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Receive a presentation from the staff of the Department of Health and Social Services on behalf of the Mental Health Advisory Board; Consider implementation of Assisted Outpatient Treatment, commonly known as “Laura’s Law,” in Solano County; and Adopt a resolution authorizing implementation of Assisted Outpatient Treatment and certifying a commitment that no voluntary mental health services for adults, and no children’s mental health program, will be reduced as a result
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Published Notice Required? Yes ___ No _x _
Public Hearing Required? Yes ___ No _x _
DEPARTMENTAL RECOMMENDATION:
The Department of Health and Social Services (H&SS) recommends that the Board receive a presentation from staff on behalf of the Mental Health Advisory Board; Consider implementation of Assisted Outpatient Treatment, commonly known as “Laura’s Law,” in Solano County; and Adopt a resolution authorizing implementation of Assisted Outpatient Treatment and certifying a commitment that no voluntary mental health services for adults, and no children’s mental health program, will be reduced as a result.
SUMMARY:
Assembly Bill (AB) 1421 was signed into California state law in 2002 and became effective January 1, 2003. The statute is commonly known as “Laura’s Law” which amended Chapter 2 of Part 1 of Division 5 of the Welfare and Institutions Code (commencing with Section 5345) relating to mental health. AB 1421 provides for the implementation under certain criteria of Assisted Outpatient Treatment (AOT) and a mechanism for counties to identify adults with serious mental illness and a history of treatment non-adherence who are at substantial risk for continued psychiatric hospitalization or incarceration as a result of their lack of treatment and to implement a court-ordered AOT program for the population of individuals who meet strict legal criteria. The individuals identified must have demonstrated, based upon a clinical determination, an inability to voluntarily access community mental health services, a substantial deterioration and an unlikeliness to survive safely in the community without supervision, and to have met certain criteria related to hospitalization or incarceration.
AOT programs are intended to engage individuals in mental health care despite their historical refusal to do so. At the same time, these individuals do not meet the criteria to be conserved under the Lanterman-Petris-Short (LPS) Act which makes provision for the involuntary treatment of individuals who, as a result of a mental disorder, are a danger to themselves or others or who are gravely disabled as defined under Welfare and Institutions Code (WIC) Section 5150. Implementation of an AOT program requires that a County Board of Supervisor authorize the use of AOT in its County and certify that no voluntary mental health services for adults, and no children’s mental health program, will be reduced as a result of the implementation. The County’s Full Service Partnership (FSP) programs, which provide intensive outpatient services and a whole person approach to supports for individuals with complex needs, are the programs that would provide services to individuals ordered by the Court through the implementation of AB1421 (Laura’s Law).
Implementation of AOT provides for a civil court process to compel an individual to receive mental health care. The law does not provide for any civil or criminal penalties for failure to comply, so there are no consequences for a person who, despite the court order, does not participate in treatment. Further, it does not allow for a court to order an individual to take prescribed medication, only to participate in treatment.
The implementation of AOT will likely require additional “slots” in the FSP programs so that an FSP program does not reach capacity due to the impact of AOT and become unable to add voluntary clients to the caseload.
FINANCIAL IMPACT:
H&SS, Behavioral Health Division anticipates clients court ordered to participate in AOT will be seen in one of the County’s internal or subcontracted FSP programs. Based on the experiences of other similar sized or larger counties in comparison to Solano County, it is estimated that fewer than six individuals would be served annually through a civil court process. FSP programs are primarily funded by the Mental Health Services Act funding with some use of Short Doyle Medi-Cal billing when applicable.
If this level of participation is accurate and MHSA funding grows, H&SS Behavioral Health believes it could absorb the estimated six individuals into existing FSP programs; however, if a significant increase in demand results after implementation, new funding/additional funds may be needed to support the AOT program as no voluntary services may be reduced as a result of this program. More clients may engage in ongoing services because of the court order or as a result of a settlement or voluntary agreement prior to any court appearance. In addition, there will be a financial and staffing impact if a large number of referrals require an investigation for eligibility and an assessment of client needs, court preparation and testimony, 60-day progress reports, and annual reports to the State Department of Health Care Services. If individuals with private insurance are referred to AOT, this could result in a lack of reimbursement to the County for services; this is not expected to be large portion of referrals but may occur for young adults 26 and under who are on their parents’ health insurance. H&SS will be providing program participation and budget updates to the Board as part of the Midyear and Requested Budget.
MHSA funds may not be used to provide any reimbursement for associated judicial system costs associated with petitions filed and court hearings held. This includes the cost of counsel’s time to prepare petitions, legal representation of referred individuals, and resources for establishing the program, providing materials and information, referral forms, training and website updates. These costs may be offset to some degree by less exposure of these individuals to inpatient care or the criminal justice system due to untreated mental illness.
DISCUSSION:
Assisted Outpatient Treatment programs are intended to engage individuals to receive mental health care despite their historical refusal to do so. AOT provides for an outpatient alternative for those individuals who are at risk of hospitalization and it may provide a proactive alternative to an eventual hospitalization and/or potential petition for LPS conservatorship. The process begins with a request to the County Behavioral Health Director to file a petition.
AOT Process/Requests
Those who can request AOT for an adult with a serious mental illness include:
1. The individual’s parent, spouse, sibling or child who is 18 or over
2. Adults residing with the individual
3. Director of any public or private agency, treatment facility, charitable organization, or licensed residential care facility providing mental health services to an individual in whose institution the individual resides
4. Director of the hospital in which the individual is hospitalized
5. Treating licensed mental health professional; and/or
6. Peace Officer, Parole or Probation Officer supervising the individual
The County Behavioral Health Director receiving the request must conduct an investigation into the appropriateness of the request for filing of the petition and shall file the petition only upon determining that there is a reasonable likelihood that all the necessary elements to sustain the petition can be proven in a court of law by clear and convincing evidence. The law does not outline a process for appeal if the referral for Assisted Outpatient Treatment is denied by the County Behavioral Health Director due to lack of meeting the required criteria described below:
1. The person is 18 years of age or older.
2. The person is suffering from a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a substance use disorder or developmental disorder or acquired traumatic brain injury unless that person also has a serious mental disorder as defined by statute.
3. There is a clinical determination that the person is unlikely to survive safely in the community without supervision.
4. The person has a lack of compliance with treatment for his or her mental illness in that at least one of the following is true:
a. The person’s mental illness has at least twice within the last 36 months been a substantial factor necessitating hospitalization or receipt of services in a forensic or mental health unit of a correctional facility, not including any period in which the person was hospitalized or incarcerated immediately preceding the filing of the petition, or
b. The person’s mental illness has resulted in one or more acts of serious and violent behavior toward oneself or another, or threats, or attempts to cause serious physical harm to oneself or another within the last 48 months, not including any period in which the person was hospitalized or incarcerated immediately preceding the filing of the petition.
c. The person has been offered an opportunity to participate in a treatment plan with the local mental health department and the person continues to fail to engage in treatment.
d. The person’s condition is substantially deteriorating.
e. Participation in the AOT program would be the least restrictive placement necessary to ensure the person’s recovery and stability
f. In view of the person’s treatment history and current behavior, the person is in need of AOT in order to prevent a relapse or deterioration that would likely result in a grave disability or serious harm to oneself or another, as defined in WIC Section 5150.
g. It is likely that the person will benefit from AOT.
If the criteria are upheld in the investigation by the Behavioral Health Director, then a petition is filed in court to order the individual to participate in AOT. The individual is entitled to counsel; if no counsel is retained, the court will appoint a Public Defender. Persons who do not comply with an AOT order may only be evaluated for hold under Welfare and Institutions Code 5150. No other court-based mechanisms are available for providing treatment to individuals who may meet AOT criteria, but do not meet 5150 criteria, and refuse to comply with the AOT order. An AOT order itself may not be effective enough to produce compliance given the law provides no legal mechanism for enforcement. An AOT order for treatment does not include authority for administration of medications involuntarily. Voluntary services and engagement efforts will be made in order to prevent most referrals from requiring a petition with the court.
Implementation of AOT is not without its risks and challenges. The estimated population in Solano County of eligible participants is 6. It should be noted that a patients’ rights and legal representation are part of the process. Seventeen counties have adopted resolutions and implemented AB 1421 since 2003. Notably other AOT programs have engaged the vast majority of eligible participants voluntarily and have needed to file petitions for small numbers. This is advantageous as engagement in programming is stronger when done so voluntarily. In addition, successful implementation of AOT, as is the case with other intensive mental health programs, is dependent upon safe and stable housing; this is a challenge locally as it is statewide.
ALTERNATIVES:
The Board may choose not to adopt the resolution authorizing implementation of AB 1421, adopt a resolution authorizing a 2-year pilot implementation, or choose to adopt the resolution as recommended. Choosing not to adopt the resolution is not recommended as the 7 member Solano County Local Mental Health Advisory Board has voted unanimously to recommended adoption to the Board and collaborative local agencies also recommend its adoption. Adopting a resolution for a 2 year pilot implementation provides H&SS and the Board the opportunity to monitor and evaluate the program without a long term commitment to the program.
OTHER AGENCY INVOLVEMENT:
Health and Social Services has heard from and received input from members of the Local Mental Health Advisory Board, County Counsel, Superior Court, Sheriff, Public Defender, District Attorney, Probation, law enforcement agencies, and Assemblymember Frazier in preparing this report on the potential implementation of AOT in Solano County.
CAO RECOMMENDATION:
APPROVE DEPARTMENTAL RECOMMENDATION