Report 2019-119

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California State Auditor's Comments on the Response From Los Angeles County

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California State Auditor's Comment on the Response From San Francisco County

Department of Justice

July 10, 2020

Elaine Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Re: Draft Audit Report – 2019-119; County Implementation of the Lanterman-Petris-Short (LPS) Act

Dear Ms. Howle,

The Department of Justice (DOJ) appreciates the opportunity to review the above-mentioned draft audit report. As the audit suggests, DOJ’s use of the mental health records is very limited to the purpose of determining someone’s eligibility to purchase or possess firearms and/or ammunition. As discussed during the audit, rather than query the mental health data from DOJ on a daily basis, the Department of Health Care Services (DHCS) may be best positioned to also receive the data directly from the mental health treatment facilities.

Furthermore, DOJ does not currently have the systematic capabilities in place to make mental illness information that treatment facilities report to DOJ, available to the DHCS. In order to comply with the recommendations as outlined in the audit report, DOJ would need to modify the pertinent automated mental health reporting systems. Express authority from the Legislature, along with additional employee and financial resources is needed to implement the recommendation.

If you have any questions or concerns regarding this matter, you may contact me at the telephone number listed above.

Sincerely,

LUIS LOPEZ, Director
Bureau of Firearms

For xavier becerra
Attorney General

cc: Sean McCluskie, Chief Deputy to the Attorney General
Edward Medrano, Chief, Division of Law Enforcement
Joe Dominic, Chief, California Justice Information Services
Chris Prasad, CPA, Director, Office of Program Oversight and Accountability

Department of State Hospitals

July 10, 2020

Elaine M. Howle, California State Auditor
Auditor of the State of California
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Subject: Department of State Hospitals Response to draft report concerning Lanterman-Petris Short Act.

Dear Ms. Howle:

Thank you for the time and attention your auditors spent with us at the Department of State Hospitals (DSH) in assessing our implementation of the Lanterman-Petris-Short (LPS) Act.

We appreciate the recognition of the challenges in implementing the LPS Act considering our resources and the growing number of persons with serious mental illness throughout the state of California in need of conservatorship.

Although not required, we did want to provide some responses clarifying a few points raised in the draft report.

On page 2, the report finds that the main reason LPS patients were waiting for an average of one year for treatment is because of a shortage of available treatment beds at DSH. This assumes that patients on our waitlist can only be treated at DSH, which is the most restrictive level of care. LPS patients on the waitlist can be treated in other settings. The report does not reflect a consideration as to whether some of these patients could be more appropriately treated in a less restrictive environment, to be identified by their conservator or guardian.

On page 15, the report finds that due to placement on a waitlist, DSH has failed to provide adequate care to those patients on our waitlist. While those patients are waiting for treatment at DSH, it is also important to note that placement at DSH is only one option for treatment. The patient’s conservator or public guardian, who is statutorily responsible for ensuring adequate care and charged with finding appropriate placement options even while patients are on the DSH waitlist, can pursue active investigation and consideration if less restrictive placement options are clinically appropriate, and available.

On page 15, the report states that we do not have sufficient treatment capacity for individuals needing services under the LPS Act due to limited space, rapidly increasing referrals, and the requirements we treat patients committed to DSH through the criminal justice system. However, it is necessary to recognize factors contributing to the waitlist. Importantly, DSH identifies a significant number of LPS Act patients currently in our care who we have found clinically appropriate to step down to a less restrictive placement but whom the counties have not transferred to such a setting. We provided the audit team data as to the number of these patients, and how long they have been waiting to be discharged by the county to a lower level of care. A failure to move discharge eligible patients is another factor that limits our treatment capacity to serve LPS patients on our waitlist.
On page 16, the report notes two LPS Act patients have waited over three years to be admitted for treatment at DSH. Regarding the first patient, the County declined the bed initially offered due to the medical needs of the patient. For the second patient - the County chose to prioritize for placement ahead of this individual seven other patients for treatment at DSH that were placed on the waitlist after this patient.

On page 19, the second paragraph refers to capacity to treat ‘involuntary holds.” DSH treats conservatorship patients, not “involuntary holds.”

We share and appreciate the concern for LPS Act patients and welcome further conversations on how best to address these patients’ needs.

Sincerely,
Stephanie Clendenin
Director

cc: Secretary Mark A. Ghaly, MD, MPH, California Health and Human Services Agency

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE DEPARTMENT OF STATE HOSPITALS

To provide clarity and perspective, we are commenting on State Hospitals’ response to our audit. The numbers below correspond to the numbers we have placed in the margin of State Hospitals’ response.

We provided State Hospitals a redacted copy of the final draft of our audit report. Accordingly, the page numbers in State Hospitals’ response do not correspond to the page numbers in the final report.

Our report acknowledges the span of treatment options available to individuals on conservatorships, but also recognizes that some of those individuals require care in a state hospital facility. As we note here, the fact that courts and counties have determined that waitlisted individuals require care in a state hospital facility indicates that they need the level of care provided in those facilities.

When we shared our final draft report text with State Hospitals, to protect the confidentiality of our report, we shared only the portions of the report directly related to State Hospitals. The full text of our report makes clear that individuals who are waiting for space in a state hospital facility sometimes receive inadequate care while they wait. For example, we summarize that Los Angeles’s records showed several instances in which individuals who were waiting for a bed in a state hospital facility were a risk to themselves or those around them while in lower levels of care.

After receiving State Hospitals’ response we amended our report text to describe the data it shared with us. These data do not change our conclusion that the predominate factor affecting the availability of treatment space at state hospital facilities is the legal mandate that requires State Hospitals to serve individuals involved with the criminal justice system.

To avoid any potential for confusion, we have amended the text here to make clear that the individuals who receive care have been placed on a conservatorship.

Los Angeles County

July 10, 2020

Elaine M. Howle, State Auditor
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Subject: “Implementation of the Lanterman-Petris-Short Act,” Report No. 2019-119, July 2020

INTRODUCTION

The Los Angeles County Department of Mental Health (LACDMH) appreciates the opportunity to respond to the "Implementation of the Lanterman-Petris-Short (LPS) Act" Audit No. 2019-119 by the California State Auditor’s Office (State Auditor). LACDMH is well versed in factors related to the LPS Act and has worked for over a year to provide solid solutions to modernize the Act to meet the growing needs of those in Los Angeles County and throughout California.

LACDMH RECOMMENDATIONS

On June 3, 2019, the Joint Legislature Audit Committee requested the State Auditor to conduct an audit on the implementation of the LPS Act. The express goal of the audit was to "examine the application of the LPS laws throughout the state to determine if any updates, clarifications or improvements [were] needed to ensure the equal application of California's mental health commitment procedures." Its scope was limited to examining the LPS process, methods of involuntary treatment, availability of treatment resources, and access to funding as potential barriers to the implementation and/or improvement of the Act.

While the State Auditor made some recommendations to improve and expand the use of Assisted Outpatient Treatment, it failed to conduct a deep analysis of LPS laws to guide the Legislature in its long-standing desire to reform the LPS Act, specifically its mental health civil commitment process. Rather, its focus shifted to county specific issues regarding the quality of mental health services and court procedures as well as the on-going myth of unspent county Mental Health Services Act (MHSA) funds.

During the audit, LACDMH provided ample recommendations for legislative changes relevant to involuntary commitment but these were not included in the final audit response. In addition to a few others, LACDMH proposes those legislative changes here.

Amend state law to redefine grave disability. While the audit states that the definition of grave disability is adequate, this is an insufficient standard. LACDMH proposes an update of the definition to better protect individuals who are unable to safely live in the community. At a minimum, legislation should address the capacity of an individual to make informed decisions and include criteria regarding the need for significant supervision and assistance, risk for substantial bodily injury, worsening physical health as well as significant psychiatric deterioration and patterns of behavior that threaten the ability of others with whom they interact to live safely in community.
Amend state law to authorize LPS conservators to manage physical health conditions, similar to the authority granted in Probate conservatorships.
Add state law that would allow medical experts to share details with a court about a proposed conservatee that are observed by other medical personnel and staff as recorded in a medical record and not just those directly observed as limited by People v. Sanchez, 63 Cal 4th 665.
Amend state law to allow for tele-testimony in LPS conservatorship hearings and trials to avoid unnecessary and often unsafe transport of clients. This issue is particularly timely given the coronavirus pandemic.
Develop and enforce a standard application of danger to self, danger to others and grave disability criteria statewide. Legislature to provide resources appropriate for the county size and client population to implement these standards.
Identify and dedicate sufficient funding to increase available treatment beds at all levels of care that provide an appropriate continuum of care that supports recovery. Some examples include: (a) Allocate funding to stabilize and prevent the loss of additional Adult Residential Facilities (ARFs) and Residential Care Facilities for the Elderly (RCFEs) and to begin to rebuild its supply. (b) Work on a long-term strategy with the State Department of Health Services (DHCS) to make beds/placements for individuals with mental illness a Medicaid benefit or establish sustainable rates and program structure to support the long-term viability of ARFs and RCFEs. (c) Work with DHCS to advocate that Centers for Medicare and Medicaid Services update the Institution for Mental Diseases IMD exclusion in Medicaid.
Identify and dedicate a funding source to increase capacity and improve the surrogate decision-making and case management services by public guardians – a critical component in the LPS Act that has not received the necessary support to ensure compliance with provisions of the Act.
Identify and dedicate resources for conserved clients including but not limited to dedicated FSP programs, guaranteed housing and access to treatment beds (locked and/or unlocked) when indicated. Provide the resources necessary to ensure conservators both public and private (family members) have the training, transportation, and support to appropriately meet the recovery needs of the conservatees.
Address the increased demand for LPS conservatorships, with appropriate resources, for the forensic population incarcerated or confined to state hospital settings. This population often requires higher levels of care and more intensive services to address their complex mental health, substance use and physical health needs but the resources to meet these needs are insufficient or non-existent.

For a deeper understanding of these recommendations and concerns related to the audit findings, LACDMH provides the following perspective.

BACKGROUND

The LPS Act was groundbreaking when it was passed in 1967 with its intent (to name just a few) to end the inappropriate, and indefinite, involuntary commitment of persons with severe mental health disorders through a conservatorship program for persons considered to be gravely disabled. Even with critiques from all sides, the LPS Act has endured the test of time and robust attempts at modification. This Audit, which seeks to determine if updates, clarifications or improvements are needed to ensure that the definitions and equal application of California’s mental health commitment procedures are adequate, has a number of limitations.

The LPS Act and specifically the use of involuntary treatment can be best contemplated as a way to set a balance between autonomy (the right to self-determination) and paternalism (relegating that determination to others) in order to best serve the interests of an individual whose disability renders their capacity to make such determinations in question. While the civil liberties and decisional capacities of every individual should always be upheld as the basic cornerstone of rights and freedom, such civil liberties can come into conflict with the very safety and health of these same individuals and others with whom they interact directly and indirectly as the result of profound mental illness.

In the context of the LPS Act, the assumed definition of "danger to self" focuses on threats or actions that indicates the intent of a person to commit suicide or inflict serious bodily harm. However, a more comprehensive and accurate definition would also focus on a person's actions or omissions that place them in serious physical jeopardy. Although not clarified within the Act, this more accurate and comprehensive interpretation should be applied. It will improve access to care and provide prompt, incremental treatment to persons with mental disorders who are unwilling or incapable of accepting treatment. In fact, grave disability is danger to self in its chronic form. As explained in judicial opinions¹In the context of grave disability, Judicial opinions actual refer to whether the non-dangerous person is capable of surviving safely in freedom." Conservatorship of Davis (1981) 124 Cal.App.3d 313; O'Connor v. Donaldson (1973) 422 U.S. 563. Additionally, the inability to live safely in community is an eligibility criteria for Assisted Outpatient Treatment., it is the inability of an individual to live safely in community, because he/she is unable to provide for food, clothing, or shelter due to his/her mental illness. This inability, over time, results in physical deterioration, which is a chronic condition. Untreated, due to the lack of judgement and capacity related to a person's mental illness, this condition becomes acute and places a person in imminent harm. Danger to others has a chronic form as well which manifests when a person, due to profound mental illness, develops a re-occurring pattern of behavior that indiscriminately and randomly causes physical harm to others.

California’s mental health system lacks not only the requisite procedural ability but also the dedicated resource capacity to properly compel treatment for individuals who are unable to live safely in the community and unable to engage meaningfully in treatment due to their mental health, physical health and/or substance use disorders.

REFRAMING THE LPS ACT

LACDMH believes it is time to reframe and update the LPS Act in the context of providing opportunities for those with mental health disorders to live safely in the community and to access to the dedicated resources needed for compelling treatment to support recovery. Using this vantage point, it is suggested that involuntary treatment be used to ensure that every person in need is guaranteed access to the services to improve their quality of life. With these principles in mind, we are mandated as a humane society to provide both surrogate decisions and requisite resources to those whose chronic illness and inability to accept resources due to their illness prohibits their ability to live safely in community.

In order to realize such a commitment, modifications to the LPS Act and the definition of grave disability are necessary for individuals who are unable to live safely in the community. As such, ongoing efforts to modernize the LPS Act must remain a priority.

In this context, we respond directly to the following recommendations.

Chapter 1

The audit declares inappropriately that Los Angeles County has failed to provide adequate care for those individuals who received involuntary treatment. The audit concludes that individuals experiencing multiple short term 72-hour holds (5150’s) are not linked to care based on data that LA County cannot access.

The audit also fails to consider that not all individuals who are assessed for a 5150 may qualify for further involuntary treatment and/or intensive specialty mental health services such as, Full Service Partnerships (FSP) or Assisted Outpatient Treatment (AOT) with its restrictive statutory eligibility criteria. Each individual should be assessed for the appropriate level of care. FSP is a high intensity, 24/7 program, reserved for the highest acuity clients. Referral to FSP services is determined by clinical history, clinical presentation, and functional assessment. Many people on brief holds are released within 24 hours or less and thus would not qualify for FSP or AOT level of services.

The issuance of a 5150 does not necessarily correlate to the need for specialty mental health services or services designed for higher acuity clients (FSP and AOT). There is a false assumption that all individuals placed on holds are “high-need” and require intensive mental health services. Although individuals should be assessed for the most appropriate level of care, individuals are at times placed on numerous 5150 holds for reasons other than a primary mental health disorder. While these individuals may need mental health treatment, outpatient services is most often the appropriate level of care. Data provided by the Mental Health Urgent Cares shows that in 85% of patients, treatment following a hold was for non-intensive services such as referrals/appointments to outpatient mental health psychotherapy, outpatient psychiatric medication management, or referrals to outpatient substance use treatment. Additionally, the audit fails to acknowledge there are important built-in federal and state structural issues of capacity, resource availability, and medical necessity requirements which impact treatment options for individuals placed on 5150’s.

LACDMH has worked tirelessly to transform the way in which mental health services are delivered within the County for those requiring involuntary treatment and/or conservatorship. We highlight some of these efforts as a counterpoint to the dramatic headings regarding the Los Angeles County mental health system, which are misleading and inaccurate.

Development of the Public Guardian conservatee FSP program. This project serves to increase the number of conservatees enrolled in an FSP program and ensure continuity of care in the event the conservatorship is terminated.

Outpatient Conservatorship program – contrary to the Audit report, LACDMH has instituted a pilot program allowing designated DMH outpatient clinical staff to refer for conservatorship without the need for an inpatient hospitalization. This program is expanding to include a pilot with the Homeless Outreach Mobile Engagement (HOME) team to make outpatient referrals to the Office of the Public Guardian.
Implementation of the Therapeutic Transportation program, an Innovation funded project. This program, using specially outfitted vans staffed with mental health clinicians, mental health counsels, Registered Nurses and peer support specialists, offers a supportive and expedited response to transportation for individuals qualifying or at risk of an involuntary hold.
Hospital in-reach from various programs:

Whole Person Care – a program focused on individuals with multiple hospitalizations, providing additional services to decrease repeat hospitalizations and increase the likelihood of successful transition back into the community.
Full Service Partnership – a 24/7 intensive outpatient program focused on working with the highest acuity, most vulnerable clients.
HOME – a specialty program working with chronically homeless individuals with serious mental illness.

Service Area Navigators and hospital liaisons – local teams in each Service Area who work with psychiatric hospitals (both County and non-County) on identifying and linking with appropriate levels of care; also provide consultation on challenging cases, and in-services for hospital staff; these teams will also provide hospital in-reach and site visits.
Prioritization of Hospital Discharge new intakes and follow up care – both appointments and walk-in services are available.
The Men’s and Women’s Reintegration programs provide the same level of follow-up for individuals placed on a 5150 in a forensic setting through in-reach services followed by conditional release to the other programs.

Specific responses to Chapter 1 recommendations are as follows:

Recommendation No. 1: 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.

LA County agrees.

Recommendation No. 2: Require treatment facilities to report to Health Care Services all short-term holds that result from the grave disability criterion.

LA County agrees.

Recommendation No. 3: Direct Health Care Services to daily obtain 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 non-resident on an involuntary hold within the county.

LA County agrees.

Recommendations No. 4 (LA specific): No later than August 2021, adopt a systemic approach 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.

LA County agrees in principal to the extent to which LACDMH can implement a systemic approach to identifying individuals placed on multiple short-term involuntary holds is dependent on resources being available and the implementation of the general recommendations by the state legislature. LACDMH will continue to deliver Medi-Cal services to individuals who qualify for specialty mental health services and voluntarily accept those services. Ultimately, the mental health network of care is comprised of various providers, including hospitals. A more appropriate recommendation, consistent with the audit scope, would be to treat and address this as a statewide network problem to address a potential gap in service.

Recommendation No. 5 (LA specific): By no later than August 2021, immediately implement a comprehensive solution such as using its own staff as expert witnesses to ensure conservatorships do not terminate because of the absence of testimony from doctors; and additionally 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.

LA County disagrees. Developing a revised approach to scheduling conservatorship hearings and trials requires the cooperation of the Mental Health Court, Public Defender and other interested parties. Scheduling of hearings is the purview of the Mental Health Court and LACDMH has little independent influence in changing the scheduling process. But if logistical changes such as use of videoconferencing on a permanent basis, designating specific testimony times to eliminate hours long wait by testifying doctors, could be implemented it would increase the likelihood that treating doctors would testify. This would reduce the need for LACDMH to use its own doctors, particularly at a time when resources are limited and physicians are needed to meet ongoing treatment needs of clients.

Chapter 2

Chapter 2 focuses on changes to Assisted Outpatient Treatment (AOT) as a mechanism to promote long-term recovery particularly for individuals who struggle to maintain stability after their conservatorships are terminated. While LACDMH agrees with most of the recommendations in this section, we point out that changes regarding medication requirements and progressive measures to ensure medication compliance are not the same as involuntary medication, which is specific to a LPS conservatorship.

Medication non-adherence is multi-factorial but the audit appears to ascribe treatment non-adherence to individuals’ choice or insight. Re-emergence of symptoms may be impacted and/or triggered by the reintroduction of substances, interpersonal stressors, and other social determinants of health and structural barriers (policies) as well as past negative experiences with treatment that contribute to medication non-adherence. For example, the more an individual is food insecure the less adherent they will be to medications as the majority of financial and other personal (time) resources will be focused on meeting basic needs. This holds true for other needs like housing and personal safety. In addition, policies obstruct individuals’ ability to adhere to medications. As one example under Medi-Cal provisions individuals can obtain only a 30-day supply of select medications at a time (including many psychotropic medications) whereas individuals with private insurance can obtain as large of a supply as is prescribed to them (e.g., 90 days). Lack of transportation to clinics or pharmacies, lack of safe places to store medications, concerns that medication side effects may place them at risk for violent victimization, cognitive deficits in psychotic disorders that limit some individuals’ ability to reliably adhere to complex (or even simple) medication regimens—there are substantial barriers to medication adherence from the policy- to individual-levels. In addition, individuals served by public mental health systems are more under-resourced and more impacted by these social and structural determinants than are the general population. In sum, a mechanism for court-ordered medication will address some barriers to medication adherence but will leave the larger network of social determinants and structural barriers to adherence untouched.

Recommendation 1: Allow individuals who are exiting or have recently exited conservatorships to be eligible for those programs.

LA County agrees.

Recommendation 2: Provide express authority to include medication requirements in court-ordered assisted outpatient plans so long as the medication is self-administered.

LA County agrees in principal that the law should be clarified to include court ordered medication but points out that court ordered medication is not involuntary medication, which should remain an order within a conservatorship.

Recommendation 3: Include progressive measures to encourage compliance with assisted outpatient treatment plans such as additional visits with medical professionals and more frequent court appearances.

LA County agrees in principal with the use of increased visits by medical professionals and increased court appearances to improve medication compliance but court appearances would require cooperation from the Mental Health Court, Public Defender and County Counsel. Furthermore, progressive interventions including taking clients to facilities for treatment to promote adherence could have the opposite effect and borders on the appearance of force.

Recommendation 4: Amend state law to require counties to adopt assisted outpatient programs and allow counties to opt-out by seeking a time-limited waiver from DHCS.

LA County has no position on this recommendation and acknowledges that there is pending AOT legislation.

Chapter 3

12a

This chapter lacks adequate understanding of the funding structure for the county public Medi-Cal behavioral health system as a whole. LACDMH disagrees with all of the stated recommendations. Mental health funding is not flexible- Medi-Cal, Realignment, and even MHSA have statutory requirements that must be followed in the delivery of these services. For context, Medi-Cal covers 13 million Californians (1 in 3) and is a $105.2 billion program. County behavioral health accounts for $6 billion of the $105.2 billion budget. It is important to consider these important factors in their proper perspective in order to fully understand the health care delivery system. For years, advocates have been saying that behavioral health is underfunded.

12b

The report fails to articulate numerous issues facing counties including these key items: (1) Fundamentally, the report demonstrated a lack of understanding of how Medicaid and the current 1915(b) waiver drives the local mental health system, with non-federal share funding streams such as MHSA and realignment supporting the Medi-Cal funding structure; (2) The importance of county-specific, stakeholder-informed process; (3) MHSA funds are distributed as three-year funding cycles and creates fiscal cliffs. In addition, MHSA funding categories and MHSA year to year volatility lead to undesirable one-time (as opposed to ongoing) programmatic funding investments; (4) Ongoing current statewide reporting exists and has demonstrated the positive impact of mental health services across the State. (5) The audit conclusions must be re-considered within the context of revenue loss at the local and State levels due to COVID-19.

The need for additional services is countercyclical to the economy. More Californians will qualify for Medi-Cal Behavioral Health due to job loss. The COVID-19 pandemic has also caused an increase in demand for services, especially for in mental health. All projections show that all mental health funding sources that counties receive will decrease significantly over the upcoming years as the U.S. and California face economic recession. New Medi-Cal beneficiaries do not come with new funding and counties will have to use declining realignment and MHSA to pay for the required non-federal share of Medi-Cal.

The Audit implies that unspent funds are those that counties have not accounted for or used in any way and are sitting on MHSA funds without serving those with mental illness. In fact, “unspent funds” are unspent because they are either unavailable to spend (i.e. Prudent Reserve which is statutorily defined), locked into spending for 5 year Innovation projects or encumbered for specific MHSA programs in the LACDMH budget that are ongoing, modified or brand new. These programs and their allocated funds/expenditures are vetted through an arduous stakeholder process with myriad client, family, neighborhood and community partners. These “unspent funds” are all accounted for and encumbered for dedicated programs through contracts and other formal mechanisms in subsequent years. See the attached diagram.

It is also important to reiterate that MHSA revenue is volatile due to being based on income tax and allocations determined by DHCS (meaning it is prudent to hold some balances so that the county could maintain services during low-revenue years). This economic reality is very relevant during this COVID-19 pandemic. In addition, it should be noted that LACDMH has not reverted any amount of MHSA funds to the State.

Recommendation 1: Assign primary responsibility to the Oversight Commission (OAC) 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.

15

LA County disagrees. LA County finds this unnecessary and counter-productive. The authors of the MHSA had the foresight and were careful to create a separation of duties such that the State Department (DMH and now DHCS) had the contractual relationships with the counties/Mental Health Plans, which includes compliance reviews separate from the oversight and accountability function fulfilled by appointed Commissioners. LA County would not endorse changes that would involve the OAC taking on functions beyond what was intended in the MHSA Act.

Counties are actively engaged in statewide reporting on MHSA programs. A leading example is the joint County Behavioral Health Directors Association- California Institute for Behavioral Health Solutions (CBHDA-CIBHS) statewide reporting initiative acknowledged by the Little Hoover Commission, called Measurements, Outcomes and Quality Assessments (MOQA) initiatives that produced reports in 2015 and 2016 on statewide FSP outcomes. Currently MOQA is focusing on MHSA Prevention program outcomes including those related to suicide prevention, stigma, and discrimination reduction.

In addition to MHSA, the Medi-Cal program established a host of reporting requirements through 42 CFR, Part 438, subpart E, including Consumer Satisfaction Surveys and Quality Improvement activities that include annual data-driven Performance Improvement Projects for clinical as well as non-clinical activities, annual quality improvement work plans that involve the establishment and evaluation of Mental Health Plan goals, participation in an annual External Quality Review and the reporting of client demographics.

The State Department of Health Care Services (DHCS) oversees the provision of Medi-Cal Specialty Mental Health Services (SMHS) to beneficiaries across the State but delegates the strategic planning of service delivery within each county to the county’s Mental Health Plan (MHP) Director. The reason for this is clear – it is the county MHP Director that can best tailor the overall service delivery priorities to the unique needs of the county. The addition of an oversight commission adds an unnecessary layer of bureaucracy to this process. Under the SMHS Contract with DHCS, DHCS requires county MHPs to assess their own capacity and need for services by “monitoring the number, type, and geographic distribution of mental health services within the delivery system.” In addition, under the Medicaid Managed Care and CHIP Managed Care Final Rule, 42 CFR 438.340, each state Medicaid agency is required to implement a written quality strategy to assess and improve the quality of health care and services furnished by all Medicaid managed care entities. The Comprehensive Quality Strategy outlines the MHP’s process for developing and maintaining a broader quality strategy to assess the quality of care that all of the County’s beneficiaries receive, regardless of delivery system, and defines measurable goals and tracks improvement while adhering to the regulatory managed care requirements of 42 Code of Federal Regulations (CFR) 438.340.

If this recommendation is acted on, LA County suggests an alternative agency for this responsibility, DHCS, because of their familiarity of Medi-Cal, Realignment, and MHSA funding. They have a performance contract with each Mental Health Plan and oversee MHSA compliance.

Recommendation 2: Require the Oversight Commission to develop categories of mental health programs and services that are tailored to inform assessments of spending patterns. The legislature should require counties to report their expenses in each of these categories as well as their unspent funding from all major funding sources.

Recommendation 3: Require counties to report to the Oversight Commission program and service level outcomes that enable stakeholders to determine whether counties use of funds benefits individuals living with mental illnesses.

16

LA County disagrees with Recommendation 2 and 3. With respect to the delivery of individual SMHS, services are not provided to Medi-Cal beneficiaries based on categorical spending patterns. The delivery of services is based on the specific needs of each client as determined by an individualized assessment and collaborative treatment planning process. In the vast majority of cases, services are voluntary, and it is the client’s choice as to which services they choose to accept as recommended by the treatment provider. This individualized client-driven approach is reflected in the guiding principle of Medi-Cal SMHS, the Rehabilitation Option under the State 1915b waiver: “The provision of services and support should … be directed and determined by the individual’s needs and desires, whenever possible. The system must focus on the individualized needs, strengths, and choices and demonstrate individual involvement in service planning and implementation.”

And within the County’s contract with the State DHCS: “Services shall be provided, in accordance with the State Plan, to beneficiaries, who meet medical necessity criteria, based on the beneficiary’s need for services established by an assessment and documented in the client plan. Services shall be provided in an amount, duration, and scope as specified in the individualized Client Plan for each beneficiary.”
In addition, the MHSA Revenue and Expenditure Report (RER) adequately classifies programs according to MHSA component. Counties are required to complete and submit annual RERs and 3-Year Plans with Annual Updates that serve as fiscal and programmatic documentation of county programs, utilization and associated funding. Each year’s RER documents Medi-Cal, 1991 Realignment, Behavioral Health Subaccount and other funding associated with each CSS work plan, each component of PEI and all other MHSA components.

MHSA currently stipulates the outcome data collection and reporting requirements, which already informs stakeholder recommendations on programs and services. Required outcome data are transmitted directly to DHCS for FSP programs and incorporated into county Annual Updates and 3-Year Plans. In addition, counties are required to submit annual reports to the OAC on PEI, including outcomes stipulated in the regulations, and Innovation projects.

Recommendation 4: Require the Oversight Commission to work with counties and other state and local agencies to use the information it collects to improve mental health in California.

LA County does not support a role beyond the role the OAC currently plays in bringing counties together who are working on similar projects for cross-county learning and dissemination.

Recommendation 5: Amend state law to identify those who have left LPS Act holds and who experience serious mental illness as a population that MHSA funds must target.

17a

LA County disagrees. This recommendation is unnecessary because MHSA funds are currently used for those individuals with serious mental illness who are released from involuntary holds.

Recommendation 6: Establish a goal in the MHSA of connecting all such individuals to the community based program and services they would benefit from and require counties to fund efforts to link these individuals to those programs and services and that goal of these programs and services is to reduce the number of repeated involuntary holds or conservatorships that occur.

18

LA County disagrees. This recommendation is unnecessary because MHSA funds are currently used to connect individuals to community-based efforts. The audit fails to recognize the need for LPS reform is not to target those that voluntarily accept treatment (core component of MHSA) but rather those individuals who do not accept care.

Recommendation 7: 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 and amend state law to explicitly require counties to including information about this balance of unspent MHSA funds in their MHSA annual revenue and expenditure reports.

17b

LA County disagrees. It is unnecessary to specify that counties can use any portion of MHSA funds to connect individuals to community-based efforts because counties currently have the ability to use funds for this purpose as long as the stakeholder process approves the expenditure as part of the 3-year plan. Amending state law to specify the format of annual revenue and expenditure reports is too restrictive and prevents state and local agencies from adjusting reports as necessary to address the changing landscape of public mental health financing.

LACDMH also comments on the lack of recommendations in Chapter 3 related to the Office of the Public Guardian.

The audit fails to address funding related to the Office of the Public Guardian and the conservatees they serve. A comprehensive review of the LPS Act and funding of the services cannot be done without looking at a core component of the Act – the county conservatorship investigator and court appointed conservator – Public Guardian. While increased reporting related to Medi-Cal and Realignment may indicate county support for the public guardian program or the placements funded for conservatees this falls short of addressing the fact that public guardian programs do not have a dedicated funding source. The extent to which a public guardian program exists or the extent to which the program can meet the needs of its conservatees is subject to the availability of realignment funding and county general funds. The issue is directly related to the scope of the audit, specifically to determine how counties fund their implementations of the LPS Act and whether access to funding is a barrier to the implementation and the audit failed to address this issue as part of their audit scope.

Conclusion

The Los Angeles County Department of Mental Health looks forward to continue working with the Auditor’s Office and with the State Legislature to enact needed changes to the LPS Act, among other issues, that would ultimately provide better services to those living with mental health disorders.
# # #

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM LOS ANGELES COUNTY

To provide clarity and perspective, we are commenting on Los Angeles’s response to our audit. The numbers below correspond to the numbers we have placed in the margin of Los Angeles’s response.

Los Angeles incorrectly asserts that we failed to conduct a deep analysis of the LPS Act. Our report includes a thorough description of our analysis of the intent of the LPS Act and counties’ implementation of the act, which was based primarily on the case files we reviewed across all three counties. We performed work in the areas the Legislature asked us to look at. As Table A shows, the Legislature specifically asked us to review the services (including county‑provided services) available to individuals receiving treatment through the LPS Act (Objective 7), the implementation of the LPS Act (Objective 4)—which includes the way in which a county pursues conservatorships in court—and the availability of funding to provide care under the LPS Act (Objective 6). Finally, Los Angeles has MHSA funding that it has not spent. Therefore, Los Angeles’s assertion that some MHSA funds are unspent is a myth is incorrect.

During our review, we considered the county’s ideas for legislative change. The recommendations we make in our report are based on the evidence we found in the course of our review. The recommendations Los Angeles suggested are either not supported by our evidence or are outside the scope of our review.

As we explain in Chapter 1, we found that the current definition of grave disability enabled designated professionals authority to treat individuals in need of services through the LPS Act. As shown in Figure 5, we found that designated professionals in the counties we reviewed applied the definition in a consistent manner. Further, we note that we observed that designated professionals in the counties we reviewed used definitions of grave disability that were not overly restrictive. As we conclude, expanding or revising the criteria for LPS Act holds could widen the use of involuntary holds and pose significant concerns about infringement on individual rights. Therefore, we do not recommend that the Legislature amend the grave disability criterion of the LPS Act.

Los Angeles presents a case that the LPS Act’s involuntary hold criteria are not well defined because there are broader ways to consider—for example—when someone is a danger to themselves other than the fact that someone is suicidal. However, we did not observe that counties only adhered to a rigid definition of danger to self. Instead, as we note, counties applied that criterion when individuals, because of their mental illness, engaged in behaviors that were apparently dangerous, such as the consumption of dangerous foreign objects. We noted similar flexibility in how the counties applied the other involuntary hold criteria as well. Because of our observations across three counties, we do not agree with Los Angeles’s assertion that California’s mental health system lacks the procedural ability to apply involuntary holds when necessary.

Our conclusion that the county failed to provide adequate care to individuals leaving involuntary holds is based on the results of our review. Specifically, as we describe, we found that only 9 percent of individuals who had experienced five or more short‑term holds from fiscal year 2015–16 through 2017–18 were enrolled in intensive outpatient treatment services in fiscal year 2018–19. Further, we describe that about one‑third of individuals from our case file review with a high number of short‑term holds in their lifetime were not enrolled in these services at any point from fiscal year 2016–17 through 2018–19. Finally, we report that six of the nine individuals we reviewed who had been held multiple times in their lifetime were not linked to services in the two weeks following the end of their short‑term hold. We acknowledge in our report that limited access to quality data contributed to this failure, and we recommend a solution to the data access problem. However, neither data issues nor other potential barriers that the county indicates absolve it of the responsibility to provide care to individuals who have experienced multiple mental health crises.

As we explain in our report , we focused our analysis on individuals who experienced multiple involuntary holds over a short period of time. We question the county’s suggestion that such individuals did not need intensive services, such as full‑service partnerships or assisted outpatient treatment. In fact, in its own response, the county indicates that such programs have been part of its attempt to transform the way in which mental health services are delivered to those requiring involuntary treatment.

Los Angeles criticizes our audit for a failure to acknowledge factors of capacity, resource availability, and medical necessity requirements. However, we addressed capacity issues, and Los Angeles was not clear what it meant by resource availability and medical necessity. Without additional detail it is not possible to more directly address Los Angeles’s concerns.

On page 50 of our report we discuss community conservatorships, which were unique to San Francisco. These programs allowed the public guardian to oversee court‑ordered medication for individuals whom the public guardian placed in community housing, instead of treatment facilities during the period of conservatorship. The program that Los Angeles cites in its response allows referrals for conservatorship to come from community settings rather than hospital settings. This does not mean that treatment during conservatorship, if one is established, would occur in the community. As we state here, the deputy director public guardian for Los Angeles expressed concerns that administering medication—which our review found was often a critical component of mental health treatment—would not be feasible in a community setting.

Los Angeles’s response indicates that it will only adopt our recommendation to the extent that resources become available and the Legislature acts on our associated recommendations. Given the importance of linking individuals to mental health services, we believe that Los Angeles should take steps now to improve how it identifies individuals who need services and links those individuals to services. We look forward to reviewing the county’s 60‑day response to our audit that should indicate the steps it is taking to implement this recommendation.

We believe the county should coordinate with the court and other parties to revise the approach to scheduling conservatorship hearings—steps the county would likely need to take to achieve the other logistical changes it suggests in its response. Our analysis of this issue, determined that a key reason why conservatorships in Los Angeles terminated was a doctor’s failure to testify. Further, on that same page we describe the county’s own determination that 20 percent of conservatorships ended because doctors did not testify. In light of these findings, our suggestion to use county doctors to provide critical medical testimony is consistent with meeting ongoing treatment needs for individuals who require conservatorships.

We acknowledge that many factors may influence whether individuals take prescribed medication. Our report focuses on an individual’s level of insight into their mental illness—the degree to which the individual believes that they have a mental health related illness—because the evidence we reviewed indicated it was a key factor influencing whether the individuals whose cases we reviewed continued to take their medication.

12a

12b

We stand by our description and analysis of issues concerning funding for mental health services in California and the recommendations we make to increase the transparency of spending on mental health services and the accountability for outcomes related to those services. Los Angeles expresses concern that our report does not explicitly describe certain statutory requirements and county‑level funding issues. However, we do not believe the issues that Los Angeles raises in its response are barriers to the implementation of our recommendations.

Los Angeles’s concerns about our characterization of unspent funds are unfounded. We clearly indicate here that the counties we reviewed explained that some of their MHSA unspent funding had already been allocated to planned uses in subsequent years. Also, we removed each county’s prudent reserve from our calculation of its unspent fund balance in Table 2.

The county did not provide this graphic to us before submitting its response to our report, We did not review the data that underlies the graphic that Los Angeles provided and therefore have no comment on the accuracy of the graphic and the information it provides about MHSA funds. However, we note that the county’s presentation does not include funding that would have been left as unspent at the close of fiscal year 2015–20.

Los Angeles’s response primarily takes issue with our recommendation that the Oversight Commission be tasked with comprehensive tracking for mental health care spending and outcomes. As we state here, we recommend the Legislature assign this responsibility to the Oversight Commission because of the overlap between existing reporting responsibilities and our proposed framework, as well as the work already performed by the Oversight Commission.

In objection to our recommendations, Los Angeles lists observations about current mental health service delivery and reporting requirements. It appears that Los Angeles misunderstands the intent of our recommendation. Our recommendation would have counties report about their spending and mental health service delivery across common categories regardless of funding source. Although we acknowledge here that there may be some overlap between our proposal and existing requirements, the existence of the current service delivery and reporting requirements does not invalidate our proposal for a comprehensive framework for understanding aggregated spending and service outcomes.

17a

17b

Los Angeles’s argument that these recommendations are unnecessary simply because counties are already allowed to spend their funds in the manner we recommend is insufficient. Put simply, there is a meaningful difference between being allowed to spend funding in a specific manner and being directed to do so. The results of our review demonstrate the need for requirements in these areas.

We disagree with Los Angeles and stand by our recommendation. Our review shows that individuals who have been treated under the LPS Act are often not successfully connected to mental health care following their involuntary treatment. We detail here how only 9 percent of individuals with a high number of involuntary holds were enrolled in intensive outpatient treatment. We also explain on that same page that some individuals who had experienced multiple holds in their lifetime were not offered any mental health services in the two weeks that followed the involuntary hold we reviewed. Los Angeles argues that simply because counties can spend their MHSA funds to link individuals to mental health care that they should not face a requirement to do so.

We reviewed county documents related to public guardian funding as part of our work to identify funding for the implementation of the LPS Act and potential barriers to implementation. In our discussion of Figure 4 we describe that counties draw on a variety of resources—including locally generated funds—to fund mental health services. Our review did not lead us to conclude that a lack of funding for public guardians was a barrier to implementing the LPS Act. Los Angeles’s response observes that the public guardian’s office is funded through realignment and county general fund monies instead of through a dedicated funding source. Our recommendations for improved reporting about the use of funds for mental health treatment should help indicate underfunded areas going forward, as the county acknowledges in its response.

San Francisco County

July 10, 2020
California State Auditor
621 Capitol Mall Suite 1200, Sacramento, CA 95814

To Whom It May Concern:

San Francisco County thanks the State Auditors for their detailed review of the LPS Act, as well as their collaboration and commitment to understand the complexities of serving individuals who have behavioral health needs, particularly those who have acute service needs. We appreciate the depth of the report and the ability to respond to the recommendations and would like to take this opportunity to share our experiences, as well as provide some additional information for consideration.

As is indicated in the report, San Francisco has always strived to be innovative in our response to serve our most vulnerable residents by providing services that are client-centered, compassionate, and intended to promote wellness and recovery. While it is both our legal and ethical duty to ensure that individuals are served in the least restrictive setting, court ordered treatment options are an important part of our continuum of care. We are pleased that the State confirmed that we are appropriately administering and overseeing mental health conservatorships, as outlined in the LPS Act. San Francisco’s approach to both Assisted Outpatient Treatment and flexibility in serving individuals on an LPS Conservatorship in the community is the result of a client centered approach, collaboration across city departments and community based organizations, and innovative and adaptive ways in which we have been able to model and serve individuals in need.

The report also highlighted San Francisco’s innovative Community Independence Participation Program (CIPP) and our Post-Acute Community Conservatorship (PACC) in the report, although they were not referenced by name. Both CIPP and PACC are innovative services models that are operated under the LPS Act that promote the client’s engagement in their own recovery while supporting a client’s placement in a non-restrictive, community based setting. These models are operated under existing LPS statute, and therefore would not be considered separate conservatorship programs or an alternative to AOT. Despite these programs, San Francisco, like many counties across California, is struggling with the severity of needs of our residents who have mental illness, particularly when this is impacted by the effects of psychoactive substances, complex trauma, homelessness, racial oppression, and medical pandemics. While COVID-19 response has a significant impact across California and the nation, we would be remiss not to highlight the impact of the virus on our most vulnerable residents, the focus of staff on mitigating the spread of the virus on our communities at this time, as well as the potentially detrimental impacts on our funding to implement the recommendations outlined in the report.

We would also like to take this opportunity to provide feedback on recommendations and conclusions in the report:

Report: Expanding the LPS Act’s criteria for involuntary holds or revising the criteria to include standards that are overly broad—such as the ability to live safely in one’s community—could potentially widen the use of involuntary holds, which would pose significant concerns about infringement on individual rights. We found no evidence to justify such a change.

Response: San Francisco agrees that the “LPS Act’s criteria appropriately enabled the designated professionals to place people who needed involuntary treatment on LPS Act holds or conservatorships.” San Francisco partners with our legal and patient’s rights partners to responsibly implement and utilize existing holds. Despite this, we still believe there is room for improvement in the LPS Act in order to ensure that those with significant behavioral health needs are able to receive acute care, and not just crisis services, when in need. While a very small proportion of individuals with serious mental illness have episodes of violence, individuals with mental illness are disproportionally victims of violence in our communities. We encourage every effort to protect these individuals and support patient rights protections to ensure that involuntary care is a last resort to support the recovery and wellness of an individual; however, as experts in behavioral health it is our professional opinion that these resources are needed in serious cases.

With the above in mind, we recommend that the legislature consider adding language to better define grave disability so that there is consistency across jurisdictions and that the subjectivity that may exist for providers and/or the Court is mitigated. San Francisco has recently implemented Housing Conservatorship (updated as Senate Bill 40 in October 2019), which attempts to address some of the gaps in the LPS Act that behavioral health professionals struggle with. Despite the ability to pilot new tools in our community, we strongly recommend there be considerations related to the LPS Act to account for advancements in our understanding of serious behavioral health needs and impact of psychoactive substances outside of chronic alcohol use.

This report provides an important opportunity to open a discussion and modernize the LPS Act to ensure that interventions are data driven and individuals receive comparable interventions across counties to further protect the rights of those that are most vulnerable and in crisis. We recognize the traumatic history of involuntary treatment, and the negative experiences that individuals may currently face when interacting with the mental health system, so these changes should not be made without the input of medical professionals and those with lived experience to ensure that we continue to approach this work from a compassionate, yet needed, stance.

Report: San Francisco Recommendation- By August 2021, San Francisco should conduct an assessment to determine the number and type of treatment beds that it needs to provide adequate care to individuals receiving involuntary treatment. Once the assessment is complete, the county should adopt plans to develop the needed capacity.

Response: In June of 2020, the San Francisco Department of Public Health published a “Behavioral Health Bed Optimization Project Analysis and Recommendations for Improving Patient Flow” report. This report utilized a robust statistical analysis of fiscal year 18/19 data to do a bed simulation model and identify recommended investments across our behavioral health system of care to maximize client flow (See Table below). This analysis represents a first step to meet the current need for beds based on wait times and additional investments may be needed to address the overall demand for beds. We are working at a county level to implement these recommendations for bed investments and look forward to conducting this analysis on an ongoing basis to identify needed investments.

In order to effectively provide services to individuals in need and to maximize investments in additional treatment beds and expanded treatment capacity, associated funding must also be flexible. The San Francisco County General Fund provides a significant portion of Behavioral Health Services funding (31 percent of total budget). While San Francisco is committed to investing in our community members, we support State efforts to reduce barriers to bill Medi-Cal and other revenue sources in order to ensure that billing is client centered and outcome driven, rather than being mired by documentation requirements and billing codes. Further, these investments must support low threshold services in order to successfully meet and engage individuals where they are at, and, when appropriate, support individuals to link to more traditional models of care.

The report notes that, “California has closed several of its state hospital facilities, which generally provide intensive treatment in locked settings for those with serious mental illnesses.” While we fully support individuals receiving treatment in their county of origin, there is a need for placements that can support individuals with serious neurobehavioral conditions and those at heightened risk of violence. At this time counties across California are attempting to access a small number of State Hospital beds, which can lead to exorbitant wait times, in some cases over a year, for individuals to receive the appropriate level of care. We believe more beds are needed across California and that the state should play a role in providing funding for those beds.

Report: San Francisco Recommendation- By August 2021, San Francisco should adopt a systemic approach to identifying individuals placed on multiple involuntary holds in its county-designated facilities, obtaining information about those individuals, and connecting them to services that support their ongoing mental health.

Response: San Francisco agrees with this recommendation and continues to support individuals with behavioral health needs by providing continuity and connection to care. While it is important to note that engagement in services is voluntary, we aim to provide care coordination and proactive wrap around services to individuals who are deteriorating in our communities. The Department of Public Health provides behavioral health services to approximately 30,000 individuals every year. We are currently engaging in a quality improvement process to analyze and enhance our response and length of time for a follow up appointment at our outpatient clinics after a crisis. Further, San Francisco recently passed legislation that would create a program called Mental Health SF, which includes the development of an Office of Care Coordination. This office would employ a “whatever and wherever it takes” approach to engage individuals in services and support navigation into ongoing care. This office will be positioned to implement the report’s recommendation.

San Francisco has also had great success in a Linkage Model of care for Transitional Age Youth to support individuals, who frequently have prodromal symptoms of serious mental illness, to successfully transition from the Children, Youth, and Families System of Care to the Adult/Older Adult System of Care. As clients in need transition to higher levels of care, it also becomes increasingly important to ensure client flow and successfully transition other clients to lower levels of care, which both creates capacity in the higher levels and ensures that clients are treated at the most appropriate level of care. In order to achieve this, the Department of Public Health has been working closely with our intensive case management providers to complete utilization management reviews and are using MHSA Innovation funds to provide peer support to individuals who are showing signs of recovery and are able to access less intensive care in the community. Through this program, clients are guided through all the various steps from preparation to successful placement and/or discharge.

Further, in our clinics, which provide integrated medical homes and mental health services, we have partnered to have Health Home Care Coordination, which allows providers to be notified if an individual they are supporting is receiving emergent services. Additionally, we have used grant funds to enhance services at Psychiatric Emergency Services at Zuckerberg San Francisco General Hospital, our primary designated LPS facility for 5150 WIC holds, to provide support and engagement to individuals who have repeated crisis contacts. Finally, our Shared Priority Project through Whole Person Care has provided us with a great deal of success and recommendations of investments to support individuals with complex medical and psychiatric needs who are experiencing homelessness. This includes the need to invest in care coordination, as well as address systemic challenges to reduce barriers to access care.

Additionally, as discussed above, we believe that the legislature should consider all alternatives to serve vulnerable individuals who cycle in and out of crisis and are deteriorating in our community. System improvements and investments to a variety of voluntary treatment options are needed; however, it remains important for a small subset of the population who are unable to participate in voluntary services to have other alternatives.

Report: Legislative Recommendation- Adjust reporting requirements for LPS Act holds to ensure that counties can access existing state-managed data about the specific individuals placed on holds.

Response: We strongly support the recommendation that counties have access to information regarding LPS holds for their residents so that we can effectively intervene and proactively support individuals who are at risk of more restrictive holds/placement. We would also like to note that many individuals that experienced psychiatric crises during the evaluation period have private insurance. As San Francisco Department of Public Health has a key role in providing behavioral health services to low income, uninsured, and vulnerable residents, we ask that recommendations also consider the role of private insurance entities to maintain responsibility for the provision of equitable services to their beneficiaries.

We also question whether the proposed solution (that DOJ information about patients on a 5150 should be made available to the State, which would make it available to the County) is viable, as it would likely take time for the data to filter through so many agencies. Care coordination for patients who are on involuntary holds requires "live" data as the clinical team needs to act quickly for appropriate linkage. We suggest that other solutions, such as those envisioned in Health Insurance Exchanges (HIE) be investigated.

Report: Legislative Recommendation- Require counties to adopt assisted outpatient treatment programs.

Response: We strongly support the adoption and implementation of Assisted Outpatient Treatment across California as a less restrictive option to support individuals in their journey to recovery and wellness. Given our innovative approach to implementation, as well as our overwhelming success with this program, we would be happy to offer our expertise as a subject matter expert should the legislature consider making changes to this program. We also encourage the consideration of including funding to implement these programs in a comprehensive way.

However, we respectfully disagree with the conclusion that the engagement period can slow access to care (Page 44). Rather, in San Francisco, the engagement period is a time where care is proactively offered by a team of clinicians and peers to support individuals in accepting ongoing voluntary services. San Francisco has seen an approximately 80% success rate in individuals accepting voluntary services through Assisted Outpatient Treatment, largely in response to this intensive engagement period. While at times it can be difficult to locate individuals over a period of time, we believe that shortening or reducing the engagement period would not provide any substantial positive impact to enroll individuals. That being said, Legislative Recommendation 1 would further allow the Assisted Outpatient Treatment team to coordinate care and identify emergent contacts at non-public hospitals, which would enhance our ability to locate and engage individuals.

Report: Legislative Recommendation-Assign the Oversight Commission primary responsibility for developing, implementing, and overseeing a comprehensive framework for reporting mental health spending across all major fund sources, as well as program-specific and statewide mental health outcomes.

Response: We strongly support the recommendation to increase transparency and community engagement around the LPS Act, outcomes, and spending. We encourage this recommendation to also include resources to develop infrastructure to ensure responsiveness and coordination across counties at the Oversight Commission level. Further, the importance of strong data collection across these efforts is needed at the county level, as well as clear and consistent metrics across counties. We recommend that there be additional funding to support data analysts for the counties.

Report: Legislative Recommendation- Direct counties to spend MHSA funds for the purpose of connecting individuals leaving LPS Act holds or conservatorships to community-based services.

Response: We support the opportunity to leverage MHSA funds to provide care to individuals who are exiting 5150 WIC hold or conservatorships. The core values of MHSA include a strength-based approach and are prevention driven. San Francisco’s ability to utilize MHSA dollars flexibly to meet the unique needs of our community remain important.

To assist stakeholders and policymakers when assessing the ability of using MHSA funds to support programs, we request that the report describe the restriction on using MHSA funds to supplant existing state or county funds used to provide mental health services.
Any proposal to use MHSA funds for mental health activities that are funded through other state resources (example - general fund or trial court trust fund) is contingent on those resources maintaining the same level of funding for those services. Per WIC 5891(a), MHSA can be used for expansions, but it cannot be used to replace another funding source.

The report also states that San Francisco has $27.9 million of unspent MHSA funds. San Francisco is committed to maintaining a consistent level of MHSA services through both periods of economic prosperity and economic downturn. To fulfill this objective, we expand our services at a pace that matches our long-term average increase in MHSA revenues.

As seen in the figure below, which depicts actual revenues and expenditures for FY2011-19 and the latest projections for FY2019-23, San Francisco’s expenditures increase an average of $1 million per year, which matches the average annual increase of MHSA revenues.

Year-over-year, MHSA revenues endure a great deal of volatility, as evident below. Despite this volatility, our services have been growing at a consistent and reliable rate. With this strategy, we expect to provide the same level of care to our MHSA clients despite the economic recession that was triggered by COVID-19.

Further, in planning for FY 2020-23 MHSA programming, the department held 19 community planning process (CPP) meetings that resulted in a mindful expansion of mental health services for the upcoming three-year term. The CPP is a cornerstone of MHSA’s mission and allows our programming to be a reflection of our community’s wants and needs. These expanded services include a steady increase to our mental health workforce development and training programs, the completion of a $3 million capital project to better integrate our behavioral health services into a primary care clinic that serves the historically underserved Bayview-Hunters Point neighborhood, the transition of several successful Innovation programs to our MHSA core program, and the launch of two new Innovations programs.

San Francisco also supports an expedited process for obtaining Mental Health Services Oversight and Accountability Commission approval to execute Innovation programs. A speedy approval process for MHSA Innovation programs will prevent delays in spending and expedite access to these innovative programs by our community.

Despite the assertion in the report, San Francisco MHSA funds are not “unspent,” but rather dedicated to existing programs/innovations over the next three years or reserved to preserve our services in times of economic recession, such as we are currently experiencing. This fiscal prudence will allow us to continue important services to underserved and disenfranchised populations in the face of our current medical and economic crises.

Thank you for the opportunity to share our experiences and respond to the recommendations in the report.

Sincerely,

Grant Colfax, M.D.
Director of Health
San Francisco Department of Public Health

Shireen McSpadden
Executive Director
Department of Disability and Ageing Services

Comment

CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM SAN FRANCISCO COUNTY

To provide clarity and perspective, we are commenting on San Francisco’s response to our audit. The numbers below correspond to the numbers we have placed in the margin of San Francisco’s response.

As we discuss in Chapter 1—we reviewed the involuntary hold criteria in the LPS Act and determined that they provide designated professionals sufficient authority to treat individuals in need of involuntary treatment under the LPS Act. Our review of case files also found that designated professionals in the three counties we audited applied the definition of grave disability in a consistent manner. Based on the evidence, we did not conclude that the grave disability criterion needed any clarification.

San Francisco had not shared this information with us before responding to our final draft report. We look forward to reviewing San Francisco’s progress in implementing this recommendation when it responds further during our post‑audit follow up.

Although San Francisco identifies Zuckerberg as its primary designated treatment facility, we note in our report that Zuckerberg is one of several designated treatment facilities in the county, and more than half—about 56 percent—of individuals leaving involuntary holds were leaving facilities other than Zuckerberg. In light of that, we are encouraged that the county agrees with our recommendation to adopt a systemic approach to identifying individuals placed on multiple involuntary holds at all designated facilities and connecting them to ongoing services.

We found that many of the individuals we reviewed were enrolled in Medi‑Cal, not in private health care insurance, and thus the county had responsibility for providing those individuals with services. As we explain here, the presence of private insurance options for some individuals does not change our conclusion that a significant number of people, including those who were eligible for county services, experienced multiple involuntary holds but were not connected to intensive outpatient treatment.

We agree that it is important to quickly share information about individuals who have been placed on involuntary holds. Treatment facilities are required to report to Justice about involuntary treatment holds within 24 hours of applying the hold and Justice updates its related data on a daily basis. We believe Justice’s existing data can be shared quickly and efficiently so that counties can make important treatment decisions.

We appreciate the county’s perspective on the value of the engagement period for assisted outpatient treatment. As we describe here, before a court can compel an individual to participate in assisted outpatient treatment the county must be able to demonstrate that it offered individual assisted outpatient treatment services and that the individual failed to engage in treatment. San Francisco informed us that the minimum length of this period was 30 days. We stand by our conclusion here that the engagement period could slow access to treatment for individuals who need treatment. In addition, as we describe in our report, we believe undelayed access to assisted outpatient treatment for individuals exiting conservatorship could improve outcomes for such individuals.

The county did not provide this graphic to us before submitting its response to our report, and therefore we have no comment about the accuracy of the graphic and the information it provides about MHSA funds. We specify here that counties may have unspent funds that they have already allocated to future planned uses.