BILL ANALYSIS Ó AB 59 Page 1 Date of Hearing: April 14, 2015 ASSEMBLY COMMITTEE ON HEALTH Rob Bonta, Chair AB 59 Waldron - As Amended April 6, 2015 SUBJECT: Mental health services: assisted outpatient treatment. SUMMARY: Changes requirements for county participation in the Assisted Outpatient Treatment (AOT) Demonstration Project and increases the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. Specifically this bill: 1)Authorizes county participation in the AOT Demonstration Project without requiring counties to make findings that no existing mental health programs will be reduced as a result of AOT implementation. 2)Deletes the January 1, 2017 repeal date of Laura's Law and extends the program indefinitely. 3)Authorizes a court to order a person to obtain AOT for an initial period not to exceed 12 months. 4)Authorizes a person who has been released from an intensive AB 59 Page 2 treatment or postcertification treatment program to be evaluated to determine whether they meet the criteria for AOT. 5)Authorizes the professional staff of the agency or facility to request the county mental health director to file a petition in the superior court for AOT if that person meets certain criteria. EXISTING LAW: 1)Permits counties to provide AOT services for people with serious mental illnesses when a court determines 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)Allows a court, after finding that an individual meets the criteria for AOT, and there is no appropriate and feasible less restrictive alternative, to order the individual to receive AOT for an initial period not to exceed six months. If the director of the assisted outpatient program determines that the individual requires further assisted outpatient services, requires that director, prior to expiration of the time period of the treatment, to apply to the court for an extension of the services, not to exceed 180 days. 3)Permits a petition for a court order authorizing AOT to be filed by the county mental health director, or his or her designee, in the superior court in the county where the person requiring treatment is present. 4)Authorizes the following individuals to make a request to the county mental health department for the filing of a petition: AB 59 Page 3 a) An adult whom the person lives with; b) Family members that include adult children, parents, siblings or spouse; c) Law enforcement, parole, or probation officer; d) Director of a public or private agency providing mental health services to that person; e) Hospital director who is providing psychiatric care to that person; or, f) Licensed mental health provider who is treating or supervising the person. 5)Grants any person subject to a petition for an order of AOT the right to legal counsel at all steps of the hearing process. 6)Requires the Department of Health Care Services (DHCS) to submit a report and evaluation to the Governor and the Legislature of all counties implementing an AOT program by July 1, 2015. 7)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 AB 59 Page 4 others, or is "gravely disabled." 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. 8)Allows, under the LPS Act, a person who is gravely disabled to be involuntarily detained for further inpatient mental health treatment for an additional 14 days, as provided, which can be extended for 14 days if the person presents an imminent threat of taking his or her own life or 30 days if the county has authorized the program and the person remains gravely disabled. 9)Allows, under the LPS Act, a court to order an imminently dangerous person to be confined for further inpatient intensive health treatment for an additional 180 days, as provided. FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee. COMMENTS: 1) PURPOSE OF THIS BILL. According to the author, AOT or "Laura's Law" provides family members with important tools for initiating outpatient treatment for severely mentally ill adults who are incapable of seeking help on their own. The author states that it helps to identify when a patient's condition is significantly worsening and to intervene before the patient becomes too ill and is subject to involuntary civil confinement. The author further states that based on previous evidence, the first six months in the program demonstrate significant improvements in self-care and community living, social functioning, task performance, and incidents of harmful behaviors in patients. According to the author, studies also show that improvement takes time AB 59 Page 5 therefore, to insure full stability of patients once the initial period is complete, this bill will require counties with available funding to implement this program and extend it from six months to one year. 2) BACKGROUND. The AOT Demonstration Project allows courts in participating counties to order a person into an AOT program if the court finds that the individual either meets existing involuntary commitment requirements pursuant to Welfare and Institutions Code Section 5150 (is gravely disabled or is a danger to self or others), or the person meets non-5150 criteria including that the person has refused treatment, their mental health condition is substantially deteriorating, and AOT would be the least restrictive level of care necessary to ensure the person's recovery and stability in the community. The law is only operative in those counties in which the county board of supervisors, by resolution, authorizes its application and makes a finding that no voluntary mental health program serving adults, and no children's mental health program, was reduced in order to implement the law. a) County Implementation. Currently, Nevada, Orange, Yolo, and the City and County of San Francisco have approved full implementation of Laura's Law; Los Angeles County implemented the law on a limited basis. According to the treatment provider that Nevada County contracts with for services, Turning Point Community Programs, Initiating the AOT process begins with a referral submitted by family members, relatives, cohabitants, treatment providers or their supervisors, or peace officers. If individuals meet AOT eligibility requirements, a preliminary care plan is developed. If the individual voluntarily engages with the treatment after initial contact, a petition is no longer necessary and the patient no longer meets the criteria for AOT referral. However if the client declines the preliminary care plan, the AOT team proceeds with a petition and a public defender is assigned to the client. The court must be notified within 10 days of the AB 59 Page 6 intervention, and a hearing must be set within five days of the filing of the petition and the judge either grants or rejects the AOT petition. If ordered, AOT is valid for up to 180 days. According to Nevada County, in the seven years the county has implemented Laura's Law, 37 AOT commitments have been ordered by the court, and six individuals have failed to complete their orders due to hospitalization, incarceration, or death. Nevada County indicates that the number of hospitalization days for program participants has been cut in half, and no patient has encountered problems with law enforcement since their commitment. In Orange County, two individuals have been ordered to fulfill an AOT commitment. The other county programs have been recently implemented and do not yet have any court ordered AOT commitments. b) Increased Treatment and Outcomes. This bill seeks to extend, from six months to one year, the time period for which an individual can be ordered to participate in AOT. New York made a similar change in 2012, extending its mandatory outpatient treatment time from six months to one year in its version of Laura's Law. Supporters have provided research papers that argue that six months is the bare minimum time period necessary to achieve positive outcomes and that those outcomes improve when treatment times are extended to one year or longer. However, it is important to note that during the time of the study in New York, the maximum initial period of imposed treatment was six months. Patients who received treatment longer than six months received extensions beyond the initial six-month treatment period, which is currently permissible by California Law 3) SUPPORT. The California Medical Association (CMA) states in support of the bill that Laura's Law provides for community-based, AOT services to a small population of individuals who meet specific criteria and as a result of AB 59 Page 7 their mental illness are unable to voluntarily access community mental health services. AOT has been consistently demonstrated to be effective in stabilizing individuals which increases the likelihood of stable housing, medical adherence, and social skill building. Laura's Law provides necessary mental health treatment to individuals, while at the same time making our communities safer. The CMA notes that Nevada County, which has fully implemented the law, has seen increased access to mental health treatment and a reduction of cost to the county in the amount of $500,000 through avoidance of hospitalizations and incarcerations. Failure to implement Laura's Law results in individuals suffering from severe mental illness failing to receive needed mental health treatment and counties incurring costs that could have been circumvented. The CMA concludes that this bill is an integral step in the statewide implementation of Laura's Law. 4) OPPOSITION. Disability Rights California (DRC) writes in opposition that this bill removes many provisions in current law that protect the rights of individuals subject to AOT. This bill removes the requirement that a county board of supervisors approve an AOT program and the county prohibition to reduce voluntary mental health services when implementing AOT programs. This bill increases the maximum duration of an AOT order from six to 12 months; broadens the group of people who can request an AOT petition; and removes the program's sunset provision. DRC states that to the extent it continues to be authorized in California, counties should retain local control and AOT should be at their election and not imposed on them by the state. DRC also notes that existing law provides that certain people who are involved in providing mental health treatment to an individual, including a licensed mental health treatment provider and the director of a hospital, public or private agency, treatment facility, charitable organization or licensed residential care facility, any request that the county mental health department file an AOT petition on behalf of that individual. This bill would add the professional staff of an agency or AB 59 Page 8 facility that provided involuntary treatment to an individual to that list. DRC argues that this increases the possibility that the petitions may be filed without adequate basis, therefore further limiting individual rights. The California State Association of Counties (CSAC), and the County Behavioral Health Directors Association (CBHDA) write in opposition to the bill, stating that it is critical that county Boards of Supervisors retain the authority and flexibility to determine whether implementing Laura's Law AOT services in their community is appropriate. CSAC states that they believe that counties should be able to use funds to best meet the needs within their county. County Boards of supervisors, as one of the levels of government that is closest to the people, are experts at grappling with significant local decisions while also remaining responsive to local needs and perspectives. The California Association of Social Rehabilitation Agencies (CASRA), and the California Psychological Association (CPA) state in opposition that outpatient commitment has not been shown to be the most effective in reducing hospitalization or other adverse outcomes and that involuntary treatment is inconsistent with current evidence-based best practice in behavioral health care. CPA further states that the White House Conference on Mental Health Fact Sheet (1999) showed that when persons with even the most serious mental illnesses are provided with appropriate and comprehensive community mental health services, they succeed. CASRA argues that research to date does not support the use of involuntary commitment to treat difficult to engage individuals and that much of the existing research is flawed by confounding variables and poor research design. 5) RELATED LEGISLATION. AB 1193 (Eggman) Mandates an increase in the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. 6) PREVIOUS LEGISLATION. AB 59 Page 9 a) AB 2266 (Waldron) of 2014 would have increased the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. AB 2266 failed passage in the Assembly Judiciary Committee. b) AB 1265 (Conway) of 2013 would have increased the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. AB 1265 also failed passage in the Assembly Judiciary Committee. c) AB 1569 (Allen), Chapter 441, Statutes of 2012, extends authorization for "Laura's Law" to January 1, 2017, and would have required DHCS to submit the report by July 1, 2015. d) SB 1606 (Yee) of 2008 would have required the Department of Mental Health (now called the Department of State Hospitals) to conduct a study of individuals whose mental health needs are not currently being met, because they do not meet existing eligibility criteria for AOT, but have mental health needs that may not be met through voluntary services. SB 1606 passed out of the Senate, but was held on the Assembly Appropriations Committee suspense file. e) AB 1421 (Thomson), Chapter 1017, Statutes of 2002, permits counties to provide court-ordered outpatient treatment services for people with serious mental illnesses when a court finds that a person's recent history of hospitalizations or violent behavior, coupled with noncompliance with voluntary treatment, indicate the person is likely to become dangerous or gravely disabled without the court-ordered outpatient treatment. 7) DOUBLE REFERRAL. This bill is double referred, upon passage of this Committee, it will be referred to the Assembly Committee on Judiciary. AB 59 Page 10 8) COMMITTEE COMMENTS. The previous version of this bill mandated county implementation of Laura's Law, where counties had available funding to implement the AOT program. This was a significant source of contention for opposition. Author's amendments of April 6, 2015 removed those provisions and maintain the provisions that permit counties to opt-in that are currently in statute. Additional author's amendments delete the requirement that counties make findings that no other existing mental health program serving adults or children may be reduced as a result of the implementation of this article before a county board of supervisors can vote to adopt Laura's Law. County boards of supervisors are still required to pass a resolution to implement Laura's Law. 9) COMMITTEE AMENDMENTS. This bill permits an initial AOT commitment of one year instead of six months as currently permitted by law. In the limited available data regarding AOT programs, there is no evidence that an increase in the initial commitment treatment period improves health care outcomes for program participants. For this reason, the Committee may wish to remove that provision from this bill and maintain the currently allowable six month initial treatment time period for AOT participants. REGISTERED SUPPORT / OPPOSITION: Support California Medical Association Opposition AB 59 Page 11 California Association of Social Rehabilitation Agencies California State Association of Counties California Psychological Association County Behavioral Health Directors Association Disability Rights California Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097