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Lanterman-Petris-Short Act California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care Report Number: 2019-119

Use the links below to skip to the chapter you wish to view:

• Chapter 1: The State and Counties Have Not Ensured That Individuals Treated Under the LPS Act Receive Appropriate Care
• Chapter 2: State Law Limits Counties’ Ability to Effectively Treat Individuals Who Require Involuntary Outpatient Care
• Chapter 3: The State Does Not Know the Extent to Which Billions in Funding Has Assisted Individuals With Mental Illnesses

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Chapter 1

THE STATE AND COUNTIES HAVE NOT ENSURED THAT INDIVIDUALS TREATED UNDER THE LPS ACT RECEIVE APPROPRIATE CARE

Chapter Summary

Designated professionals in California have sufficient authority and guidance under the LPS Act to place people experiencing a crisis because of their mental health conditions on involuntary holds or conservatorships and provide them with treatment. However, counties, state facilities, and the Los Angeles Superior Court have sometimes failed to provide adequate care and sufficient privacy safeguards to those who have received involuntary treatment. For example, insufficient state hospital resources have caused individuals needing a high level of care to wait an average of one year to receive care in a state facility. Further, the Los Angeles Superior Court has held public conservatorship proceedings that included discussions of individuals’ confidential health information. Los Angeles and San Francisco also have high numbers of individuals who have been subject to multiple short‑term holds but who have not received continuing care in their broader mental health systems. We believe that changes to state law are necessary to address treatment challenges and privacy concerns, given their profound potential ramifications for people with serious mental illnesses.

The LPS Act’s Criteria Provide Sufficient Authority for the Use of Involuntary Holds or Conservatorships When Individuals Require Crisis Treatment

In the cases we reviewed, the LPS Act’s criteria enabled first responders, designated professionals, and courts to place people who needed crisis treatment on involuntary holds or conservatorships. As the Introduction describes, the LPS Act allows designated professionals to place such individuals into short‑term holds if, as the result of their mental disorders, those individuals are dangerous to themselves, dangerous to others, or gravely disabled—meaning they are unable to provide for basic personal needs. Further, for individuals who cannot provide for their basic needs, the LPS Act also allows for longer‑term treatment through conservatorships, which we observed were typically sought by the public guardian. Each county we reviewed has guidance to help define these involuntary hold or conservatorship criteria. Our review of case files at each county included cases in which the county’s first responders and designated professionals did not place people on involuntary holds. However, we did not definitively identify any situations in which first responders and designated professionals failed to hold individuals when they might have met the standards in the counties’ guidance for such measures. In one case we were unable to reach a definitive conclusion based on the documentation available. We also did not identify any situations in which individuals were involuntarily held when the holds were not justified under the county’s standards.

Some organizations have raised concerns that designated professionals have inconsistently applied the involuntary hold criteria across the State, in part because the LPS Act does not define the criteria clearly enough. A wide disparity in the application of these criteria could lead to significant differences in the types of mental health care provided and who receives such care in different parts of the State. In other words, the level of service one received would depend on where one resided. Further, the director of Los Angeles’s Department of Mental Health stated that the grave disability criterion—the only criterion for establishing a conservatorship under the LPS Act—does not adequately account for the range of threats someone can present to the public or to themselves and that he believed that California must have more systematic ways of determining whether someone can live safely in their community. However, we found that the designated professionals in the three counties we reviewed have generally interpreted and applied the LPS Act criteria similarly when making decisions about involuntary holds, and they have used definitions of grave disability that were not overly restrictive. Figure 5 provides examples of cases we reviewed in which designated professionals in the counties used the involuntary hold criteria to address substantively similar circumstances.

Figure 5
Individuals Placed on Holds or Conservatorships in Each of the Three Counties Exhibited Similar Indications That They Had Met the LPS Act Criteria

Although the LPS Act does not elaborate on what it means to be a danger to oneself or to others, the three counties generally defined these two criteria the same way. Specifically, each county’s guidance indicates that first responders should consider individuals a danger to themselves if, as a result of mental illness, they engage in behavior that would hurt themselves or they have the intent to hurt themselves. Staff at each county clarified that individuals who are suicidal and have plans to carry out those intentions meet the criterion of being a danger to themselves. San Francisco also noted that individuals do not necessarily need to have expressed suicidal thoughts to be considered a danger to themselves and that behaviors such as walking into traffic because of delusions would also meet this criterion. The counties’ guidance defines being a danger to others similarly to being a danger to oneself. Each county’s guidance states that someone is a danger to others if, as the result of a mental illness, their words or behaviors indicate that they would harm another person. According to the counties, individuals who express homicidal intent would meet this criterion.

In the cases we reviewed, the designated professionals followed their counties’ definitions when placing individuals on involuntary holds when they believed the individuals presented a danger to themselves or to others. Among the 60 short‑term hold decisions we reviewed—which were split evenly among the three counties—we identified 51 cases in which the reasons for the hold included danger to self or others. In more than 85 percent of those cases, the records indicated that the individuals clearly met the standards of being either suicidal or homicidal with plans to carry out those intentions. In the remaining cases, the individuals were also apparent dangers to themselves or others around them even though they were not clearly homicidal or suicidal. For example, one case involved an individual whose mental illness led them to consume foreign objects that could have killed them. ⁴ To protect the identities of the individuals we discuss in this report, we have chosen to use the pronoun they or them when presenting examples from our case reviews. In another case, an individual whose symptoms led to self‑injurious behavior was unable to communicate clearly with first responders because of the severity of those symptoms.

Designated professionals in the counties also followed similar standards when applying the grave disability criterion. Shasta’s guidance related to this criterion is more detailed than Los Angeles’s and San Francisco’s in that it provides examples of situations that would qualify a person as gravely disabled. However, designated professionals in all three counties applied consistent standards in the cases we reviewed. Specifically, in nine of the 60 short‑term hold decisions we reviewed, the sole reason for the holds was that the individuals were gravely disabled. In these cases, the individuals were generally unable to articulate clear plans for their own care and were sometimes experiencing delusions. Our review of these cases, as well as a selection of 60 instances in which first responders decided not to place individuals on holds, indicates that the responders and designated professionals generally did not use overly narrow definitions of grave disability that left people who appeared unable to provide for their own basic needs without crisis care.

Our findings were similar when we reviewed 60 conservatorship cases, all of which involved individuals the courts had determined were gravely disabled. The records we reviewed included the county public guardians’ investigation reports and supporting court documentation for the conservatorship appointment and termination. In the cases we reviewed, the judicial review process mandated by the LPS Act—in which a person cannot be placed on conservatorship without a hearing before a court to consider the necessity of the conservatorship—explicitly considered the individuals’ rights by requiring proof of grave disability beyond a reasonable doubt while also considering the individuals’ need for treatment. In these cases, public guardians and superior courts did not limit the use of conservatorship by, for example, requiring homelessness as proof of inability to provide shelter. Rather, we saw reasonable variations among the factors that demonstrated that individuals could not adequately provide for their own basic needs. In addition, the documentation demonstrated that each county’s public guardian and superior court considered the level of insight these individuals had into their illnesses and their voluntary treatment history when determining whether conservatorships were necessary.

The stated intent of the Legislature in enacting the LPS Act was to provide for prompt evaluation and treatment, to protect the public, and to safeguard personal rights through consistent standards. Our review, which was limited to three counties and a selection of case files, leads us to conclude that the LPS Act’s criteria are defined well enough to serve those purposes. The LPS Act was not intended to provide involuntary treatment to those who are mentally ill but are not a danger to themselves or others or who are able to provide for their own basic needs. It was also not intended to provide involuntary treatment for extended periods of time when individuals would otherwise be able to independently care for their own needs. Therefore, the criteria appropriately do not encompass people experiencing less acute symptoms of mental illness and are not meant to apply to individuals simply because they choose not to seek voluntary treatment. Expanding or revising the LPS Act’s criteria for involuntary holds to include standards that are overly broad—such as the ability to live safely in one’s community—could widen the use of involuntary holds and pose significant concerns about infringement on individual rights. We found no evidence to justify such a change.

However, the fact that the LPS Act’s criteria for involuntary holds are sufficient for their purpose does not mean that the State is adequately caring for Californians with mental illnesses. In our review of cases that did not result in short‑term holds, we found numerous instances in which individuals with mental illnesses were experiencing difficult circumstances that indicated their need for some level of mental health services although designated professionals determined that the symptoms of their mental illnesses did not rise to the level of the LPS Act’s criteria for involuntary treatment. Further, involuntary holds are but one component of a more comprehensive mental health care system, and individuals who receive crisis intervention are not always being effectively served by that broader system. As we discuss in more detail later in this chapter, Los Angeles and San Francisco have high percentages of people who exited holds but were not enrolled in supportive services. Additionally, in Chapter 2, we explain that the State could more effectively serve individuals who cycle in and out of crisis care treatment if it expanded treatment options. Despite the current adequacy of the LPS Act criteria, significant change is necessary to ensure that the State is providing adequate mental health treatment to those who need it.

The State and Local Governments Do Not Have Sufficient Treatment Capacity to Assist All Individuals Needing Services Under the LPS Act

State and local facilities lack adequate capacity to treat all individuals who require care under the LPS Act, and in some cases, this lack of capacity has jeopardized the well‑being and safety of both individuals receiving treatment and facility staff. Individuals receiving treatment under the LPS Act can require treatment space for both short‑term and long‑term periods of time. However, state hospital facilities have limited space to admit and treat individuals whom counties refer under the LPS Act because of rapidly increasing referrals and a competing obligation to treat individuals involved with the criminal justice system. Because of this shortage of beds, individuals treated under the LPS Act who were waiting for treatment in a state hospital facility as of August 2019 had waited on average one year for admission to a state hospital facility, and some had waited multiple years. While they waited for treatment space at a state hospital facility, some individuals received care that was not adequate for their level of need. Further, at the local level, some counties have indicated that they do not have the adequate number or types of beds—such as for longer‑term, around‑the‑clock treatment—to treat individuals near their communities. However, of the counties we reviewed, only Los Angeles was able to more thoroughly demonstrate its current and future need for treatment space relative to its current capacity across different levels of care.

A Shortage of State Hospital Beds Has Compromised Treatment for Some Patients

When determining the correct placement for individuals receiving treatment through a conservatorship the counties generally considered similar factors. Documentation from Los Angeles and San Francisco and statements made to us by the chief deputy public guardian in Shasta indicated that the counties consider factors such as whether an individual’s history includes episodes of violent behavior or leaving treatment facilities without authorization, which may necessitate a higher level of care. The counties also had similar policies for transferring people from more restrictive to less restrictive facilities when their treatment needs decreased, and we found that the counties considered individuals’ symptoms and behaviors to identify the least restrictive setting that was appropriate to their needs. Generally, the counties had stepped individuals down to lower levels of care by the time their conservatorships terminated. As a result of their assessments for proper placement, counties may conclude that the most appropriate level of care for some individuals is in a state hospital facility.

Counties may base this determination on limited available private facility space and the fact that private treatment facilities can refuse to accept individuals who have severe symptoms, are violent, or have medical complications unrelated to their mental illnesses. According to the director of the Department of State Hospitals (State Hospitals), the providers in state hospital facilities generally have the advanced expertise necessary to treat individuals with serious mental illnesses who are the most difficult to serve. However, as of August 2019, patients on State Hospitals’ waitlist who were being treated through the LPS Act had been waiting an average of about one year for a bed, as Figure 6 shows. In fact, two of these individuals had been waiting nearly three years to be admitted to a state hospital facility. Information that State Hospitals shared with us indicated that as of January 2020 there were 138 individuals being treated under the LPS Act in state hospital facilities that State Hospitals recommended be discharged, but who had not yet been discharged to lower levels of care. This factor certainly influences how long individuals receiving care under the LPS Act wait to be admitted to a state hospital facility. However, as we explain later in this section, we determined the primary factor that narrows access to state hospitals facilities is State Hospitals' mandate to care for another significantly sized population of individuals.

Figure 6
A Shortage of State Hospital Facility Beds Has Delayed Critical Treatment for Individuals Placed on LPS Act Conservatorships

Individuals waiting for admission to a state hospital facility sometimes receive inadequate levels of care while they wait. As we explain in more detail in the next section, the only county we reviewed that retained historical waitlist and referral information related to LPS placements was Los Angeles. Our review of that county’s records found that while individuals were waiting for placement at a state hospital facility, they most often received their care in general acute hospitals or similar treatment facilities. However, Los Angeles’s records demonstrate that in several instances, these lower levels of care created risk for both the waitlisted individuals and the staff of the facilities. For example, in one case, an individual exhibiting repeated self‑injurious behavior was referred to a state hospital facility. While waiting for an available state hospital bed, they were taken off the state hospital facility referral list and admitted to a private facility. During their stay at the private facility, they engaged in additional self‑injurious behavior, requiring several emergency room visits at a general hospital. Because of this behavior, the private facility would not readmit that individual to its care, so they remained at the general hospital. They were placed back on the state hospital’s facility’s waitlist, and the state hospital facility eventually admitted the individual three months after the second referral and five months after the initial referral. This case and others demonstrate that while individuals wait for space at a state hospital facility, they may not receive care that fully protects them or others around them.

State Hospitals has different populations who compete for space in its facilities, and legal mandates require it to treat individuals involved with the criminal justice system; however, these mandates do not exist for individuals receiving treatment through the LPS Act. In particular, state law permits individuals charged with certain felonies—whom courts have found incompetent to stand trial (IST defendants)—to be placed in a state hospital or other secured facility in order to be restored to competency. A significant body of case law has established that the due process rights of IST defendants include the right to timely and adequate treatment. State law generally requires IST defendants charged with certain felonies to be transferred to state hospital facilities for placement and allows for treatment at other facility types only under specified circumstances. According to recent case law, the State has up to 60 days from the date of commitment to a state facility by a court to admit an IST defendant. In addition to the legal obligation to preserve due process by quickly admitting these defendants, federal courts have more broadly required the State of California to address prison overcrowding and inadequate in‑prison medical and mental health care. Further, state law requires State Hospitals to provide inpatient services to certain paroled offenders who pose a danger to others because of their mental illnesses unless the department certifies that there is reasonable cause to believe that the individual can be treated effectively in an outpatient setting. Except under limited circumstances, the LPS Act does not similarly and explicitly require other individuals to be placed in state hospital facilities.

Because State Hospitals is legally required to treat individuals involved with the criminal justice system, state hospital facilities have comparatively few beds to treat individuals placed on a conservatorship through the LPS Act, even though those facilities may provide the most appropriate level of care. State Hospitals’ data show that the total capacity in its facilities as of November 2019 was just under 6,300 beds and that 84 percent of these beds were occupied by individuals who were involved with the criminal justice system. At that time, individuals receiving treatment through the LPS Act occupied fewer than 720 beds—about 11 percent of bed capacity. According to its chief of fiscal and program research, State Hospitals typically maintains a bed occupancy rate of 95 to 97 percent, with vacancies occurring most often in units that are not available to the general patient population because they provide specialized services or medical treatment. She explained that vacancies in beds also occur because of the overall flow of patients as admissions, discharges, and temporary discharges take place.

As of February 2019, nearly 650 individuals statewide who had been found incompetent to stand trial were waiting to receive treatment at state hospital facilities to improve their mental condition. At the same time, 200 people receiving care through the LPS Act were also waiting for state hospital facility beds. While the average monthly population of individuals being treated under the LPS Act in state hospital facilities increased by about 28 percent from 2014 to 2018, the average number of individuals waiting for placement in a state hospital facility who were receiving treatment through the LPS Act increased by more than 500 percent, from an average of 31 individuals in fiscal year 2014–15 to an average of 197 in fiscal year 2018–19. Although State Hospitals has allocated some additional beds for individuals receiving their care through the LPS Act, it projects that this waitlist will continue to grow. The fact that courts or counties have determined that these individuals require care at state hospital facilities indicates that these facilities represent one of the few, if not only, opportunities for these individuals to obtain the treatment they need to improve their mental health. When the State does not provide timely access to treatment at state hospital facilities to those who need it, it fails to adequately care for these vulnerable individuals.

Despite the upward trend in the need for space at its facilities, State Hospitals has not acted to significantly increase its capacity to treat individuals on conservatorships. The director of State Hospitals stated that it has largely focused its requests for additional funding on the criminal justice population that it has a mandate to serve. In response to our request for the cost to reduce and stabilize its waitlist for individuals receiving treatment under the LPS Act, State Hospitals estimated that it needs an additional 330 beds and that the cost for staffing to support these new beds would be about $85 million annually, in addition to one‑time construction costs between $250 million and $425 million. However, the department cautioned that these numbers are preliminary and rough order‑of‑magnitude estimates and are not the result of a formal operational budget estimate or a formal construction estimate process performed by the Department of General Services.

Some Counties May Not Have Enough Beds to Treat All Patients Who Require Care

Beyond state hospital facility capacity, Los Angeles and Shasta reported that they have a shortage of local treatment beds for a variety of levels of care, while San Francisco could not state whether it has a need for additional local treatment beds, as we discuss later in the section. However, the three counties have not uniformly tracked the number of individuals waiting for placement. The Department of Health Care Services (Health Care Services) and State Hospitals do not require counties to report this information, nor did the three counties elect to send it of their own accord. As a result, although Los Angeles was able to demonstrate how many treatment beds it needs in comparison to its current capacity, San Francisco and Shasta did not have similar information.

Los Angeles has a robust assessment of its treatment bed capacity and needs. Its Department of Mental Health issued an extensive report to the county board of supervisors in October 2019 that assessed the shortage of mental health treatment beds in the county. The report included a discussion of the county’s current and future needs for treatment beds and services, an assessment of all contracted beds, and plans for the creation of new beds. Among a wide range of recommendations for additional treatment resources and beds, the report concluded that the county needed more than 1,500 additional beds to serve individuals who need longer‑term, around‑the‑clock treatment. Los Angeles also maintains historical information on its bed waitlists and referrals to certain types of facilities, and it has publicly stated that it is developing an application (app) for tracking the availability of mental health treatment beds throughout the county, including urgent care and crisis beds.

In contrast, San Francisco and Shasta have not assessed their needs to the same extent. Shasta does not maintain historical waitlist information, and San Francisco has only limited historical waitlist data. San Francisco’s deputy director of care coordination in its Department of Public Health stated that since February 2019, the department has tracked wait times until admission for individuals once they have been accepted to long‑term care facilities, but it does not track wait‑time data for individuals before acceptance. According to the deputy director, the department will begin tracking all referrals in July 2020. Although San Francisco has been increasing the number of its short‑term psychiatric stabilization beds, a program coordinator for mental health reform in its department of public health stated that it has not completed a needs assessment similar to the one Los Angeles performed; however, the policy and planning director in that department stated that the county is working on a project to use modeling to simulate bed need, the results of which should be available in the summer of 2020. San Francisco also recently launched an app on a public dashboard to track bed resources for substance use disorder in the county, and according to the mental health reform program coordinator, the county plans to expand this public dashboard to mental health treatment beds soon.

Given Shasta’s comparatively smaller size, it is able to know at a point in time each month how many people are waiting for treatment beds because county staff convene monthly to manage placement. Consequently, the county can roughly estimate its need for a limited number of additional beds. However, it does not have a comprehensive assessment based on its needs over a longer period.

Recent actions taken by the California Mental Health Services Authority (CalMHSA)—a joint powers authority composed predominantly of counties—also indicate that counties beyond those we reviewed require additional treatment bed capacity. In response to the shortage of available state hospital facility beds, CalMHSA has researched available sites for a new alternative to state hospital facilities. It has identified potential sites in two counties that could offer member counties additional beds for their residents being treated through the LPS Act. CalMHSA surveyed its member counties in 2018 to determine the total number and types of beds that they are interested in having in a new facility, which collectively ranged between nearly 80 to slightly more than 330 beds depending on the location.

Further complicating an assessment of the available treatment bed resources, neither Health Care Services nor State Hospitals tracks wait times or the need throughout the State for treatment facilities based on county‑specific conditions or the demand for different levels of care. Public guardians and county mental health departments may struggle to place individuals at treatment facilities in their own counties because their facilities lack capacity or the ability or willingness to provide the needed services. In these contexts, counties sometimes place individuals at treatment facilities in other counties. For example, we noted that Shasta sometimes sends individuals for whom it is the conservator to Riverside County for placement. In Chapter 3, we present a potential solution for tracking statewide information about the resources counties use to provide treatment and the related outcomes. The State could thus better position itself to know when counties have treatment resource challenges through data collection efforts such as those we recommend in Chapter 3.

Los Angeles’s Department of Mental Health and Superior Court Have Not Adequately Served Individuals on Conservatorship

Los Angeles’s Department of Mental Health and superior court have engaged in practices that do not ensure that individuals subject to conservatorship receive adequate privacy protections and appropriate treatment. The Los Angeles Superior Court (Los Angeles Court) has held conservatorship proceedings in public settings instead of safeguarding the confidentiality of individuals’ private health information, as the superior courts in San Francisco and Shasta have. Further, many conservatorships in Los Angeles ended when doctors failed to provide essential testimony in court proceedings. In these cases, the court could no longer authorize involuntary treatment, even though some individuals may have still needed it.

Los Angeles Court Has Not Acted to Protect the Privacy of Individuals in Conservatorship Proceedings

The Los Angeles Court has not provided the same level of privacy protection to individuals in conservatorship proceedings as San Francisco Superior Court (San Francisco Court) and Shasta Superior Court (Shasta Court). Case law holds that conservatorship proceedings are presumptively nonpublic, in part to protect individuals’ privacy interests. Thus, unless a party to the hearing demands a public hearing, the law effectively requires that conservatorship court proceedings, during which confidential patient records may be discussed, be closed to the public. That mental illness can have a stigmatizing effect on those who are ill is widely acknowledged, and courts have recognized that conservatorship proceedings can pose a threat to the personal reputations of the people involved. The San Francisco Court and Shasta Court have mitigated this threat by holding conservatorship proceedings in closed courtrooms unless the individuals who are the subjects of the hearings grant access to outside parties. As a result, members of the public may not hear individuals’ private information at conservatorship proceedings in these two counties, unless the individuals choose to have public hearings.

Contradicting legal precedent, the Los Angeles Court conducts conservatorship proceedings that are open to the public unless individuals specifically request closed hearings. Further, the court does not fully ensure that individuals are aware that they can make such a request. According to a judge at the Los Angeles Court, the court’s practice is to presume that proceedings are open unless closed proceedings are requested. During these open proceedings, individuals in Los Angeles testify about their mental health and hear testimony about their medical records in the presence of many others, including medical providers, other individuals in conservatorship proceedings, and community members. The information discussed routinely includes individuals’ full names, specific mental health diagnoses, medications, and symptoms. In effect, the practice of holding public conservatorship proceedings unless an individual requests a closed hearing contradicts legal precedent and potentially deprives individuals of their right to privacy during these proceedings.

The Los Angeles Court indicated to us that it believes conservatorship proceedings are not presumptively nonpublic and stated that its procedures are intended to maximize the number of cases it can handle in a fair and expeditious manner. We believe handling cases in a way that maximizes privacy and minimizes potential stigma is of overriding importance and a clear requirement under the law. The Legislature’s express intent is to protect the dignity and privacy of the people being treated involuntarily under the LPS Act. Allowing public access to the confidential and sensitive information presented at court proceedings clearly contradicts that intent, creating a situation in which the very process meant to protect individuals’ rights simultaneously threatens to erode them.

Further, the practice we observed in Los Angeles could be occurring elsewhere in the State. Data published by the Judicial Council of California (Judicial Council) show that the Los Angeles Court receives far more mental health‑related court filings than any other court in the State. To the extent that other courts, because of their size or staffing, are facing workload pressures similar to those that the Los Angeles Court indicated it faces, they may be engaging in similar practices. In light of that and of the Los Angeles Court’s incorrect interpretation of the law, we believe the Legislature should take steps to provide more explicit direction to courts. Although we believe case law, in conjunction with state law, makes it clear that conservatorship proceedings are to be held in closed courtrooms unless an individual demands a public hearing, the Los Angeles Court’s incorrect interpretation and practices demonstrate that an explicit statutory prohibition would likely benefit the individuals whose privacy is at risk in these proceedings.

Los Angeles’s Poor Coordination of the Conservatorship Process Has Disrupted Care

As we explain in the Introduction, a court can place an individual on a conservatorship if they are unable to meet their basic personal needs for food, clothing, or shelter because of a mental illness. Unless renewed, these conservatorships can be up to a year long and are ordered by a court following either a hearing or, if requested by the individual in question, a trial. An essential component of a conservatorship hearing or trial is the medical evidence that courts consider to determine whether the individual is unable to meet their basic personal needs because of a mental illness. A county seeking to impose or to renew a conservatorship must prove beyond a reasonable doubt that the person meets the grave disability criteria, which, at trial, is typically done by having a doctor testify and answer questions about the individual. However, in Los Angeles, 10 of the 20 conservatorship cases we reviewed were terminated when the county was seeking to renew the conservatorships, and six of those 10 conservatorships ended after doctors failed to testify. The presence of a doctor at the trial—as opposed to the doctor submitting written testimony to the court—is important because courts have found that one purpose of a trial is to provide the person who is the subject of a conservatorship proceeding the opportunity to cross‑examine the doctor. In the six cases above, the court could not proceed because the doctors failed to testify; and as a result, the associated conservatorships terminated without renewal.

The effect of prematurely terminated conservatorships can be devastating. One of these six cases involved an individual whose health had improved during the conservatorship period. However, they had limited insight into their illness and refused treatment after their conservatorship terminated. County documentation related to the case indicated that without treatment, the individual grew violent toward others and neglectful of their own well‑being. In this case, the disruption to the individual’s care caused harm and also did not facilitate their successful return to the community, as several months later the public guardian petitioned for another conservatorship, which the court granted.

Although we observed six cases in which a doctor’s failure to testify at the trial meant that a conservatorship terminated, this breakdown in the conservatorship process is a widespread problem in Los Angeles. According to a February 2019 report from the director of Los Angeles’s Department of Mental Health to the county’s board of supervisors, nearly 20 percent—106 out of 618—of the conservatorships that ended in fiscal year 2017–18 did so because doctors did not testify in court. The deputy director of the Los Angeles Office of the Public Guardian (deputy director public guardian) explained that doctors are sometimes available only on certain days and that the county attempts to schedule court proceedings for those days; for one case we reviewed, she indicated that the court scheduled a proceeding for a date on which the doctor was not available. She further noted that testifying in court is not a reimbursable medical service for private doctors, which may also factor into their absence. However, she also acknowledged that the county has not addressed this problem in a systemic manner. Instead, the county has implemented solutions case by case and only by, for example, attempting to resolve scheduling conflicts or, as a last resort, issuing subpoenas for doctors to testify.

A more comprehensive solution is available that the county has not used. Both the director of the Department of Mental Health and the deputy director public guardian told us that doctors employed by the county could testify at conservatorship trials as expert witnesses. Having them do so would provide the county with a reliable resource to provide essential medical testimony in those cases when an individual’s treating doctor does not appear in court. According to the deputy director public guardian, the county has not implemented this solution in part because of concerns that the doctor providing care to the individual during conservatorship can provide more thorough testimony than an expert witness can present and that this fact may affect the effectiveness of the testimony. These concerns notwithstanding, Los Angeles’ current practice is resulting in terminated conservatorships that may result in harm to individuals who still need care. In light of that, Los Angeles should do all that it can to attempt to continue conservatorships that it believes are benefiting individuals.

Los Angeles and San Francisco Have High Percentages of Individuals Who Were Not Enrolled in Ongoing Care After Leaving Involuntary Holds

Los Angeles’s and San Francisco’s lack of coordination with medical facilities has often left individuals who are released from involuntary holds without connections to county mental health treatment services. These connections are important because counties are responsible for implementing significant aspects of the LPS Act, and they also have critical responsibilities for delivering services as part of the State’s public mental health care system. Thus, they are uniquely placed to ensure that individuals released from LPS Act holds are connected to the treatment they need. Treatment following a hold can range from appointments for wellness visits and therapy services to more intensive levels of care, such as full‑service partnerships or assisted outpatient treatment programs. In particular, full‑service partnerships and assisted outpatient treatment involve a personal case manager for each client who coordinates care across a variety of services, including psychiatric services and housing assistance. These programs are the most comprehensive and intensive methods available to all counties for providing community‑based care to individuals with serious mental illnesses. According to guidelines published by the Center for Mental Health Services within the U.S. Department of Health and Human Services, meaningfully improving an individual’s prospects for success after crisis intervention requires good discharge planning. The guidelines further note that crisis intervention is only one part of a larger system of care. The guidelines state that taking meaningful measures to reduce the likelihood of future emergencies is a key principle of providing crisis care. Nonetheless, the two counties have high percentages of individuals who were not enrolled in intensive services after leaving involuntary holds.

To assess the counties’ success in ensuring ongoing county services, we identified all the people who had been placed on five or more short‑term holds from fiscal years 2015–16 through 2017–18 and reviewed whether the counties had enrolled those individuals in full‑service partnerships or assisted outpatient treatment in fiscal year 2018–19. Los Angeles had nearly 7,400 individuals with five or more short‑term holds over that time, and only 9 percent of those individuals were enrolled in full‑service partnerships or assisted outpatient treatment. The percentage of people enrolled in these intensive treatment services in San Francisco was even lower. ⁵ We do not present the number of individuals held five or more times in Shasta during this period to protect the confidentiality of these few individuals. Figure 7 summarizes these results. Because individuals with such a high number of short‑term holds in three years represent a very high‑need population, it is important that a much higher percentage of these individuals be connected to counties’ most intensive treatment programs. In Los Angeles, about one‑third of the individuals from our case file review who had a high number of 72‑hour holds in their lifetimes were not enrolled in these intensive outpatient service programs at any point from fiscal year 2016–17 through 2018–19. These included one individual who had been held more than 10 times and had been refusing medication and threatening to kill others and themselves.

Figure 7
A Small Proportion of Individuals Who Were Held Multiple Times for Involuntary Treatment Were Then Enrolled in Intensive Outpatient Services in Los Angeles and San Francisco

Additionally, we identified individuals from our case file review who had been placed on multiple short‑term holds and then determined whether the counties had followed up with them in the two weeks following the hold to connect them to any type of service. In Shasta, only one person from our selection was a county resident and had been placed on multiple holds, and the county had connected that individual to supportive services. However, San Francisco did not provide supportive services to four of the six individuals we reviewed who had been held multiple times. Two returned to incarceration at the end of their holds. Similarly, Los Angeles did not provide services to six of the nine individuals we reviewed who had been held multiple times.

In Los Angeles and San Francisco, county staff presented several reasons why they might not have provided aftercare services to individuals who had repeatedly been involuntarily held for treatment. Specifically, these counties indicated that some individuals choose not to participate in the voluntary services that they offer. Both counties also stated that they might have provided these individuals with connections to other services beyond full‑service partnerships and assisted outpatient treatment. Although this may be true, these two service types are comprehensive and intensive treatment programs. Therefore, we expected a greater percentage of high‑need individuals to be connected to them. Los Angeles also noted that it has no mandate to serve individuals who are privately insured and can receive their mental health care through a private provider. However, among the randomly selected cases we reviewed—for which documentation was available in the involuntary hold records—we found that a high percentage of individuals were enrolled in Medi‑Cal or had received county mental health services. Further, although our selection of cases suggests that the percentage of individuals with private insurance is low, the presence of private health care coverage and other post‑hold treatment options does not change the overall conclusion that Los Angeles and San Francisco have significant numbers of individuals who are not enrolled in intensive outpatient treatment despite being involuntarily held many times. For example, if half of the 7,400 individuals we identified as being held five or more times in a three‑year span were privately insured, Los Angeles’s enrollment rate in intensive mental health services among these individuals would still be only 17 percent. Finally, Los Angeles also offered other explanations for why its percentage of individuals enrolled in full service partnerships or assisted outpatient treatment was low. We assessed each of these reasons and found none of them adequately explained why such a high‑need population would be so infrequently enrolled in intensive outpatient services.

Both Los Angeles and San Francisco are aware of the gaps in their ability to connect individuals leaving holds with aftercare. Table 1 summarizes these gaps. Los Angeles’s staff acknowledged the weaknesses in the county’s system for coordinating continued care with medical facilities, stating that in some cases the county is only aware of individuals being discharged from short‑term holds if the treatment facilities holding them decide to notify it. San Francisco stated that it is aware of individuals who are placed on holds only at Zuckerberg San Francisco General Hospital and Trauma Center (Zuckerberg), one of its seven designated treatment facilities in the county. However, from January 2014 through October 2019, about 56 percent of individuals leaving short‑term holds in San Francisco were leaving treatment facilities other than Zuckerberg. Further, the county explained that it does not receive automatic alerts about short‑term holds even at this facility; instead, to know whether someone has been on a hold, the county must actively search for that individual’s name—which severely limits the usefulness of the data for the purpose of connecting people to supportive services. The lack of knowledge of these two counties regarding short‑term holds makes it difficult—if not impossible—for them to connect individuals to ongoing treatment.

Table 1
Los Angeles and San Francisco Have Not Adequately Coordinated With Treatment Facilities to Ensure That Individuals Receive Ongoing Care

	The county mental health agency…
	…HAS A PROCESS TO ENSURE THAT IT IS AWARE OF ALL HOLDS.	…WORKS WITH ALL TREATMENT FACILITIES TO COORDINATE ONGOING CARE.	…FOLLOWS UP TO ENSURE THAT INDIVIDUALS WITH HIGH LEVELS OF NEED RECEIVE THE SERVICES THEY REQUIRE.
Los Angeles	NO	NO	NO
San Francisco	NO	NO	NO

Los Angeles has connections it could expand with designated facilities to ensure that it is aware of individuals leaving holds so it can transition those individuals to the appropriate continuing treatment. Its Department of Mental Health provides liaisons to the county hospitals it operates, and these liaisons attempt to link individuals leaving holds to appropriate post‑hold care. However, Los Angeles operates only three of the 49 designated facilities in the county. The interim director of the Department of Mental Health’s intensive care division informed us that in January 2020, Los Angeles added liaisons to two additional hospitals as part of a pilot program. In addition, according to the director of that department, the county plans to make improvements to its collection and analysis of data related to short‑term holds, but the exact data that it needs and how it will obtain such data is still under discussion. If it improves its awareness of short‑term involuntary holds, Los Angeles could then better coordinate care for individuals leaving those holds.

San Francisco has also taken some steps to connect individuals to the ongoing care they need. It operates a number of lower‑level treatment and residential facilities for individuals receiving care after a short‑term LPS Act hold, and according to a social worker with San Francisco’s Department of Public Health, the county is aware of the need for follow‑up care when a designated treatment facility discharges someone to one of these facilities. In addition, the county operates a number of small programs to which it attempts to connect individuals with complex needs, which it attested frequently includes individuals who have recently been on short‑term holds. Although it is encouraging that Los Angeles and San Francisco have made some efforts to connect individuals leaving short‑term holds to additional mental health services, there is more they must do.

The challenges that Los Angeles and San Francisco face in attempting to connect individuals to services following short‑term holds are made worse by the lack of available data about those individuals’ previous short‑term holds. Counties are largely unable to access information about when individuals are placed on short‑term holds and when they are discharged. As we describe earlier, treatment facilities in the counties we reviewed do not always share information about short‑term holds with the counties’ mental health departments. However, state law requires these facilities to report certain short‑term holds to the California Department of Justice (Justice) so that Justice can use this information to determine whether individuals are prohibited from owning firearms. ⁶ Under state law, individuals who are the subject of short‑term holds are prohibited from owning or possessing a firearm for a period of five years from the date of the hold, or under certain conditions, for the remainder of their lives. Although Justice has both express permission to and a valid business reason for possessing information about holds, state law deems that this information is confidential unless it is relevant to a court proceeding regarding an individual’s right to own or possess a firearm, and Justice indicated that it has not entered into any interagency agreements with other state agencies or county mental health departments to share these data. In other words, the sole possessor of the most comprehensive data about short‑term holds is an agency without direct responsibility for overseeing or providing for mental health care.

Because counties cannot access statewide data about short‑term holds, they lack information that might enable them to provide adequate ongoing care to individuals with mental illnesses. Even if counties were to develop local agreements with their designated facilities to share information, that would still leave counties without information about individuals’ holds in other counties. This information could be essential to knowing what types of services an individual requires. For example, staff at all three counties we reviewed stated that they may make different decisions about the level of follow‑up care to support an individual who they believe has been only held once versus someone they know has been held three or four times in the recent past.

The State would experience at least two benefits if the Legislature allowed Justice to share its repository of information about short‑term holds with Health Care Services. First, the agency that is primarily responsible for administering the LPS Act would have access to significant and important data about the use of the act. State law charges Health Care Services with collecting and publishing quantitative information concerning LPS Act holds. However, state law prohibits Health Care Services from having any information that would reveal individuals’ names, and the information it does possess is limited and incomplete. The problems with its data are substantive enough that when we were considering how to answer straightforward questions for this audit—such as how many times individuals were placed on short‑term holds—we determined that we had to base our conclusions on data we obtained from Justice rather than Health Care Services. If the Legislature granted Health Care Services permission to access the treatment facility reports that Justice maintains, it would likely enhance its ability to oversee the implementation of the LPS Act.

Second, if Health Care Services had more complete data, it would be able to share information about short‑term holds with counties. As we describe earlier, counties cannot easily access information about an individual’s previous short‑term holds, even though this information may be valuable to them in making decisions about the type of services with which to connect people. If Health Care Services had access to comprehensive data about short‑term holds and express permission in state law to share those data, it could make information about previous holds available to counties when individuals are held at treatment facilities in their jurisdictions. To protect individuals’ privacy, Health Care Services should ensure that counties can only access information about short‑term holds for residents and allow access to out‑of‑county residents’ information only when they are placed on holds and only for the duration of that treatment. Further, this change would allow Justice to continue to maintain the data it needs to determine whether individuals can legally own firearms.

Finally, the Legislature would need to take one additional action to ensure that the information that Health Care Services shares with counties is as complete as possible. Treatment facilities are not currently required to report to Justice short‑term holds that are the result of grave disability. Therefore, any holds resulting from this criterion would not be among the information that Justice would share with Health Care Services. To address this gap in information, the Legislature could require treatment facilities to report all short‑term holds resulting from grave disability directly to Health Care Services.

Recommendations

Legislature

To ensure that counties are able to access important data about individuals whom they place on involuntary holds under the LPS Act, the Legislature should amend state law to do the following:

• Require Justice to make the information that mental health facilities report to it about involuntary holds available to Health Care Services on an ongoing basis.
  
• Require treatment facilities to report to Health Care Services all short‑term holds that result from the grave disability criterion.
  
• Direct Health Care Services to obtain daily the mental health facility information from Justice and make that information, as well as the information that facilities report directly to it, available to county mental health departments for county residents, and for a limited time for nonresidents on an involuntary hold within the county.
  

To ensure that it is informed about the costs of providing adequate care to individuals treated through the LPS Act, the Legislature should require State Hospitals to report by no later than April 2021 about the cost of expanding its facilities’ capacities to reduce and stabilize the LPS waitlist. The report should include a range of options including, but not limited to, reducing the LPS waitlist to limit wait times to within 60 days.

To protect the privacy of individuals who are the subject of conservatorship proceedings, the Legislature should amend state law to explicitly prohibit these proceedings from being open to the public unless the subjects of the proceedings direct otherwise.

San Francisco and Shasta

To evaluate and address shortages in the capacity of their treatment facilities, San Francisco and Shasta should, by August 2021, conduct assessments that determine the number and type of treatment beds that they need to provide adequate care for individuals who require involuntary treatment. Once the counties complete the assessments, they should adopt plans to develop the needed capacity.

Los Angeles and San Francisco

To ensure that they connect patients who have been placed on multiple short‑term holds to appropriate ongoing treatment, Los Angeles and San Francisco should, by no later than August 2021, adopt systematic approaches to identifying such individuals, obtaining available mental health history information about these individuals, and connecting these individuals to services that support their ongoing mental health.

Los Angeles

To ensure that conservatorships do not terminate because of the absence of testimony from doctors, Los Angeles should immediately implement a comprehensive solution to this problem, such as using its own staff as expert witnesses when individuals’ treating physicians are unable to testify. In addition, by no later than August 2021, it should develop a revised approach to scheduling conservatorship hearings and trials so that it significantly reduces the rate at which doctors’ failures to testify result in terminated conservatorships.

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Chapter 2

STATE LAW LIMITS COUNTIES’ ABILITY TO EFFECTIVELY TREAT INDIVIDUALS WHO REQUIRE INVOLUNTARY OUTPATIENT CARE

Chapter Summary

Individuals in Los Angeles, San Francisco, and Shasta were repeatedly placed on involuntary holds and conservatorships by designated professionals, such as medical facility staff, and by courts. Although those with mental illness who cycle through involuntary treatment receive frequent care, the intended outcome of that care is to prevent immediate harm rather than to promote long‑term recovery from the symptoms of their mental illnesses. This type of recovery generally requires ongoing outpatient treatment rather than crisis care. Many of the individuals who were placed on repeated conservatorships struggled to maintain their stability after leaving the treatment facilities, in large part because they frequently failed to take medication that was essential to managing their symptoms. State law already includes a less restrictive involuntary treatment option—assisted outpatient treatment—that could support these individuals in their efforts to maintain stability in their communities so that they do not cycle back to restrictive involuntary holds. By amending requirements for assisted outpatient treatment, the Legislature could improve counties’ ability to effectively serve individuals who require this level of care.

Many Individuals Are Subject to Repeated Short‑Term Holds and Conservatorships

The LPS Act’s short‑term holds and conservatorships do not sufficiently provide the ongoing care that some individuals need to remain healthy. Our review found that many individuals have repeatedly cycled in and out of short‑term involuntary holds or in and out of conservatorships. These individuals likely also need intensive care while they are in their communities rather than involuntary treatment under the LPS Act alone. However, the nature of their mental illnesses can make ensuring that they receive voluntary treatment challenging.

The Counties Held Thousands of Individuals More Than Once, Some of Whom Cycled Through Many Involuntary Holds

In alignment with the Legislature’s intent to end the inappropriate, indefinite, and involuntary commitment of persons with mental illness, state law requires individuals on 72‑hour holds to be released before the 72‑hour period has elapsed if designated professionals determine they no longer require evaluation or treatment through an involuntary hold. However, there is a meaningful difference between being stable enough to be released from an involuntary hold and being able to maintain self‑care and sustained mental health. Therefore, people who are released from short‑term holds are still at risk for experiencing difficult and disruptive symptoms of their mental illnesses and potentially requiring additional involuntary holds to receive care.

Many people in each of the three counties we reviewed were placed on involuntary holds multiple times, and some were placed on a high number of holds, indicating that these individuals repeatedly received crisis care because of symptoms related to mental illness. As Figure 8 shows, Los Angeles had the highest percentage of repeated 72‑hour holds. Los Angeles also had the highest number of individuals placed on multiple short‑term holds; in fact, from fiscal years 2014–15 through 2018–19, Los Angeles’s designated professionals placed more than 500 people on 72‑hour holds who had each already been subject to at least 50 prior holds. These numbers are troubling because they indicate that these individuals consistently had difficulty managing their mental illnesses. The crisis care they received during involuntary holds, on its own, did not help them achieve long‑term recovery or stabilization.

Figure 8
Many Individuals Have Been Subject to Multiple Short‑Term Holds

Further, experiencing repeated crises can have negative effects on people. Crisis care can itself be traumatic, particularly when individuals cycle through it more than once. Each hold can include aspects of care that are likely stressful and may even seem punitive to the individual being held, including being taken into custody by law enforcement, placed in seclusion, or put in physical restraints at a treatment facility. Further, mental health research and literature suggest that psychosis in general, and repeated psychotic episodes in particular, may cause physical damage to the brain and make treatment more difficult.

Finally, crisis care is costly for treatment facilities and counties. The counties and treatment facilities we reviewed estimated that providing services during one 72‑hour hold can cost a treatment facility between about $2,800 and $8,400, depending on the type of facility. These costs largely relate to services that psychiatrists or other professionals provide during the hold. In addition, Shasta indicated that it can incur administrative costs as well.

Many Individuals Experienced Multiple Conservatorships Because Their Mental Health Deteriorated After Their Involuntary Treatment Ended

In addition to the people who cycled through short‑term holds multiple times, 18 of the 60 people whose conservatorship cases we reviewed had been placed in conservatorships more than once. About one in four people—14 of the 60 people whose conservatorships we reviewed—were placed on conservatorship again despite having successfully recovered during a previous conservatorship. Individuals who are subject to repeated conservatorships are of particular concern because each conservatorship can represent years spent in a restrictive treatment facility, away from loved ones and community life. The average total time that individuals in the 60 cases we reviewed were held in conservatorships was about three years.

The individuals in those 18 cases who were subject to multiple conservatorships typically experienced deteriorating mental health while living independently. In four cases, these individuals’ conservatorships terminated for reasons such as doctors not testifying. However, in 14 of the 18 cases, the individuals left conservatorship because they had recovered their ability to provide for basic needs. Afterward, however these people experienced symptoms of mental illnesses that compromised their ability to continue to care for themselves or exposed them to risks. For example, delusions interfered with one person’s ability to maintain housing; another person who was experiencing disorganized thoughts lost a significant amount of weight after neglecting to eat, even though they had funds for food and offers of assistance. These declines occurred despite the fact that after they left conservatorship, most of these individuals—unlike many of those discharged from short‑term involuntary holds—were connected to or offered continuing mental health services while living in their communities.

A key reason these individuals’ conditions worsened was their illnesses made it extremely difficult for them to voluntarily take the medications that were critical to their continued health. All but one of the 60 people whose conservatorships we reviewed had a history of not taking medication or limited understanding that they had mental illness. For example, people diagnosed with schizophrenia, which interferes with one’s perception of reality, often did not recognize that they had a mental illness, even though their symptoms were severe enough that they had qualified as gravely disabled and therefore were placed on conservatorships. Most of the 14 people whose cases we reviewed who were subject to repeated conservatorships had incomplete awareness of their illnesses, and some also believed medications could be poisoning them or causing unusual behavior. Figure 9 illustrates why certain people cycled through multiple conservatorship periods. We found that they frequently recovered during conservatorship, then stopped taking medication after they returned to their communities, and, as a result, eventually were placed on conservatorship again.

Figure 9
Many People Cycled Back to Conservatorships After They Stopped Taking Their Medications

Under the LPS Act, and in keeping with its intent, a conservatorship must end when the individual is no longer unable to provide for their basic needs because of their mental illness. The case files we reviewed documented the damage that symptoms had inflicted on people’s lives before their conservatorships: delusions interfered with their ability to work, paranoia strained their relationships with family, and disorganized thinking led to behaviors for which they were arrested. These symptoms became manageable for many individuals during conservatorship, when courts could grant the conservators the authority to administer the medication that was essential to recovery. In fact, two‑thirds of the 60 conservatorships we reviewed ended when public guardians or courts found that the individuals demonstrated they were no longer gravely disabled by their mental health conditions; in other words, their treatment had achieved the desired results. ⁷ We detail the reasons for the terminations of the 60 conservatorship cases we reviewed in Table C.6 of Appendix C. Nonetheless, many individuals who were subject to multiple conservatorships stopped taking the medication after their conservatorships terminated and, as a result, some experienced effects such as homelessness or incarceration that further degraded their quality of life. These individuals’ experiences suggest the need for the State to do more to ensure that counties can meet their needs, as we discuss in greater detail in the next section.

Counties Have Only Limited Ability to Use the LPS Act to Provide Involuntary Outpatient Treatment

Without continuous intensive treatment, some individuals in the cases we reviewed cycled through restrictive involuntary holds, experienced homelessness and incarceration, and refused medication. To reduce inappropriate, indefinite, and involuntary commitments, the LPS Act intends that individuals will receive services in the least restrictive setting appropriate to their needs. To meet this goal, assisted outpatient treatment—which can provide involuntary treatment in a community setting—may be necessary for some individuals with serious mental illnesses who lack insight into their conditions, and evidence shows it successfully improves outcomes. However, counties face limitations offering assisted outpatient treatment to some individuals because of restrictions in state law that make it difficult to use this treatment option as a step‑down program from conservatorship and because it does not explicitly allow medication to be ordered as a part of treatment plans. Although San Francisco has adopted an innovative approach to its conservatorship program that allows for supervising medication in a community setting, the Legislature could foster a more uniform, statewide solution by revising the LPS Act.

Fewer Than a Third of California’s Counties Have Adopted Assisted Outpatient Treatment

Since 2003 the LPS Act has allowed—but not required—counties to adopt assisted outpatient treatment programs. ⁸ The Legislature’s authorization of assisted outpatient treatment is not permanent and is set to expire on January 1, 2022. However, the Legislature has extended the authorization for this treatment option several times in the past. These programs serve individuals in need of intensive mental health treatment who do not meet the criteria for an involuntary hold or conservatorship. Under state law, assisted outpatient treatment can either be court‑ordered or voluntary. Consistent with the LPS Act’s emphasis on providing care in the least restrictive environment, assisted outpatient treatment programs must ensure that the individuals they treat are in the most independent and least restrictive housing available in the community. State law requires counties that provide assisted outpatient treatment to include services such as psychiatric and psychological services, vocational rehabilitation, substance abuse services, and assistance with housing. Further, state law requires that counties use highly trained mental health teams that assign a high number of staff to each client, and the law specifies that every person receiving assisted outpatient treatment must have a clearly designated mental health personal services coordinator. Counties that operate assisted outpatient treatment programs are required by the LPS Act to report information about their programs to Health Care Services.

The State’s approach of allowing counties to choose whether to adopt assisted outpatient treatment programs is in contrast to New York, which has required local governments to operate assisted outpatient treatment programs since 1999. Research in New York has shown this treatment approach has substantially reduced both psychiatric hospitalizations and the likelihood of arrest. Researchers have also identified that individuals with mental illnesses are significantly more likely to possess adequate supplies of their prescribed medications if they are receiving assisted outpatient treatment.

However, despite the potential benefits of assisted outpatient treatment, only 19 of California’s 58 counties have reported to Health Care Services that they have adopted these programs. Because the three counties we reviewed have all adopted either full or pilot assisted outpatient treatment programs, we assessed the reasons why three additional counties—Butte County (Butte), San Bernardino County (San Bernardino), and Santa Clara County (Santa Clara)—had not yet done so. ⁹ We selected these counties because of the range of locations, sizes, and populations that they represent. Behavioral health commission meeting minutes and statements from county supervisors and behavioral health directors indicate that San Bernardino has been reluctant to adopt another program that would need to be funded, and Santa Clara and San Bernardino expressed concern about how assisted outpatient treatment might be redundant to existing programs. In 2016 Butte’s behavioral health department raised concerns about the level of resources needed to support assisted outpatient treatment, the lack of an enforcement mechanism to ensure participation in treatment, and limited data from counties with programs. However, at a January 2020 meeting of its Board of Supervisors, Butte discussed its plans to adopt a pilot assisted outpatient treatment program if it were awarded grant funding. Chapter 3 of this report presents possible funding options to support the establishment and expansion of assisted outpatient treatment programs.

The requirements for assisted outpatient treatment present challenges to successfully enrolling individuals in the treatment. Before a court can compel an individual to participate in assisted outpatient treatment, the county must be able to demonstrate that it has offered the individual assisted outpatient treatment services and that the individual failed to engage in treatment. The three counties we reviewed each satisfies this criterion by demonstrating a sufficient period of outreach to individuals offering them voluntary services. According to county staff in San Francisco and Los Angeles, the minimum period of outreach and engagement before each county may attempt to pursue a court order is 30 days. A social worker in Shasta’s Health and Human Services Agency explained that it determines the appropriate duration of outreach case by case. Thus, in all three counties, the outreach period for obtaining voluntary participation may slow access to treatment. Further, the records from Los Angeles and San Francisco show that a common reason that they did not enroll individuals in assisted outpatient treatment was that they were unable to locate those who had been referred for the services. San Francisco explained that in many cases it makes attempts to contact referred individuals but cannot locate them because those individuals have had very limited to no previous contact with its assisted outpatient treatment care team.

Changes to the LPS Act’s Criteria for Assisted Outpatient Treatment Could Help Counties Serve Individuals Who Cycle Through Involuntary Holds

The LPS Act’s existing eligibility requirements for involuntary assisted outpatient treatment are a barrier to participation for some of the people who would benefit from the program. Specifically, as we previously explain, some individuals on conservatorships have psychiatric histories that indicate they face a high risk of returning to restrictive institutional care if they do not receive medication and continuing intensive services after their conservatorships end. However, under the LPS Act’s criteria for assistant outpatient treatment, individuals exiting from conservatorships are unlikely to be eligible for court‑ordered participation in the program, as Figure 10 shows. Specifically, to receive this treatment, individuals’ conditions must be substantially deteriorating. Further, within specified recent time frames, either they must have been hospitalized or received services in a mental health unit at least twice, or they must have committed, attempted, or threatened serious acts of violence toward themselves or others as a result of their mental health conditions. In contrast, state law requires that conservatorships end when a court determines that individuals are no longer gravely disabled—in other words, they are able to care for their own basic needs. Thus, these individuals are unlikely to satisfy the criterion that they are substantially deteriorating. Because the requirements to exit a conservatorship are inconsistent with the eligibility criterion for assisted outpatient treatment, individuals are left without access to the type of help that could stop them from cycling through the crisis care system.

Figure 10
Assisted Outpatient Treatment Helps Some Individuals Receive Critical Treatment in Their Communities, But Its Criteria Limit Access for Those Who Recently Were Gravely Disabled

Counties could transition individuals who leave conservatorships to involuntary assisted outpatient treatment if the Legislature expanded the eligibility criteria for that treatment. Counties could then use involuntary assisted outpatient treatment as a bridge from an LPS Act conservatorship to less intensive, voluntary services in the community while still providing services that could help individuals remain stable and healthy. Although this step‑down approach would represent a continuation of involuntary care, the LPS Act includes numerous protections to prevent indefinite enrollment in involuntary assisted outpatient treatment. For example, initial enrollment cannot exceed six months, and once a court orders an individual to participate in assisted outpatient treatment, the director of the treatment program must file a written statement with the court every 60 days to affirm that the individual continues to meet the program’s criteria. Finally, during each 60‑day interval, the individual can petition the court to require that the director of the program prove that the individual still meets those criteria.

Further, although the LPS Act permits courts to order assisted outpatient treatment plans that provide for coordination and access to medication, it does not explicitly permit courts to order medication that may be essential to an individual’s successful transition to living in their community. As we indicate in the previous section, we found that medication was a central element that allowed many of the individuals who were subject to conservatorships to reach a point where the court no longer found them to be gravely disabled. However, a lack of insight into their mental illnesses can cause some people to stop taking medication. Absent limited circumstances, the LPS Act explicitly prohibits court‑ordered assisted outpatient treatment plans from including involuntary medication—in other words, medication that treatment providers would forcibly administer. However, the LPS Act neither explicitly prohibits nor allows counties to include in treatment plans that an individual will self‑administer medication. In other words, the LPS Act does not explicitly permit courts to order medication as part of such plans.

California’s assisted outpatient treatment program contrasts with the practices in at least 12 other states, whose versions of outpatient treatment expressly permit court‑ordered medication for individuals living in the community. For example, in New York, an assisted outpatient treatment plan can include court‑ordered medication to treat a person’s mental illness and specifies that the treatment plan must describe how the medication will be administered and the type and dosage of the medication. If California explicitly allowed for court‑ordered medication as a component of assisted outpatient treatment, it would provide counties an important tool for ensuring that individuals with a high risk of noncompliance continue to take the medication that helps them maintain stability.

Additionally, the State would benefit from adopting clear enforcement mechanisms for court‑ordered medication. According to the most recent available report from Health Care Services on the implementation of assisted outpatient treatment programs, counties have used methods such as increasing the number of status hearings before the court to try to encourage medication compliance during assisted outpatient treatment. If California expressly permitted court‑ordered medication as part of an assisted outpatient treatment plan, it would also benefit from clear enforcement mechanisms. A resource document from the American Psychiatric Association suggests that court hearing officers clearly express that taking medications is an expected behavior if individuals hope to avoid hospitalization. Further, assisted outpatient treatment teams already have the capacity to visit an individual’s residence and could supervise them taking their medication, if requested. If an individual refuses to comply with court‑ordered medication, the American Psychiatric Association suggests this should constitute sufficient evidence of lack of compliance and cause the team to take that person to an outpatient facility for treatment. At the facility, the individual would again be offered medication but would not be forced to take it. This gradual process of progressive measures to promote adherence, short of force, would likely facilitate compliance for many individuals and help to prevent rehospitalization. The State could also adopt similar approaches to encouraging compliance with other areas of the individual’s treatment plan.

Using this approach, counties could better ensure that individuals whose conservatorships have ended continue to take medication that keeps them from needing more restrictive care. Although court‑ordered medication under these circumstances could be considered a further restriction of individual rights, we believe that requiring people to take medication while living within their communities ultimately provides them more freedom than if they were required to take medication while placed on short‑term involuntary holds or in some conservatorship settings. Our review of conservatorships and the significant role that medication noncompliance plays in some individuals’ returns to conservatorships shows that court‑ordered medication may represent treatment in the least restrictive care environment, which is the intent of the LPS Act. Provided that decisions about court‑ordered medication result from a process in which individuals are able to argue against the medication orders if they so desire, the State would appropriately balance the restriction of individuals’ rights with its goal of treating them in the least restrictive environment.

The counties we reviewed agreed that assisted outpatient treatment as a step‑down from conservatorship would be an effective approach to keeping people stable and in the least restrictive environment possible. The director of Los Angeles’s Department of Mental Health stated that involuntary assisted outpatient treatment tied to the end of a conservatorship with the option of court‑ordered medication would eliminate the period of outreach and engagement—meaning individuals might receive treatment sooner—and also stated that clear authority to include medication would help treatment plans to be more successful. San Francisco’s director of Justice‑Involved Behavioral Health Services agreed that such an approach might be beneficial and that it would still represent a less restrictive treatment setting for individuals than conservatorship. The former branch director of Adult Services for Shasta’s Health and Human Services Agency agreed that an option for assisted outpatient treatment plans that includes court orders for medication is sound as long as staff members understand that they do not have legal authority to forcibly medicate clients.

Finally, assisted outpatient treatment has been a cost‑effective approach to treating individuals with serious mental illness. A December 2013 article in the American Journal of Psychiatry found after a comprehensive cost analysis of New York’s assisted outpatient treatment program that such treatment requires a substantial investment of resources but can reduce overall service costs for individuals with serious mental illness—with substantially reduced costs for inpatient mental health treatment. The article reports that in the state of New York, where courts can order medication for participants, average costs for those enrolled in assisted outpatient treatment declined by 50 percent in New York City and by 62 percent in a broader, five‑county sample compared to average costs pre‑enrollment. Further, in March 2019, San Francisco issued a three‑year evaluation report on assisted outpatient treatment that estimated an average monthly savings of over $400,000 for its pool of 129 participants—a reduction of about 83 percent compared to average costs before enrollment.

San Francisco Has Created an Alternative to Assisted Outpatient Therapy, But a Uniform Approach Would Better Serve All Counties

San Francisco has developed two conservatorship programs that allow its public guardian to oversee court‑ordered medication for some patients living in the community (community conservatorships). These programs serve individuals who face the possibility of conservatorship in restrictive treatment facilities, such as locked facilities, but who could likely live safely in the community if they took their prescribed medications. Once conservatorship is established, the court grants the public guardian the right to require the individuals to receive psychiatric treatment, and the public guardian places the individuals in community housing instead of treatment facilities. The programs also connect individuals to case managers and outpatient services.

As part of one of San Francisco’s community conservatorship programs, individuals may also choose to participate in a collaborative court program that further supports their transition to fully voluntary treatment. This program serves individuals who are willing to voluntarily accept conservatorship and be subject to a court order for medication. Each month, the individuals, their case managers, the public guardian, and the public defender report to a judge to ensure that the individuals are engaging in treatment successfully. We saw evidence that this program has led to positive treatment outcomes, such as individuals returning to family homes, holding jobs that align with their ability to meet their basic needs, and engaging in relationships and activities in their communities. San Francisco’s analysis indicates that this program has saved the county an average of as much as $10,000 per person per month because the individuals who participated in it used services like crisis care and hospitalization less frequently.

Although the community conservatorship option has been successful in San Francisco, neither Los Angeles nor Shasta offers a similar program, and officials in those counties indicated concerns about the feasibility of creating one. For example, the deputy director public guardian for Los Angeles explained that neither the cooperation necessary to administer medication in a community setting nor collaborative court hearings might be feasible in Los Angeles. However, the court‑ordered assisted outpatient treatment programs we previously described must be composed of community‑based, multidisciplinary, and highly trained mental health professionals who work together to provide a wide range of services to individuals. Because the assisted outpatient treatment option is recognized as successful and involves these professional supports that conservatorships do not, we believe that it would be the more effective solution for the State. Amending the requirements in the LPS Act related to assisted outpatient treatment would support a uniform approach to treating people who need court‑ordered medication but who do not need restrictive, facility‑based care.

Recommendations

Legislature

To allow counties to provide effective treatment to individuals in the least restrictive setting, the Legislature should amend the criteria for assisted outpatient treatment programs to do the following:

• Allow individuals who are exiting or have recently exited conservatorships to be eligible for those programs.
  
• Provide express authority to include medication requirements in court‑ordered assisted outpatient treatment plans so long as the medication is self‑administered.
  
• Include progressive measures to encourage compliance with assisted outpatient treatment plans, such as additional visits with medical professionals and more frequent appearances before the court.
  

Further, the Legislature should amend state law to require counties to adopt assisted outpatient treatment programs. However, to ensure the counties’ ability to effectively implement such programs, the amended law should allow counties to opt out of adopting assisted outpatient treatment programs by seeking a time‑limited waiver from Health Care Services. The Legislature should require a county seeking a waiver to specify what barriers exist to adopting an assisted outpatient treatment program and how the county will attempt to remove those barriers. The Legislature should require Health Care Services to make a final determination as to whether a county will be permitted to opt out of adopting an assisted outpatient treatment program.

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Chapter 3

THE STATE DOES NOT KNOW THE EXTENT TO WHICH BILLIONS IN FUNDING HAS ASSISTED INDIVIDUALS WITH MENTAL ILLNESSES

Chapter Summary

California invests billions of dollars each year in county mental health services, yet policymakers and other stakeholders remain unable to easily or fully understand the impacts of that spending on individuals with mental illnesses. Counties can use any of their major mental health funding sources to provide a range of programs and services that may ultimately reduce the need for LPS Act holds. However, despite the wide variety of services counties can provide, the State’s current public reporting for mental health funds relies on disjointed and incomplete tools—a result of multiple funding sources with different requirements and levels of transparency.

We outline here a framework for overhauling mental health reporting that includes capturing information across all major funding sources, reporting counties’ spending in useful and uniform categories, and publishing robust outcomes for counties’ specific programs and for the State’s overarching mental health system. Without such a framework for consolidating information about the full range of mental health services, the State will remain unable to understand the effects of its investments and to determine whether it should make changes to better serve those coping with mental illnesses. Further, in the near term, the Legislature should amend state law to encourage counties to use Mental Health Services Act (MHSA) funds to provide programs and services to those who are leaving LPS Act holds and who could benefit from continuing care in their communities. Such care could prevent subsequent involuntary treatment and reinforce the community care that the MHSA and the LPS Act intended people to receive.

The State Lacks a Comprehensive View of the Effect of Funding on the Lives of People With Mental Illnesses

Public accountability for the State’s mental health funds currently relies on reporting tools that are disjointed and incomplete. As we detail in the Introduction, California has a largely county‑based system for providing public mental health care to those living with serious mental illnesses. In fiscal year 2018–19, counties received more than $7.5 billion in state and federal mental health dollars from three major types of funds: Medi‑Cal, realignment, and MHSA. Although restrictions prevent counties from using some of these funds to provide involuntary treatment, counties can use any of the types of funds to provide a broad range of supportive services for those with mental illnesses—services that may ultimately reduce the need for involuntary holds. Further, counties combine fund types to provide those services—such as by using MHSA, realignment, and Medi‑Cal funds to pay for the same service. However, existing reporting requirements do not provide decision makers and stakeholders with a clear view of the effectiveness of the State’s public mental health services. Without a statewide framework for determining spending and outcome information across all funding sources, the State will remain unable to fully and efficiently understand the effects of its investments in mental health services and, if necessary, make changes to better serve those who need critical services.

Most troubling is that we identified no source of consistent public reporting dedicated to the billions of dollars in annual realignment funds that counties can use to support those with serious mental illnesses and the outcomes of those services. As Figure 4 in the Introduction shows, counties received nearly $3 billion in realignment funds that were available for mental health services in fiscal year 2018–19. State law governing realignment funds indicates that locally managed mental health programs should be cost‑effective, should meet the needs of those with serious mental illnesses, and should be evaluated based on client outcomes. To hold counties accountable for meeting these goals, stakeholders and oversight agencies must know, at a minimum, the types of mental health services that counties fund with realignment dollars and the outcomes they achieve through those programs. Having information about services and outcomes would provide stakeholders a better understanding of whether counties’ spending—such as using realignment funds to pay for involuntary treatment—has effectively served individuals who need help managing their mental illnesses. Although we identified certain reports that include some information about realignment funds, each of these reports is limited; for instance, one is not designed for public reporting, and another does not include all realignment funds. We did not identify any public reports that specify how counties spent all of their realignment funds or how that spending contributed to improved outcomes for people.

The State reports some information about the mental health services that it funds through Medi‑Cal, the single largest source of funds that counties receive for mental health services. Health Care Services has published reports—including legislatively mandated performance outcomes reports—that detail the types of services Medi‑Cal supported, the amount of Medi‑Cal funding used for each type of service, and some outcomes, such as how many people eligible for Medi‑Cal services received them and how promptly certain services were provided. Although relevant for the narrower purpose of explaining Medi‑Cal funding and its functions, these reports are insufficient for providing a comprehensive understanding of county mental health systems because they are, by their nature, limited to the services for which Medi‑Cal pays. For example, Medi‑Cal reports do not contain information about care that some individuals treated under the LPS Act receive in state hospital facilities because Medi‑Cal often does not cover this care. Moreover, the Medi‑Cal reports we examined did not include outcomes that showed whether or how Medi‑Cal services affected the individuals who received them.

MHSA funds come with the most comprehensive public reporting requirements among the major mental health funding sources, but these requirements are still insufficient for providing statewide accountability for mental health funding. State law and regulations require counties to publicly report information each year about programs they provide with MHSA funds, such as descriptions of the programs, the populations that programs serve, the amounts spent on each program, and certain outcomes. For example, for full‑service partnership programs—through which counties must assign a case manager to each participant and offer a broad range of services—counties must report information that includes updates about participants’ health, participants’ living situations, and events of hospitalization or incarceration. However, similar to the limitations of the Medi‑Cal reporting, this reporting is relevant for MHSA‑funded programs but is insufficient for knowing the full range of counties’ mental health spending.

In addition, current MHSA reporting requirements make it difficult for stakeholders to determine the balances of unspent MHSA funds that counties are maintaining, some of which may be available to provide additional services to those with mental illnesses. The three counties we reviewed have continued to maintain millions in unspent MHSA funds, a portion of which might benefit those with mental illnesses. As Table 2 shows, the counties’ unspent funds after fiscal year 2018–19—excluding their prudent reserves, which state law places limits upon—represented between 73 and 175 percent of their respective 2018–19 MHSA revenues. Further, total balances of unspent funds increased over the preceding five‑year period in each county we reviewed. The counties provided several explanations for maintaining these balances, including that MHSA revenue is volatile and that they have already allocated some of the unspent funds to planned uses in subsequent years. Nevertheless, it is important for stakeholders to be able to access information about the balances of unspent funds, some of which might be available to help those with mental illnesses.

Table 2
Health Care Services’ Revenue and Expenditure Report Template Did Not Require the Three Counties to Disclose Their Millions in Unspent MHSA Funds

		BASED ON AUDITOR ANALYSIS
		LOS ANGELES	SAN FRANCISCO	SHASTA	EASILY ACCESSIBLE IN HEALTH CARE SERVICES’ REVENUE AND EXPENDITURE REPORT TEMPLATE?
	Total MHSA Revenue for Fiscal Year 2018–19	$560.2 million	$38.2 million	$9.3 million	NO
Cumulative Unspent Funds At End of Fiscal Year 2018–19	Community Services and Supports	$451.9 million	$13.5 million	$7.1 million	NO
	Prevention and Early Intervention	$288.9 million	$6.8 million	$3.6 million	NO
	Innovation	$172.6 million	$6.0 million	$2.2 million	NO
	Other*	$66.5 million	$1.7 million	–	NO
	Total unspent funds, not including prudent reserves	$980.0 million†	$27.9 million	$10.7 million‡	NO
	Total unspent funds as a percent of revenue	175%	73%	114%	NO
	Reported prudent reserve balances after fiscal year 2018–19	$116.5 million	$7.3 million	–	YES

In the past, counties uniformly reported their unspent funds in their annual MHSA revenue and expenditure reports (MHSA reports). In fact, in a report we issued in February 2018, we relied on information from those uniform revenue and expenditure reports to identify more than $2.5 billion in unspent MHSA funds statewide. However, after we published that report, Health Care Services issued a template for revenue and expenditure reporting that no longer asked counties to provide their total unspent funds. Consequently, the MHSA reports no longer directly identify counties’ unspent funds, and we had to perform analyses using data from the three counties’ reports and from the State Controller’s Office allocations of MHSA funds to counties to arrive at the totals that we show in Table 2.

Omitting the unspent fund totals from the MHSA reports decreases the transparency of the counties’ use of these funds. According to the chief of its Policy, Monitoring, and Financing section, Health Care Services removed the reporting requirements for unspent funds because it wanted to include in the MHSA reports only information that was required by statute and necessary to calculate reversion—a process by which counties send certain unspent funds back to the State. However, state law establishes that one purpose of these reports is to identify unspent funds. Although the counties we reviewed did include some information about their unspent MHSA funds in other reports, these other reports are narrative in nature, can be hundreds of pages long, and do not always adhere to the same format in each county. In contrast, the MHSA reports have qualities that make them useful for transparency and accountability purposes. For example, state law requires counties to adhere to uniform accounting standards in preparing MHSA reports, and Health Care Services may withhold funds if counties do not submit the reports on time. By removing unspent funds from the MHSA reports, Health Care Services has made it more difficult for stakeholders to assess counties’ financial positions, especially at a statewide level.

After it removed unspent funds information from the MHSA reports, Health Care Services adopted regulations that effectively prohibit the department from changing the content of the reports without revising its regulations. Therefore, the department would need to adopt revised regulations to once again include unspent funds in the MHSA reports. Health Care Services estimated that the earliest it could begin advancing revised regulations was July 2021. However, shortly before the planned release of this audit report, the department shared with us a new approach it planned to take that—if implemented—would result in publicly available information about unspent MHSA funds on the department’s website. Health Care Services shared with us that it plans to begin posting information about unspent funds to its website starting in the late summer and early fall of 2020. If the department does not follow through with its planned actions, legislative action will be necessary to restore transparency to the use of MHSA funds.

Because of the limitations in reporting and accountability for each of the funding sources that we describe above, the State lacks a comprehensive view of counties’ spending and outcomes in the area of mental health care. Legislators, oversight agencies, and other stakeholders should be able to understand holistically how counties spend billions of dollars in mental health funds and whether their spending improves the lives of Californians living with mental illnesses. Improving the quality of information that the State collects about mental health spending and outcomes would likely enhance discussions about the future of mental health care in California.

By Reforming Mental Health Reporting Requirements, the State Could More Clearly Identify Spending and Increase Accountability for Outcomes

An overhaul of reporting requirements is necessary to understand how the billions of dollars that the State invests in its mental health care system affect those coping with mental illnesses. To facilitate a complete understanding of the cost and effectiveness of its mental health care system, the State needs a framework for collecting information about how counties spend mental health funds—across all major funding sources—and the extent to which that spending improves the lives of individuals with mental illnesses. Figure 11 is an outline for that framework, which we developed based on our work and on conversations with staff at the three counties, at Health Care Services, and at the Mental Health Services Oversight and Accountability Commission (Oversight Commission). This approach would provide clearer and more complete information to state and local policymakers and could assist them as they make decisions about how to direct future funding.

Figure 11
A Unified Framework for Reporting Spending and Outcomes Could Help Policymakers and Others Better Understand the State’s Mental Health System

If the State is to realize the full benefits of restructuring its reporting framework, the approach it adopts must contain a few essential elements. As we previously indicate, the framework must include all major funding sources. Additionally, the framework should require uniform reporting about specific, tailored categories that describe the types of services counties provide. Finally, an effective framework for monitoring mental health spending should contain information about outcomes of the specific programs that counties fund and also broader countywide and statewide outcomes.

The MHSA has established a precedent for counties’ reporting their mental health spending to the State based on tailored categories. As we mention earlier, MHSA funds have the most comprehensive public reporting requirements among the major funding sources for mental health services. Counties must spend MHSA funds in the categories we show in the text box, and these categories are the basis for how counties annually report their MHSA spending totals. As a result, the categories are foundational to how the State and stakeholders understand the way that counties use MHSA funds. For instance, the Oversight Commission—which oversees the implementation of the MHSA—has published in its online fiscal reporting tool the amount of funds counties spend in each of the MHSA categories, and it has also aggregated this information to produce a statewide spending total for each category.

Despite the prominence of the MHSA categories in statewide reporting, they are broad and do not convey specific information about how counties spend their funds. For example, about three‑quarters of counties’ MHSA funds fall under the Community Services and Supports category, which can include services ranging from crisis intervention to outreach and engagement efforts. As a result, the Oversight Commission’s fiscal reporting tool shows that counties spent a total of $1.1 billion on Community Services and Supports in fiscal year 2016–17, but the tool does not consistently identify how much of that $1.1 billion supported specific types of services, such as crisis intervention or housing programs. Some detailed information about county programs is available in another tool on the Oversight Commission’s website, but that tool primarily allows users to search for specific programs and is dependent on how counties report information. Without additional specificity about how counties spend funds within the broad MHSA categories, policymakers and other stakeholders will likely continue to encounter difficulties in assessing the State’s current spending patterns and determining where it may be necessary to direct future resources. For instance, the current MHSA categories do not allow policymakers to assess the levels of spending on crisis intervention services and compare those to the levels of spending on services that could prevent people from experiencing a crisis in the first place.

As we show in Figure 11, the State could require counties to report their spending in more specific categories, such as inpatient care or intensive outpatient services. In contrast to the broader categories in the MHSA‑related reporting, treatment categories such as these could provide a more specific overview of statewide mental health spending, as well as specific points of comparison between counties. For instance, policymakers and other stakeholders could identify the total amount of mental health funds that counties dedicate to emergency care statewide, and they could compare this amount to the total amount counties spend on outpatient services or basic social supports. Moreover, stakeholders could compare this spending information between different counties.

Further, an effective framework for monitoring mental health spending would also contain information about the outcomes of counties’ specific programs. This level of reporting would capture important details that could help identify successful programs and inform prioritization of future investments. For instance, if a county with several different housing programs experienced overall improvement in assisting people with mental illnesses in finding and maintaining housing, program‑specific outcomes could show which of the county’s housing programs contributed most to the improvement.

Adopting a program‑level outcome reporting requirement would be similar to requirements that the State has already adopted for certain MHSA‑funded programs. For example, as we mention in the previous section, counties must report certain outcomes for their full‑service partnership programs, such as updates about participants’ health, living situations, and hospitalizations or incarcerations. Expanding this practice to require robust, program‑specific reporting of outcomes for the full range of MHSA‑funded programs, as well as programs that are not MHSA‑funded, would provide a broader range of outcome data that decision makers could use to identify effective and ineffective programs. Doing so could provide, for instance, information about the capacity of treatment facility beds, which counties cannot pay for using MHSA funding if the beds are for long‑term care. This information could include the availability of beds and the timeliness with which counties place individuals in appropriate treatment facilities. In Appendix B, we identify other possible program outcomes that counties could report.

The State would also benefit from a tool for collecting and reporting information about overarching indicators of mental health that are not limited to specific programs but may reveal how well the State is meeting the mental health needs of its residents. As we show in Figure 11, these indicators could include rates of suicide, percentages of incarcerated individuals who have mental illnesses, and rates of repeated LPS Act holds. The Oversight Commission has already contracted with researchers from the University of California, Los Angeles, to begin identifying and displaying statewide data related to homelessness, incarceration, suicide, and other metrics that state law identifies as negative outcomes that may result from untreated mental illnesses. The contract specifies that the research was to be completed by June 2020. The State could build upon this research to move toward a statewide tool for reporting high‑level indicators of mental health that could demonstrate whether funding is improving the lives of Californians coping with mental illnesses.

The first step in overhauling reporting requirements as we describe should be to consider and make use of existing information to the extent possible. In addition to the work that the Oversight Commission has already begun, the State may be able to leverage other existing systems and research to develop the framework we recommend. For example, Health Care Services maintains a data system that the Department of Mental Health and other entities developed to collect client‑level information—such as the services individuals receive, their current employment statuses, and their living arrangements—for people who receive certain county‑provided mental health services. These data could show, for example, whether people receiving certain county services have housing or employment. Although Health Care Services uses the data system for purposes such as reporting information to the federal government, the State currently lacks a statewide dashboard or other tool that consolidates and publicly reports outcomes information from the data system. When we asked about the system, the analytics and research methods section chief at Health Care Services indicated that its data could conceivably support a statewide reporting tool for outcomes.

If the State established the reporting framework we describe above without also updating existing reporting requirements, it would place an additional administrative burden on counties. In particular, the reporting framework we outline would likely overlap with the existing requirements for counties to report certain spending and outcomes information for MHSA‑funded programs. Considering the amount of overlap between the reforms we recommend and the requirements that currently exist for the MHSA, it would be most efficient to couple any new requirements with simultaneous changes to MHSA reporting. For example, the reporting that counties would produce under the new framework could expand upon or replace existing MHSA reports. Because of the need to reduce the administrative burden of a new reporting system and because the Oversight Commission already holds key MHSA oversight responsibilities and has taken measures to analyze and display spending and outcomes information related to MHSA reporting—which is the reporting that is closest to our recommended model—it would make sense for the Legislature to assign the Oversight Commission primary responsibility for managing and implementing the new reporting framework that we recommend.

Changes to the MHSA Could Ensure That Counties Leverage Those Funds to Provide Critical Services for Individuals Who Need Them Most

Policymakers have raised the possibility of altering how counties spend MHSA funds. At a December 2019 hearing, members of the Legislature were interested in discussing whether the MHSA should be reformed and whether the State should invest more resources in the Prevention and Early Intervention funding category. In addition, in his February 2020 State of the State address, the Governor indicated that reforms should focus MHSA funds on specific populations, such as individuals experiencing homelessness or involved in the criminal justice system. The solution we outline in this chapter—to collect spending and outcomes information for all major mental health funding sources—could provide a useful context for decisions about redirecting funding or adding funding to the State’s mental health system. However, in the near term, the State should take action to ensure that counties use MHSA funds to provide services to people who have left short‑term holds or conservatorships, which is a population our review identified as inadequately served.

To better serve individuals who have been on LPS Act holds and experience serious mental illnesses, the Legislature should identify them as a population that MHSA funds must target and require counties to use MHSA funds to connect that population to community‑based care. Individuals who have been on short‑term involuntary holds have experienced mental health crises, and the results we present in Chapter 2 show that these individuals sometimes experience multiple crises in their lifetime. Nevertheless, as we discuss in Chapter 1, Los Angeles and San Francisco—the largest counties we reviewed—have often not ensured that people leaving short‑term holds receive ongoing care. Although we focused our review on three counties, providing community‑based care to individuals who have been held involuntarily is an issue of statewide importance and is consistent with the LPS Act’s intent of ending the inappropriate, indefinite, and involuntary commitment of individuals with mental illness.

Because MHSA funding is intended to support community‑based services and not more restrictive treatment, we believe it would be consistent with the purpose of the MHSA if the Legislature required counties to spend some MHSA funding to support a stated goal of connecting all individuals who are leaving LPS Act holds—and who could benefit from subsequent services—with those services. Although the MHSA permits counties to spend MHSA funds for this purpose under current law, requiring them to do so would ensure that all counties make concerted efforts to provide services to an important and underserved population and report about those services to the public. For example, linkage to treatment could reasonably be attributed to both the Community Services and Supports and the Prevention and Early Intervention categories of MHSA funding—the latter of which includes linkage to treatment programs for individuals with serious mental illnesses—that together compose 95 percent of counties’ MHSA revenues. The Legislature should therefore specify that counties can use either of these funding categories to meet this goal.

If it made individuals who have been treated under the LPS Act a population for MHSA funds to target, the Legislature would also position those funds to provide the expanded outpatient care that we recommend in this report. In Chapter 2, we note that fewer than a third of California’s counties have adopted assisted outpatient treatment programs and that eligibility requirements for this treatment are a barrier to participation for some who would benefit from the program; as a result, we recommend changes that would promote wider use of assisted outpatient treatment. This wider use would likely help to reduce the number of individuals who cycle through crisis care when they are held multiple times for involuntary treatment or who experience multiple conservatorships. Further, the assisted outpatient treatment approach is consistent with the aim of MHSA and of the LPS Act to serve individuals in their communities and not in institutional settings. This linkage makes MHSA funding a prime vehicle to fund assisted outpatient treatment—including court‑ordered assisted outpatient treatment, for which state law already allows counties to use MHSA funds—and the counties we reviewed each have reported using MHSA funds for assisted outpatient treatment programs. More broadly, any counties that fund these programs—including any expansions of assisted outpatient treatment resulting from our recommendation in Chapter 2—could use the programs to provide the continuing care we describe in this section for eligible individuals who have left LPS Act holds. By defining these individuals as a population for MHSA funds to target and by requiring counties to connect them to care such as assisted outpatient treatment, the Legislature could ensure that counties are providing community‑based treatment and services to those who are among the most in need.

Recommendations

Legislature

To increase the accountability for and effectiveness of the counties’ use of mental health funds, the Legislature should amend state law to do the following:

• Assign primary responsibility to the Oversight Commission for comprehensive tracking of spending on mental health programs and services from major fund sources and of program‑and service‑level and statewide outcome data. The Legislature should require the Oversight Commission to consult with state and local mental health authorities to carry out this responsibility. The Legislature should also require the Oversight Commission to explore available data and information when developing this reporting framework, and it should grant the Oversight Commission authority to obtain relevant data and information from other state entities.
  
• Require the Oversight Commission to develop categories of mental health programs and services, similar to those we present in Figure 11, that are tailored to inform assessments of spending patterns. The Legislature should subsequently require counties to report to the Oversight Commission their expenses in each of these categories as well as their unspent funding from all major funding sources.
  
• Require counties to report to the Oversight Commission, in a format prescribed by the commission, program‑and service‑level outcomes that enable stakeholders to determine whether counties’ use of funds benefits individuals living with mental illnesses.
  
• Direct the Oversight Commission to develop statewide measurements of mental health—such as those we highlight in Figure 11—and report publicly about those measurements annually so that stakeholders and policymakers can assess the progress the State is making in addressing mental health needs.
  
• Require the Oversight Commission to work with counties and other state and local agencies as necessary to use the information it collects to improve mental health in California.
  

To better serve individuals who are among the most in need of critical, community‑based treatment and services, the Legislature should amend state law to do the following:

• Identify those who have left LPS Act holds and who experience serious mental illnesses as a population that MHSA funds must target.
  
• Establish a goal in the MHSA of connecting all such individuals to the community‑based programs and services that they would benefit from—such as assisted outpatient treatment—and require counties to fund efforts to link these individuals to those programs and services. The Legislature should also establish that a goal of providing those programs and services is to reduce the number of repeated involuntary holds or conservatorships that occur.
  

• Specify that counties can use any portion of their MHSA funds for this purpose as long as they comply with other statutory and regulatory requirements.
  

If Health Care Services does not follow through with its plan to provide, on its website, information about each county’s unspent MHSA funds, the Legislature should amend state law to explicitly require counties to include information about their balances of unspent MHSA funds in their MHSA annual revenue and expenditure reports.

We conducted this performance audit in accordance with generally accepted government auditing standards and under the authority vested in the California State Auditor by Government Code 8543 et seq. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on the audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

ELAINE M. HOWLE, CPA
California State Auditor

July 28, 2020

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