BILL ANALYSIS �
AB 2397
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Date of Hearing: April 17, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2397 (Allen) - As Introduced: February 24, 2012
SUBJECT : Mental health: state hospitals: ancillary clinical
staff-to-patient ratios.
SUMMARY : Requires state hospitals under the jurisdiction of the
Department of Mental Health (DMH) to have, at a minimum, an
ancillary clinical staff-to-patient ratio of 1-to-25 (1:25) for
each applicable staff classification, based on the facility's
licensed bed capacity with a specified shift relief factor.
Specifically, this bill :
1)Requires a state hospital under the jurisdiction of DMH to
have, at a minimum, ancillary clinical staff-to-patient ratio
of 1:25 for each applicable staff classification.
2)Requires the ancillary clinical staff-to-patient ratios to be
based on the facility's licensed bed capacity with a shift
relief factor of 0.2 as calculated by DMH to reflect absences,
such as those due to illness, vacation, and training.
3)Defines ancillary clinical staff to include, but not limited
to, psychiatric, psychological, social worker, and
rehabilitative staff.
EXISTING LAW establishes state hospitals, under the jurisdiction
of DMH, to provide for the care, treatment, and education of
mentally disordered persons. Authorizes DMH to adopt
regulations regarding the conduct and management of these
facilities.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill
would establish minimum ancillary clinical staff-to-patient
ratios of 1:25 in each of the five state hospitals to ensure
adequate mental health treatment as well as minimum standards
for a safe working and living environment for staff and
patients. The author maintains that in May of 2006, the
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federal government and the State entered into a consent
judgment that required reforms in state hospitals to ensure
patients received basic safety and treatment as required by
the United States Constitution and other federal laws. To
implement many of the court mandated improvements, DMH
improved the staff-to-patient ratio for ancillary clinical
staff from 1:35 to the current 1:25. The author argues that
the vast majority of patients are committed to state hospitals
due to a severely untreated mental illness or an inadequately
treated mental illness that resulted in a violent crime in the
community. According to the author, a current review of over
20 hospital systems indicates that the average
psychiatrist-to-patient ratio for admission units is 1:15 and
for longer term units 1:25. This community standard of
caseloads provides strong evidence of the needed levels of
psychiatric staff. The author argues that reducing staff
levels jeopardizes the treatment required under the federal
consent judgment, opens the door for renewed federal
involvement and possibly federal receivership, and will erode
the minimal safety improvements made over the last fifteen
months. The author maintains that this bill is necessary to
mandate minimum clinical staff caseloads of 1:25 to ensure
stability in treatment and safety.
2)BACKGROUND . According to a March 1, 2012 brief by the
Legislative Analyst's Office (LAO Report) regarding the
oversight and accountability of state hospitals, DMH oversees
the operation of the following five state hospitals that
provide inpatient psychiatric care to more than 5,000
individuals committed to the hospitals civilly or in
connection with criminal proceedings:
a) Atascadero State Hospital (ASH) located in the Central
Coast treats an all-male maximum security forensic patient
population and houses over 1,000 patients;
b) Coalinga State Hospital, located in the city of
Coalinga, houses over 900 patients, most of whom are
sexually violent predators;
c) Metropolitan State Hospital (MSH), located in the City
of Norwalk houses over 400 individuals who have a history
of escape from a detention center, a charge or conviction
of a sex crime, or one convicted murder;
d) Napa State Hospital (NSH), located in the City of Napa,
is classified as a low-to-moderate-security level state
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hospital with slightly less than 1,000 patients; and,
e) Patton State Hospital (PSH), located in San Bernardino
County, treats approximately 1,500 patients and is
primarily a forensic hospital.
In May 2006, four out of five of the state hospitals were
found to be in violation of the Federal Civil Rights of
Institutionalized Persons Act. The investigation found that
these hospitals failed to provide a safe environment for its
patients, failed to provide complete psychiatric assessments,
and in some cases neglected to regularly review a patient's
needs before prescribing medication. The United States
Department of Justice (USDOJ) and the State reached a
settlement, through a consent judgment, which required MSH,
NSH, PSH, and ASH to implement an "Enhancement Plan" (EP) to
improve conditions. The extensive reforms required by the EP
were intended to ensure that individuals in the hospitals are
adequately protected from harm and provided adequate services
to support their recovery and mental health. A court monitor
and a team of clinical experts were appointed to review the
compliance of each hospital.
A cornerstone of the EP requires each state hospital to use a
recovery philosophy of care and psychiatric rehabilitation
model of service delivery. Key to providing this care is
integrated therapeutic and rehabilitative services planning to
be based on a comprehensive interdisciplinary assessment of
each individual patient, consistent with generally accepted
professional standards of care. The EP specifies the
interdisciplinary team membership to include the following
ancillary clinical and nursing staff:
a) Treating Psychiatrist - functions as the team leader,
making decisions about the general course of treatment,
assigning a diagnosis, and prescribing medications and all
other orders for a patient;
b) Treating Psychologist - responsible for considering
behavioral aspects of the patient, creating behavior
guidelines and support plans, and assisting in the
development of a diagnosis;
c) Treating Rehabilitation Therapist - responsible for
facilitating groups that focus on building social skills,
leisure pursuits, and physical wellness and also uses other
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various modalities to provide treatment;
d) Treating Social Worker - functions as a liaison between
the courts, the Forensic Conditional Release Program, and
other outside agencies regarding a patient's
hospitalization. Treating social workers are primarily
responsible for creating and tracking a patient's progress
towards meeting discharge criteria;
e) Registered Nurse (RN) - responsible for the day-to-day
medical and psychiatric care of patients. RNs provide
medical treatments, group interventions, administer
medications, and are extensively involved in the operation
of a unit (where patients live and receive treatment); and,
f) Psychiatric Technician - responsible for the milieu of
the unit and are involved in the day-to-day care of
patients. Psychiatric technicians provide group
interventions, escort patients to and from medical
appointments and generally interact with patients on a
24-hour cycle.
The EP also sets staffing ratios that prohibits a case load
for the interdisciplinary teams from exceeding 1:15 for newly
admitted patients of 90 days or less and, on average, 1:25 in
all other teams at any point in time.
In November 2011, the USDOJ released PSH and ASH from
oversight, deeming them in compliance with the majority of the
EP's demands. However, USDOJ officials asked for an extension
of federal oversight of NSH and MSH, finding that these
facilities have failed to comply with critical provisions of
the EP.
3)GOVERNOR'S 2012-13 BUDGET PROPOSAL . The Governor's budget
plan includes a proposal to eliminate DMH and create a new
Department of State Hospitals (DSH). The Governor's plan
would shift community mental health programs and state
functions related to them to other departments, offices, and
commissions or would eliminate some programs entirely. Under
the Governor's plan, the workload that would remain at DMH
would mainly be the administration of the state hospitals. To
reflect this shift to a narrower focus for DMH, the Governor
proposes to change the department's name from DMH to DSH.
In December 2011, DMH released a report to assist in the
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proposal for a new DSH. The scope of the report was to
recommend the administrative structure for a DSH, to identify
processes that might be organized differently for better
performance and accountability, and to collect information on
the DMH's budget deficit. As a part of its proposal, DMH is
proposing to increase the interdisciplinary treatment team
staff-to-patient ratio for patients requiring intermediate
care from 1:25 to 1:35. According to DMH, the proposed staff
ratio increase is a part of the state hospital savings plan
that has been carefully designed to eliminate the projected
$180 million deficit in the state hospital budget. DMH
maintains that this proposal will not affect the quality of
required mental health care to patients, or reduce safety and
security at state hospitals. Under the DMH proposal, staffing
ratios for newly admitted patients and those who require acute
care will continue at an interdisciplinary treatment team
ratio of 1:15. DMH also maintains that the ratio increase
does not apply to frontline nursing staff, nurse-to-patient
ratios, or hospital police officers. According to DMH staff
in positions that may be impacted by these staffing reductions
received surplus notices in mid-March. According to DMH, if
the staffing ratio increase is approved as a part of the state
budget by the Legislature, the earliest employees could be
laid off in mid-July. DMH maintains that just over 600
positions have been identified for elimination, of which the
majority are currently vacant (about 422 of the 600 are
associated with staffing ratio changes).
4)SUPPORT . According to the sponsors of this bill, the American
Federation of State, County and Municipal Employees (AFSCME)
and the Union of American Physicians and Dentists (UAPD), this
bill ensures the clinical welfare of DMH state hospital
patients by mandating an ancillary clinical staff-to-patient
ratio of 1:25. The sponsors maintain that, in recent years,
the DMH hospital resident population has shifted to include
mostly forensic commitments, including many violent offenders
like the one who murdered psychiatric technician Donna Gross
in the fall of 2010. The sponsors assert that workers from
all five California state hospitals were spurred into action
by Ms. Gross' murder. Five unions, including AFSCME Local
2620 and the UAPD, formed the Safety Now Coalition. The
supporters claim the Coalition's repeated calls for enhanced
staffing on the units have been ignored by the DMH, thus
warranting the need for this legislation. AFSCME and UAPD
assert that DMH recently announced a transition plan calling
for greater fiscal accountability and part of the plan
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includes reducing the number of treatment staff working in
each hospital. The sponsors argue that the overall long-term
clinical costs of this proposal will far outweigh any monetary
savings realized in the short run and that having adequate
treatment staff is essential, if DMH hopes to improve overall
patient behavior and mental health.
5)SUPPORT IF AMENDED . The Service Employees International Union
(SEIU) writes that SEIU is pleased to support this bill if it
is amended to clarify that nurses are included amongst the
"ancillary clinical staff." SEIU asserts that it is necessary
to maintain current staffing levels and safety in state
hospitals. As a crucial member of the clinical care team,
nurses should be included in those ratios. SEIU argues that
in order to fulfill the intent of the legislation and to
maintain a decent standard of patient care, it is vital for
current staffing levels of nurses to be maintained and indeed
augmented.
6)RELATED LEGISLATION . AB 2399 (Allen) would require each of
the five state hospitals under the jurisdiction of DMH to
update its injury and illness prevention plan (IIPP) at least
once a year and establish an IIPP committee to provide
recommendations for updates to the plan. AB 2399 (Allen) is
scheduled to be heard by the Assembly Health Committee on
April 17, 2012.
7)POLICY CONCERNS :
a) The bill language regarding who are considered
"ancillary clinical staff" is vague. The author may wish
to clarify language regarding to whom the ratios in this
bill apply;
b) Currently, the interdisciplinary treatment team ratios
are 1:15 for new admissions (new admissions 90 days or
less). The ratio is currently 1:25 for intermediate care
patients. This bill, as currently drafted, would raise the
ratios and lessen protections for new admissions to 1:25.
The Committee may wish to suggest the author clarify the
bill's intent;
c) The author's rationale for this bill is to ensure
adequate mental health treatment as well as minimum
standards for a safe working and living environment for
staff and patients. If patient care is the concern the
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Committee may wish to consider other clinical staff in
addition to "ancillary clinical staff" ratios such as
nurses and psychiatric technicians be considered. What is
the justification for one over the other?; and,
d) The current ratios for medical personnel in State
hospitals are not in statute. Are there unintended
consequences of codifying the ratios proposed in this bill
without having a clear understanding of what the most
appropriate ratios are for effective treatment and patient
care? The LAO Report makes a recommendation that a
detailed review of the needed personnel by state hospitals
should be analyzed. On April 9, 2012, the Assembly Budget
Subcommittee No. 1, Health and Human Services, adopted
placeholder Trailer Bill Language to adopt the LAO Report
recommendation to ask the Office of Statewide Audits and
Evaluations to do a follow-up audit of the state hospitals.
The Committee may wish to support this recommendation and
suggest that any staffing ratios included in this bill be
subject to a sunset date pending an independent study to
determine the appropriate staffing ratios required for
effective patient treatment.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO (Cosponsor)
Union of American Physicians and Dentists (Cosponsor)
California Association of Psychiatric Technicians
California Psychiatric Association
California Psychological Association
California Statewide Law Enforcement Association
National Association of Social Workers, California Chapter
Service Employees International Union Local 1000
Opposition
None on file.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
AB 2397
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