Existing law provides for the licensing, regulation, and inspection of various types of health facilities by the State Department of Public Health, including general acute care hospitals. Existing law requires certain building standards and regulations to prescribe standards of adequacy, safety, and sanitation of the physical plant, of staffing with duly qualified licensed personnel, and of services, based on the type of health facility and the needs of the persons served. Existing law requires specified financial and utilization data to be reported to the department by a hospital at the end of a calendar quarter.

Existing law generally makes a violation of the licensure provisions for health facilities a misdemeanor.

This bill would require a general acute care hospital to adopt policies to respond to a patient requiring behavioral health emergency services, as defined. for behavioral health personnel to respond to patients with a mental health or substance use crisis. The bill would require that these protocols meet standards established by the department and consist of various parameters such as minimum staffing requirements for behavioral health emergency services, responses, procedures for response by behavioral health emergency services personnel in a timely manner, and annual training, as specified. The bill would require the department to adopt regulations on standards for general acute care hospitals related to behavioral health emergency services. response. The bill would require all hospitals to maintain records related to certain data on behavioral health emergency services provided for a period of 3 years and to report that data to the department on a quarterly basis. The bill would require the department to post quarterly reports on that data on its internet website. general acute care hospitals to maintain records on each patient who receives care from behavioral health response personnel and the number of hours of services provided for a period of 3 years. The bill would require hospitals to include related data in their quarterly summary utilization data reported to the department.

Existing law establishes the Department of Health Care Access and Information, which is responsible for administering various programs with respect to health care professions and establishes various programs to facilitate the expansion of the health care workforce.

Existing law authorizes the board of supervisors in each county to establish and maintain a county hospital to provide public health care services within the county. Existing law authorizes the board to prescribe rules for the hospitals government and management, and to appoint a county physician and other necessary officers and employees of the hospital, as specified.

This bill would establish the Behavioral Health Emergency Response and Training Fund to provide grants to qualifying applicants for the purpose of funding a new program or supporting an existing program that increases the staffing in general acute care hospitals of direct care personnel who are trained in behavioral health care and behavioral health emergency services response or intervention.

The bill would also require the department to evaluate the program and report to the Legislature annually.

By expanding the scope of a crime under the above paragraphs, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law provides for the licensing, regulation, and inspection of various types of health facilities by the State Department of Public Health, including general acute care hospitals. Existing law requires certain building standards and regulations to prescribe standards of adequacy, safety, and sanitation of the physical plant, of staffing with duly qualified licensed personnel, and of services, based on the type of health facility and the needs of the persons served. Existing law requires specified financial and utilization data to be reported to the department by a hospital at the end of a calendar quarter.

Existing law generally makes a violation of the licensure provisions for health facilities a misdemeanor.

This bill would require a general acute care hospital to adopt policies to respond to a patient requiring behavioral health emergency services, as defined. The bill would require that these protocols meet standards established by the department and consist of various parameters such as minimum staffing requirements for behavioral health emergency services, procedures for response by behavioral health emergency services personnel in a timely manner, and annual training, as specified. The bill would require the department to adopt regulations on standards for general acute care hospitals related to behavioral health emergency services. The bill would require all hospitals to maintain records related to certain data on behavioral health emergency services provided for a period of 3 years and to report that data to the department on a quarterly basis. The bill would require the department to post quarterly reports on that data on its internet website.

Existing law establishes the Department of Health Care Access and Information, which is responsible for administering various programs with respect to health care professions and establishes various programs to facilitate the expansion of the health care workforce.

Existing law authorizes the board of supervisors in each county to establish and maintain a county hospital to provide public health care services within the county. Existing law authorizes the board to prescribe rules for the hospitals government and management, and to appoint a county physician and other necessary officers and employees of the hospital, as specified.

This bill would establish the Behavioral Health Emergency Response and Training Fund to provide grants to qualifying applicants for the purpose of funding a new program or supporting an existing program that increases the staffing in general acute care hospitals of direct care personnel who are trained in behavioral health care and behavioral health emergency services response or intervention.

The bill would also require the department to evaluate the program and report to the Legislature annually.

By expanding the scope of a crime under the above paragraphs, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

ASSEMBLY THIRD READING

ATR Bill Id:AB 1001

Author:(Haney)

As Amended Ver:April 13, 2023

Majority vote

SUMMARY

Requires General Acute Care Hospitals (GACHs) to adopt policies to respond to a patient with a mental health or substance use crisis. Requires that these protocols meet standards established by the Department of Public Health (DPH) and consist of various parameters such as minimum staffing requirements for behavioral health responses, procedures for response by behavioral health personnel in a timely manner, and annual training. Creates the Behavioral Health Response and Training (BHRT) Fund to provide grants to fund new programs or support existing programs that increases the staffing of direct care personnel who are trained in behavioral health care and behavioral health services response or intervention, in specified hospitals.

Major Provisions

COMMENTS

According to the National Institute of Mental Health, nearly one in five United States (U.S.) adults live with a mental illness. In California, that equates to nearly 8 million people in 2020. According to the California Health Care Foundation, an average of 2.9 million Californians per year, age 12 and older (8.8%), had a substance use disorder in 2018-2019. According to data from the Department of Health Care Access and Information (HCAI), in 2020, patients with behavioral health diagnoses accounted for 1,144,835 inpatient hospitalizations and 2,090,085 emergency department (ED) treat and release visits, which is one third of all in-patient hospitalizations (3,444,532) and one fifth of all ED visits (10,023,851).

Lack of inpatient psychiatric beds. According to the California Hospital Association (CHA), since 1995 the state has lost at least 37 facilities, either through the elimination of psychiatric inpatient care, or complete hospital closure, representing a 20% drop. CHA states that while there has been an increase in psychiatric beds over the past several years, California has lost nearly 30% of the psychiatric beds it had in 1995. On a per capita basis, accounting for the growth in California's population, this translates into a loss of more than 42% of the psychiatric inpatient beds per capita since 1995. California now has only 17 psychiatric beds for every 100,000 residents, compared to nearly 30 beds per 100,000 in 1995, and well short of the recommended minimum number of 50 psychiatric beds per 100,000.

Emergency Medical Treatment and Labor Act (EMTALA). EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient's medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.

Nurse-to-patient staffing ratios. In 2004, regulations adopted to implement nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999, went into effect. However, long before California had specific nurse-to-patient ratios, hospitals were required by regulation to establish a patient classification system. This patient classification system is a method by which hospitals establish staffing requirements by unit, patient, and shift, and includes a method by which the amount of nursing care needed for each category of patient is validated for each unit. The regulations implementing the AB 394 nurse-to-patient ratios law set the minimum ratio of nurses-to-patient by unit, including one-to-one in operating rooms, one-to-two in intensive care units, and one-to-five in general medical-surgical units. The nurse-to-patient ratio regulations require that the minimum ratios must be met at all times.

This bill would set additional minimum staffing requirements for behavioral health emergency services.

Patient boarding. According to a 2020 Journal of America College of Emergency Physicians study "Quantifying the impact of patient boarding on ED length of stay: All admitted patients are negatively affected by boarding," ED boarding negatively impacts emergency physicians, physician assistants, nurse practitioners, nurses, and ancillary staff. ED teams are designed and trained to deliver high-quality episodic care. Patients boarding in the ED require care usually provided by an inpatient care team. The study notes that the ED's culture and performance may be eroded by poor job satisfaction and decreased staff engagement. ED boarding is impacted by hospital inpatient throughput and occupancy and, therefore, is frequently beyond the direct control of the ED or its operations. EDs can improve "front door" processes to mitigate some of the hospital occupancy constraints. A holistic systems approach, focusing on process improvement and optimization at multiple levels, involving all stakeholders, and including human factors, is necessary to address ED boarding.

Mental health care workforce needs. Approximately 16% of Californians live in a Mental Health Professional Shortage Area (MHPSA). To qualify for MHPSA designation, an area must be a rational service area; the population-to-core mental health professional and/or the population-to-psychiatrist ratio must meet established shortage criteria; and, there is a lack of access to mental health care in surrounding areas because of excessive distance, overutilization, or access barriers.

Core mental health providers include psychiatrists, clinical psychologists, licensed clinical social workers, psychiatric nurse specialists, and marriage and family therapists (MFTs). The distribution of licensed mental health providers varies considerably among California regions. The Bay Area has the greatest concentration of licensed mental health professionals, far exceeding the state average. The Inland Empire and San Joaquin Valley fall well below the state average for all mental health professions. The Northern and Sierra region is below average in the numbers of psychiatrists and psychologists, but above average for MFTs.

Budget ask. The California Nurses Association (CNA), the sponsor of this bill, has requested budget funds for acute care behavioral health emergency services to be reserved within the following budget proposals: the Behavioral Health Community-Based Continuum Demonstration ($6.1 billion), HCAI Health Care Workforce General Fund Investments ($1 billion), Private Hospital Supplemental Fund ($118 million), and Nondesignated Public Hospital Supplemental Fund ($1.9 million). Several funds across California Health and Human Services departments and the California Health Facilities Financing Authority include investments to strengthen the continuum of behavioral health services in California, to improve the health care workforce, or to ensure health facilities, including GACHs, are safe and reliable. CNA requests that a portion of existing behavioral health continuum, health care workforce, and hospital supplemental funds are reserved to support GACH capacity to establish, maintain, or train behavioral health emergency services staff and programs. CNA notes that investments into behavioral health emergency response teams in hospitals would help address the immediate care needs of hospital patients with behavioral health needs and would help address rising rates of workplace violence in hospital EDs. Additionally, investment into behavioral health in GACHs, in particular behavioral health emergency response teams, would result in timely transfer of patients and patient access to care, enabling California's investments into the community-based continuum of behavioral health programs to be successful.

According to the Author

Under current law, there are no requirements for hospitals to have mental health and addiction staff in their EDs. The result is that hospitals are unprepared, understaffed, and lack a dedicated mental health and addiction workforce to respond to patients experiencing emergency health crises – and both health care workers and their patients are placed in dangerous conditions. The author states that in order to protect health care workers and their patients, this bill requires that hospitals have trained staff that can appropriately respond to patients who are experiencing a mental health and addiction emergency.

Arguments in Support

CNA is the sponsor of this bill and notes that patients entering hospital EDs with behavioral health considerations may require non-psychiatric acute care in a hospital, hospital admission, or discharge. CNA states that currently, there are no hospital standards to ensure appropriate staff are trained and available throughout acute-care facilities who may experience a behavioral health crisis. Hospitals that are unprepared, understaffed and lack dedicated behavioral health nurses and other appropriately trained and licensed staff place nurses, other health care workers, and patients in dangerous conditions. For ED nurses and other health care workers, the number of patients with psychiatric needs being held in EDs is associated with increased rates of workplace violence. Patients with behavioral health needs may be inappropriately boarded in EDs or under observation status, leading to delays in receiving mental health or acute-care treatment that can lead to worse outcomes and preventable errors.

Arguments in Support if Amended

The California Chapter of the American College of Emergency Physicians (California ACEP), states that while California ACEP supports the goal of this bill, they are concerned with some of the definition provisions. Specifically, the term "emergency services and care" is currently defined in the Health and Safety Code and includes behavioral and psychiatric emergency medical conditions. This terminology is well established and understood by clinicians, facilities, and payers. By creating a new definition for "behavioral health emergency services" and "behavioral health emergency condition," this bill creates potential confusion about a patient's right to care and coverage for their care under existing law. For these reasons, California ACEP notes they would be pleased to support this bill if it is amended to reference and rely on the existing definitions.

Arguments in Opposition Unless Amended

The California Hospital Association (CHA) states that while CHA supports the good intentions behind this bill, they must respectfully oppose the bill unless it is amended to address the concerns below.

First, CHA notes that efforts to reduce or prevent violence in a hospital setting should acknowledge the whole patient population, so as not to fuel the myth that people with mental illness are dangerous and violent. According to the U.S. Department of Health and Human Services: "The vast majority of people with mental health problems are no more likely to be violent than anyone else. Most people with mental illness are not violent and only 3% to 5% of violent acts can be attributed to individuals living with a serious mental illness.

Second, the one-size-fits-all approach to staffing in this bill is rigid and unrealistic, especially given current health care workforce challenges. CHA states that California is facing a shortage of nearly 500,000 allied health professionals and 40,000+ RNs. CHA states that hospitals need flexibility and cannot support a new, statewide mandate for hiring requirements that does not account for their local needs and resources. Instead of mandating an inflexible staffing pattern in every California hospital, this bill could be revised to achieve the author's goals and CHA would be happy to discuss amendments to the bill. Examples include, but are not limited to:

1. Strengthening hospital-wide training and education;
2. Updating the standards that hospitals use to determine staff resource allocation (e.g.: patient classification system); and,
3. Increasing hospitals' consideration of non-clinical staff who, based on training and shared life experiences, make a huge difference in de-escalating situations where people are experiencing a crisis. CHA supports efforts to expand and provide ongoing resources for these models, such as Behavioral Health Navigators from the California Bridge Program or trained volunteers from the National Alliance on Mental Illness’ Friends in the Lobby program.

Third, this bill does not clearly fund implementation. While it would set up a "BHRT Fund" the bill does not identify any funds committed to fill it. Further, grants from the fund would only be available to public or non-profit hospitals, even though more than half of all hospitals in California are operating in the red. The financial devastation caused by the unprecedented COVID-19 crisis did not discriminate by hospital type.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, DPH anticipates that it will need approximately $300,000 in fiscal year (FY) 2023-24, $1.2 million in FY 2024-25, $1.6 million in FY 2025-26, $1.5 million in FY 2026-27, and $1.2 million in FY 2027-28 and annually thereafter (Licensing and Certification Fund). These costs will cover up to 8.5 positions, including 1.5 limited-term positions and funding over three years to develop regulations establishing standards for hospital behavioral health response and training programs. The other ongoing positions will evaluate existing behavioral health response and training programs, establish goals for and measure the progress for hospitals to meet timely access to care and reducing the rate of workplace violence, evaluate hospital response and training programs for compliance with DPH's regulatory standards on an annual basis, and investigate formal behavioral health response complaints.

HCAI estimates costs totaling $175,000 in FY 2024-25 and ongoing to implement the new data collection provision of this bill (California Health Data and Planning Fund). This estimate covers one full time staff position for the increased workload to audit the quarterly financial and utilization reports and review the additional data for reasonableness and consistency.

Additionally, HCAI assumes unknown, significant General Fund (GF) cost pressure, likely several million dollars, to develop, establish, and fund the grant program for the purpose of funding new or existing programs that increase the behavioral health staffing in hospitals. HCAI also estimates needing 5% of the funds appropriated to the grant program for administration and oversight of the program (GF and potentially funds derived from nonstate entities).

VOTES

ASM HEALTH: 11-2-2

YES: Wood, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Maienschein, McCarty, Rodriguez, Santiago, Villapudua, Weber

NO: Flora, Vince Fong

ABS, ABST OR NV: Waldron, Joe Patterson

ASM APPROPRIATIONS: 11-4-1

YES: Holden, Bryan, Calderon, Wendy Carrillo, Mike Fong, Hart, Lowenthal, Papan, Pellerin, Weber, Ortega

NO: Megan Dahle, Dixon, Mathis, Sanchez

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: April 13, 2023

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0000755

Date of Hearing: May 17, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1001

Author:(Haney) – As Amended Ver:April 13, 2023

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

SUMMARY:

This bill, for the purposes of improving behavioral health (BH) care in hospitals, establishes new requirements for a general acute care hospital (hospital), the California Department of Public Health (CDPH), and the Department of Health Care Access and Information, and creates the Behavioral Health Response and Training Fund (BHRT Fund) in the State Treasury.

Specifically, this bill:

1. Requires a hospital to adopt policies and protocols for BH personnel to respond to a patient requiring BH emergency services, as specified, and requires the adopted policies to meet standards established by CDPH and include specified parameters, such as minimum staffing requirements for BH response. The bill also requires a hospital to ensure at least one team of BH response personnel meeting staffing requirements for BH response to be available at all times, and to maintain, for three years, records on each patient who receives BH care.
2. Requires CDPH to adopt regulations on BH standards for a hospital and develop procedures to evaluate existing BH response and training programs utilized by hospitals for compliance with the requirements of this bill.
3. Establishes the Behavioral Health Response and Training (BHRT) Fund in the State Treasury for the purpose of funding grants to designated public hospitals, county hospitals, and non-profit hospitals to fund programs that increase staffing of direct care personnel who are trained in BH care.
4. Requires the Department of Health Care Access and Information (HCAI) to administer the grant program in 3), above, including annually establishing the total amount of funding needed and conducting an evaluation of the grant program.
5. States the intent of the Legislature to provide, in the annual budget act, sufficient supplemental funding for programs pursuant to this bill and to deposit that funding in the BHRT Fund in 2025.

FISCAL EFFECT:

1. CDPH anticipates that it will need approximately $300,000 in fiscal year (FY) 2023-24, $1.2 million in FY 2024-25, $1.6 million in FY 2025-26, $1.5 million in FY 2026-27, and $1.2 million in FY 2027-28 and annually thereafter (Licensing and Certification Fund). These costs will cover up to 8.5 positions, including 1.5 limited-term positions and funding over three years to develop regulations establishing standards for hospital BH response and training programs. The other ongoing positions will evaluate existing behavioral health response and training programs, establish goals for and measure the progress for hospitals to meet timely access to care and reducing the rate of workplace violence, evaluate hospital BH response and training programs for compliance with CDPH’s regulatory standards on an annual basis, and investigate formal BH response complaints.
2. HCAI estimates costs totaling $175,000 in FY 2024-25 and ongoing to implement the new data collection provision of this bill (California Health Data and Planning Fund). This estimate covers one full time staff position for the increased workload to audit the quarterly financial and utilization reports and review the additional data for reasonableness and consistency.
   
   Additionally, HCAI assumes unknown, significant General Fund cost pressure, likely several million dollars, to develop, establish, and fund the grant program for the purpose of funding new or existing programs that increase the BH staffing in hospitals. HCAI also estimates needing 5% of the funds appropriated to the grant program for administration and oversight of the program (General Fund and potentially funds derived from nonstate entities).

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurses Association (CNA). According to the author:

Under current law, there are no requirements for hospitals to have mental health and addiction staff in their emergency departments. The result is that hospitals are unprepared, understaffed, and lack a dedicated mental health and addiction workforce to respond to patients experiencing emergency health crises – and both health care workers and their patients are placed in dangerous conditions. To protect health care workers and their patients, AB 1001 requires that hospitals have trained staff that can appropriately respond to patients who are experiencing a mental health and addiction emergency.

1. Background. HCAI data show that in 2020, patients with BH diagnoses accounted for 1,144,835 inpatient hospitalizations – one-third of all inpatient hospitalizations – and 2,090,085 emergency department (ED) treat and release visits – one-fifth of all ED visits.

According to the California Hospital Association (CHA), since 1995, the state has lost at least 37 psychiatric facilities, representing a 20% drop, and nearly 30% of the state’s psychiatric beds. California now has only 17 psychiatric beds for every 100,000 residents, well short of the recommended minimum number of 50 psychiatric beds per 100,000.

1. Budget Request. The author and CNA requested budget funds in unspecified amounts for acute care BH emergency services to be reserved within the following budget proposals:
   
2. Behavioral Health Community-Based Continuum Demonstration ($6.1 billion).
   
3. HCAI Health Care Workforce General Fund Investments ($1 billion).
   
4. Private Hospital Supplemental Fund ($118 million).
   
5. Nondesignated Public Hospital Supplemental Fund ($1.9 million).
   

CNA contends investment into BH in hospitals, in particular BH emergency response teams, would result in timely transfer of patients and patient access to care, enabling California’s investments into the community-based continuum of BH programs to be successful.

1. Proposed Budget Trailer Bill Language to Implement HCAI Workforce Grant Delays. The governor has proposed language that would pause funding for certain initiatives until 2024-2025, including $15 million for Nursing Initiative Grants, $23.5 million for addiction and psychiatric medicine fellowships, and $26 million for university and college behavioral health workforce grants.
   
2. Recent HCAI workforce awards. On March 30, 2023, the Governor’s Office announced HCAI is issuing more than $150 million in grants to bolster the health care workforce: $117.7 million in grants to support BH providers at 134 nonprofit community-based organizations; and a $33.7 million award to the California Social Work Education Center, administered by the University of California at Berkeley to 892 students pursuing careers in social work.
3. Modernizing California’s Mental Health System. In March 2023, Governor Newsom announced his plan to modernize California’s mental health system. His proposal authorizes a general obligation bond to:
   
   1. Build thousands of new community BH beds in residential settings to house Californians with mental illness and substance use disorders, to potentially serve 10,000 people every year in residential-style settings that have on-site services.
      
   2. Provide more funding specifically for housing for homeless veterans.
   3. Amend the Mental Health Services Act (MHSA), leading to at least $1 billion every year in local assistance for housing and residential services for people experiencing mental illness and substance use disorders, and allowing MHSA funds to serve people with substance use disorders.
      
   4. Include new accountability and oversight measures for counties to improve performance.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 11, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1001

Author:(Haney) – As Introduced Ver:February 15, 2023

SUBJECT: Health facilities: behavioral health emergency services.

SUMMARY: Creates a new definition of “behavioral health emergency condition” which applies specifically to patients in the emergency department (ED) of general acute care hospitals (GACHs). Requires GACHs to adopt policies to respond to a patient requiring behavioral health emergency services, as defined. Requires that these protocols meet standards established by the Department of Public Health (DPH) and consist of various parameters such as minimum staffing requirements for behavioral health emergency services, procedures for response by behavioral health emergency services personnel in a timely manner, and annual training. Creates the Behavioral Health Emergency Response and Training (BHERT) Fund to provide grants to fund new programs or support existing programs that increases the staffing of direct care personnel who are trained in behavioral health care and behavioral health emergency services response or intervention, in specified hospitals. Specifically, this bill:

Behavioral Health Emergency Services

1. Defines “behavioral health emergency condition” by incorporating the existing definition of a psychiatric emergency medical condition, as described in 5) in existing law below, with the addition of the following language: or a cognitive, mental health, substance use, or stress-related crisis that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following:
   1. An immediate danger or risk of danger to themselves or to others; or,
   2. Immediately unable to provide for, or utilize, food, shelter, or clothing, due to a cognitive, mental health, substance use, or stress-related condition.
      
2. Specifies that a behavioral health emergency condition does not require a psychological evaluation or a psychiatric or mental health diagnosis.
   
3. Specifies that the provision described in 2) above does not expand, restrict, or otherwise affect the scope of licensure or clinical privileges for clinical psychologists or medical personnel.
   
4. Defines “behavioral health emergency services” to mean services provided by a GACH for medical screening, examination, and evaluation by a physician and surgeon or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if a behavioral health emergency condition exists, and if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the behavioral health emergency condition, within the capability of the facility.
   
5. Authorizes behavioral health emergency services to include the use of a bed, monitoring by nursing and other staff, and any other services that are reasonable and necessary to safely assess a patient’s condition or determine the need for response and intervention by behavioral health emergency services personnel to respond to a behavioral health emergency condition or for a possible inpatient admission to the hospital that has a behavioral health emergency condition.
   
6. Specifies that 5) above does not expand, restrict, or otherwise affect the scope of licensure or clinical privileges for clinical psychologists or other medical personnel.
   
7. Requires, by January 1, 2025, each GACH to adopt policies and protocols to respond to patients requiring behavioral health emergency services that meet standards established by DPH and that consist of all of the following:
   1. The names or job titles of the hospital staff responsible for implementing the behavioral health emergency services policies and protocols;
   2. Minimum staffing requirements for behavioral health emergency services in accordance with 12) below and all of the following:
      1. At least two registered nurses (RNs) who have experience and competency in providing psychiatric care; and,
      2. At least one staff member, in addition to those specified in i), who is licensed to provide direct patient care and has experience and competency in providing psychiatric care. Authorizes these additional staff to include an additional RN, or a physician and surgeon or a psychiatric technician.
   3. At least one staff member who can respond to the psychosocial needs of patients who have a behavioral health emergency condition. Authorizes this staff to include a licensed clinical social worker or clinical psychologist;
   4. Procedures to ensure the availability of behavioral health emergency services personnel in each patient care area at all times, including a requirement that behavioral health emergency services personnel are not considered to be available if those personnel have other assignments that prevent them from participating in behavioral health emergency services response in a timely manner;
   5. Procedures for identifying and assessing a patient’s condition to determine the need for response or intervention by behavioral health emergency services personnel;
   6. Procedures for response by behavioral health emergency services personnel in a timely manner;
   7. Procedures to ensure timely transfers or admissions as required under 23) below;
   8. Training and education on a continuing annual basis for behavioral health emergency services personnel who provide direct patient care to ensure competency in existing and new skills in psychiatric care, behavioral health, and substance use treatment services;
   9. Training and education on a continuing annual basis for all behavioral health emergency services personnel on behavioral health emergency services response, including on providing trauma-informed care and ensuring access to linguistically and culturally competent care;
   10. Annual training and education for all hospital staff who are required to be present in a patient care area to recognize patient interactions that require response by behavioral health emergency services personnel and how to obtain that response or intervention;
   11. Procedures to ensure the provision of linguistically and culturally competent behavioral health emergency services to each patient with a behavioral health emergency condition;
   12. Procedures to evaluate a behavioral health emergency services patient for substance use treatment and counseling needs and to ensure the provision of that treatment and counseling;
   13. Procedures for hospital staff to report concerns regarding the availability of sufficient staff to perform behavioral health emergency services and concerns regarding the availability, condition, storage, and maintenance of equipment; and,
   14. Procedures to coordinate implementation of response and intervention by behavioral health emergency services personnel with the workplace violence prevention plan adopted by a hospital as required in the standard adopted by the Occupational Safety and Health Standards Board, including methods of reporting and investigating any incidents of workplace violence related to a patient receiving behavioral health emergency services;
       
8. Requires policies and protocols adopted pursuant to 7) above to be maintained and implemented at all times in all units of the GACH where patient care is provided and to be available to all hospital staff at all times.
   
9. Requires DPH, by July 1, 2024, to develop procedures to evaluate existing programs utilized by GACHs to provide behavioral health emergency services response and training for compliance with the requirements of this bill.
   
10. Requires every GACH to designate a licensed RN or physician who has experience and competence in psychiatric services as a director who will be responsible for the management of the policies and protocols adopted under 7) above.
    
11. Requires policies and protocols adopted under 7) above to be developed, implemented, and reviewed annually with the meaningful input and active involvement of the following GACH staff, including their recognized collective bargaining agent or agents, if any:
    1. RNs who provide emergency medical services;
    2. RNs who provide psychiatric nursing care or provide care in a psychiatric unit, if any;
    3. Psychiatrists and other physicians who provide inpatient psychiatric services or provide care in a psychiatric unit, if any;
    4. Ancillary staff who provide inpatient psychiatric services or provide care in a psychiatric unit, including psychiatric technicians;
    5. Behavioral health emergency services personnel as identified in hospital policies and protocols adopted under 7) above; and,
    6. Hospital staff who are required to be present in a patient care area that are reasonably anticipated to require response by behavioral health emergency services personnel;
12. Requires development, implementation, and annual review of policies and protocols pursuant to 11) above to include the participation of GACH staff in evaluating the effectiveness of the policies and protocols in providing timely access to care for behavioral health services patients, reducing rates of workplace violence, and designing and implementing training on behavioral health emergency services response.
    
13. Requires training and education required by this bill to be provided in person and to be designed to provide an opportunity for interactive questions and answers with a person knowledgeable about the behavioral health emergency response and training policies and protocols adopted by the GACH under 7) above.
    
14. Requires each GACH to develop, implement, and annually review training and education required by this bill with the meaningful input and active involvement of GACH staff identified in 11) above, including development of curricula and training materials, and review and revision of the training program.
    
15. Requires training materials developed to meet the requirements of this bill to be appropriate in content and vocabulary to the educational level, literacy, and language of GACH staff receiving the training.
    
16. Requires behavioral health emergency services provided to patients receiving services to comply with the same licensed registered nurse-to-patient ratios as supplemental emergency services or, if the patient is in an inpatient bed or unit, the licensed registered nurse-to-patient ratio of that bed or unit, whichever ratio is lower. Specifies that this requirement does not alter or amend the effect of existing nurse-to-patient ratio regulations.
    
17. Prohibits a patient who requires behavioral health emergency services with an order by a provider for admission to a GACH or transfer to another health facility, from being provided care and treatment as a patient receiving observation services, as defined, or in an observation unit, as defined, for more than 24 hours.
    
18. Requires DPH to adopt regulations on standards for GACHs on behavioral health emergency services, including on behavioral health emergency services response and training.
    
19. Requires all GACHs to maintain records of the following for a period of three years:
    1. Each transfer of a behavioral health emergency services patient;
    2. Each admission of a behavioral health emergency services patient to an inpatient psychiatric unit of the hospital, if any;
    3. Each patient readmission within 30 days of being discharged or transferred after receiving behavioral health emergency services at the hospital; and,
    4. Each patient who received behavioral health emergency services in an observation unit or while receiving observation services.
       
20. Requires all hospitals providing behavioral health emergency services to file quarterly reports with DPH on forms prescribed by DPH that describe the aggregate number for each of the data listed in subdivision 19) above, and reasons for transfer, admission, readmission, or placement in an observation unit or receipt of observation services.
    
21. Requires DPH to post quarterly reports pursuant to 20) above on DPH’s publicly accessible internet website within five calendar days of receipt.
    
22. Requires DPH, in consultation with the Department of Health Care Services (DHCS), the Department of Health Care Access and Information (HCAI), and the Division of Occupational Safety and Health (DOSH), to inspect a representative sample of behavioral health emergency response and training programs utilized by GACHs. Requires DPH, in evaluating a behavioral health emergency response and training program, to examine patient outcomes and rates of workplace violence at each facility. Requires DPH, if it determines that a program is not complying with 7) above or regulations or is not meeting goals related to timely access to care or to workplace violence rate reduction established by DPH pursuant to 23) below, DPH to immediately notify a GACH that utilized the program in writing. Requires DPH’s district offices to inspect facility-based behavioral health emergency response and training programs as utilized by GACHs as part of their annual survey.
23. Requires DPH, in consultation with DHCS and HCAI, to establish goals related to timely access to care for behavioral health emergency services in GACHs. Requires DPH, in consultation with DOSH, to establish goals to reduce the rates of workplace violence related to behavioral health emergency services in GACHs.
    
24. Requires training components of behavioral health emergency response and training programs to be conducted during the normal working hours of the hospital staff unless the staff receives at least the normal hourly wage for any additional time spent in the training component of the approved program.

BHERT Fund

1. Establishes the BHERT Fund in the State Treasury for the purpose of providing grants to support programs described in 30) below and to be administered by HCAI.
   
2. Requires HCAI to annually establish the total amount of funding necessary to support programs described in 30) below and states that it is the intent of the Legislature to provide sufficient supplemental funding for these programs pursuant to this bill in the annual Budget Act and to deposit that funding in the fund in 2025.
   
3. Authorizes HCAI to receive and deposit moneys in the fund from the following entities:
   1. Non-state entities, such as private sector or philanthropic entities; and,
   2. Local and federal governmental agencies.
      
4. Allows no more than 5% of the moneys in the fund to be available for HCAI’s administrative activities related to planning and production of grants.
   
5. Requires the BHERT Fund, beginning no later than July 1, 2024, to be available to receive moneys from non-state entities.
   
6. Requires HCAI to use moneys in the BHERT Fund to administer grants to GACHs in California that are designated public hospitals, county hospitals, or hospitals that are operated by nonprofit organizations in California that are exempt from taxation under Section 501(c) of the Internal Revenue Code. Requires a grant recipient to use the funds awarded to fund a new program or support an existing program that increases the staffing in GACHs of direct care personnel who are trained in behavioral health care and behavioral health emergency services response or intervention. Authorizes, but does not limit the program and the awarded funds to be used for any of the following:
   1. Behavioral health emergency response training programs;
   2. Costs associated with hiring or retaining behavioral health emergency services personnel who provide behavioral health emergency services that meet the requirements of 7) above;
   3. Costs associated with training hospital staff in the provision behavioral health emergency services that meet the requirements of 7) above; and,
   4. Costs associated with implementation of policies and procedures adopted by a hospital to meet the requirements of 7) above.
      
7. Specifies, unless otherwise specified by HCAI, grants made under this bill are to be for a period of one year and may be renewed.
   
8. Requires an application for a grant to be made on a form to be developed by HCAI.
   
9. Requires decisions regarding the grants and the funding level of the grant to be made after consideration of all relevant factors, such as the grantee’s anticipated level of need and the availability of funds.
   
10. Requires HCAI, in administering the fund, to use moneys in the BHERT Fund to pay direct and indirect costs of HCAI, including hiring or administrative costs.
    
11. Requires HCAI to use moneys in the fund to maintain a system of financial reporting on all aspects of the fund. Requires the financial reporting to include, but not be limited to, information from the grantees on their expenditures and activities using grant funds associated with this bill as HCAI deems necessary to ensure the use of the funds are consistent with the purposes of this bill and the terms of any grant award.
    
12. Prohibits HCAI from requiring the submission of any identifying personal information about individuals receiving behavioral health or emergency services as part of an application for a grant or reporting of expenditures and activities using grant funds. Limits information required by HCAI, or its contracted vendor, to only include information in summary, statistical, or other forms that do not identify particular individuals.
    
13. Exempts contracts entered into or amended pursuant to this bill from the review or approval of any division of the Department of General Services.
    
14. Requires HCAI to conduct an evaluation of the grant program and to report its findings to the Legislature no later than January 1, 2026, and on an annual basis no later than each January 1 thereafter. Requires the first annual report to cover the period before July 1, 2025. Requires each subsequent annual report to cover the previous fiscal year. Authorizes HCAI to use moneys in the fund, upon appropriation by the Legislature, for the evaluation of the program.
    
15. Requires the quarterly summary utilization data currently reported to HCAI by a hospital to also include all of the following:
    1. Number of inpatient psychiatric visits and number of hours of services provided;
    2. Number of behavioral health emergency service visits and number of hours of services provided;
    3. Number of observation service visits and the number of hours of services provided, including the number of behavioral health emergency service hours provided during observation service visits;
    4. Number of behavioral health emergency service inpatient admissions, including the number of behavioral health emergency service admissions to an inpatient psychiatric unit; and,
    5. Number of behavioral health emergency service readmissions within 30 days of discharge or transfer.
       
16. Requires all hospitals to maintain records of aggregate data listed in 39) above for a period of three years.
    

EXISTING LAW:

1. Licenses and regulates hospitals, including GACHs and acute psychiatric hospital (APH), by DPH. Permits GACHs, in addition to the basic services all hospitals are required to offer, to be approved by DPH to offer special services, including, among other services, an ED, and psychiatric services. [Health and Safety Code [HSC] §1250 and §1255, et seq.]
   
2. Licenses psychiatric health facilities by DHCS, which are defined as health facilities that provide 24-hour inpatient care for people with mental health disorders, whose physical health needs can be met in an affiliated hospital or in outpatient settings. [HSC §1250.2]
   
3. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 United States Code §1395dd; HSC §1317]
   
4. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1317.1 (a)(1)]
5. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a GACH, or to an APH. [HSC §1317.1 (a)(2)]
6. Defines “emergency medical condition” to means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

a) Placing the patient’s health in serious jeopardy;

b) Serious impairment to bodily functions; or,

c) Serious dysfunction of any bodily organ or part. [HSC §1317.1 (b)]

1. Prohibits a person needing emergency services and care from being transferred from a hospital to another hospital for any nonmedical reason (such as the person’s inability to pay for any emergency service or care) unless certain conditions are met, including that the person has been provided with emergency services so that it can be determined, within reasonable medical probability, that the transfer will not create a medical hazard to the person. [HSC §1317.2]
2. Establishes the Lanterman-Petris-Short (LPS) Act to end the inappropriate, indefinite, and involuntary commitment of individuals with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard their rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to their needs. Permits involuntary detention of an individual deemed to be a danger to self or others, or “gravely disabled,” as defined, for periods of up to 72 hours (known as “5150 holds”) for evaluation and treatment; for up-to 14 days after certification of the need for initial intensive treatment; and up-to 30 days for additional intensive treatment in counties that opt in to provide additional intensive treatment. [Welfare & Institutions Code (WIC) §5000, et seq.]
3. Provides that the up-to 72-hour involuntary detention time limit begins at the time when an individual is first detained. [WIC §5150]
4. Defines “gravely disabled,” for purposes of evaluating and treating an individual who has been involuntarily detained or for placing an individual in conservatorship, as a condition in which they, as a result of a mental disorder or impairment by chronic alcoholism, are unable to provide for their basic personal needs for food, clothing, or shelter. [WIC §5008]
5. Authorizes a peace officer, member of the attending staff of a “designated facility,” as defined, member of the attending staff of a designated facility, or other professional person designated by the county, upon probable cause, to take a person with a mental disorder who is a danger to self or others, or is gravely disabled, into custody (referred to as a “5150” hold) and place them in a designated facility. [WIC §5150]
6. 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, and includes, but is not limited to, a licensed psychiatric hospital, a licensed psychiatric health facility, and a certified crisis stabilization unit. [WIC §5008]
   
7. Defines “observation services” to mean outpatient services provided by a GACH and that have been ordered by a provider, to those patients who have unstable or uncertain conditions potentially serious enough to warrant close observation, but not so serious as to warrant inpatient admission to the hospital. Authorizes observation services to include the use of a bed, monitoring by nursing and other staff, and any other services that are reasonable and necessary to safely evaluate a patient’s condition or determine the need for a possible inpatient admission to the hospital. [HSC §1253.7]
8. Defines “observation unit” to mean an area in which observation services are provided in a setting outside of any inpatient unit and that is not part of an ED of a GACH. Authorizes a hospital to establish one or more observation units that must be marked with signage identifying the observation unit area as an outpatient area. Requires the signage to use the term “outpatient” in the title of the designated area to indicate clearly to all patients and family members that the observation services provided in the center are not inpatient services. Requires an observation unit to comply with the same licensed nurse-to-patient ratios as supplemental emergency services. [Id.]
9. Requires the Occupational Safety and Health Standards Board, no later than July 1, 2016, to adopt standards that require a licensed hospital, as specified, to adopt a workplace violence prevention plan as a part of its injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. [Labor Code §6401.8]
   
10. Designates HCAI as the state agency that collects health facility data for use by all state agencies, including various financial data reports. [HSC §128730, et seq.]
    
11. Requires hospitals to make and file with HCAI certain reports, including a Hospital Discharge Abstract Data Record that is required to include 19 specified data elements for each admission, including information on diagnoses and disposition of the patient. Requires hospitals to also file an Emergency Care Data Record for each patient encounter in a hospital ED, and hospitals and freestanding ambulatory surgery clinics are required to file an Ambulatory Surgery Data Record for each patient encounter during which at least one ambulatory surgery procedure is performed, with both of these data records including similar data elements to the discharge data record. [HSC §128735, §128736, and §128737]
    
12. Requires the following summary financial and utilization data to be reported to HCAI by a hospital within 45 days of the end of a calendar quarter. Adjusted reports reflecting changes as a result of audited financial statements may be filed within four months of the close of the hospital’s fiscal or calendar year. The quarterly summary financial and utilization data to conform to the uniform description of accounts as contained in the Accounting and Reporting Manual for California Hospitals and to include all of the following:
    1. Number of licensed beds;
    2. Average number of available beds;
    3. Average number of staffed beds;
    4. Number of discharges;
    5. Number of inpatient days;
    6. Number of outpatient visits;
    7. Total operating expenses;
    8. Total inpatient gross revenues by payer, including Medicare, Medi-Cal, county indigent programs, other third parties, and other payers;
    9. Total outpatient gross revenues by payer, including Medicare, Medi-Cal, county indigent programs, other third parties, and other payers;
    10. Deductions from revenue in total and by component, including the following: Medicare contractual adjustments, Medi-Cal contractual adjustments, and county indigent program contractual adjustments, other contractual adjustments, bad debts, charity care, restricted donations and subsidies for indigents, support for clinical teaching, teaching allowances, and other deductions;
    11. Total capital expenditures;
    12. Total net fixed assets;
    13. Total number of inpatient days, outpatient visits, and discharges by payer, including Medicare, Medi-Cal, county indigent programs, other third parties, self-pay, charity, and other payers;
    14. Total net patient revenues by payer including Medicare, Medi-Cal, county indigent programs, other third parties, and other payers;
    15. Other operating revenue; and,
    16. Non-operating revenue net of non-operating expenses. [HSC §128740]
        

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, under current law, there are no requirements for hospitals to have mental health and addiction staff in their EDs. The result is that hospitals are unprepared, understaffed, and lack a dedicated mental health and addiction workforce to respond to patients experiencing emergency health crises – and both health care workers and their patients are placed in dangerous conditions. The author states that in order to protect health care workers and their patients, this bill requires that hospitals have trained staff that can appropriately respond to patients who are experiencing a mental health and addiction emergency.
2. BACKGROUND. According to the National Institute of Mental Health, nearly one in five U.S. adults live with a mental illness. In California, that equates to nearly 8 million people in 2020. According to the California Health Care Foundation, an average of 2.9 million Californians per year, age 12 and older (8.8%), had a substance use disorder in 2018-2019.

According to HCAI data, in 2020, patients with behavioral health diagnoses accounted for 1,144,835 Inpatient hospitalizations and 2,090,085 ED treat and release visits, which is one third of all IP hospitalizations (3,444,532) and one fifth of all ED visits (10,023,851).

• 1. Lack of inpatient psychiatric beds. According to the California Hospital Association (CHA), since 1995 the state has lost at least 37 facilities, either through the elimination of psychiatric inpatient care, or complete hospital closure, representing a 20% drop. CHA states that while there has been an increase in psychiatric beds over the past several years, California has lost nearly 30% of the psychiatric beds it had in 1995. On a per capita basis, accounting for the growth in California’s population, this translates into a loss of more than 42% of the psychiatric inpatient beds per capita since 1995. California now has only 17 psychiatric beds for every 100,000 residents, compared to nearly 30 beds per 100,000 in 1995, and well short of the recommended minimum number of 50 psychiatric beds per 100,000.
  2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
  3. Nurse-to-patient staffing ratios. In 2004, regulations were adopted to implement nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999, went into effect. However, long before California had specific nurse-to-patient ratios, hospitals were required by regulation to establish a patient classification system. This patient classification system is a method by which hospitals establish staffing requirements by unit, patient, and shift, and includes a method by which the amount of nursing care needed for each category of patient is validated for each unit.
     
     The regulations implementing the AB 394 nurse-to-patient ratios law set the minimum ratio of nurses-to-patient by unit, including one-to-one in operating rooms, one-to-two in intensive care units, and one-to-five in general medical-surgical units. These regulations also incorporated the patient classification system requirement. In essence, the specific nurse-to-patient ratios establish the minimum number of nurses by unit, while the patient classification system determines whether there needs to be a higher level of staffing beyond the minimum ratio after taking into consideration factors such as the severity of the illness, the need for specialized equipment and technology, and the complexity of clinical judgment needed to evaluate the patient care plan, among other factors. The nurse-to-patient ratio regulations require that the minimum ratios must be met at all times.
     
     This bill would set additional minimum staffing requirements for behavioral health emergency services.
  4. Patient boarding. According to a 2020 Journal of America College of Emergency Physicians study “Quantifying the impact of patient boarding on ED length of stay: All admitted patients are negatively affected by boarding,” ED boarding negatively impacts emergency physicians, physician assistants, nurse practitioners, nurses, and ancillary staff. ED teams are designed and trained to deliver high-quality episodic care. Patients boarding in the ED require care usually provided by an inpatient care team. The study notes that the ED’s culture and performance may be eroded by poor job satisfaction and decreased staff engagement. ED boarding is impacted by hospital inpatient throughput and occupancy and, therefore, is frequently beyond the direct control of the ED or its operations. EDs can improve “front door” processes to mitigate some of the hospital occupancy constraints. A holistic systems approach, focusing on process improvement and optimization at multiple levels, involving all stakeholders, and including human factors, is necessary to address ED boarding.
     
  5. Mental health care workforce needs. Approximately 16% of Californians live in a Mental Health Professional Shortage Area (MHPSA). To qualify for MHPSA designation, an area must be a rational service area; the population-to-core mental health professional and/or the population-to-psychiatrist ratio must meet established shortage criteria; and, there is a lack of access to mental health care in surrounding areas because of excessive distance, overutilization, or access barriers.

Core mental health providers include psychiatrists, clinical psychologists, licensed clinical social workers, psychiatric nurse specialists, and marriage and family therapists (MFTs). The distribution of licensed mental health providers varies considerably among California regions. The Bay Area has the greatest concentration of licensed mental health professionals, far exceeding the state average. The Inland Empire and San Joaquin Valley fall well below the state average for all mental health professions. The Northern and Sierra region is below average in the numbers of psychiatrists and psychologists, but above average for MFTs.

• 1. ED workplace violence associated with mental health boarding. According to a February 2022 article in the journal Ethics, Medicine and Public Health, the number of mental health holds in the ED was associated with an increase in ED violence. However, a causal association could not be established, and the article noted that further investigation and discussion on the topic is warranted and that system-wide efforts to improve acute psychiatric care, and therefore reduce the number of patients on mental health holds boarding in the ED, could potentially reduce ED workplace violence.
     
  2. Budget ask. The California Nurses Association (CNA), the sponsor of this bill, has requested budget funds for acute care behavioral health emergency services to be reserved within the following budget proposals: the Behavioral Health Community-Based Continuum Demonstration ($6.1 billion), Department of Health Care Access and Information Health Care Workforce General Fund Investments ($1 billion), Private Hospital Supplemental Fund ($118 million), and Nondesignated Public Hospital Supplemental Fund ($1.9 million). Several funds across California Health and Human Services departments and the California Health Facilities Financing Authority include investments to strengthen the continuum of behavioral health services in California, to improve the health care workforce, or to ensure health facilities, including GACHs, are safe and reliable. CNA requests that a portion of existing behavioral health continuum, health care workforce, and hospital supplemental funds are reserved to support GACH capacity to establish, maintain, or train behavioral health emergency services staff and programs. CNA notes that investments into behavioral health emergency response teams in hospitals would help address the immediate care needs of hospital patients with behavioral health needs and would help address rising rates of workplace violence in hospital EDs. Additionally, investment into behavioral health in GACHs, in particular behavioral health emergency response teams, would result in timely transfer of patients and patient access to care, enabling California’s investments into the community-based continuum of behavioral health programs to be successful.
     
  3. Proposed budget trailer bill language to implement HCAI workforce grant delays. The Administration has proposed language that would pause funding for the following initiatives until 2024-2025:
     1. Fifteen million dollars ($15,000,000) of the amount appropriated for Nursing Initiative Grants;
     2. Twenty-three million five hundred thousand dollars ($23,500,000) of the amount appropriated for Addiction Psychiatric/Medicine Fellowships; and,
     3. Twenty-six million dollars ($26,000,000) of the amount appropriated for University/College Behavioral Health Workforce grants.
        
  4. Recent HCAI workforce awards. On Thursday, March 30, 2023, the Governor’s Office announced that HCAI is issuing more than $150 million in grants to bolster the health care workforce: $117.7 million in grants to support the behavioral health providers at 134 nonprofit Community-Based Organizations across California; and a $33.7 million award to the California Social Work Education Center, administered by the University of California at Berkeley to 892 students pursuing careers in social work.
     
  5. Modernizing California’s Mental Health System. In March 2023, Governor Newsom announced in his plan to modernize California’s mental health system. His proposal authorizes a general obligation bond to:
     1. Build thousands of new community behavioral health beds in state-of-the-art residential settings to house Californians with mental illness and substance use disorders, which could serve over 10,000 people every year in residential-style settings that have on-site services – not in institutions of the past, but locations where people can truly heal;
     2. Provide more funding specifically for housing for homeless veterans;
     3. Amend the Mental Health Services Act (MHSA), leading to at least $1 billion every year in local assistance for housing and residential services for people experiencing mental illness and substance use disorders, and allowing MHSA funds to serve people with substance use disorders; and,
     4. Include new accountability and oversight measures for counties to improve performance.

1. SUPPORT. CNA is the sponsor of this bill and notes that patients entering hospital EDs with behavioral health considerations may require non-psychiatric acute care in a hospital, hospital admission, or discharge. CNA states that currently, there are no hospital standards to ensure appropriate staff are trained and available throughout acute-care facilities who may experience a behavioral health emergency. Hospitals that are unprepared, understaffed and lack dedicated behavioral health nurses and other appropriately trained and licensed staff place nurses, other health care workers, and patients in dangerous conditions. For ED nurses and other health care workers, the number of patients with psychiatric needs being held in EDs is associated with increased rates of workplace violence. Patients with behavioral health needs may be inappropriately boarded in EDs or under observation status, leading to delays in receiving mental health or acute-care treatment that can lead to worse outcomes and preventable errors.

CNA contends that California must create hospital standards to ensure that hospitals have appropriate staff available and trained to respond to patients who may experience behavioral health emergencies. CNA concludes that existing law should be amended to include requirements that hospitals have appropriately trained psychiatric health care professionals, including psychiatric registered nurses, available to immediately respond to hospital patients outside of psychiatric units who may require behavioral health emergency services.

1. SUPPORT IF AMENDED. The California Chapter of the American College of Emergency Physicians (California ACEP), states that while California ACEP supports the goal of this bill, they are concerned with some of the definition provisions. Specifically, the term “emergency services and care” is currently defined in the HSC and includes behavioral and psychiatric emergency medical conditions. This terminology is well established and understood by clinicians, facilities, and payers. By creating a new definition for “behavioral health emergency services” and “behavioral health emergency condition,” this bill creates potential confusion about a patient’s right to care and coverage for their care under existing law. For these reasons, California ACEP notes they would be pleased to support this bill if it is amended to reference and rely on the existing definitions.
   
2. OPPOSE UNLESS AMENDED. The California Hospital Association (CHA) states that while CHA supports the good intentions behind this bill, they must respectfully oppose the bill unless it is amended to address the four concerns described below.

First, CHA notes that efforts to reduce or prevent violence in a hospital setting should acknowledge the whole patient population, so as not to fuel the myth that people with mental illness are dangerous and violent. According to the U.S. Department of Health and Human Services: “The vast majority of people with mental health problems are no more likely to be violent than anyone else. Most people with mental illness are not violent and only 3% to 5% of violent acts can be attributed to individuals living with a serious mental illness.

Second, the one-size-fits-all approach to staffing in this bill is rigid and unrealistic, especially given current health care workforce challenges. CHA states that California is facing a shortage of nearly 500,000 allied health professionals and 40,000+ RNs. CHA states that hospitals need flexibility and cannot support a new, statewide mandate for hiring requirements that does not account for their local needs and resources. Instead of mandating an inflexible staffing pattern in every California hospital, this bill could be revised to achieve the author’s goals and CHA would be happy to discuss amendments to the bill. Examples include, but are not limited to:

1. Strengthening hospital-wide training and education;
2. Updating the standards that hospitals use to determine staff resource allocation (e.g.: patient classification system); and,
3. Increasing hospitals’ consideration of non-clinical staff who, based on training and shared life experiences, make a huge difference in de-escalating situations where people are experiencing a crisis. CHA supports efforts to expand and provide ongoing resources for these models, such as Behavioral Health Navigators from the California Bridge Program or trained volunteers from NAMI’s Friends in the Lobby program.

Third, this bill does not clearly fund implementation. While it would set up a “Behavioral Health Emergency Response and Training Fund,” the bill does not identify any funds committed to fill it. Further, grants from the fund would only be available to public or non-profit hospitals, even though more than half of all hospitals in California are operating in the red. The financial devastation caused by the unprecedented COVID-19 crisis did not discriminate by hospital type.

Finally, it is critical to acknowledge the important role of other agencies in the community when managing challenging or violent behavior that occurs in hospital settings. Hospitals rely heavily on the partnership and response of their local partners in both preventing and responding to challenging or violent behavior, especially law enforcement and county behavioral health agencies.

1. RELATED LEGISLATION.
   1. AB 1164 (Lowenthal) requires a licensed GACH with an ED to determine the range of crowding scores that constitute each category of the crowding scale, as provided, for its ED. Requires the hospital to calculate and record a crowding score at a minimum every four hours, except as specified, to assess the crowding condition of the hospital’s ED. Requires, by January 1, 2025, the hospital to develop and implement a full-capacity protocol for each of the categories of the crowding scale, and requires the hospital to file its protocol with HCAI and to annually report any revisions to its protocol. AB 1164 is pending in the Assembly Health Committee.
   2. AB 1316 (Irwin and Ward) revises the definition of “psychiatric emergency medical condition” to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment. Authorizes a hospital to transfer a patient on a 5150 prior to the patient receiving an assessment as mandated by the LPS Act. Requires the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, for all services medically necessary to stabilize the beneficiary. AB 1316 is pending in the Assembly Health Committee.
   3. AB 1577 (Low) requires a GACH, as a condition of licensure, to provide clinical placements for postsecondary educational students enrolled in an approved school of nursing or an approved program of nursing education, as defined. AB 1577 is pending in the Assembly Health Committee.
2. PREVIOUS LEGISLATION.
   1. SB 929 (Eggman), Chapter 539, Statutes of 2022, requires DHCS to collect and publish information about involuntary detentions to include additional information, such as clinical outcomes, services provided, and availability of treatment beds.
   2. SB 964 (Wiener) of 2022, would have established the “Behavioral Health Workforce Preservation and Restoration Fund” to stabilize the current licensed clinical behavioral health workforce. Would have established a stipend program for students pursuing a master’s degree in social work with a specialized focus on public behavioral health. Would have required HCAI to create an online jobs board for behavioral health workers. Would have required an analysis of the current behavioral health workforce, the state’s needs, and recommendations to the Legislature on how to address the behavioral health workforce shortage.
      
      SB 964 was vetoed by Governor Newsom, who stated in part, “This bill duplicates existing efforts in assessing workforce needs and analyzing trends through HCAI's Workforce Education and Training Council and its Workforce Research Data Center. Furthermore, this bill would require approximately $1.5 million to implement, which was not accounted for in the budget. With our state facing lower-than-expected revenues over the first few months of this fiscal year, it is important to remain disciplined when it comes to spending, particularly spending that is ongoing. We must prioritize existing obligations and priorities, including education, health care, public safety and safety-net programs.”
   3. AB 451 (Arambula) Chapter 438, Statutes of 2021, requires a psychiatric unit of a GACH, a psychiatric health facility with more than 16 beds that is not county operated, and an APH, to accept a transfer of a person with a psychiatric emergency medical condition, regardless of whether the facility operates an ED, if the facility has appropriate facilities and qualified personnel available to provide the services.
3. POLICY COMMENT. This bill and AB 1316 are focused on the growing problem of patient boarding in EDs, particularly individuals who may be suffering from a mental health condition or substance use disorder. AB 1316 would clarify state versus county responsibility for payment of emergency mental health services, and allow a hospital to transfer a patient if they cannot provide an inpatient bed or necessary services, regardless of whether or not they are there voluntarily, or involuntarily, even if an involuntary patient on a 5150 hold has not received the LPS mandated assessment. This bill would, among other provisions, require a hospital to ensure staff in the ED are trained to provide mental health treatment as necessary, and prohibits a patient from being placed in observation (or boarded) for more than 24 hours.

While both bills propose solutions that will hopefully provide more positive outcomes for individuals suffering a mental health crisis they do not address the root cause of the problem causing ED boarding of patients presenting with behavioral health emergencies; it is apparent that the most pressing problem facing hospitals, medical providers, and most importantly, their patients, is the lack of inpatient psychiatric beds, and the length of time it takes counties to provide mental health assessments to individuals placed on a 5150 hold.

7) SUGGESTED AMENDMENTS. The Committee may wish to amend this bill as follows:

• 1. To remove the new definition of “behavioral health emergency condition” due to possible confusion and conflicts with existing law;
  2. To strike the language that specifies that a behavioral health emergency condition does not require a psychological evaluation or a psychiatric or mental health diagnosis;
  3. To clarify that the four person teams required by the protocols described in 7) of “what this bill does” above, are not required in each patient care area at all times, but rather are available at all times;
  4. To delete the requirement that collective bargaining agents be included in the review of the policies and protocols required in 7) of what the bill does;
  5. By prohibiting a patient who requires behavioral health emergency services with an order by a provider for admission to a GACH or transfer to another health facility, from being provided care and treatment as a patient receiving observation services, as defined, for more than 24 hours, the provisions of this bill may conflict with both the LPS, and EMTALA. The Committee may wish to strike that provision from this bill.
  6. Current law requires some entities to report on mental health outcomes to DHCS, and others to report to HCAI. Moving forward the author should work with DPH, HCAI and DHCS to ensure mental health patient reporting requirements are not duplicative.

REGISTERED SUPPORT / OPPOSITION:
Support

California Nurses Association (sponsor)

AFSCME

Board of Registered Nursing

California Association of Psychiatric Technicians

California Labor Federation, AFL-CIO

National Association of Social Workers, California Chapter

The California Association of Local Behavioral Health Boards and Commissions
Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097