SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 480 (Salas) - Mental health: older adults

Bill Summary:

AB 480 would create an Older Adult Mental Health Services Administrator (Administrator) within the Department of Health Care Services (DHCS) who is required to oversee mental health services for older adults.

Fiscal Impact:

• Ongoing costs of approximately $680,000 per year for the Administrator position and support staff. Support staff would be needed to assist in coordinating and collaborating with stakeholders, developing outcomes and indicators for older adults, monitoring the quality of programs for older adults, preparing the required report, preparing regulations to specify the data that counties would be required to report, specifying a process to sanction non-compliant counties, and drafting conforming language for DHCS’s Performance Contract. (MHSF)
• One-time costs of $500,000 for a consultant contract to provide expert guidance to the development of the geriatric training module, and data collection and reporting of training requirements. (MHSF)

Background:

Proposition 63 (now known as the Mental Health Services Act or MHSA) was approved by voters in November 2004 and provides increased funding, personnel and other resources to support county mental health programs and monitor progress toward statewide goals for children, transition age youth, adults, older adults and families. The MHSA requires each county mental health program to prepare and submit a three-year plan to DHCS that must be updated each year and approved by DHCS after review and comment by the Mental Health Services Oversight and Accountability Commission (MHSOAC). DHCS is required to provide guidelines to counties related to each component of the MHSA. In the three-year plans, counties are required to include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. The MHSA provides funding for programs within five components: Community Services and Supports (CSS), Prevention and Early Intervention (PEI), Innovation, Capital Facilities and Technological Need, and Workforce Education and Training.

MHSA establishes the continuously appropriated Mental Health Services Fund (MHSF) to fund various mental health programs, including the Adult and Older Mental Health System of Care Act. The Fund is projected to have revenues of $2.2 billion in the 2019-20 Fiscal Year. Of this, five percent is set aside for administrative activities, from which the Administrator position proposed in this bill would be funded.

On June 10, 2019, Governor Newsom signed Executive Order N-14-19 calling for the creation of a Master Plan for Aging to be developed by October 1, 2020, to serve as a blueprint that can be used by state government, local communities, private organizations, and philanthropy to build environments that promote healthy aging.

Proposed Law:

This bill would establish within DHCS and funded by the MHSF, the Older Adult Mental Health Services Administrator to oversee mental health services for older adults. Specifically, this bill would:

• Require the administrator to work in close coordination and collaboration with stakeholders, including, but not limited to MHSOAC, CDA, county behavioral services departments, and other relevant stakeholders;
• Require the Administrator’s responsibilities to include, but not be limited to:
  • Service integration for MH services for older adults;
  • Determining which outcome and related indicators counties collect, and services offered;
  • Developing outcome and related indicators for older adults, as specified;
  • Ensuring that indicators reflect such things as screenings and assessments of affective disorders, suicide risk and suicide rates, medication review, substance use and misuse, housing and independent living assessment, and social connections and isolation;
  • Working with all relevant stakeholders to develop a strategy to identify high-level indicators, when information is not readily available, as specified;
  • Utilization review of the new outcome and related indicators to prepare and disseminate annually to DHCS, the MHSOAC, and counties, as specified; and,
  • Establishing a standardized geriatrics training module for MH professionals, in close coordination and consultation with experts, as specified, to be made available to MH professionals and other providers.
• Require the Administrator to receive any data, as permitted by state or federal law, necessary to develop outcome-related indicators, as specified, including data held by other state agencies or departments. The Administrator would be required to maintain the confidentiality of information received, as specified;
• Authorize the Administrator to establish one or more advisory bodies to guide and inform the selection of outcome and related indicators, and the strategy for developing and reporting those indicators. Further, an existing state entity such as the California Commission on Aging, would be authorized to act as an advisory body;
• Require the Administrator to report to DHCS, the California Behavioral Health Planning Council, the Office of Statewide Health Planning and Development, the MHSOAC, the Department of Public Health, and any other state agency that receives MHSA administrative funds by July 1, 2022, of all the outcome and related indicators developed by the Administrator and to include recommendations on way to establish a system for monitoring those indicators, as specified. The report may be made available to the Legislature;
• Require the Administrator to develop a strategy and standardized training for all county mental health personnel involved in delivering MHSA-funded mental health care and prevention service to older adults in order for counties to assist the Administrators in obtaining the data necessary to develop the outcome and related indicators, as specified.

Related Legislation:

SB 228 (Jackson, 2019) would require the Governor to appoint a Master Plan Director and establish an Aging Task Force, as specified, to work with representatives from impacted state departments, stakeholders, and other agencies to identify the policies and priorities that need to be implemented in California to prepare for the aging of its population. The measure is pending in the Assembly Appropriations Committee.

AB 1382 (Aguiar-Curry, 2019) would require the state to develop a Master Plan for Aging, emphasizing workforce priorities. The measure is pending in the Senate Appropriations Committee.

SB 1004 (Wiener and Moorlach, Chapter 843, Statutes of 2018) among other things, requires the Mental Health Services Oversight and Accountability Commission (MHSOAC) to establish priorities for the use of PEI funds to include, but are not limited to, early psychosis and mood disorder detection and intervention, and mood disorder and suicide prevention programming that occurs across the lifespan, and strategies targeting the mental health needs of older adults.

Staff Comments:

Previously, there was a position within the California Department of Aging – a geriatric mental health specialist funded by MHSA funds – who was responsible for overseeing mental health services for older adults. However, this position was eliminated in 2011.

Currently, there are existing methods for addressing the mental health needs of the older adult population, particularly through the MHSOAC, the state’s Commission on Aging, DHCS’s existing responsibilities, the Governor’s proposed Master Plan for Aging taskforce, and the recently enacted SB 1004, which prioritizes Prevention and Early Intervention (PEI) funds to focus on various populations, including older adults. The goals of the Administrator position proposed in this bill may overlap with some of the state’s already existing efforts.

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SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 480

SUBJECT: Mental health: older adults

SUMMARY:

Creates an Older Adult Mental Health (MH) Services Administrator (Administrator) within the Department of Health Care Services who is required to oversee MH services for older adults. Sets forth various responsibilities for the Administrator, including working in close coordination and collaboration with various state and local entities, as specified.

Existing law:

1. Establishes the Bronzan-McCorquodale Act to organize and finance community MH services for those with MH disorders in every county through locally administered and controlled programs. [WIC §5600, et seq.]
2. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14001.1]
3. Requires DHCS to require counties to use available state and matching funds for specified client target populations, which includes adults and older adults who have a serious mental disorder, and to develop a comprehensive array of services, as specified. Requires DHCS to require counties that receive funding to develop interagency collaboration with shared responsibilities, including provision of interagency case management services to coordinate resources to target population members who are using the services of more than one agency [WIC §5805, 5807]
4. Requires DHCS, pursuant to the MHSA and in coordination with counties, to establish a program designed to prevent mental illnesses from becoming severe and disabling, and requires the program to emphasize strategies to reduce the following negative outcomes that may result from untreated mental illness:
   1. Suicide;
   2. Incarcerations;
   3. School failure or dropout;
   4. Unemployment;
   5. Prolonged suffering;
   6. Homelessness; and,
   7. Removal of children from their homes. [WIC §5840]
5. Establishes the Mental Health Services Oversight and Accountability Commission (MHSOAC) to oversee the implementation of the Mental Health Services Act (MHSA), enacted by voters in 2004 as Proposition 63 to provide funds to counties to expand services, develop innovative programs, and integrate service plans for mentally ill children, adults, and seniors through a 1% income tax on personal income above $1 million. Requires the MHSOAC to consist of 16 voting members, including a family member of an adult or senior with a severe mental illness. [WIC §5845]
6. Establishes the Mello-Granlund Older Californians Act, which establishes the Department of Aging (CDA), and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of aging in place. [WIC §9100, et seq.]

This bill:

1. Creates an Administrator within DHCS who is required to oversee MH services for older adults. Requires the Administrator’s position to be funded by MHSA administrative funds, as specified.
2. Requires the Administrator to work in close coordination and collaboration with stakeholders, including, but not limited to, MHSOAC, CDA, county behavioral health services departments, and other relevant stakeholders, as specified.
3. Requires the Administrator’s responsibilities to include, but not be limited to, the following:
   1. Service integration for MH services for older adults;
   2. Determining which outcome and related indicators counties collect, and services offered;
   3. Developing outcome and related indicators for older adults, as specified;
   4. Ensuring that indicators reflect such things as screenings and assessments of affective disorders, suicide risk and suicide rates, medication review, substance use and misuse, housing and independent living assessment, and social connections and isolation;
   5. Working with all relevant stakeholders to develop a strategy to identify high-level indicators, when information is not readily available, as specified;
   6. Utilization review of the new outcome and related indicators to prepare and disseminate annually to DHCS, the MHSOAC, and counties, as specified; and,
   7. Establishing a standardized geriatrics training module for MH professionals, in close coordination and consultation with experts, as specified, to be made available to MH professionals and other providers.
4. Requires the Administrator to receive any data, as permitted by state or federal law, necessary to develop outcome-related indicators, as specified, including data held by other state agencies or departments. Requires the Administrator to maintain the confidentiality of information received, as specified.
5. Permits the Administrator to establish one or more advisory bodies to guide and inform the selection of outcome and related indicators, and the strategy for developing and reporting those indicators. Permits an existing state entity, such as the California Commission on Aging, to act as an advisory body.
6. Requires the Administrator to report to DHCS, the California Behavioral Health Planning Council, the Office of Statewide Health Planning and Development, the MHSOAC, the Department of Public Health, and any other state agency that receives MHSA administrative funds on or before July 1, 2022, of all the outcome and related indicators developed by the Administrator, and to include recommendations on ways to establish a system for monitoring those indicators, as specified. Permits the report to be made available to the Legislature, upon request.
7. Requires the Administrator to develop a strategy and standardized training for all county MH personnel, including clinicians, involved in delivering MHSA-funded MH care and prevention services to older adults in order for counties to assist the Administrator in obtaining the data necessary to develop the outcome and related indicators, as specified.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, as this bill was amended on April 22, 2019, with the Administrator within CDA:

1. Estimated one-time costs of up to $1million (General Fund [GF]) for CDA to develop the database that would collect specified MH-related data from a variety of sources. Additional annual costs in the range of $50,000 to $150,000 GF for ongoing maintenance of the database.
2. Estimated one-time costs in the range of $75,000 to $500,000 (Mental Health Services Fund [MHSF]), depending on the scope of work, for a consultant contract to provide expert guidance to the development of the geriatric training module and data collection and reporting training.
3. Estimated ongoing annual costs of approximately $686,000 MHSF to CDA for three positions to oversee and carry out the duties of the bill.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the Centers for Disease Control and Prevention estimates that 20% of people aged 55 years or older experience some type MH concern, but less than one-third of all older adults in the U.S. who need MH care receive it. In California, the older adult population will increase 64% by 2035 to 12 million adults aged 60 and above. By that same time, the U.S. Census Bureau projects seniors will outnumber youth for the first time in our nation’s history. Given the rapidly growing segment of the state’s population that is made up of older adults, and the significant and unique challenges that older adults face as it relates to MH, it is critical that the state appoint a leader and adopt a plan to increase, improve, and integrate MH services for older adults.
2. MHSA. The MHSA requires each county MH program to prepare and submit a three-year plan to DHCS that must be updated each year and approved by DHCS after review and comment by the MHSOAC. DHCS is required to provide guidelines to counties related to each component of the MHSA. In the three-year plans, counties are required to include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. The MHSA provides funding for programs within five components:
   1. Community Services and Supports (CSS): Provides direct MH services to the severely and seriously mentally ill, such as MH treatment, cost of health care treatment, and housing supports. Regulations require counties to direct the majority of its CSS funds to Full-Service Partnerships (FSPs). FSPs are county coordinated plans, in collaboration with the client and the family, to provide the full spectrum of community services. These services consist of MH services and supports, such as peer support and crisis intervention services; and non-MH services and supports, such as food, clothing, housing, and the cost of medical treatment. Outside of FSPs, counties do not use CSS funds to assist with housing;
   2. Prevention and Early Intervention (PEI): Provides services to MH clients in order to help prevent mental illness from becoming severe and disabling;
   3. Innovation: Provides services and approaches that are creative in an effort to address MH clients’ persistent issues, such as improving services for underserved or unserved populations within the community;
   4. Capital Facilities and Technological Needs: Creates additional county infrastructure such as additional clinics and facilities and/or development of a technological infrastructure for the MH system, such as electronic health records for MH services; and,
   5. Workforce Education and Training: Provides training for existing county MH employees, outreach and recruitment to increase employment in the MH system, and financial incentives to recruit or retain employees within the public MH system.

SB 1004 (Wiener and Moorlach, Chapter 843, Statutes of 2018) requires, among other things, the MHSOAC, on or before January 1, 2020, to establish priorities for the use of PEI funds and to develop a statewide strategy for monitoring implementation of PEI services, including enhancing public understanding of PEI and creating metrics for assessing the effectiveness of how PEI funds are used and the outcomes that are achieved. SB 1004 also requires PEI funds in a county’s three-year plan to focus on priorities established by the MHSOAC that include the following, at a minimum:

• 1. Childhood trauma prevention and early intervention to deal with the early origins of MH needs;
  2. Early psychosis and mood disorder detection and intervention, and mood disorder and suicide prevention programming that occurs across the lifespan;
  3. Youth outreach and engagement strategies that target secondary school and transition age youth, with a priority on partnership with college MH programs;
  4. Culturally competent and linguistically appropriate prevention and intervention;
  5. Strategies targeting the MH needs of older adults; and,
  6. Other programs the MHSOAC identifies, with stakeholder participation, that are proven effective in achieving, and are reflective of, the goals of the MHSA.

1. MH of older adults. According to the World Health Organization, older adults (those aged 60 or above) make important contributions to society as family members, volunteers, and as active participants in the workforce. While most have good MH, many older adults are at risk of developing mental disorders, neurological disorders, or substance use problems, as well as other health conditions, such as diabetes, hearing loss, and osteoarthritis. Furthermore, as people age, they are more likely to experience several conditions at the same time. Between 2015 and 2050, the proportion of the world’s older adults is estimated to almost double from about 12% to 22%, an expected increase from 900 million to two billion people over the age of 60. Older people face special physical and MH challenges. Over 20% of adults aged 60 and over suffer from a mental or neurological disorder (excluding headache disorders), and 6.6% of all disability among people over 60 years is attributed to mental and neurological disorders. The most common mental and neurological disorders in this age group are dementia and depression, which affect approximately 5% and 7% of the world’s older population, respectively. Anxiety disorders affect 3.8% of the older population, substance use problems affect almost 1%, and around a quarter of deaths from self-harm are among people aged 60 or above. Substance abuse problems among older people are often overlooked or misdiagnosed. MH problems are under-identified by health care professionals and older people themselves, and the stigma surrounding these conditions makes people reluctant to seek help.
2. UCLA Center for Health Policy Research. A study conducted by the UCLA Center for Health Policy Research, “California’s Public Mental Health Services: How are Older Adults Being Served,” found a number of deficiencies in the current structure as it relates to MH services for older adults, including that the availability of a complete system of services for older adults with mental illness is a work in progress and there is a need for programs to engage in targeted outreach specifically tailored to older adults. The study found that implementation of older adult MH services is uneven; MHSA outcome reporting is inadequate for measuring the reach and effectiveness of services among older adults; there are significant and persistent deficits in the geriatrics workforce; and, there are numerous barriers to MH services for older adults. The study concluded that California counties with a formal, designated older adult system of care offered more programming and services tailored to older adult needs than those without. The report recommended that such a dedicated system should be implemented in all counties.
3. Governor’s Master Plan for Aging. On June 10, 2019, Governor Newsom signed Executive Order (EO) N-14-19 calling for the creation of a Master Plan for Aging to be developed by October 1, 2020, to serve as a blueprint that can be used by state government, local communities, private organizations, and philanthropy to build environments that promote healthy aging. The EO directs the Secretary of the California Health and Human Services Agency (CHHSA) to convene a cabinet-level Workgroup for Aging to advise the Secretary in developing and issuing the Master Plan. CHHSA, along with other state partners, will also convene a Master Plan for Aging Stakeholder Advisory Committee, which will include a Research Subcommittee and a Long-Term Care Subcommittee, with an interest in building an age-friendly California. These subcommittees are expected to include older Californians, adults with disabilities, local government representatives, health care providers, health plans, employers, community-based organizations, foundations, academic researchers, and organized labor. The Long-Term Care Subcommittee is tasked with issuing a report to the Governor by March 2020 on stabilizing state long-term care programs and infrastructure, including In-Home Supportive Services, with the full Master Plan completed by October 2020. The Workgroup’s focus will go beyond the health and human services area to include transportation and housing issues and their impact on an individual’s health outcomes and well-being, as well as focus outside of public programs as many older Californians do not utilize or have access to public programs and services the state administers.
4. Double referral. This bill was heard in the Senate Human Services Committee on June 10, 2019, and passed out by a vote of 5-0.
5. Related legislation. AB 1287 (Nazarian) requires CDA, in partnership with other specified departments and in consultation with stakeholders, to develop a plan and strategy for a phased statewide implementation of the No Wrong Door system, as specified. Requires CHHSA, in consultation with specified departments, to develop a universal tool and process to assess individual need and determine initial eligibility for programs and services available in the long-term services and supports delivery network. AB 1287 is set to be heard in the Senate Human Services Committee on July 8, 2019.

AB 1382 (Aguiar-Curry) requires the state to develop a Master Plan for Aging, emphasizing workforce priorities, as provided in this section. Requires the Master Plan for Aging to prioritize the following issues related to preparing and supporting California’s paid paraprofessionals, professionals, and unpaid family caregiver. AB 1382 is set to be heard in the Senate Human Services Committee on July 8, 2019.

SB 228 (Jackson) requires the Governor to appoint a Master Plan Director (MPD) and establishes an Aging Task Force, as specified. Requires the MPD and the task force, to work with representatives from impacted state departments, stakeholders, and other agencies to identify the policies and priorities that need to be implemented in California to prepare for the aging of its population. SB 228 was heard in the Assembly Aging and Long-Term Care Committee and passed by a vote of 7-0 on June 25, 2019.

SB 611 (Caballero) establishes the Master Plan for Aging Housing Task Force to, among other things, make recommendations to the Legislature for legislation that will help increase the supply of affordable housing for older adults and reduce barriers to providing health care and social services to older adults in affordable housing. SB 611 is set to be heard in the Assembly Aging and Long-Term Care Committee on July 9, 2019.

1. Prior legislation. SB 1004 (Wiener and Moorlach, Chapter 843, Statutes of 2018) among other things, requires the MHSOAC to establish priorities for the use of PEI funds to include, but are not limited to, early psychosis and mood disorder detection and intervention, and mood disorder and suicide prevention programming that occurs across the lifespan, and strategies targeting the MH needs of older adults.
2. Support. Supporters of this bill, largely MH and senior advocates, state that there currently is no behavioral health structure for older adults, and while one-in-five experience mental illness, less than one-third who need MH care receive it. Supporters argue that often mental wellness in older adults is overlooked in order to treat existing physical health needs, despite that mental and physical well-being are connected. Supporters also argue that as the aging population is expected to increase dramatically, coupled with a sharp increase in suicide rates among this population, it is critical to establish and prioritize geriatrics training for MH professionals.
3. Policy comment. While there is a stated need for attention to the aging population and their health care needs in general, it appears that there are existing methods for addressing the MH needs of the older adult population, particularly through the MHSOAC, the state’s Commission on Aging, DHCS’s existing responsibilities, the Governor’s proposed Master Plan for Aging taskforce, and the recently enacted SB 1004, which prioritizes PEI funds to focus on various populations, including older adults. It is unclear why an Administrator focusing only on older adults and not all populations suffering mental illness is needed to perform tasks that may be accomplished through increased coordination by existing entities focusing on MH issues and the aging population.

SUPPORT AND OPPOSITION:

Support: California Alliance for Retired Americans

California Assisted Living Association

California Association for Health Services at Home

California Behavioral Health Planning Council

California Commission on Aging

California Council of Community Behavioral Health Agencies

California Hospital Association

California State Retirees

LeadingAge California

Steinberg Institute

Oppose: None received

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SENATE COMMITTEE ON HUMAN SERVICES

Senator Hurtado, Chair

2019 - 2020 Regular

Subject: Mental health: older adults.

SUMMARY

This bill establishes an Older Adult Mental Health Services Administrator within the California Department of Aging (CDA) to oversee mental health service for older adults.

ABSTRACT

Existing Law:

1. Establishes the Mental Health Services Act (MHSA), an initiative enacted by the voters as Proposition 63 (November 2004), which provides for the continuously appropriated Mental Health Services Fund to support various county mental health programs, including the Adult and Older Adult Mental Health System of Care Act.
2. Authorizes, pursuant to Proposition 63, the MHSA to be amended by a 2/3 vote of the Legislature if the amendments are consistent with, and further the purposes of, the MHSA, and also permits the Legislature to clarify procedures and terms of the MHSA by a majority vote.
3. Establishes the Adult and Older Adult Mental Health System of Care Act. (WIC 5800 et seq.)
4. Requires the Department of Health Care Services (DHCS) to require counties to use available state and matching funds for specified client target population, which includes adults and older adults who have a serious mental disorder, and to develop a comprehensive array of services, as specified. (WIC 5805)
5. Requires, subject to the availability of funds from the Mental Health Services Fund, the state to distribute funds for the provision of specified services to county mental health programs. Further requires that services shall be available to adults and seniors with severe mental illnesses, as specified. (WIC 5813.5)
6. Requires that funding shall be provided at sufficient levels to ensure that counties can provide each adult and senior with the medically necessary mental health services, medications, and supportive services set forth in the applicable treatment plan. (WIC 5813.5 (a))
7. Creates the Mental Health Services Fund in the State Treasury and requires that all moneys in the fund are continuously appropriated, without regard to fiscal years, for the purpose of funding specified programs, including the Adult and Older Adult Mental Health System of Care Act, and other related activities, as specified. (WIC 5890)
8. Establishes the Mello-Granlund Older Californians Act, which establishes CDA, and sets forth its duties and powers, including, among other things, entering into a contract for the development of information and materials to educate Californians on the concept of “aging in place.” (WIC 9100 et seq.)

This Bill:

Creates within CDA an Older Adult Mental Health Services Administrator (Administrator) who shall oversee mental health services for older adults and requires that the position shall be funded with administrative funds from the Mental Health Services Fund, as specified.

Requires the Administrator to work in close coordination and collaboration with stakeholders including, but not limited to, the Mental Health Services Oversight and Accountability Commission (MHSOAC), the director of DHCS, county behavioral health services departments, and any other relevant stakeholder.

Establishes the responsibilities of the Administrator to include, but not be limited to, the following:

1. Service integration for mental health services for older adults.
2. Determining which outcome and related indicators counties are currently collecting, and which current services are being offered.
3. Developing outcome and related indicators for older adults, using existing data, for the purpose of assessing the status of mental health services for older adults, for monitoring the quality of programs intended to serve those older adults, and to guide decision-making on how to improve those services.
4. Ensuring that indicators reflect the following specified issues, including, but not limited to, screenings and assessments of affective disorders; suicide risk and suicide rates; medication review; cognitive review and assessment; alcohol use and substance misuse; housing and independent living assessment; social connections and social isolation; consumer and family satisfaction with care; access to care overall and for diverse populations; continuity and integration of care; health service utilization such as psychiatric hospitalizations and emergency room use of mental and behavioral health; the number of eligible older adults with a mental health service need compared with the number of eligible older adults who received services in the measurement year; and services provided on a regional basis to determine regional areas with the greatest need for services.
5. To the extent that data does not exist to sufficiently determine specified outcome and related indicators, working with all relevant stakeholders to develop a strategy to identify high-level indicators, including, but not limited to, those indicators that cannot be sufficiently defined using existing and available data.
6. Utilization of the new outcome and related indicators to prepare and disseminate, on an annual basis, reports to DHCS, MHSOAC, and counties that include, but are not limited to, numbers of older adults served by age, differences in age categorization of older adult groups served, and effectiveness of services.
7. In close coordination and consultation with experts in the field, establishing a standardized geriatrics training module for mental health professionals that would include a plan to account for cultural, linguistic, ethnic, geographic, and socioeconomic diversity among the older adult population, and that address barriers and stigma experienced by older adult populations. The standardized training module shall be made available to mental health professionals and other providers.
8. Requires the Administrator to receive any data, the access to which is not restricted by any state or federal law, necessary to develop specified outcome-related indicators, including, but not limited to, data held by other state agencies or departments.
9. Requires the Administrator to maintain the confidentiality of information received pursuant to this section in a manner that is equal to the manner in which other state agencies or departments maintain the confidentiality of data.
10. Permits the Administrator to establish one or more advisory bodies to guide and inform the selection of outcome and related indicators and the strategy for developing and reporting those indicators. Permits an existing state entity that involves diverse representation of older adults, including, but not limited to, the California Commission on Aging, to act as an advisory body.
11. Requires the Administrator to report to specified entities, on or before July 1, 2022, all of the outcome and specified related indicators. Requires the report to also include recommendations on ways to establish a system for monitoring those indicators on a continual basis, including additional staffing or technology that might be necessary, and any regulatory or fiscal barriers that may hinder future progress on the development of a monitoring system. Permits the report to be made available to the Legislature, upon request by the Legislature.
12. Requires the Administrator to develop a strategy and standardized training for all county mental health personnel, including clinicians, involved in delivering MHSA mental health care and prevention services to older adults in order for counties to assist the administrator in obtaining the data necessary to develop specified outcome and related indicators.

Provides that the Legislature finds and declares that this act clarifies procedures and terms of the MHSA within the meaning of Section 18 of the MHSA.

FISCAL IMPACT

According to an analysis prepared by the Assembly Appropriations Committee dated May 16, 2019, this bill would likely have the following fiscal effect:

1. Estimated one-time costs in the range of $75,000 (MHSF) to $500,000 (MHSF), depending on the scope of work, for a consultant contract to provide expert guidance to the development of the geriatric training module and data collection and reporting training.
2. Estimated ongoing annual costs of approximately $686,000 (MHSF) to CDA for three positions to oversee and carry out the duties of the bill.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

According to the author, this bill intends “to increase service integration and standardize needs assessment and data reporting requirements as it relates to older adults receiving mental health services.” It is further the intent of the author to “establish and prioritize standardized geriatrics training for mental health professionals to account for the increasingly diverse population and to address barriers and stigma experienced by older adult populations.”

Aging Demographics

In California, the senior population is projected to increase by four million in the next ten years. In 40 years, California’s Department of Finance projects California’s senior population will grow to approximately 13.5 million. According to AARP, California’s age 85 and older population will grow 243 percent from 2015 to 2050 and the state’s age 65 and older population will increase 119 percent.

Causes of the projected rapid growth of senior population include aging baby boomers and increasing longevity, in general. With longevity comes increased need for care. Statistics show that more than half of adults 65 years and older will require some form of long-term care.

California Department of Aging (CDA)

CDA administers programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the state. The department administers funds allocated under the federal Older Americans Act, the Older Californians Act, and through the Medi-Cal program. CDA contracts with the network of area agencies on aging (AAAs), who directly manage a wide array of federal and state-funded services that help older adults find employment; support older and disabled individuals to live as independently as possible in the community; promote healthy aging and community involvement; and assist family members in their vital care giving role. CDA also contracts directly with agencies that operate the Multipurpose Senior Services Program through the Medi-Cal home and community-based waiver for the elderly, and certifies Adult Day Health Care centers for the Medi-Cal program

Mental Health Services Act (MHSA)

Proposition 63 (now known as the Mental Health Services Act or MHSA) was approved by voters in November 2004 and provides increased funding, personnel and other resources to support county mental health programs and monitor progress toward statewide goals for children, transition age youth, adults, older adults and families.  The Act addresses a broad continuum of prevention, early intervention and service needs and the necessary infrastructure, technology and training elements that support this system. MHSA imposes a one percent income tax on personal income in excess of $1 million. 

MHSA establishes the continuously appropriated Mental Health Services Fund to fund various mental health programs, including the Adult and Older Mental Health System of Care Act. The Fund is projected to have revenues of $2.2 billion in the 2019-20 Fiscal Year. Of this, five percent is set aside for administrative activities, from which the new Administrator position would be funded.

Mental Health Services Oversight and Accountability Commission

The Commission was established in 2004 to provide oversight and accountability for portions of the MHSA, Adult and Older Adult System of Care Act and Children's Mental Health Services Act. The Commission's primary roles include: (1) providing oversight, review, accountability, and evaluation of projects and programs supported by MHSA funds, (2) assessing whether services that are provided pursuant to the MHSA are cost-effective and in accordance with recommended best practices, (3) participating in the decision making process for training, technical assistance, and regulatory resources to meet the mission and goals of the state’s mental health system, (4) reviewing and approving county Innovation Program and Expenditure Plans, (5) providing counties technical assistance in MHSA program plan development to accomplish the purposes of the MHSA, and (6) administering the Mental Health Wellness Act of 2013 Triage Personnel grants. The Commission also advises the Governor and the Legislature regarding state actions to improve care and services for people with mental illness.

Mental Health Needs for Older Adults

According to the Centers for Disease Control and Prevention, it is estimated that 20 percent of people age 55 years or older experience some type mental health concern.

Mental health issues faced by older adults can range from anxiety and depression to serious mental illness. These can be complicated by other ailments and chronic diseases common among older adults, such as dementia, heart disease, diabetes, arthritis, or cancer. Moreover, older adults diagnosed with a mental illness are more likely to develop chronic conditions and dementia as they age.

Often older adults do not seek or receive the help they need, despite that fact that one in five older adults experience mental health concerns. By the age of 75, close to half of all Americans will have experienced a diagnosable mental disorder. The World Health Organization estimates that worldwide, 15 percent of adults age 60 and over live with mental illness.

Mental health issues are often implicated as a factor in cases of suicide and older adults also have the highest suicide rate in the country. The increase in suicides from 1996 to 2016 in California has risen dramatically, notably among older adults. From 1991 to 2017, California saw a 58 percent increase in the number of suicides for those aged 65-84 and 50 percent for those 85 and older (compared with a 14.8 average increase statewide across all age groups). Suicide rates are particularly high in rural parts of California where access to mental health care is severely lacking.

A study conducted by the UCLA Center for Health Policy Research, titled “California’s Public Mental Health Services: How are Older Adults Being Served,” found a number of deficiencies in how mental health services are provided for older adults. According to the study, there is unmet need among older adults with mental illness and “the availability of a complete system of services for older adults with mental illness is a work in progress.” The study also identified a need for programs to engage in targeted outreach specifically tailored to the older adults.

The study found that implementation of older adult mental health services is uneven; MHSA outcome reporting is inadequate for measuring the reach and effectiveness of services among older adults; there are significant and persistent deficits in the geriatrics workforce; and there are numerous barriers to mental health services for older adults. The study concluded that counties with a designated Older Adult System of Care (OASOC) offered more programming and services tailored to older adult needs than those without one. The report recommended that the OASOC approach should exist in all counties that have the capacity to do so.

Master Plan on Aging

The increasing urgency of need to build a system that can address the socioeconomic needs and demands of our growing and diverse older adult population has recently elevated in profile. Governor Newsom announced plans to create a statewide Master Plan on Aging and an Alzheimer’s Prevention and Preparedness Task Force. During the State of his 2019 State Address, Governor Newsom declared “It’s time for a new Master Plan on Aging. It must address: person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage, and demand for In-Home Supportive Services that far outpaces its capacity.”

Related/Prior Legislation:

SB 512 (Pan, 2019) establishes the California long term services and supports (LTSS) Benefits Board and requires the Board to manage and invest revenue deposited in the California LTSS Benefits Trust Fund, which is also created by SB 512, for the purpose of financing LTSS for eligible individuals. This bill has been double-referred to the Assembly Aging and Long-Term Care Committee and the Assembly Human Services Committee.

SB 611 (Caballero, 2019) establishes the Master Plan for Aging Housing Task Force to, among other things, make recommendations to the Legislature for legislation that will help increase the supply of affordable housing for older adults and reduce barriers to providing health care and social services to older adults in affordable housing. This bill is at waiting to be heard in the Assembly.

AB 567 (Calderon, 2019) establishes a task force to design a statewide, public long-term care insurance program. This bill is has been double referred to the Senate Insurance Committee and the Senate Health Committee.

AB 1136 (Nazarian, 2019) establishes the California Department of Community Living and requires that department to establish a statewide NWD system to support seamless access to information regarding available long-term services and supports, as provided. This bill was held in the Assembly Appropriations Committee.

AB 1287 (Nazarian, 2019) states Legislative intent to establish the Master Plan for an Aging California that responds to population needs in a comprehensive manner, including, but not limited to, implementing the No Wrong Door system that facilitates access to a universal assessment process and streamlined information and support and that the No Wrong Door system will support statewide seamless access to LTSS, including universal assessment, while building upon the information and referral standards established through the Aging and Disability Resource Connection program, which is currently limited to eight counties. This bill is waiting to be heard in the Senate.

AB 1382 (Aguiar-Curry, 2019) requires the state to develop a Master Plan for Aging, emphasizing workforce priorities, as provided in this section. Requires the Master Plan for Aging to prioritize the following issues related to preparing and supporting California’s paid paraprofessionals, professionals, and unpaid family caregiver. This bill is waiting to be heard in the Senate.

COMMENTS

Previously, there was a position within CDA – a geriatric mental health specialist funded by MHSA funds - who was responsible for overseeing mental health services for older adults. However, this position was eliminated in 2011. The Administrator position proposed by the bill appears to align with that eliminated positon.

The National Alliance on Mental Illness (NAMI) – California has expressed concern (but did not take a position on this bill) that the use of MHSA Administrative Funds for this purpose is inconsistent with the intent of the act and its prohibition on the use of MHSA funds to supplant other funding sources. They argue that state general fund would be a more appropriate funding source. Should this bill move forward, the author may wish to seek clarification on this issue.

This bill has been double-referred and, should it move out of this committee, it will be referred to the Senate Housing Committee.

PRIOR VOTES

POSITIONS

Support:

California Association for Health Services At Home

California Hospital Association

Oppose:

None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 480

Author:(Salas)

As Amended Ver:April 22, 2019

Majority vote

SUMMARY:

Establishes within the State Department of Aging an Older Adult Mental Health Services Administrator to oversee mental health services for older adults.

Major Provisions

1. Requires that position to be funded with administrative funds from the Mental Health Services Fund.
2. Prescribes the functions of the administrator and its responsibilities, including, but not limited to, developing outcome and related indicators for older adults for the purpose of assessing the status of mental health services for older adults, monitoring the quality of programs for those adults, and guiding decision-making on how to improve those services.
3. Requires the administrator to receive data from other state agencies and departments to implement these provisions, subject to existing state or federal confidentiality requirements.
4. Requires the administrator to report to the entities that administer the Mental Health Services Act (MHSA) on those outcome and related indicators by July 1, 2022, and would authorize the administrator to make the report available to the Legislature, upon request.
5. Requires the administrator to develop a strategy and standardized training for all county mental health personnel in order for the counties to assist the administrator in obtaining the data necessary to develop the outcome and related indicators.

COMMENTS:

According to the Centers for Disease Control and Prevention, it is estimated that 20% of people age 55 years or older experience some type mental health concern.

Far too often older adults do not seek or receive the help they need, despite that fact that one in five older adults experience mental health concerns. By the age of 75, close to half of all Americans will have experienced a diagnosable mental disorder. The World Health Organization estimates that worldwide, 15% of adults age 60 and over live with mental illness.

Mental health issues are often implicated as a factor in cases of suicide and older adults also have the highest suicide rate in the country. The percentage increase in suicides from 1996 to 2016 in California has risen dramatically, notably among older adults. From 1991 to 2017, California saw a 58% increase in the number of suicides for those aged 65-84 and 50% for those 85 and older (compared with a 14.8 average increase statewide across all age groups). Suicide rates are particularly high in rural parts of California where access to mental health care is severely lacking.

According to a study conducted by the UCLA Center for Health Policy Research, less than one-third of all older adults in the United States who need mental health care receive it. The study found a number of deficiencies in the current structure as it relates to mental health services for older adults. It found that: a) implementation of older adult mental health services is uneven; b) MHSA outcome reporting is inadequate for measuring the reach and effectiveness of services among older adults; c) there are significant and persistent deficits in the geriatrics workforce; and, d) there are numerous barriers to mental health services for older adults.

Under existing law, the MHSA, an initiative measure approved by voters as Proposition 63 in 2004, establishes the continuously appropriated Mental Health Services Fund to fund various mental health programs, including the Adult and Older Mental Health System of Care Act.

Since the passage of Prop. 63 until 2014, over $13 billion in the state's tax revenue has been allocated for public mental health services, yet a distinct administrative structure and specific funding older adult services are not mandated in MHSA, as they are for children under the age

of 18.

According to the Author:

"Given the rapidly growing segment of the state's population that is made up of older adults, and the significant and unique challenges that older adults face as it relates to mental health, it is critical that the state appoint a leader and adopt a plan to increase, improve and integrate mental health services for older adults."

Arguments in Support:

The California Hospital Association writes, "This new position would better integrate physical and mental health care for older adults, leading to higher-quality care for California's elderly. In addition, the position would ensure that funds from the Mental Health Services Act are used efficiently and as the bill intended."

Arguments in Opposition:

None on file.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Estimated one-time costs of up to $1million (GF) for CDA to develop the database that would collect specified mental health-related data from a variety of sources. Additional annual costs in the range of $50,000 to $150,000 (GF) for ongoing maintenance of the database.
2. Estimated one-time costs in the range of $75,000 (MHSF) to $500,000 (MHSF), depending on the scope of work, for a consultant contract to provide expert guidance to the development of the geriatric training module and data collection and reporting training.
3. Estimated ongoing annual costs of approximately $686,000 (MHSF) to CDA for three positions to oversee and carry out the duties of the bill.

VOTES:

ASM AGING AND LONG-TERM CARE: 7-0-0

YES: Nazarian, Voepel, Boerner Horvath, Kalra, Lackey, Reyes, Blanca Rubio

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: April 22, 2019

CONSULTANT: Barry Brewer / AGING & L.T.C. / (916) 319-3990 FN: 0000681

Date of Hearing: May 16, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 480

Author:(Salas) – As Amended Ver:April 22, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill establishes within the California Department of Aging (CDA) an Older Adult Mental Health Services Administrator (Administrator) to oversee mental health services for older adults.

The bill specifies the responsibilities of the Administrator, including collaboration with relevant stakeholders to ensure older adults have access to necessary behavioral health services and support, and requires the position be paid from administrative funds from the Mental Health Services Fund (MHSF). The bill also requires the Administrator to develop outcome and related indicators using existing data and to report, by January 1, 2022, to the Department of Health Care Services and others the indicators and recommendations for monitoring the indicators on a continual basis. The bill further requires the Administrator to develop a strategy and standardized geriatrics training for mental health professionals.

FISCAL EFFECT:

1. Estimated one-time costs of up to $1million (GF) for CDA to develop the database that would collect specified mental health-related data from a variety of sources. Additional annual costs in the range of $50,000 to $150,000 (GF) for ongoing maintenance of the database.
2. Estimated one-time costs in the range of $75,000 (MHSF) to $500,000 (MHSF), depending on the scope of work, for a consultant contract to provide expert guidance to the development of the geriatric training module and data collection and reporting training.
3. Estimated ongoing annual costs of approximately $686,000 (MHSF) to CDA for three positions to oversee and carry out the duties of the bill.

COMMENTS:

1. Purpose. This bill seeks to address the mental health needs of the state’s older population. According to the author:

Given the rapidly growing segment of the state’s population that is made up of older adults, and the significant and unique challenges that older adults face as it relates to mental health, it is critical that the state appoint a leader and adopt a plan to increase, improve and integrate mental health services for older adults.

1. Background. LeadingAge California states California’s older population will increase by 64% in the next 15 years, bringing the number of individuals aged 60 and above to over 12 million people. The Centers for Disease Control and Prevention estimates 20% of people age 55 years or older experience some type mental health concern. Data shows, from 1991 to 2017, California had a 58% increase in the number of suicides for those aged 65-84 years and a 50% increase for those 85 years and older (compared with a 15% average increase statewide across all age groups). Suicide rates are particularly high in rural parts of California where access to mental health care is severely lacking.

Under existing law, the Mental Health Services Act (MHSA), an initiative approved by voters as Proposition 63 in 2004, establishes the continuously appropriated Mental Health Services Fund to fund various mental health programs, including the Adult and Older Mental Health System of Care Act. Since the passage of Prop. 63 until 2014, over $13 billion in the state’s tax revenue has been allocated for public mental health services. However, specific funding for older adult services is not mandated in MHSA. This bill would utilize existing MHSA funds to increase service integration and standardize needs assessments and data requirements for older adults receiving mental health services.

1. Related Legislation. There are several bills in this legislative session addressing California’s aging population, due, in part, to a governor’s announcement the state needs a “Master Plan on Aging” to address the needs of our growing older population. Additional bills include:

AB 1136 (Nazarian) addresses system fragmentation and the need for state-level administrative reorganization of aging and disability services. It is pending hearing in this committee.

AB 1287 (Nazarian) addresses access to a coordinated system of information and supports through a “No Wrong Door” approach. It is pending hearing in this committee.

AB 1382 (Aguilar-Curry) requires the state to adopt a Master Plan for Aging, emphasizing workforce priorities. It is pending hearing in this committee.

SB 228 (Jackson) establishes the parameters and outlines the goals of the master plan. It is pending hearing in the Senate Appropriations Committee.

SB 611 (Caballero) focuses on the need for affordable, accessible housing for older adults. It is pending hearing in the Senate Appropriations Committee.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: April 23, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 480

Author:(Salas) – As Amended Ver:April 22, 2019

SUBJECT: Mental health: older adults

SUMMARY: Establishes within the State Department of Aging (DOA) an Older Adult Mental Health Services Administrator (OAA) to oversee mental health services for older adults. Specifically, this bill:

1. Establishes within DOA an OAA to oversee mental health services for older adults.
2. Requires the OAA to be funded with administrative funds from the Mental Health Services Fund.
3. Requires the OAA to work in coordination and collaboration with stakeholders including, but not limited to the Mental Health Services Oversight and Accountability Commission (MHSOAC), the director of the State Department of Health Care Services (DHCS), County Behavioral Health Services Departments, and any other relevant stakeholders to ensure that older adults have access to necessary behavioral health services and support.
4. Establishes the OAA’s responsibilities to include, but not be limited to:
   1. Service integration for mental health services for older adults;
   2. Determine which outcome and related indicators counties are currently collecting, and which current services are being offered;
   3. Develop outcome and related indicators, using existing data, for older adults for the purpose of assessing the status of mental health services for older adults, for monitoring the quality of programs intended to serve those older adults, and to guide decision making on how to improve those services;
   4. Using existing data, ensure that indicators reflect, but not be limited to, the following issues:
      1. Screening and assessments of affective disorders;
      2. Suicide risk and suicide rates;
      3. Medication review;
      4. Cognitive review and assessment;
      5. Alcohol use and substance misuse;
      6. Housing and independent living assessment;
      7. Social connections and social isolation;
      8. Consumer and family satisfaction with care;
      9. Access to care overall and for diverse populations;
      10. Continuity and integration of care;
      11. Health services utilization such as psychiatric hospitalizations and emergency room use for mental and behavioral health care;
      12. The number of eligible older adults with a mental health service need compared with the number of eligible older adults who received services in the measurement year; and,
      13. Services provided on a regional basis to determine regional areas with the greatest need for services.
   5. To the extent that data does not exist to sufficiently determine outcome and related indicators listed in d) above, the OAA will work with stakeholders to develop a strategy to identify high-level indicators including, but not limited to, the indicators listed in d) above which could not be sufficiently defined using existing and available data;
   6. Utilization of the new outcome and related indicators to prepare and disseminate, on an annual basis, reports to DHCS, MHSOAC, and counties that would also include but not be limited to the following issues: number of older adults served by age, difference in age categorization; older adult groups served; and, effectiveness of services; and,
   7. In close coordination and consultation with experts in the field, establish a standardized geriatrics training module for mental health professionals that would include a plan to account for cultural, linguistic, ethnic, geographic, and socioeconomic diversity among the older adult population, and that address barriers and stigma experienced by older adult populations. Those standards are to be made available to mental health professional and other providers.
5. Requires the OAA to receive data, the access to which is not restricted by any state or federal law, that is necessary to develop outcome related indicators as specified in 4)d) above, including, but not limited to data held by other state agencies or departments.
6. Requires the OAA to prescribe in a manner to ensure the confidentiality of information in the possession of the DOA received under this bill, that is equal to, or greater than, the protections in place for data received by other state agencies or departments.
7. Authorizes the DOA to establish one or more advisory bodies to guide and inform the selection of outcome and related indicators and the strategy for developing and reporting those indicators. Permits existing state entities that involves diverse representation of older adults, including but not limited to the Commission on Aging, to act as an advisory body for purposes of this bill.
8. Requires the OAA on or before July 1, 2022 to report to the DHCS, the California Behavioral Health Planning Council, the Office of Statewide Health Planning and Development, the MHSOAC, the Department of Public Health, and any other state agency implementing the Mental Health Services Act all of the outcome and related indicators developed by the OAA under 4) above. Requires the report to include recommendations on ways to establish a system for monitoring those indicators on a continual basis, including additional staff or technology that might be necessary as well as any regulatory or fiscal barriers that may hinder future progress on the development of a monitoring system. Provides that upon request by the Legislature, the report may be made available to the Legislature.
9. Requires the OAA to develop a strategy and standardized training for all county mental health personnel, including clinicians, involved in delivering MHSA mental health care and prevention services to older adults in order for counties to assist the OAA in obtaining the data necessary to develop the outcome and related indicators specified in 3) above.

EXISTING LAW:

1. Establishes the DOA to administer programs and services for older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the state.
2. Establishes the MHSA, enacted by voters in 2004 as Proposition 63, to provide funds to counties to expand services, develop innovative programs, and integrated service plans for mentally ill children, adults, and seniors including the Adult and Older Adult Mental Health System of Care Act through a 1% income tax on personal income above $1 million.
3. Authorizes the MHSA to be amended by a 2/3 vote of the Legislature if the amendments are consistent with, and further the purposes of, the MHSA, and also permits the Legislature to clarify procedures and terms of the MHSA by a majority vote.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, given the rapidly growing segment of the state’s population that is made up of older adults, and the significant and unique challenges that older adults face as it relates to mental health, it is critical that the state appoint a leader and adopt a plan to increase, improve, and integrate mental health services for older adults.
2. BACKGROUND. According to the Centers for Disease Control and Prevention, it is estimated that 20% of people age 55 years or older experience some type of mental health concern. Mental health issues that older adults face – which range from anxiety and depression to serious mental illness – can be complicated by other ailments and chronic diseases that are more common among older adults, such as dementia, heart disease, diabetes, arthritis, or cancer. Moreover, older adults diagnosed with a mental illness are more likely to develop chronic conditions and dementia as they age. Far too often older adults do not seek or receive the help they need, despite the fact that one in five older adults experience mental health concerns. By the age of 75, close to half of all Americans will have experienced a diagnosable mental disorder. The World Health Organization estimates that worldwide, 15% of adults age 60 and over live with mental illness. Mental health issues are often implicated as a factor in cases of suicide and older adults also have the highest suicide rate in the country. The percentage increase in suicides from 1996 to 2016 in California has risen dramatically, notably among older adults. From 1991 to 2017, California saw a 58% increase in the number of suicides for those aged 65-84 and 50% for those 85 and older (compared with a 14.8% average increase statewide across all age groups). Suicide rates are particularly high in rural parts of California where access to mental health care is severely lacking.
   1. UCLA Center for Health Policy Research. In a study conducted by the UCLA Center for Health Policy Research, entitled “California’s Public Mental Health Services: How are Older Adults Being Served,” the study found a number of deficiencies in the current structure as it relates to mental health services for older adults. The study found that the availability of a complete system of services for older adults with mental illness is a work in progress and there is a need for programs to engage in targeted outreach specifically tailored to the older adults. The study found that: i) implementation of older adult mental health services is uneven; ii) MHSA outcome reporting is inadequate for measuring the reach and effectiveness of services among older adults; iii) there are significant and persistent deficits in the geriatrics workforce; and, iv) there are numerous barriers to mental health services for older adults. The study concluded that counties with a formal, designated Older Adult System of Care (OASOC) offered more programming and services tailored to older adult needs than those without an OASOC. The report recommended that the OASOC approach should be in all counties.
   2. Master Plan on Aging. During the State of the State Address delivered on February 12, 2019, Governor Newsom declared “It’s time for a new Master Plan on Aging. It must address: person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage, and demand for In-Home Supportive Services that far outpaces its capacity.” The Governor stated that for the first time in history, older Californians will outnumber young children and that over the next decade, our statewide senior population will increase by 4 million. In 25 years it will double. And, more than half will require some form of long-term care. A new master plan is needed to address the socioeconomic needs and demands of our growing and diverse older adult population.
3. DOUBLE REFERRAL. This bill has been double referred. It passed the Assembly Aging and Long Term Care Committee on a vote of 8-0 on April 3, 2019.
4. SUPPORT. LeadingAge California states that California’s older population will increase by 64% in the next 15 years, bringing the number of individuals aged 60 and above to over 12 million people. Many older adults currently face significant mental health issues, which can often by complicated by existing co-morbid chronic conditions. Oftentimes, the mental wellness of an older adult is overlooked in order to the treat the existing physical needs of an individual, despite mental and physical well-being directly connected to one another. LeadingAge California concludes by stating, this bill would utilize existing MHSA funds to increase service integration and standardize needs assessments and data requirements for older adults receiving mental health services.
5. RELATED LEGISLATION.
   1. AB 1136 (Nazarian) establishes the California Department of Community Living (DCL) within the California Health and Human Services Agency to consolidate leadership on issues and programs serving California’s older adults, people with disabilities, and caregivers. Requires DCL to establish a statewide No Wrong Door system to assist older adults, people with disabilities, and caregivers in obtaining accurate information and timely referrals to appropriate community services and support. AB 1136 is pending referral to the Assembly Committee on Human Services.
   2. AB 1287 (Nazarian) requires DOA, in partnership with other specified departments and stakeholders, to develop a plan and strategy for a statewide implementation of the No Wrong Door system, as described, on or before July 1, 2020. Specifies the purpose of the No Wrong Door system as assisting older adults, people with disabilities, and caregivers in obtaining accurate information and timely referrals to appropriate community services and supports. AB 1287 has passed out of the Assembly Committee on Human Services by a vote of 8-0 and is pending before the Assembly Aging and Long Term Care Committee.
   3. AB 1382 (Aguilar-Curry) requires the state to adopt a Master Plan for Aging, emphasizing workforce priorities. Requires the plan to prioritize specified issues related to preparing and supporting the state’s paid paraprofessionals and professionals, as well as unpaid family caregivers. AB 1382 is pending before the Assembly Aging and Long Term Care Committee.
   4. SB 228 (Jackson) requires the appointment of a Master Plan Director (MPD) and the establishment of an Aging Task Force, as specified. Requires the MPD and the task force, to work with representatives from impacted state departments, stakeholders, and other agencies to identify the policies and priorities that need to be implemented in California to prepare for the aging of its population. SB 228 is pending before the Senate Human Services Committee.
   5. SB 611 (Caballero) establishes the Department of Housing and Community Development (HCD) in the Business, Consumer Services, and Housing Agency. Requires the HCD to be responsible for administering various housing and home loan programs throughout the state. Establishes the Master Plan for Aging Housing Task Force, composed of specified stakeholders and representatives of government agencies to, among other things, make recommendations to help increase the supply of affordable housing for older adults and reduce barriers to providing health care and social services to older adults in affordable housing. SB 611 is pending before the Senate Housing Committee.
6. PREVIOUS LEGISLATION. SB 62 (Jackson) of 2017 would have enacted the Affordable Senior Housing Act of 2017, establishing the Affordable Senior Housing Program within HCD, the purpose of which would have been to guide and serve as a catalyst for the development of affordable senior housing and supportive care campuses. SB 62 was held in the Assembly Appropriations Committee.

REGISTERED SUPPORT / OPPOSITION:

Support

Ca Council of Community Behavioral Health Agencies
California Assisted Living Association
California Association of Area Agencies on Aging

California Association for Health Services at Home
California Hospital Association/California Association of Hospitals and Health Systems
LeadingAge California
Steinberg Institute

Opposition

None on file.

Analysis Prepared by: Judy Babcock / HEALTH / (916) 319-2097

Date of Hearing: April 2, 2019

ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE

Adrin Nazarian, Chair

ABPCA Bill Id:AB 480 (

Author:Salas) – As Introduced Ver:February 12, 2019

SUBJECT: Mental health: older adults.

SUMMARY: Relates to mental health. Specifically, this bill:

1. Establishes within the State Department of Health Care Services an Older Adult Mental Health Services Administrator to oversee mental health services for older adults.
2. Requires that position to be funded with administrative funds reserved to the department from the Mental Health Services Fund.
3. States Legislative intent to increase service integration for older adults receiving mental health services funded by the Mental Health Services Fund.
4. States legislative intent to establish and prioritize standardized geriatrics training for mental health professionals to account for the increasingly diverse population and to address barriers and stigma experienced by older adult populations.

EXISTING LAW:

1. Under existing law, the Mental Health Services Act (MHSA), an initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general election, establishes the continuously appropriated Mental Health Services Fund to fund various county mental health programs, including the Adult and Older Adult Mental Health System of Care Act.
2. Authorizes the MHSA to be amended by a 2/3 vote of the Legislature if the amendments are consistent with, and further the purposes of, the MHSA, and also permits the Legislature to clarify procedures and terms of the MHSA by a majority vote.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

Author’s Statement: “Given the rapidly growing segment of the state’s population that is made up of older adults, and the significant and unique challenges that older adults face as it relates to mental health, it is critical that the state appoint a leader and adopt a plan to increase, improve and integrate mental health services for older adults.”

BACKGROUND

According to the Centers for Disease Control and Prevention, it is estimated that 20 percent of people age 55 years or older experience some type mental health concern.

Mental health issues that older adults face – which range from anxiety and depression to serious mental illness – can be complicated by other ailments and chronic diseases that are more common among older adults, such as dementia, heart disease, diabetes, arthritis, or cancer. Moreover, older adults diagnosed with a mental illness are more likely to develop chronic conditions and dementia as they age.

Far too often older adults do not seek or receive the help they need, despite that fact that one in five older adults experience mental health concerns. By the age of 75, close to half of all Americans will have experienced a diagnosable mental disorder. The World Health Organization estimates that worldwide, 15 percent of adults age 60 and over live with mental illness.

Mental health issues are often implicated as a factor in cases of suicide and older adults also have the highest suicide rate in the country. The percentage increase in suicides from 1996 to 2016 in California has risen dramatically, notably among older adults. From 1991 to 2017, California saw a 58 percent increase in the number of suicides for those aged 65-84 and 50 percent for those 85 and older (compared with a 14.8 average increase statewide across all age groups). Suicide rates are particularly high in rural parts of California where access to mental health care is severely lacking.

According to a study conducted by the UCLA Center for Health Policy Research, less than one-third of all older adults in the United States who need mental health care receive it. The study found a number of deficiencies in the current structure as it relates to mental health services for older adults. It found that: a) implementation of older adult mental health services is uneven; b) MHSA outcome reporting is inadequate for measuring the reach and effectiveness of services among older adults; c) there are significant and persistent deficits in the geriatrics workforce; and, d) there are numerous barriers to mental health services for older adults.

Under existing law, the Mental Health Services Act (MHSA), an initiative measure approved by voters as Proposition 63 in 2004, establishes the continuously appropriated Mental Health Services Fund to fund various mental health programs, including the Adult and Older Mental Health System of Care Act.

Since the passage of Prop. 63 until 2014, over $13 billion in the state’s tax revenue has been allocated for public mental health services, yet a distinct administrative structure and specific funding older adult services are not mandated in MHSA, as they are for children under the age
of 18.

Previously, there was a position within the California Department of Aging – the Geriatric Mental Health Specialist – that was funded by MHSA funds who was responsible for overseeing mental health services for older adults. However, this position no longer exists with the California Department of Aging.

Suggested Amendment:

Would establish within the State Department of Aging an Older Adult Mental Health Services Administrator to oversee mental health services for older adults.

Why: There are several bills this year that focus on a master plan for aging. The Governor also mentioned a master plan on aging in his state of the state address to the legislature. One of the issues that is being discussed as part of a master plan on aging is better coordinated services and a no wrong door approach. Given the current fragmentation of the system, the department of aging would be the more appropriate place to coordinate mental health services for seniors where it was previously housed.

Argument in Support: The California Hospital Association writes, “This new position would better integrate physical and mental health care for older adults, leading to higher-quality care for California’s elderly. In addition, the position would ensure that funds from the Mental Health Services Act are used efficiently and as the bill intended.”

Argument in Opposition: None.

REGISTERED SUPPORT / OPPOSITION:

Support

California Association for Health Services at Home (CAHSAH)

California Council of Community Behavioral Health Agencies

California Hospital Association

LeadingAge California

Opposition

None on file.

Analysis Prepared by: Barry Brewer / AGING & L.T.C. / (916) 319-3990