19-year old college
student who was gunned down by a man suffering from serious
delusional paranoia. Specifically, Laura's Law permits
counties to provide court-ordered outpatient treatment
services for people with serious mental illness. To implement
the order, a court must find that a person's recent history of
hospitalizations or violent behavior, coupled with the
noncompliance with voluntary treatment, indicates the person
is likely to become dangerous or gravely disabled without
treatment. The petition requesting the court-ordered treatment
must be made to the county health department by an adult
living with the mentally disabled individual, the parent,
spouse, sibling, adult child of that person, mental health
workers or law enforcement personnel. Laura's Law is simply
another tool for treating the severely mentally ill who
chronically refuse voluntary treatment and are a danger to
themselves or others but are not so gravely disabled that they
qualify for conservatorship. A model program for treatment,
Laura's Law provides the legal and clinical treatment
structure necessary to give certain severely mentally disabled
people the support they need to achieve stability and
meaningful recovery.
2.The AOT Act. In the 2001-02 legislative session,
then-Assemblywoman Helen Thomson authored AB 1421, Chapter
1017, Statutes of 2002, called the AOT Act or "Laura's Law."
AB 1421 established a new court-ordered outpatient treatment
statute aimed at individuals with mental illness who meet
specified criteria but who do not meet the criteria (danger to
self/others or gravely disabled) for commitment to an
inpatient facility.
The AOT Act authorizes county mental health directors to
petition for a court order for a person to obtain AOT if the
person is 18 years of age or older and is suffering from a
mental illness and the court finds, by clear and convincing
evidence, that the person who is the subject of the petition
meets specified criteria. These criteria include a clinical
determination that the person is unlikely to survive safely in
the community without supervision; the person has a history of
noncompliance with treatment for his or her mental illness (as
AB 1569 | Page 4
described); the person has been offered an opportunity to
participate in a treatment plan and the person continues to
fail to engage in treatment; the person's condition is
substantially deteriorating and participation in the AOT
program would be the least restrictive placement necessary to
ensure the person's recovery and stability; the person is in
need of AOT in order to prevent a relapse or deterioration
that would be likely to result in grave disability or serious
harm to himself or herself or to others in view of the
person's treatment history and current behavior; and it is
likely the person will benefit from AOT.
A county that chooses to provide AOT must offer AOT services
that meet specified requirements. The AOT Act outlines who can
request the county mental health department to petition for an
order for AOT, the requirement that the county mental health
director conduct an investigation into the appropriateness of
the filing of the petition, the content of the petition, the
right of the person who is the subject of the petition to be
represented by counsel, requirements for a court hearing on
the petition, including requirements related to the timing of
the hearing, and the rights of the person subject to the
petition.
After hearing all relevant evidence, if the court finds that
the person who is the subject of the petition meets the
criteria for AOT and there is no appropriate and feasible less
restrictive alternative, the court can order the person to
receive AOT for an initial period of not more than six months.
Existing law establishes the process and requirements for a
180-day extension of AOT.
3.DMH report. In July 2011, DMH issued an evaluation of the AOT
Act. DMH reported that no county implemented an AOT program
until 2008, and only Nevada County currently operates such a
program (through Turning Point Providence Center), which has
an intensive community support program. DMH's report states
the AOT program has served a total of four court-ordered
individuals over two years (two individuals were served each
year). For fiscal years 2008-2009 and 2009-2010, data show
that the program has succeeded primarily in assisting clients
to significantly reduce hospitalization days (from 239 to 97
for all participants), the four individuals did not have
contact with local law enforcement during their participation
in the program, three of the individuals were able to live in
homes or independently, one individual was victimized
AB 1569 | Page
5
financially by another person, one individual used alcohol and
methamphetamines, and two individuals maintained their
housing. Following the end of the court orders, three
individuals maintained contact with Turning Point, and the
fourth individual was contacted in the hospital by Turning
Point periodically for support.
4.Nevada and Los Angeles counties. In April 2008, Nevada
County's Board of Supervisors authorized AOT, and
implementation began in May 2008. As of January 2012, Nevada
County indicates 37 people have been referred and evaluated
for AOT, 22 people engaged in treatment with no court order,
and the county obtained 11 court orders for treatment. Nevada
County reports a reduction in actual hospital costs of
$213,300, a reduction in actual incarceration costs of
$75,600, and a net savings to the county of $503,621 over 31
months.
The Los Angeles County Department of Mental Health (LADMH)
implemented a voluntary pilot AOT program administered for
individuals with mental illness involved in the criminal
justice system, in the psychiatric units of county hospitals
or in Institutions for Mental Diseases (IMDs). The program is
considered voluntary in that the county petitions for a court
order for AOT, and if the individual agrees to a settlement
agreement, the individual voluntary enrolls in the program and
receives housing and integrated mental health services. If the
person contests the court petition, the petition does not go
to court hearing and the individual is still eligible for the
services. Enrollment in this program is capped, and DMH does
not consider the LADMH program to be an AOT program under the
AOT Act. In addition to the AB 1421 criteria, eligibility
criteria for the LADMH AOT program include:
� Misdemeanor "incompetent to stand trial" defendants who
have been adjudicated, "restored to competency" by the
LADMH, and are exiting the legal system;
� Misdemeanor defendants at risk for becoming incompetent
to stand trial;
� Individuals transitioning from alternative sentencing
programs; and
� Individuals transitioning from county hospitals and IMDs
who would be able to live safely in the community if they
participated in the recommended AOT program.
In its March 2012 Outcomes Report on individuals served and
clinical outcomes of the Los Angeles voluntary pilot AOT
AB 1569 | Page 6
program from April 2010 to December 2011, LADMH indicated it
served eighteen individuals, seven of whom were discharged to
lower levels of care, five went absent without official leave,
two were hospitalized, one was arrested and three remain in
the program. LADMH reported reduced incarcerations and
hospitalizations and increased treatment compliance during the
six months of AOT enrollment as compared to the six months
prior to enrollment in AOT.
1.Double referral. This bill is double-referred. Should it pass
out of this committee, it will be referred to the Senate
Judiciary Committee.
2.Related legislation. AB 2134 (Chesbro) requires a county that
elects to provide AOT services to develop best practices for
the purposes of responding to a mental health crisis, and
requires these best practices to include, but are not limited
to, the utilization of crisis intervention teams, mobile
crisis teams, or psychiatric emergency response teams, with an
emphasis on peer support. AB 2134 exempts a county that, as of
January 1, 2012, is providing services under the AOT Act.
3.Prior legislation. AB 1421 enacted the AOT Act with a January
1, 2008 sunset date.
AB 2357 (Karnette and Yee), Chapter 774, Statutes of 2006
extended the AOT Act sunset date to January 1, 2013, and
required DMH to submit a progress report to the Governor and
Legislature in 2011.
4.Support. This bill is sponsored by the California Psychiatric
Association (CPA) to extend the sunset date of Laura's Law
which expires at the end of 2012. CPA states Laura's Law is
simple in concept: it allows court-supervised community
treatment for a small group of individuals who meet certain
stringent criteria. CPA states Laura's Law is an early-
intervention alternative to hospitalizations and jail and a
violence prevention program, and this process has been
demonstrated to be successful with patients who have failed to
engage with voluntary programs and as a consequence have
suffered repeated revolving door hospitalizations and/or
arrests and incarcerations, or engage in threats or acts of
violence, and whose history indicates that they will continue
to do so unless there is more powerful intervention. CPA
states Laura's Law is not a panacea, and in a county's
continuum of care, it occupies a unique niche that supports
AB 1569 | Page
7
recovery from severe and persistent mental illness. CPA argues
that, for about half of the individuals who have a psychotic
disorder, participation in these programs is endangered by a
neurological phenomenon called anosognosia which simply means
that the individual lacks the capacity to stand outside of
themselves, look at themselves, and realize they are sick.
Even when exhibiting symptoms of anosognosia, many patients
can be convinced to participate in mental health programs,
those programs help them, and they continue to take their
medications and show up to their appointments. Laura's Law
helps those remaining individuals who can't or won't engage in
services to step toward the road to recovery.
The California Hospital Association (CHA) writes in support
stating that AOT is a necessary component of the mental health
delivery system and when implemented, dramatically impacts the
inappropriate use of hospital emergency departments, the most
costly level of service delivery in the mental health care
continuum. CHA writes that the data from Nevada County support
the effectiveness of AOT services and the need for AOT
services has increased since its enactment.
The Treatment Advocacy Center (TAC), which is a national
non-profit whose mission is to eliminate barriers to the
timely and effective treatment of severe mental illnesses,
writes that extending the sunset in this bill provides
counties with a proven mechanism to save the state significant
costs in emergency room visits, repeated hospitalizations,
homelessness and law enforcement involvement. TAC states that
failure to preserve this life-saving law would deprive
counties of the option of cost-effective community treatment
for individuals who lack insight into their lives.
5.Support and amend. The Los Angeles County Board of Supervisors
supports the sunset extension in this bill and requests
amendments to: (a) include state implementation funds; (b)
allow more flexibility for county mental health departments in
the provision of AOT services by changing the requirement to
provide the same services for individuals not in court-ordered
AOT; and (c) streamline and facilitate the administrative and
legal processes for admission, readmission, and ongoing
treatment, including the administration of medication.
The Urban Counties Caucus (UCC) writes that, while it supports
the extension of Laura's Law, many counties have decided not
AB 1569 | Page 8
to use this law due to concerns over the fiscal impact of the
program. UCC states that this law can save funding in other
areas of county-provided services, but there is no limit on
how many individuals could apply or be ordered into the
program. UCC argues that, for more counties to utilize this
law, UCC counties would like to have a cap placed in the bill
so that costs would be limited and would like the bill to
provide a funding source for the program.
6.Opposition. Disability Rights California (DRC) writes in
opposition that AOT is unnecessary, as there are good
alternatives to ensure access to needed mental health
services, such as through voter-approved Proposition 63-funded
mental health services. DRC is opposed to the AOT statute
expanding involuntary treatment to people who will never be
dangerous or gravely disabled. DRC states the outcome data on
involuntary outpatient treatment shows forced treatment is
often counterproductive in that it can renew trauma, destroy
trust, and steer people away from the mental health system
altogether, and scarce public dollars are better spent
expanding voluntary treatment programs that provide the surest
path to recovery. DRC states the better solution is for more
to be done to make mental health services available to people
who need them and for counties to track people who have
applied for services and are not currently receiving them due
to funding limitations. Finally, DRC states only one county
has implemented an AOT program and there have only been four
individuals under an order in nearly a decade since the law
was first enacted, and current law already provides for
involuntary treatment through conservatorships for individuals
who are gravely disabled (which can last up to a year, and the
court can give the conservator the power to require
involuntary treatment on an outpatient basis) and for the six
month detention of individuals who are a danger to others.
The California Association of Mental Health Peer Run
Organizations and the California Client Action Workgroup write
in opposition that this bill opens old wounds and undermines
the hard-won trust and collaboration that has made California
the leader in mental health in the country, that AB 1421
resulted in no significant achievements and has only been
implemented in one and a half counties, that the arguments in
favor of this bill perpetuate the most negative, demeaning and
inaccurate stereotypes of people with mental health conditions
as either violent and out-of-control or incapable of making
their own decisions, and that a better answer is to build on
AB 1569 | Page
9
the success of Proposition 63 that respects the rights and
dignity of the people involved.
Mental Health America of California (MHAC) and the California
Council of Community Mental Health Agencies (CCCMHA) write in
opposition that the detriments of the AOT Act far outweigh its
benefits, and it is time to end the exaggerations and
misconceptions that this law is based upon. MHAC and CCCMHA
argue very few people ever meet the criteria of the AOT Act,
the enormous extra costs that this law requires to implement
means they deprive many others of care, and other approaches,
such as the comprehensive care funded through California's
systems of care, have succeeded in treating tens of thousands
of mentally ill individuals who were homeless and believed to
be treatment-resistant by their families, police and
physicians.
SUPPORT AND OPPOSITION :
Support: California Psychiatric Association (sponsor)
American Federation of State, County and Municipal
Employees, AFL-CIO
California Association of Marriage and Family
Therapists
California Association of Psychiatric Technicians
California Hospital Association
California Medical Association
California Probation, Parole and Correctional
Association
California State Sheriffs' Association
California Treatment Advocacy Coalition
Friends Committee on Legislation in California
Los Angeles County Board of Supervisors
Mental Illness Policy Org.
National Alliance on Mental Illness California
National Alliance on Mental Illness, Mendocino County
-- Coast
National Alliance on Mental Illness, Orange County
National Alliance on Mental Illness, Westside-Los
Angeles
Nevada County Suicide Prevention Taskforce
Treatment Advocacy Center
35 individuals
Oppose:American Civil Liberties Union of California
California Association of Mental Health Patients'
AB 1569 | Page 10
Rights Advocates
California Association of Mental Health Peer Run
Organizations
California Association of Social Rehabilitation
Agencies
California Client Action Workgroup
California Council of Community Mental Health Agencies
California Right to Life Committee, Inc.
Disability Rights California
Mental Health America of California
Mental Health Association of San Francisco
MindFreedom International
Eight individuals
-- END --