AB 1569 | Page 1

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 illnessobtain 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 AOTwhereby 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.
  1. 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.
  1. Sunsets the AOT Act on January 1, 2013.
  1. 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 authorizingthe AOT Act, from January 1, 2013, until January 1, 2017.
  1. 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.
  1. 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

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.
  1. 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 illnesswho 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 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 othersin view of the person's treatment history and current behavior; andit 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.

  1. 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 showthat the program has succeeded primarily in assisting clients to significantly reduce hospitalization days (from 239 to 97 for all participants),the four individualsdid not have contact with local law enforcement during their participation inthe program, three of the individuals were able to live in homes or independently, one individual was victimized 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.
  2. 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, andDMH 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 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.

  1. Support.This bill is sponsored by theCalifornia 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 ofindividuals who meet certain stringent criteria. CPA states Laura’s Law is an early- intervention alternative to hospitalizationsand jail and a violence prevention program, and this process has been demonstrated to be successful withpatients who have failed to engage with voluntary programs and as a consequence havesuffered repeated revolving door hospitalizations and/or arrests and incarcerations, or engage in threats oracts of violence, and whose history indicates that they will continue to do so unless there is morepowerful intervention.CPA states Laura's Law is not a panacea, and in a county’s continuum of care, it occupies a unique niche that supportsrecovery from severe and persistent mental illness. CPA argues that, for about half of the individuals who have a psychoticdisorder, participation in these programs is endangered by a neurological phenomenon calledanosognosia 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 toparticipate in mental health programs, those programs help them, and they continue to take theirmedications and show up to their appointments. Laura's Law helps those remaining individuals whocan'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. CHAwritesthat 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.
  2. 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 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 toprovide a funding source for the program.
  1. 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 Californiathe 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 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.