Date of Hearing: April 3, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 682

Author:(Eggman) – As Introduced Ver:February 15, 2019

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

SUMMARY:

This bill requires the California Department of Public Health (CDPH) to apply for a specified federal grant to develop a real-time, web-based database to collect, aggregate and display information about available beds in inpatient psychiatric facilities, crisis stabilization units, residential community mental health facilities, and licensed residential alcoholism or drug abuse recovery or treatment facilities.

FISCAL EFFECT:

1. One-time staff costs to research and submit a grant proposal, likely in the range of $50,000 (GF or Licensing and Certification Fund).
2. Assuming a grant were available and the state’s proposal were successful, estimated one-time cost potentially in excess of $1 million in contract information technology costs (federal funds).
3. Annual ongoing contract funding for approximately $100,000 for maintenance of the registry system, and $100,000 in staffing costs (GF or Licensing and Certification Fund).
4. Contract costs for an evaluation report, estimated in the low hundreds of thousands of dollars (federal funds or Licensing and Certification Fund).

COMMENTS:

1. Purpose. The author indicates this bill is necessary in order to facilitate the identification and designation of facilities for the temporary treatment of individuals in mental or substance use disorder crisis.
2. Background. Finding appropriate behavioral health care is difficult for those in crisis. According to 2011 OSHPD data analyzed by the California Hospital Association, California has lost nearly 32%, or nearly 3,000 inpatient psychiatric beds compared to 1995. California’s bed rate is one bed for every 5,975 people, as of 2011, compared to the nation’s average of one bed for every 4,758 people. Additionally, 26 of California’s 58 counties have no inpatient psychiatric services. Other states have implemented similar registries to track availability of inpatient psychiatric beds, generally on a voluntary basis. Virginia, however, recently implemented mandatory electronic reporting to a registry. An independent evaluation noted this approach had some important strengths but also significant challenges and limited impact in reducing wait times for locating facilities.
3. Available Federal Funding. The federal 21^st Century Cures Act, enacted in December of 2016, authorized funding to support psychiatric bed registries, among other projects, but there are no funds appropriated and there is no funding opportunity available at this time.

There was a recent grant program called the called the Transformation Transfer Initiative (TTI), administered by the National Association of State Mental Health Program Directors, with funding from the Substance Abuse and Mental Health Services Administration’s (SAMHSA). This program provided $150,000 grants to 23 states to develop statewide psychiatric bed registries. It is unclear whether there will be additional funding made available through this program for the purpose in future years.

1. Support. The California Psychiatric Association, a cosponsor of this bill, argues that the need is critical because the loss of about 3,000 California psychiatric beds in the last two decades has made open beds more difficult to find. The California Chapter of the American College of Emergency Physicians (Cal/ACEP) also writes in support.
2. Opposition. The California Hospital Association (CHA) opposes this bill, contending an electronic bed registry would do little to improve the availability or access to inpatient beds for individuals in need of emergency inpatient psychiatric care and would redirect critical staff within the hospitals to administrative functions and away from patient care. CHA argues that “real-time” bed registries have been tried in other states (both on a voluntary and mandated basis) and they have proven to be very difficult to implement and have not shown significantly improved efficiencies.
3. Staff Comment. The author may wish to consider identifying a specific grant opportunity with available funding to target this bill’s requirements.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: March 26, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 682

Author:(Eggman) – As Introduced Ver:February 15, 2019

SUBJECT: Health facilities: residential mental health or substance use disorder treatment.

SUMMARY: Requires the Department of Public Health (DPH) to develop and submit a proposal to solicit a federal grant under the Federal 21^st Century Cures Act (Cures Act) to develop a real-time, Internet-based database to help identify and designate facilities with available beds for the treatment of individuals experiencing a mental health or substance use disorder (SUD) crisis. Requires DPH to submit an evaluation of the effect of the grant to the federal Department of Health and Human Services (HSS) Secretary and to the Legislature. Specifically, this bill:

1. Requires DPH, in consultation with the Department of Health Care Services) DHCS, the Department of Social Services (DSS), and the County Behavioral Health Directors Association of California (CBHDAC), to develop and submit a proposal to solicit a grant under the Cures Act to develop a real-time, Internet-based database to collect, aggregate, and display information about beds in inpatient psychiatric facilities, crisis stabilization units, residential community mental health facilities, and licensed residential alcoholism or drug abuse recovery or treatment facilities in order to facilitate the identification and designation of facilities for the temporary treatment of individuals in mental health or SUD crisis.
2. Requires the database to have the capacity to collect data and enable searches to identify beds that are appropriate for the treatment of individuals in a mental health or SUD crisis and to include, at a minimum, all of the following:
3. The contact information for the facility’s designated employee;
4. The facility’s license type;
5. If the facility provides SUD, mental health, or medical treatment;
6. If the bed is secure for the treatment of a person who, as a result of a mental health disorder, is a danger to others, or to themselves, or gravely disabled, (commonly known as a “5150” hold);
7. The types of diagnoses for which the bed is appropriate;
8. The age ranges for which the bed is appropriate; and,
9. Whether the bed is available.
10. Prohibits the database from including information relating to hospitals under the jurisdiction of the Department of State Hospitals.
11. Requires DPH to confer with stakeholders to inform the development of the proposal including, but not be limited to, DHCS, DSS, CBHDAC, and organizations that have experience providing inpatient psychiatric care, psychiatric crisis stabilization, residential community mental health services, and residential alcoholism or drug abuse recovery or treatment services.
12. Requires DPH and stakeholders to consider strategies for facility use of the database.
13. Requires DPH, in consultation with DHCS, DSS, and CBHDAC, to submit to the HHS Secretary, and to the Legislature, an evaluation of the effect of any grant funds received for the development of a database on all of the following:
14. Local crisis response services and measures for individuals receiving crisis planning and early intervention supports;
15. Individuals reporting improved functional outcomes; and,
16. Individuals receiving regular follow-up care following a crisis.

Existing federal law establishes the Cures Act which authorizes the Helping Families in Mental Health Crisis Reform Act of 2016 for the purpose of increasing the availability of psychiatric hospital beds and supports the creation of a database of beds at facilities that treat those with mental health and SUDs, as specified. Appropriates $12.5 million for the period of fiscal years 2018 through 2022 for states to establish an enhanced community-based crisis response system or electronic bed database.

EXISTING LAW:

1. Establishes DPH to license and regulate hospitals, including general acute care hospitals and acute psychiatric hospitals.
2. Establishes the DHCS to license and regulate adult residential alcoholism or drug abuse recovery or treatment facilities (RTFs).
3. Establishes the DSS to license community care facilities, including any facility, place, or building that is maintained and operated to provide nonmedical residential care, day treatment, adult day care, or foster family agency services for children, adults, or children and adults, including, but not limited to, the physically handicapped, mentally impaired, incompetent persons, and abused or neglected children, and may include crisis residential services.
4. Requires DHCS and counties to provide specialty mental health services for Medi-Cal beneficiaries through a county mental health plan (MHP), as specified, which may include crisis stabilization services and inpatient psychiatric care.
5. Establishes psychiatric health facilities, licensed by DHCS, which provide 24-hour inpatient care for people with mental health disorders that includes, but is not limited to, the following basic services: psychiatry; clinical psychology; psychiatric nursing; social work; rehabilitation drug administration; and, appropriate food services for those persons whose physical health needs can be met in an affiliated hospital or in outpatient settings.
6. Establishes the Lanterman-Petris-Short Act, which authorizes a person to be involuntarily detained for a period of up to 72 hours for assessment, evaluation, and crisis intervention (“5150” hold), when as a result of a mental disorder the person is a danger to self or others, or is “gravely disabled”. Defines “gravely disabled” as a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter.
7. Requires facilities, for the purposes of detaining a person for up to 72-hours of treatment and evaluation, to be designated by a county and approved by DHCS. Defines “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as defined by DPH regulations, and may include, but is not limited to, a licensed psychiatric hospital, a licensed psychiatric health facility, and a certified crisis stabilization unit.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, mental illness, like many other health conditions, when treated early and with appropriate supports and services, can resolve in recovery. Although 16% of California adults live with a mental illness, more than 60% do not receive treatment. From 2004 to 2013, the number of hospital beds in the state remained largely unchanged, while the number of acute psychiatric beds decreased by 22%. A Web-based psychiatric bed registry would improve mental health service access by getting patients dealing with mental health crises to the appropriate professionals more quickly and streamlining communication and reduce patient waiting time. The author concludes that AB 682 demonstrates California’s dedication to improving access to mental health services, while leveraging federal dollars to maximize the benefit to the state.
   
2. BACKGROUND.
   
   1. Psychiatric Bed Shortages. According to 2016 Office of Statewide Health Planning and Development data analyzed by the California Hospital Association, California has lost 37 psychiatric facilities from 1999-2016, either through the elimination of psychiatric inpatient care, or complete hospital closure. While the number of facilities is slightly larger than in 2011, it still reflects a 20.4% drop in psychiatric facilities during a time when California’s population grew by 24% or 7.6 million people. This represents a loss of 2,651 beds compared to 1995. An independent panel of 15 psychiatrists concluded that 50 public psychiatric beds per 100,000 individuals (1:3,000) is the absolute minimum number required to meet current needs. In 1995, California fell short of this target by nearly 1,400 beds. In 2016, that gap increased by nearly 4,000 beds with the state having only 17.05 psychiatric inpatient beds for every 100,000 residents – a loss of more than 42% of the beds per capita since 1995. The following graph reflects additional facts demonstrating the current situation in California.

• 1. Crisis Residential Programs and Crisis Stabilization. According to a 2010 report by the California Mental Health Planning Council, crisis residential programs are a lower-cost, community-based treatment option in home-like settings that help reduce emergency department (ED) visits and divert hospitalization and incarcerations. These programs include peer-run programs such as crisis respites that offer safer, trauma-informed alternatives to psychiatric emergency units, or other locked facilities. The report indicates that crisis residential programs reduce unnecessary stays in psychiatric hospitals, reduce the number and expense of ED visits, and divert inappropriate incarcerations while producing the same or superior outcomes to those of institutionalized care. The report states that, as the costs for inpatient treatment continue to rise, the need to expand an appropriate array of acute treatment settings becomes more urgent, and state and county mental health systems should encourage and support alternatives to costly institutionalization and improve the continuum of care to better serve individuals experiencing an acute psychiatric episode. Crisis stabilization services are those lasting less than 24 hours for individuals who are in psychiatric crisis whose needs cannot be accommodated safely in a residential service setting. Crisis stabilization must be provided onsite at a 24-hour health facility, hospital-based outpatient program, or at other certified provider sites. The goal of crisis stabilization is to stabilize consumers and re-integrate them back into the community quickly. According to various reports, costs of providing care in a crisis stabilization unit are significantly lower than inpatient hospitalization. Crisis stabilization units include both EDs and urgent care units licensed for the purpose of crisis stabilization.
  2. Licensed SUD Facilities. Licensed RTFs provide 24-hour non-medical care and specialize in providing services to chemically dependent adults who do not require treatment in an acute-care medical facility on an inpatient, intensive outpatient, outpatient, and partial hospitalization basis. These facilities range in size from six-bed facilities in residential neighborhoods to centers that accommodate more than 100 beds. The basic services provided by facilities include group, individual, and educational sessions, alcoholism or drug abuse, recovery and treatment planning. Detoxification services are also provided and are defined by DHCS as services to support and assist an individual in the alcohol and/or drug withdrawal process and to explore plans for continued treatment. These services can be provided by a variety of health care providers such as alcohol and drug counselors, mental health therapists, social workers, psychologists, nurses, and physicians.
  3. Virginia Registry. In 2014, the State of Virginia launched the Virginia Acute Psychiatric and Community Services Board Bed Registry, a mandatory Web-based registry. A January 2016 report published by the Virginia Office of the State Inspector General (OSIG report) examined the utility of the registry as a tool for emergency services staff to facilitate the identification and designation of facilities for the temporary detention and treatment of individuals, including the registry’s successes, challenges, and efficiencies, and the impact of the current registry-related operations on various health facilities and stakeholders. While the OSIG report found full compliance with the mandates in statute, a survey of registry users indicated that for 55% of respondents it was taking more time to locate a willing facility than prior to the implementation of the registry. Additionally, 36% of respondents indicated that the registry did not improve the time that it took to identify an available bed, and only 9% reported that the amount of time it took to identify an available bed decreased. The OSIG report states that the lack of regular updating of the registry, in addition to requiring duplicative efforts by staff, resulted in diverting limited staff time and resources, preventing individuals from placement in an appropriate bed in the most efficient manner, and preventing emergency services staff from proceeding to other emergencies.
  4. National Association of State Mental Health Program Directors (NASMHPD) Brief. A 2018 NASMHPD brief addressing bold approaches for better mental health outcomes across the continuum of care entitled, “Experiences and Lessons Learned in States with On-Line Databases of Available Mental Health Crisis, Psychiatric Inpatient and Community Residential Placements,” reported that sixteen states had bed registries and that an additional eight states were in the process of planning or developing a bed registry. In just over half the states with bed registries, participation in the registry was voluntary. NASMHPD concluded by stating that a bed registry, in its simplest form is just a tool for people searching for a placement of a patient that allows them to make placement in a more efficient manner than having to call every single facility in the area. According to the brief, many of the states built their system for under $100,000 and are able to maintain their system for under $100,000 a year. If a system performs well, many hours of work can be reduced. One cost identified is the cost to facilities to keep records in the registry updated. Facilities are willing to support that cost if they feel that participating in the registry is to their benefit. Of the states with registries, 11 of the states had registries that were not updated in real-time but periodically, ranging from several times a day to daily. Very few states reported having registries that were updated 24/7 with real-time information. According to the brief, a bed registry that doesn’t have buy-in from the providers of inpatient services is going to have difficulty in succeeding, even if participation is mandatory. However, if hospital administrators see the registry as a way to fill their beds in a way that is to their benefit, they are likely to work hard at making sure that the information on the registry is timely and accurate.

1. SUPPORT. The California Psychiatric Association (CPA), a co-sponsor of this bill states that the need for this bill is even more critical because the loss of about 3,000 California psychiatric beds in the last two decades has made open beds more difficult to find. When patients with mental health issues are in extremely vulnerable or fragile states, their condition may be deteriorating, and particularly if they are verging on being a danger to themselves, or a danger to others, a bed in a facility where they can get intensive inpatient treatment quickly is critical. CPA goes on to state, the sooner that consumers can get into an appropriate level of care, the sooner they can start being treated. If an individual is a danger to themselves or others, this aspect may also be a public safety issue. So it is critical to find an open bed, and to do so quickly. A bed registry is one tool that would help identify open beds not otherwise readily identifiable.
2. OPPOSITION. The California Hospital Association (CHA) in opposition to this bill states that California’s hospitals are on the front lines of the state’s behavioral health crisis – a crisis that is pushing our health care system to a breaking point. The cost to build one inpatient psychiatric bed in California is now $1 million dollars. Another unproven and unfunded mandate will do little to improve the availability of or access to inpatient beds for individuals in need of emergency inpatient psychiatric care. Instead, it would redirect critical hospital staff to administrative functions away from patient care. CHA concludes by stating it is important to understand that, even with the proposed registry, medical professionals would still be required to call facilities with available beds to ascertain appropriateness for the patient’s admission, as well as the facility’s capability and capacity to care for the patient.
3. RELATED LEGISLATION.
   1. AB 1055 (Levine) requires a psychiatrist, psychologist, or medical director approving the release of an individual from a 72-hour 5150 hold with a referral for further care and treatment on a voluntary basis, to, prior to that release, ensure that an initial outpatient appointment with a psychiatrist or psychologist is scheduled for within five business days of the release. AB 1055 is pending hearing in Assembly Health Committee.
   2. AB 1443 (Maienschein) requires the Mental Health Services Oversight and Accountability Commission (MHSOAC) to establish technical assistance centers to support counties in addressing mental health issues that are of statewide concern and to establish, with stakeholder input, which mental health issues are of statewide concern. AB 1443 is pending in Assembly Health Committee.
   3. AB 1572 (Chen) changes the definition of “gravely disabled” to be in part, a condition in which a person, as a result of a mental health disorder, is incapable of making informed decisions about, or providing for, the person’s own basic personal needs for food, clothing, shelter, or medical care without significant supervision and assistance from another person and, as a result of being incapable of making these informed decisions, the person is at risk of substantial bodily harm, dangerous worsening of a concomitant serious physical illness, significant psychiatric deterioration, or mismanagement of essential needs that could result in bodily harm. Appropriates $20 million to the DHCS to establish a four-year grant program to assist local jurisdictions to maintain appropriate caseloads for individuals who manage conservatorship cases. AB 1572 is pending in the Assembly Health Committee.
   4. SB 40 (Weiner) authorizes the court to establish a temporary conservatorship for a period of 30 days or less if the court is satisfied of the necessity, as specified. Defines “serious mental illness and substance use disorder” and changes the definition of “frequent detention for evaluation and treatment” to mean eight or more detentions in a 12-month period. Requires that a petition seeking to establish the above-described conservatorship be filed with the court no later than 180 days following the eighth detention in a 12-month period. Makes the establishment of the conservatorship subject to a finding by the court, as specified. SB 40 is pending in the Senate Judiciary and upon passage will be referred to Senate Public Safety.
   5. SB 604 (Bates) requires MHSOSAC, by January 1, 2021, to establish centers of excellence to provide the counties with technical assistance to implement best practices related to elements of the act. AB 604 is pending in Senate Health.
   6. SB 640 (Moorlach) is substantially similar to AB 1572. AB 64 is pending in Senate Health.
4. PREVIOUS LEGISLATION.
   1. AB 1136 (Eggman) of 2017 was substantially similar to this bill. AB 1136 was held in Senate Appropriations.
   2. AB 1300 (Ridley-Thomas) of 2015 would have made numerous changes to the provisions regarding evaluation procedures, terms, and lengths of detention, and criteria for release and transfer protocol related to the involuntary detention of individuals. AB 1300 was held in the Senate Rules Committee
   3. AB 1194 (Eggman), Chapter 570, Statutes of 2015, requires, when an individual is determining if a person is a danger as a result of a mental health disorder, the individual to consider available relevant information about the historical course of the person's mental disorder, if the individual concludes that the information has a reasonable bearing on the determination and specifies danger is not limited to danger of imminent harm.
   4. AB 1372 (Levine) of 2017 would have permitted a certified crisis stabilization unit, as specified, to provide medically necessary crisis stabilization services to individuals beyond the service time of 24 hours, as required in current law, in cases where an individual needs inpatient psychiatric care or outpatient care, and inpatient psychiatric beds or outpatient services are not reasonably available. AB 1372 was held on the inactive file on the Senate Floor.
   5. AB 1971 (Santiago, Chen, and Friedman) of 2018 would have expanded the definition of “gravely disabled” in existing law to include a person’s inability to provide for his or her personal needs for “medical treatment,” as defined, if the failure to receive medical treatment results in a deteriorating physical condition or death. AB 1971 was held on the inactive file on the Senate Floor.

REGISTERED SUPPORT / OPPOSITION:

Support

California Psychiatric Association (cosponsor)

California Chapter of the American College of Emergency Physicians

National Association of Social Workers – California Chapter

Opposition

California Hospital Association

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