Report 2019-119 All Recommendation Responses

Report 2019-119: Lanterman-Petris-Short Act: California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care (Release Date: July 2020)

Recommendation for Legislative Action

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.

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of July 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

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.

Description of Legislative Action

SB 565 (Jones, 2021) would have required State Hospitals, on or before July 1, 2022, to develop a plan to expand the capacity of its facilities to reduce wait times for a person committed to a State Hospitals facility pursuant to the LPS Act to 60 days or less. The bill would require State Hospitals, on or before July 1, 2022, to submit to the Legislature a copy of the plan and a report regarding the anticipated cost of implementing the plan. The bill would require State Hospitals, on or before January 1, 2027, to implement that plan. This bill died in the Senate on February 1, 2022.

California State Auditor's Assessment of Annual Follow-Up Status: Legislation Proposed But Not Enacted

SB 565 (Jones, 2021) died on February 1, 2022.

Description of Legislative Action

SB 565 (Jones, 2021) would require State Hospitals, on or before July 1, 2022, to develop a plan to expand the capacity of its facilities to reduce wait times for a person committed to a State Hospitals facility pursuant to the LPS Act to 60 days or less. The bill would require State Hospitals, on or before July 1, 2022, to submit to the Legislature a copy of the plan and a report regarding the anticipated cost of implementing the plan. The bill would require State Hospitals, on or before January 1, 2027, to implement that plan.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

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.

Description of Legislative Action

SB 578 (Chapter 389, Statutes of 2021) requires a conservatorship hearing to be presumptively closed to the public if that hearing involves the disclosure of confidential information, and authorizes the individual who is the subject of the proceeding to demand that the hearing be public and be held in a place suitable for attendance by the public. A judge, hearing officer, or other person conducting the hearing is authorized to grant a request by any other party to the proceeding to make the hearing public if the judge, hearing officer, or other person conducting the hearing finds that the public interest in an open hearing clearly outweighs the individual's interest in privacy. "Hearing" for these purposes is defined to mean any proceeding conducted under the LPS Act.

California State Auditor's Assessment of Annual Follow-Up Status: Legislation Enacted

Description of Legislative Action

SB 578 (Jones, 2021) would require a conservatorship hearing to be presumptively closed to the public, but would authorize the individual who is the subject of the proceeding to demand that the hearing be public, and be held in a place suitable for attendance by the public. The bill would also authorize a judge, hearing officer, or other person conducting the hearing to grant a request by any other party to the proceeding to make the hearing public if the judge, hearing officer, or other person conducting the hearing finds that the public interest in an open hearing clearly outweighs the individual's interest in privacy. The bill would define "hearing" for these purposes to mean any proceeding conducted under the LPS Act.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation #4 To: San Francisco Department of Public Health

To evaluate and address shortages in the capacity of its treatment facilities, San Francisco should, by August 2021, conduct an assessment that determines the number and type of treatment beds that it needs to provide adequate care for individuals who require involuntary treatment. Once the county completes the assessment, it should adopt plans to develop the needed capacity.

1-Year Agency Response

As discussed in the previous reports, The San Francisco Department of Public Health has been working to implement bed expansion recommendations from the DPH/ Mosimtec simulation model. Bed acquisition and implementation is ongoing.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

In alignment with bed expansion recommendations from the DPH/ Mosimtec simulation model, DPH is actively planning and initiating procurement of a minimum of 117 beds across the recommended levels of care. Securing properties within the County of San Francisco has been a limiting factor in developing immediate long-term beds; however, DPH is committed to providing interim support while permanent solutions are developed. We are pursuing temporary acquisitions of contracted beds in and outside of the county from various contractors. We anticipate that some beds will be available to clients as early as the second quarter of 2021. Estimated timelines for projects are as follows:

1. Locked Subacute Treatment, beds contracted and ready to serve clients by April 2021;

2. Mental Health Residential beds in May 2021,

3. Adult Residential Facility (ARF and RCFE, Board and Care) by December 2021, and anticipated opening of an interim program for both ARF and RCFE participants. Longer term ARF and RCFE planning in development;

4.Psychiatric Skilled Nursing by June 2022. Long term bed acquisition and service delivery will be further developed in the coming months.

An important note is the lack of availability of State Hospital beds as these have extensive waits and individuals in need of these beds are not able to be served at less restrictive options.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

60-Day Agency Response

In early 2020 the DPH Mental Health Reform team engaged a simulation modeling vendor, Mosimtec, to answer the question: How many beds are needed in each behavioral health bed category to maintain consistent patient flow for adult clients in San Francisco with zero wait time? Through an in-depth analysis of patient placements in nearly 1,000 beds in the DPH behavioral health system of care in Fiscal Year 2018-2019, bed simulation modeling offered quantitative recommendations for improving patient flow. Recommendations include 1. Invest in additional bed capacity in Locked Subacute Treatment, Psychiatric Skilled Nursing Facilities, Residential Care Facilities (Board and Cares and facilities for the Elderly), and 12-month Mental Health Residential Treatment; 2. Complement all behavioral health bed investments one-to-one with long-term housing placements such as Permanent Supportive Housing to better serve people experiencing homelessness; 3. Create a robust wait time and patient placement data-tracking system to better understand the impact of operational barriers on patient wait time; and 4. Repeat bed simulation annually to understand trends and inform long-term planning, mitigate data limitations, and explore other interventions that would improve patient experience. The study, which included the bed needs of conserved individuals awaiting placement, resulted in a budget request for 117 additional beds at a cost of $10.6 million. This budget request was approved by the SF Board of Supervisors on 9/22/2020 and we anticipate its approval by Mayor London Breed on 10/1/2020. Next, DPH will identify a plan to achieve the additional capacity recommended by the study.

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Recommendation #5 To: Shasta County Health and Human Services Agency

To evaluate and address shortages in the capacity of its treatment facilities, Shasta should, by August 2021, conduct an assessment that determines the number and type of treatment beds that it needs to provide adequate care for individuals who require involuntary treatment. Once the county completes the assessment, it should adopt plans to develop the needed capacity.

1-Year Agency Response

Please see report

California State Auditor's Assessment of 1-Year Status: Fully Implemented

The agency's August 2021 Behavioral Health Bed Optimization Report includes an assessment of treatment bed needs and the plans for increasing treatment capacity. By providing this report, the agency demonstrated it has fully implemented our recommendation.

6-Month Agency Response

Between now (six-month review) and the 12-month review, Shasta will implement the areas described and outlined in the six-month report submitted here.

Summary Recommendations of Findings & Implementation Responsibilities:

1. Invest in additional Mental Health Rehabilitation Centers (MHRC) with life skills components to ensure bed capacity with fixed beds dedicated for use by the Shasta County's HHSA Behavioral Health program. Responsible for Implementation: HHSA Adult Services Transition, Admissions & Discharges (TAD), Public Guardian, Contracts departments and leadership

2. Complement all behavioral health bed investments with temporary supportive housing, permanent supportive housing or residential care facilities. Responsible for Implementation: HHSA Office of the Director, Economic Mobility Branch - Housing Department, Adult Services Contracts department, STAR program, leadership and system partners

3. Develop more capacity of subacute beds and services, residential treatment beds and services which provide longer-term care, including supportive housing units and services, and board and cares. Responsible for Implementation: HHSA Office of the Director, Adult Services Contracts department and leadership

4. Work to improve quality of care and client transitions across subacute and residential treatment beds and services. Responsible for Implementation: HHSA Adult Services Public Guardian, Mental Health and leadership

5. Support efforts to relax or eliminate the federal Medicaid SMI/SED IMD exclusion. Responsible for Implementation: HHSA Director, Adult Services Branch Director

6. Build out Pre-Hospital services - enhanced mobile crisis services, psychiatric ER (CSU), MH/SUD treatment options. Responsible for Implementation: HHSA Office of the Director, Adult Services Branch, crisis program, SUD program, leadership

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Shasta provided an additional report of its treatment resources and needs. However, at this time the county's report does not specify the number or type of treatment beds that it needs. The county also has not set measurable goals for the actions it plans to take, as indicated in the response above. For example, the county plans to invest in additional mental health rehabilitation centers with dedicated beds to ensure capacity for county patients, but it is unclear how many beds the county needs to add. It will be difficult to assess the county's progress in this area if it does not quantify its needs.

60-Day Agency Response

1. Shasta County HHSA analysts Joseph Carpenter and Josette McKrola, Adult Services Clinical Division Chiefs Monteca Zumalt and Genell Restivo, Deputy Director Robin Bowman, Public Guardian Program Manager Amparo Buck and Director Paige Greene will work collaboratively to conduct an assessment to determine the number and type of treatment beds needed to provide adequate care to individuals receiving involuntary treatment by the six-month review date.

2. After assessment is complete, Adult Services contract Analysts Stewart Buettell and Patricia Pratt, Clinical Program Coordinator Mey Chao-Lee, Clinical Division Chiefs Monteca Zumalt and Genell Restivo, Deputy Director Robin Bowman, and Director Paige Greene will adopt plans to develop needed capacity.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #6 To: Los Angeles County Department of Mental Health

To ensure that it connects patients who have been placed on multiple short-term holds to appropriate ongoing treatment, Los Angeles should, by no later than August 2021, adopt a systematic 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.

1-Year Agency Response

LACDMH agreed in principal with this recommendation but only on the condition that data regarding short-term holds (5150's) currently in possession of DOJ be made available to LACDMH. This will require legislative action which to date has not occurred. Transparent access to data on short-term holds can further improve LACDMH's ongoing efforts to identify those in need of additional engagement interventions. In the meantime, LACDMH continues to utilize available data to identify individuals who qualify for specialty mental health services and voluntarily accept these services. LACDMH utilizes hospital liaisons, to the extent, these liaisons are available, to identify individuals who are placed on multiple short-term holds so they can be referred for outreach and engagement or linked to the clinically appropriate level of treatment.

California State Auditor's Assessment of 1-Year Status: No Action Taken

We maintain the county does not need to wait for state law to change to take the actions available to it to better serve individuals who are experiencing mental illness. As we have described, during our 2019 audit Los Angeles was expanding its hospital liaison efforts, but these efforts had only reached five of the 49 designated facilities in the county. By declining to implement our recommendation, the county loses an opportunity to improve connections to care for those in need.

6-Month Agency Response

6 Month Agency Response

LACDMH agreed in principal with this recommendation but only on the condition that data regarding short-term holds (5150's) currently in possession of DOJ be made available to LACDMH. This will require legislative action which to date has not occurred. Transparent access to data on short-term holds can further improve LACDMH's ongoing efforts to identify those in need of additional engagement interventions. In the meantime, LACDMH continues to utilize available data to identify individuals who qualify for specialty mental health services and voluntarily accept these services. LACDMH utilizes hospital liaisons, to the extent, these liaisons are available, to identify individuals who are placed on multiple short-term holds so they can be referred for outreach and engagement or linked to the clinically appropriate level of treatment.

California State Auditor's Assessment of 6-Month Status: Pending

It is important for the county to take the actions available to it to better serve individuals who are experiencing mental illness. As we describe in our report, during our 2019 audit Los Angeles was expanding its hospital liaison efforts, but these efforts had only reached five of the 49 designated facilities in the county. The county could better connect individuals to the care they need by continuing to expand its hospital liaison efforts. The county does not need to wait for any changes to state law to do so. We look forward to reviewing the county's progress in the one year update on this recommendation.

60-Day Agency Response

LACDMH agreed in principal with this recommendation but only on the condition that data regarding short-term holds (5150's) currently in possession of DOJ be made available to LACDMH. This will require legislative action. Transparent access to data on short-term holds can further improve LACDMH's ongoing efforts to identify those in need of additional engagement interventions. In the meantime, LACDMH continues to utilize available data to identify individuals who qualify for specialty mental health services and voluntarily accept these services. LACDMH utilizes hospital liaisons, to the extent these liaisons are available, to identify individuals who are placed on multiple short-term holds so they can be referred for outreach and engagement or linked to the clinically appropriate level of treatment.

California State Auditor's Assessment of 60-Day Status: Pending

It is important for Los Angeles to make progress in identifying individuals placed on multiple short-term holds. We did not condition our recommendation on changes to state law. In our report we describe how Los Angeles was expanding its hospital liaison efforts but that these efforts had only expanded to five of the 49 designated facilities in the county. Without additional information from Los Angeles, we cannot assess the progress it has made. We look forward to the six-month update on this recommendation.

Recommendation #7 To: San Francisco Department of Public Health

To ensure that it connects patients who have been placed on multiple short-term holds to appropriate ongoing treatment, San Francisco should, by no later than August 2021, adopt a systematic 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.

Annual Follow-Up Agency Response From September 2023

Mental Health Sn Francisco created an Office of Coordinated Care (OCC) to centralize care coordination efforts, improve access to care and behavioral health linkages, and support individuals making transitions between levels of care. OCC launched a team in January 2022 that supports individuals exiting an LPS hold and connecting to appropriate levels of behavioral health care. In November 2022, the OCC moved into an integrated electronic health record with our public hospital, Zuckerberg San Francisco General Hospital (ZSFG), which houses the county's Psychiatric Emergency Services. This move was foundational to our work on systematic identification and planning for individuals exiting 5150WIC holds and allowed OCC and ZSFG staff, in conjunction with Department of Public Health data and IT teams, to create a daily report identifying all individuals placed on 5150WIC holds and summarizing their connections to behavioral health care. Over the last year the OCC has expanded its centralized triage and tracking functions with a goal of increasing rate of follow up. OCC has also added additional field-based teams to support the work of engaging with individuals at high level of need and with multiple system contacts, including street-based teams and teams focused at shelters and permanent supportive housing sites.

The Department of Public Health has continued to work with all local hospitals to systematically identify individuals existing a 5150WIC hold and fully implement SB929 and AB2242.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From December 2022

Mental Health SF creates an Office of Coordinated Care (OCC) to centralize care coordination efforts, improve behavioral health linkages, and support individuals making transitions between levels of care. OCC launched a team in January 2022 that supports individuals exiting an LPS hold and connecting to appropriate levels of behavioral health care. In November 2022, the OCC moved into an integrated electronic health record with our public hospital, Zuckerberg San Francisco General Hospital (ZSFG). This move was foundational to our work on systematic identification and planning for individuals exiting 5150WIC holds and allowed OCC and ZSFG staff, in conjunction with Department of Public Health data and IT teams, to create a daily report identifying all individuals placed on 5150WIC holds and summarizing their connections to behavioral health care. In the next year the OCC will add more staff and the Department of Public Health will work with all local hospitals to systematically identify individuals existing a 5150WIC hold to support establishing or reestablishing planned behavioral health services.

Additionally, there is a team that is dedicated to supporting individuals seen by the Street Crisis Response Team (SCRT), a specialized 24/7 non-law enforcement response to behavioral health emergencies that diverts individuals away from emergency rooms and criminal justice settings into care. The SCRT OCC team prioritizes individuals who are placed on or have a history of being placed on a 5150WIC hold to ensure that a robust plan is in place prior to discharge.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We appreciate the department's update on its continuing efforts to implement this recommendation. We look forward to receiving the department's next annual update following its expected completion of those efforts in December 2023.

Annual Follow-Up Agency Response From October 2021

Mental Health SF creates an Office of Coordinated Care (OCC) to oversee behavioral health linkages, which is a priority for planning and implementation. OCC will provide systematic behavioral health care coordination and support linkage to appropriate levels of care, prioritizing people who are exiting an LPS hold. There is currently a team that is dedicated to supporting individuals seen by the Street Crisis Response Team (SCRT), a specialized 24/7 non-law enforcement response to behavioral health emergencies that diverts individuals away from emergency rooms and criminal justice settings into care. The SCRT OCC team prioritizes individuals who are placed on or have a history of being placed on a 5150WIC hold to ensure that a robust plan is in place prior to discharge. Full implementation of OCC is pending hiring.

DPH has met with the Hospital Council of Northern California twice (June and August 2021) to discuss revising Designated Facility Agreements that would allow for enhanced data sharing, care coordination, and treatment planning for individuals exiting a hold, with particular attention for those with repeated involuntary holds. We requested that hospitals across San Francisco identify a point of contact for coordination by August 2021. At the time of this report, we have received a point for contact from one facility. We have informed hospitals that our goal is to partner with hospitals to update agreements, with their input, by Spring 2022 (with possible delays due to ongoing COVID response/surges and/or delays in response from hospital leadership).

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

The department's response and supporting documentation it provided demonstrate that San Francisco has taken a proactive approach to connecting individuals to appropriate mental health care. As the department notes in its response, it is still in the process of implementing components of that approach, including its agreements with hospitals to share data and coordinate care for individuals who are placed on involuntary holds for mental health treatment. Therefore, we consider this recommendation partially implemented and look forward to assessing the outcome of San Francisco's continued efforts when it provides its next update.

1-Year Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee behavioral health linkages and was discussed in our previous reports. The OCC continues to be an implementation priority. OCC currently has a team of clinicians and peer health workers that provides dedicated support to individuals who have been served by the Street Crisis Response Team (SCRT), a non-law enforcement response to behavioral health emergencies in public spaces. As of August 2021, the crisis teams will provide 24/7 city-wide coverage, which allows for a specialized and humanistic response to behavioral health crisis and diverts individuals away from emergency rooms and criminal justice settings into behavioral health care. The OCC team that provides follow up has frequent contact with individuals who have a history of being placed on a 5150WIC hold and prioritizes individuals who are placed on a hold by the SCRT team to ensure that a robust treatment plan is in place prior to discharge.

In addition to these efforts, The Department of Public Health has met with the Hospital Council of Northern California to discuss revising existing Memorandums of Understanding (MOU) that would allow for enhanced data sharing, case conferencing, and joint treatment planning for individuals exiting a hold, with particular attention to those who have had repeated involuntary holds. We have requested that all San Francisco hospitals identify a point of contact to coordinate enhanced MOU's and share information on individuals who have multiple involuntary holds by August 2021.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

The department's response and supporting documentation it provided regarding the Street Crisis Response Teams demonstrate that San Francisco has taken a proactive approach to connecting individuals to appropriate mental health care. However, because the department has reported that its Street Crisis Response Teams only respond to calls that do not demonstrate a significant safety concern, these efforts alone will not fully ensure that individuals who are placed on involuntary holds when they pose a danger to themselves or others will get connected to the care they need. To the extent San Francisco succeeds in also improving coordination with hospitals, its approach should ensure better care for individuals not treated by the Street Crisis Response Teams. Therefore, we consider this recommendation partially implemented and look forward to assessing the outcome of San Francisco's additional efforts when it provides its annual update.

6-Month Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee behavioral health services and was discussed in our previous report. The OCC continues to be a priority for planning and implementation. While not fully implemented, DPH is hiring OCC staff specifically to support a new Street Crisis Response Team (SCRT).

SCRT launched November 2020 and is in progress of launching a second team February 2021. These teams provide a non-law enforcement response to behavioral health emergencies in public spaces and divert individuals away from emergency rooms and criminal justice settings into behavioral health care. Each team includes a community paramedic, a behavioral health clinician, and behavioral health peer. Each team provides coverage in a specific geographic area with a goal of 24/7 city-wide coverage Spring 2021. In addition to diverting individuals from emergency rooms who may have otherwise been placed on an involuntary psychiatric hold, SCRT will likely be engaging with individuals who have previously been placed on a 5150WIC. Collaboration with the OCC will allow for enhanced data on supporting individuals who are at risk of psychiatric hospitalization.

As discussed, DPH has spoken to one of our largest private hospitals regarding obtaining alerts when individuals with frequent involuntary psychiatric holds are treated at their site. This is in process and will inform future collaborations. We also look forward to seeing State and/or legislative changes as recommended in the original audit to support the sharing of information both within and across counties.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

60-Day Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee mental health and substance use services. The OCC is responsible for 1) Maintaining an up-to-date inventory of available space in all City operated and funded mental health and substance use programs; 2) Providing and supervising case managers responsible for monitoring compliance with individual treatment plans and identifying appropriate housing placements; and 3) Coordinating the care of patients who are exiting the County Jail system or General Hospital's Psychiatric Emergency Services. Funding for the OCC has been budgeted pending mayoral approval, and includes a Bed and Patient Tracking System; Jail and PES Linkage Support; Crisis Linkage Support; and more positions for Case Management, Intensive Case Management, and Critical Care Management.

SF-DPH recently reached out to the Manager of Community Health of one of our largest private hospitals asking to discuss the feasibility of obtaining alerts when individuals are admitted for involuntary detention who have had multiple prior involuntary detentions. By working through the details of such a data sharing agreement, we hope to establish a workflow that could be replicated in our other Designated Receiving Facilities.

A Street Crisis Response Team is being developed which will provide a non-law enforcement response to behavioral health emergencies and divert individuals in crisis away from emergency rooms and criminal justice settings into behavioral health treatment facilities. Each team will include a paramedic from the Fire Department, and a behavioral health clinician and behavioral health peer from the Department of Public Health.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #8 To: Los Angeles County Department of Mental Health

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.

1-Year Agency Response

LACDMH disagreed with this recommendation but can report that due to COVID the court adopted tele- testimony for LPS conservatorship hearings, eliminating the physical appearance of treating physicians or forensic evaluators at the mental health court. LACDMH continues to advocate for the use of tele-testimony but recently the court announced a return to in-person hearings for any contested hearings. The Office of the Public Defender also expressed their desire for in-person hearings so the future of tele-testimony is in doubt. Use of LACDMH doctors in the LPS conservatorship process will continue to be limited to outpatient conservatorship cases and other cases in which LACDMH doctors already serve as the treating physician.

California State Auditor's Assessment of 1-Year Status: Will Not Implement

Both our audit and the county's own review of conservatorship proceedings found that termination of conservatorship because a doctor did not testify was a significant problem, causing care to end in six of ten terminated conservatorships we reviewed and 20 percent of terminated conservatorships the county reported for fiscal year 2017-18. Without changes to its practices, it is likely that the problems we observed will continue. We stand by our recommendation that Los Angeles change its practices to address this problem.

6-Month Agency Response

6 Month Agency Response

LACDMH disagreed with this recommendation but can report that due to COVID the court adopted tele- testimony for LPS conservatorship hearings, eliminating the physical appearance of treating physicians or forensic evaluators at the mental health court. Tele-testimony continues due to ongoing COVID orders. LACDMH has advocated strongly with the Los Angeles County Public Defender Office to allow tele-testimony to continue after COVID orders are lifted. Tele-testimony has been widely accepted and praised by physicians because they have increased opportunities to appear without negatively affecting their primary responsibility to treat their patient. LACDMH can report that a review of LPS Conservatorship Terminations data for Fiscal Year 2019-2020 as compared to FY 2018-2019 finds a nearly 50% decrease in the number of conservatorships terminated due to a lack of a doctor at the conservatorship hearing. LACDMH believes tele-testimony had some impact on this reduction. Unfortunately, due to COVID and the significant reductions in revenue for LACDMH and the County of LA, use of LACDMH doctors in the LPS conservatorship process will continue to be limited to outpatient conservatorship cases and other cases in which LACDMH doctors already serve as the treating physician.

California State Auditor's Assessment of 6-Month Status: Pending

As Los Angeles acknowledges, the temporary implementation of tele-testimony is due to pandemic conditions and does not guarantee a long-term solution to the county's problem of conservatorships that terminate due to the unavailability of doctors to testify. We maintain that the county should implement a comprehensive solution to this problem and look forward to reviewing its progress at the one year update on this recommendation.

60-Day Agency Response

LACDMH disagreed with this recommendation but can report that due to COVID the court has adopted tele- testimony for LPS conservatorship hearings, eliminating the physical appearance of treating physicians or forensic evaluators at the mental health court. LACDMH has advocated strongly with the Los Angeles County Public Defender Office to allow tele-testimony prior to COVID. This development has been widely accepted and praised by physicians because they have increased opportunities to appear without negatively impacting their primary responsibility to treat their patient. A preliminary review of terminated LPS cases shows a decrease in the number of cases terminated since March 2020 due to lack of a doctor testifying. Permanent adoption of tele-testimony will likely continue this trend of more doctors testifying and less cases being terminated due to lack of a doctor. This will require legislative action. Unfortunately, due to COVID and the significant reductions in revenue for LACDMH and the County of LA, use of LACDMH doctors in the LPS conservatorship process will be limited to outpatient conservatorship cases and other cases in which LACDMH doctors already serve as the treating physician.

California State Auditor's Assessment of 60-Day Status: Pending

Los Angeles describes a temporary change in court practices as having a beneficial effect on the availability of testimony from doctors. However, the solution is not guaranteed to continue once pandemic conditions subside. We look forward to Los Angeles's future updates about its long term proposed solution to the problem of conservatorships that terminate due to the unavailability of doctors to testify.

Recommendation for Legislative Action

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.

Description of Legislative Action

SB 507 (Chapter 426, Statutes of 2021) expands the criteria for a court to order assisted outpatient treatment if a clinical determination has been made that in view of the person's treatment history and current behavior, at least one of the following is true: a) the person is unlikely to survive safely in the community without supervision and the person's condition is substantially deteriorating, or b) the person is in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to the person or to others. This statute also expands the criteria for assisted outpatient treatment to include an eligible conservatee who is the subject of a pending petition for termination of a conservatorship under the LPS Act. Finally, the examining mental health professional is required to determine if the subject of the assisted outpatient treatment petition has the capacity to give informed consent regarding psychotropic medication in their affidavit to the court, and permits the subject of the petition or the examining mental health professional to appear before the court for testimony by video conferencing.

California State Auditor's Assessment of Annual Follow-Up Status: Legislation Enacted

Description of Legislative Action

SB 782 (Glazer, 2021) would authorize the filing of a petition to obtain assisted outpatient treatment for a conservatee or former conservatee who would benefit from assisted outpatient treatment to reduce the risk of deteriorating mental health while living independently.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

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.

Description of Legislative Action

AB 1976 (Chapter 140, Statutes of 2020) commencing July 1, 2021, requires counties to offer assisted outpatient programs, unless they opt out by a resolution passed by the governing body stating the reasons for opting out and any facts or circumstances relied on in making that decision. Counties are also authorized to offer assisted outpatient programs in combination with one or more counties, and prohibited from reducing existing voluntary mental health programs serving adults, or children's mental health programs, as a result of implementing the assisted outpatient programs.

California State Auditor's Assessment of 60-Day Status: Legislation Enacted

Recommendation for Legislative Action

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.

Description of Legislative Action

SB 749 (Glazer, 2021) would require, to the extent the Legislature makes an appropriation for these provisions, the Oversight Commission, in consultation with state and local mental health authorities, to create a comprehensive tracking program for county spending on mental and behavioral health programs and services including funding sources; funding utilization; and outcome data at the program, service, and statewide levels. The bill would require each county to report specified data to the Oversight Commission. The bill would also require the Oversight Commission to report the results of the county reporting to the Governor's office and the Legislature and to publish that information on its website in a location accessible to the public. As of September 2, 2022, this bill was pending in the Assembly.

California State Auditor's Assessment of Annual Follow-Up Status: Legislation Introduced

As of September 2, 2022, this bill was pending in the Assembly.

Description of Legislative Action

SB 749 (Glazer, 2021) would require, to the extent the Legislature makes an appropriation for these provisions, the Oversight Commission, in consultation with state and local mental health authorities, to create a comprehensive tracking program for county spending on mental and behavioral health programs and services including funding sources, funding utilization, and outcome data at the program, service, and statewide levels. The bill would require each county to report specified data for the preceding fiscal year to the Oversight Commission on or before July 31 of each year. The bill would also require the Oversight Commission to report the results of the county reporting to the Governor's office and the Legislature on or before September 1 of each year, and to publish that information on its website in a location accessible to the public.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

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.

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

AB 1340 (Santiago, 2021) would require State Hospitals to create a model discharge plan for counties and hospitals to follow when discharging those held under temporary holds or conservatorship. The bill would require county mental health departments to collaborate with facilities and hospitals to develop, implement, and adhere to an adequate discharge plan that ensures continuity of services and care in the community for all individuals exiting holds or conservatorship and to implement that plan across the entire network of acute and subacute facilities on or before July 1, 2023. This bill would clarify that counties may pay for these services using funds from the MHSA Fund when included in county plans, and would also authorize counties to pay for those services with specified funds from the Local Revenue Fund and the Local Revenue Fund 2011. The bill would require Health Care Services to, on or before July 1, 2022, issue guidance specifying which services authorized under the LPS Act may be paid by counties with funds from the MHSA Fund.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

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.

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of July 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of January 28, 2021, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

All Recommendations in 2019-119

Agency responses received are posted verbatim.