Senate Standing Committee on Health

The Senate Judiciary and Health Committees will come to order. I'm here with my colleague and friend, Senator Menjivar. This hearing actually was the brainchild of Senator Menjivar. And we're pleased that you all are here in Orange County. Orange County Superior Court. Before I forget, Happy birthday to Senator Menjivar. Those who don't know Senator Menjivar is.

250 years old today.

She's 250 years old just a couple of days ago. Right. You don't know that Senator Menjivar used to be Sergeant Menjivar back in the day of the Marine Corps. So happy birthday.

Thank you, brother.

We're here to talk about the Community Assistance Recovery and Empowerment Program, commonly known as the CARE Court. There are a number of people that were responsible for putting this hearing together. I just wanted to make mention of them. Reyes, Diaz, thank you very much for all your help.

And of course, Chief Counsel of Senate Judiciary Committee, Margie Estrada. Alison Meredith is not here with us, but was one of the folks that bore laboring or Anna Gonzalez, my district Director. And I see the entire Umberg team is here. Thank you very much. The Senate Democratic Caucus was also very helpful.

Brian Shaden, Grace Davis, Maya Velasquez, Lake Hooper, John Roman, Marcos Hilbert, and most importantly, the Orange County Superior Court Judge Maria Hernandez. The presiding judge and the presiding judge elect Sheila Hanson were also incredibly helpful.

So Care Court, the original concept of CARE Court was initiated by the Governor and Senator Eggman and I were proud to be able to take up the mantle to try to advance CARE Court several years ago. And the original concept, which remains the concept today, is that folks with schizophrenia or schizophrenia like conditions can recover.

The conventional wisdom often is that they are not able to recover. That's not true. But in order to recover, they need to be in an environment that provides stability, provides behavioral health, professional support, and also provides for housing.

And so those elements are critical in making sure that those that have schizophrenia, schizophrenia like conditions, bipolar with psychotic features, that they get the care that they need and deserve. Important for them, important for their families.

Now, Dr. Mark Galley, who is no longer in the governor's office, but was incredibly helpful in making sure that those elements were all incorporated in the CARE Court as it was designed. Much like anything else that's new and different, though it bears improvement.

And each year since its inception, I've carried legislation and others have carried legislation in order to make improvements in CARE Court.

One of the purposes here today is to continue to discuss what we can do, what the status is, but also what we can do to make sure that the mission, the vision, the goal of CARE Court is ultimately fulfilled. And with that, let me turn the microphone over to my friend and colleague, Senator Manjar.

Thank you so much, Senator Umberg, and welcome again, everyone. Happy to be here in your home, your hometown, your district.

While I was not around when Senator Umberg and then Senator Eggman created or passed or led the legislation and the framework for care, the CARE Act, I now have the ability for the next couple of years to ensure that the accountability and the transparency is seen throughout, that the implementation is being done in the way that it was all intended to do, that the initiative from back then is being spread out through the cohort.

So in the report, the first report we've seen of the first nine months on only Cohort 1 had some good promising data points.

There's still some outstanding questions regarding the lack of tracking the elective clients, ensuring that we also get information from them, ensuring that to close the gaps on some of the social services that are not being delivered to the clients and really getting at the core reasoning as to why they're not being handled.

Recognizing this is the first report in nine months. It's not a long time to do data points. But just like Senator to obtain data points. But just like Senator Umberg has mentioned, legislation has passed since then to close the gap.

We know that starting earlier this year in January, more data points were added to the collection of Care Corps, which is really great. And hopefully the next report we're going to get a more robust understanding of of this and then we're tracking everybody.

But what I'm really excited to see of this preliminary report is that these, these petitions are coming from family Members. Majority of them are family Members. This isn't a system that was created by provider petitions. This wasn't a, a Care Corps or Care Act wasn't created just so providers can put people into institutions.

These are family Members that are seeing that their loved ones need additional support. So I'm glad to see majority of that is coming out of that. I'm also glad to see that reports are showing that one of the least needed service or such substance use disorder that the core of what people need here have been housing.

Unstable housing has been the number one need and supportive family Members around there. I know there's gaps around the lack of involvement or barriers that exist with family Members that get of the loved ones of the petitioners to be included.

I know more legislation is needed and this is one of the first of many conversations to ensure that what we've wanted to do or what Senator Umberg and Eggman wanted to do is really what is happening in across California. So thank you, Senator, for indulging me and ensuring that we have this conversation.

And I'm ready to get going.

Well, thank you very much. And before we do get going, Judd, we have the Assistant Presiding Judge elect here with us today. Thank you, Judge, for being with us here today. And as you walk up, I spent many years.

I spent three years in this courtroom, standing right over there in front of Judge Alice Marie Stotler, alone and afraid. So thank you. Floor is yours.

Thank you. Good morning, everybody, and welcome. My name is Terry Flynn Peaster. I am the incoming assistant Presiding Judge here in Orange County. I will take office in January. Our Presiding Judge, Maria Hernandez, and our current Assistant Presiding Judge Sheila Hansen, are unfortunately away from the court today, so could not be here.

They send their regrets, but are very honored to have our court be here and be able to host this wonderful event. As a County of over 3 million people, we have been a partner with these statewide efforts to implement the CARE Court.

So I'm excited to hear from the various stakeholders, family members, community partners, attorneys, judges, about their experiences with CARE Court. While you're here, if you need anything today, please let me know or any of the wonderful staff from the Orange County Superior Court. Thank you.

Thank you, Judge. All right, let's call up our very first panel, which consists of Stephanie Welch, Ivan Bardwaj and Hadreas. Thank you. And while you're coming up, also another thank you to our ledge Director, Zach Keller, for all the work he's put into CARE Court from the very beginning. He's our in house resident expert on CARE Court.

This first panel will dive into the first nine months of the CARE Act, a deeper dive.

I got the memo on the colors today, so happy birthday. Happy birthday. Good morning. Good morning, everyone. Hi, I'm Stephanie Welch. I'm the Deputy Secretary of Behavioral Health at our Health and Human Services Agency. And I'm also our lead on care implementation. I wanted to thank our elected leaders here today for their dedication to supporting vulnerable Californians.

I've worked in behavioral health for over 25 years, and I think I can attest that the last six years that we've been doing all of these behavioral health initiatives, we're really, really starting to see profound changes impact people's lives. And the CARE act is part of that.

The CARE act provides proactive, or, I'm sorry, Health and Human Services provides proactive coordination. Part of our job is to be responsible for leading the coordination between the partners that you see up here, the Department of Healthcare Services and the Judicial Council.

We also facilitate a transparent advisory body, the CARE act working group, which statute requires us to hold until the end of next calendar year solely for the purpose of really overseeing the initial implementation of care. I'm here today to kick us off and really want to focus on what have we learned so far.

And I'm going to take a little bit of the luxury to go beyond the first nine months because my colleague from the Department of Healthcare Services, we'll go into detail about the findings in the first annual report.

But what we have learned so far is that care is effectively countering what is a lack of accountability for people who are suffering with the most complex and chronic conditions, behavioral health conditions.

And that is by putting in place a new civil court process that makes sure that those with the highest needs are the ones who are served. No more is it the client or the consumer who is held accountable for their recovery alone.

But the civil court process is empowered to hold counties to the highest standards to deliver the most impactful programs to those with the highest needs. Courts order counties to prioritize care participants. We do this in healthcare all the time. We call it triage, and we do triage to save lives.

While care is designed for a small but high need population, it does operate as part of the larger in a larger concert of initiatives that are in the process of changing and fortifying the fabric of California's safety net.

This Administration, with the support of the Legislature, has invested nearly $14 billion in funding to transform our behavioral health system. A significant amount of that funding has been directly to invest in infrastructure. Infrastructure for housing, infrastructure for facilities, and most importantly, infrastructure for people to deliver services for this population. We are starting to see those investments materialize.

We are not just having groundbreakings for our infrastructure program. We are actually having grand openings and ribbon cutting ceremonies. We have also really learned that care is making a difference in people's lives. There are over 6,000 individuals who have been helped, specifically the most recent numbers.

And I know that my colleagues here will go into a little bit more detail, but as of September of this year, 2,873 petitions have been submitted.

Ms. Welch, we're going to come back. Those numbers are important. Okay, I'll start. We're going to come back to you because that's my first question.

So for the audience, each panelist will have three minutes and then Senator Mengavar and all, and I will have an opportunity to ask questions and you put a pin in that, because that's going to be my first question in terms of the numbers.

So let me jump ahead and give some more reflections of the things that we've seen so far. We believe that care is effectively disrupting the cycle of an over reliance on crisis services and hospitalization. And particularly more work can be done to reduce the incarceration in. From in 2023 to 2025. And this statistic shocked me as well.

The active mental health cases in our jails has risen by 10%. This is at the same time that the overall daily jail population has decreased by 1%. Care is a far better use of funds than continuing a legacy of people with untreated mental illness being incarcerated. If an individual.

We're going to come back to you. Okay? So. All right, you want me to skip ahead? You can skip ahead. Why don't you finish up and then we'll come back during the question period.

Okay. I think one of the important points in my time here that I want to make is that care is working very well in some counties, and in others it is not. How care has been implemented on a statewide basis is variable.

So one concrete example, we have one cohort, one county, who submits five times more petitions per month than another cohort, one county.

And so I think what we have been really trying to do in partnership with the counties is to figure out how to make sure that they're getting high quality petitions and getting a diverse set of petitions.

It is incredibly important and unique of care, not just that there's a civil court process that Holds County accountable, but that parents and families can submit petitions. But from our perspective, we actually believe that providers, first responders, hospitals, frankly, Clinicians who are working in jail settings and other places like that should also clearly be petitioners.

And for those counties who are working with those entities, we are seeing more petitions.

So we're going to come right back. All right? Okay.

All right, thank you.

So we're going to turn to our next witness. Before we do, I see Supervisor Foley, Orange County Supervisor Foley is here. Thank you very much. And I know this is an area of great interest and passion, both mental illness as well as homelessness. So thank you for your interest and your presence.

All right, next, why don't we turn to Mr. Bardwaj.

Thank you. What an honor it is to be here, to be able to share about this program. I am Ivan Bardwaj and I am the Chief of the Medi Cal Behavioral Health Policy Division at the California Department of Healthcare Services and my team and I support the implementation of the CARE Act.

And you know, while counties are responsible for implementing locally, DHCS is responsible for kind of some of the broader system changes in order to be able to support counties in making the system changes locally.

So that includes training and technical assistance, data collection and reporting, an independent evaluation, and then the fiscal components of care, so including startup and ongoing costs. And we'll just cover quickly what our support has looked like since CARE was conceived.

You know, probably the kind of largest and most visible aspect of our work is our training and technical assistance support that DHCS provides. You know, I think, I think of it as bifurcated.

There is the larger system changes that we know need to happen between our courts, between our county behavioral health, between all of our other system partners.

So we focus training on behavioral health plans, justice, the justice involved system providers, state hospitals, public safety, first responders, social services, housing, supportive services, and then sort of the nuts and bolts of care as well.

So I think of that as like care eligibility, care process, the petitioning process, even clinical education, which we know county behavioral health plans have, but really supplementing that with specialty mental health services and what that looks like, the role of peers and volunteer supporters, psychiatric advanced directives. To date, we have more than 3,000 participants in these trainings.

We have a kind of a vast resource library available on our website that includes all of these trainings, but also includes a host of forms, templates, supportive guidance. And I think one of the unique aspects of CARE is that every county is different. Stephanie had mentioned. This is where every county's implementing CARE a little bit differently.

There's unique challenges right with the population, geographic challenges. And what we've offered is customized code coaching and consultation and technical assistance support. So we have liaisons that work directly with the counties on their unique challenges. So they could be kind of administrative and operational in nature.

They can, you know, relating to data collection or reporting, or it can be something like outreach and engagement with the CARE act population themselves. So we're intending to kind of, it's a, it's all systems go.

We're trying to get as much work done with our county, with our county partners as possible and have as many liaisons available for them as possible. And then I'll also just wanted to quickly cover our data collection and reporting.

And what that looks like is essentially we've deployed, you know, entirely new systems to be able to collect all of this data.

We have a huge data dictionary that is hundreds of pages long that helps support all of the different data elements that we need from our counties to be able to share the story about care, what's happening. And I think that's really what the purpose of today is.

We also have the independent evaluation that's got two reports that are forthcoming. One by December 312026 the second by December 312028. And then in addition to all of that, we're responsible for the fiscal as well. So we've deployed $57 million in startup funds.

In 2022, that was $26 million to Cohort 1 counties, $31 million to all the other counties. And, you know, counties can use for hiring, you know, developing policies and procedures. Our guidance is actually like two pages long, which is for, you know, government guidance is quite short.

And that's intentional because we wanted to give counties the most flexibility to be able to address their unique administrative and operational challenges. I also want to note that we're, you know, administering administrative cost funding.

So any administrative activities, you know, whether it's attending court hearings, preparing court reports, notifying CARE respondents, data reporting, and one important thing I oversee medical. And one thing that we don't reimburse in Medi Cal.

Go ahead and wrap it up and then we're come back. Sure. Yeah.

Just one aspect that we don't reimburse in Medi Cal is outreach and engagement. That is a key difference with CARE is that we provide funding for that. So I'll just conclude there, I do have notes on our CARE act annual report if we want to cover that at any point.

Thank you. Thank you, Ms. Hydras.

Good morning and thank you to the chairs and to the court for having us. My name is Anne Hadreas and I am a supervising attorney at the Judicial Council. And I and my team work on the implementation of CARE from the court side. And so just briefly, you know, since the beginning, the judicial branch has sought.

Sought to partner with both the Legislature and the Executive branch, understanding that CARE act is a priority for both the legislation, Legislature and the Governor. We've worked to implement this legislation and identify areas where further legislative action is needed. We are proud to say that all 58 trial courts implemented successfully and on time.

And the program has grown since that implementation. The Judicial Council has led the courts in fulfilling all of their statutory requirements in terms of trainings, engaging with stakeholders, convenings, and creating rules and forms.

The council has provided more than 20 trainings to judicial officers and staff, published a comprehensive bench guide as well as checklists, bench cards and scripts, convened regional convenings with relevant stakeholders and provided specialized training to staff and our self help centers who work particularly with lay petitioners like family Members.

In this process, the courts have learned a lot. In this process, the courts have learned a lot. But there are two pieces that I want to highlight. The first is that care serves a complex, unique and vulnerable population. And this is not a surprise. But I think for some courts, the.

The depth of that has been a surprise. The CARE act participants are some of the highest need individuals, may be difficult to locate and engage, and maybe high utilizers of other services. This is a population that requires time and most of all patience in order to be successful.

For these reasons, the courts have modified how they work with this population. And I will say that that pays dividends not just for individuals in Care act cases, but for litigants with mental health needs across the board in our courts.

So the counsel has provided extensive training to judges not just on the practical nuts and bolts piece, but on working with clients with serious mental illness, trauma informed courtrooms, effective communication with court users with psychiatric disabilities, and motivational interviewing.

They've also made changes to make their courtrooms more trauma informed in terms of changing layouts, putting things on walls, also changing the way judges talk to individuals who are coming before them, recognizing that for many folks, coming to court is not their favorite thing and they may have traumatic experiences of that in the past.

The second thing I want to highlight is the benefit of court involvement. I think there's a kind of ongoing question of the need for courts to be involved here. And I do want to point out two.

Ms. Hadrius, I've got a question right on point here, so if you'd wrap it up and we'll come back.

Certainly I will end it there. Just that the courts are still implementing and we are seeing improvements continuously.

All right. I'm informed that we all, including me, need to be closer to the mic so that folks not just here in this room, but folks that are at home in other locations watching us as we're being streamed. So let me turn to Senator Mengibar.

Senator Menjewar, thank you so much. Chief, I'm going to start with you because he touched on the data points and expansion of it. Can you share? I don't think I found it in the report. There were missing gaps regarding the reasons for dismissal and then missing data points regarding what happens to an elective client.

I know some additional data points were added earlier this year. Can you share if anything is happening in those two areas?

Yes, thank you. Great question and great overview provided earlier. I was really impressed with the details that you're, you're able to catalog.

I'll just note that SB 1400, as you noted, really made a lot of difference, made a lot of changes in terms of how we're able to track our voluntary, our clients that are getting voluntary services, those elective clients.

So in the report, we noted there were 15, which is just a small subset of the total ones that we were able to track.

And so we, we are working on understanding what the cause of those dismissals are and reporting that in a future iteration of the annual report, most likely the very next version, which will be published by July 2026.

Because SB 1400 was passed, it means that we're going to have a lot more data around those counties are going to be tracking this actively. This was not something that was actively tracked before, and it's a major change that we're looking forward to showing the results for.

So both things will be be captured in upcoming reports. Great. Thank you. Care Corps. The CARE act was created for individuals with schizophrenia and other psychotic disorders. The other psychotic disorders has encountered a couple of barriers, hesitancy in the implementation or anything that has to do with this conversation around who gets treated.

I'm wondering if, of the individuals that have received services, is there anyone that falls outside of the schizophrenia diagnosis? Are there other psychotic disorders being treated with CareCorps as the mission intended to.

I'm going to try. I actually am not sure that we would know the answer to that at this point. As you know, SB 27 did pass, which allowed for the inclusion of individuals with bipolar one with psychotic features. I think the intent there is that the existence of the psychotic symptoms are debilitating.

And so, the goal was to make sure that there was no. There was every opportunity to capture and consider, including ongoing clinical evaluations that this was an individual, even though they may have a bipolar 1 diagnosis that might meet the appropriate criteria for this level of programming.

So, we always think of CARE as its criteria is really driven by who would benefit most from having such a rich array of services. So, we call it—we call it the three-legged stool, but it's making sure that people have comprehensive wraparound services like the ACT model, that people have access to stabilizing medications, and that people are in a safe home like environment, so housing.

And so, I think that's really been our motivating factor, is thinking about the type of client who would best benefit from all of those things working in concert.

And frankly, the more important part that we don't talk about enough being prioritized for that level of service at the local level because they have the highest need. So, and I think we would have to get back to—I don't want to be, I don't want to be incorrect if we can get you that information, but I'm not sure that we do have it.

The only reason why I bring it up is one of the feedbacks we get from a lot of family members is who else is eligible for this? It's my loved one who has...

I'll just add that I don't know that we have the statistics by diagnosis, but there are, I believe, 13 eligible diagnoses within the schizophrenia spectrum. The biggest ones being schizophrenia and schizoaffective disorder, which is a psychotic disorder also having a mood disorder component, but there are an array of other disorders that are eligible.

Okay. And I have some familiarity with SB 27—it's intent, since I wrote it. The intent is to focus on those who are most acute, those who are having psychotic episodes. Doesn't mean that it won't expand. It just means that we began very narrowly, as Ms. Welch knows.

Ms. Welch was at the right hand of the Governor and Dr. Galley when this process began. And we may well expand it to those who are most acute, most in need, most challenging in terms of getting them well.

Well, thank you, Senator. As I mentioned in my opening remarks, majority—68%—of the petitions come from loved ones. So, we have the data breakdown of who is petitioning. Of the ones that have been approved and gone through the process, I didn't see any data of the breakdown.

Are people having a higher chance of getting approved if a family member petitions or a provider petitioner? Was that not included and we have that information? Anecdotally, are we hearing? I'm just wondering if it seems that those who understand the system more have a better chance of getting their petition approved versus a loved one filing the petition.

I don't think we have data that's kind of readily available. Speaking to that, I will say that family members, like you said, do make up the vast majority of petitions. And each petition is looked at kind of objectively on the merits of the petition.

And so, what the individual's condition is, what other eligibility criteria they meet, and then it's kind of moved forward at that point.

So, no matter who the petitioner is, it's just that I think family members are often in the position, having worked in behavioral health, it's basically, they're often in a position where they've lost all other options available to them.

This might be the one last option that they can think of that they can track, that they can be part of that family member's treatment. And so, I think of it in some ways as being kind of, you know, it's that last resort to get that petition out there.

And in some cases, that person may not be eligible, may not be completely eligible for the program. And as you know, there are changes being made in order to expand that eligibility criteria.

And I see that we've got later panels—and that's an important question—and I see we got later panels with those practitioners and those who are court or judges who may want to put a pin in that and respond to it.

Absolutely. Thank you. And chief, you, and Madam Attorney, you've talked about the investment in training, how many trainings you've had, and then the technical assistance that's given, given the different geographic areas of the counties.

One of the things we saw as to why services were not provided, I mean, it's in the 80%, which is really disappointing to see that. Over, I think it was 80—82%—of social services were not provided to the client, to the participant. And the breakdown is from it doesn't exist, the client declined.

But the services that aren't available in the county. Wondering what capacity building is included in the training for judges? Are we providing a service into a CARE agreement or CARE plan, knowing that it doesn't exist in the county, and then what building capacity is being provided to counties to bring up those services in those areas?

I can't speak on any individual case, but I would say part of the agreement process is the county and their county council and the respondent and their council coming together to create an agreement. So, creating one where the services don't exist is kind of setting up for failure.

Part of the strength of this is having not just the people at the table, but also people whose job it is to advocate for them and the role of the court to kind of oversee that. So, it wouldn't make sense to have a lot of agreements where they couldn't meet it.

But it also, it's a goal to kind of push to get the services that are best for that person.

The report says 12% of the reason why services weren't provided because they didn't exist in the county. And then counties reported that they didn't have that social service in the county. So, it seems like there's still room for ensuring that whatever is put in the plan or agreement is of a service that exists in the county.

I also just want to note, you know, that 93% did receive some sort of some form of mental health treatment, which I think is really promising. And then importantly, I think one of the most interesting statistics within the report is that 76% engaged received community based specialty mental health services.

And so, that is inclusive of assertive community treatment and full-service partnership. And I think that indicates that, you know, that's the ultimate goal. I think the ultimate realization of CARE is that folks are staying in the community, are staying in their homes, and are getting those intensive specialty mental health services.

And so, that I think is particularly promising. There are other initiatives that the state is deploying that expand assertive community treatment. That is a new Medi-Cal Benefit.

Full-service partnership continues to grow under the Behavioral Health Services Act, but there are a host of coordinated specialty care for first episode psychosis and other evidence-based practice that is being deployed as a new Medicaid benefit.

And so, counties are increasingly opting in to be able to offer those services as Medi-Cal benefits or through the Behavioral Health Services Act.

51% of the participants had Medi-Cal, the report noted, so we're getting a lot of this reimbursed through Medi-Cal.

And those new evidence-based practices I mentioned were effective as of January 1st, 2025. Okay, so also new.

Thank you. Thank you, Senator.

Oh, thank you, Senator Menjivar. Ms. Welch, let me go back to where I stopped you earlier. You were about to give us some numbers. And I am interested in those, those numbers.

Oh, sure. So, we've been talking a lot about the annual report, and it is—well, I'll just speak frankly. It is a little frustrating, right? Because it's just the first nine months. And at least for the Cohort 1 counties, they've been in operation now for two years.

And the—we've been fully statewide just shy of a few weeks here of a full year. So, it is kind of—I know it's frustrating for us, too, that that's what we're focusing on. But we do, in partnership with the Judicial Council, really monitor petition numbers.

And as of September, this is the most recent that I have, unless Anne can tell me we have something more recent, but as of September 30th, we have 2,873 petitions. And then, we are also tracking what we call diversions.

So, individuals where maybe a family member or somebody working in a hospital reaches out, calls a hotline and says, hey, this person might be great and meet the criteria for CARE. And in some, in some fashion of engagement. And this is what's really important.

Just getting back to how CARE, in our opinion, can also be almost like a reorientation to support county behavioral health and their core mission. And their core mission as the specialty behavioral health system is to serve people with the highest needs.

And so, we have over 3,000—3,042—individuals who have been diverted into programming without needing to go through the CARE civil process.

And that is, I mean, I think that's the story that we're hoping to work with counties to continue to tell, that this isn't just about the individuals who get into a CARE agreement and have the oversight of the court, which is very important and has its benefits, that I know Anne will talk about, because I've had the benefit of watching a lot of court proceedings in the last year, and I'm seeing people's lives change in front of us because of what the court process brings to the individual.

But, you know, I think we are also wanting to work with counties to get stories about how does someone who may have only been engaged in behavioral health services by utilizing the hospital or frankly, getting treatment when they spend 12 nights in jail, how are we shifting that and having those individuals engage in regular outpatient services that the county behavioral health has to offer?

So, I've heard from a variety of counties that they can't, or they can't adequately, implement the CARE Act because of lack of resources and of course, all of us in government would care to have more resources. But how do you respond to that concern raised by several counties?

Well, speaking of the point that we just mentioned about these are individuals who are on Medi-Cal, if you meet the criteria for CARE and you're on Medi-Cal, then the county is contractually obligated to provide an array of services under the Medi-Cal program that could be very helpful to this individual.

And so, I think that's one piece.

And so, we kind of have always said that we would prefer for the county family to think about the importance of maximizing their Medi-Cal revenue and investing in programs as an alternative to things like as I mentioned, that 10% growth that we have in individuals with open mental health cases in local county jails.

And so, we think that there are resources there. We just have to figure out how to prioritize them. And the other piece that I would add, and, again, it is, we are, I want to acknowledge that we are in early implementation. That is only fair. But we also, like I said, are seeing facilities open.

We are on basically the eve of officially Prop 1 kind of launching in July of next year. That is another significant initiative that says we need to focus resources on high priority populations that have high needs, put them in things like Act and Fact Models and speaking from Health and Human Services, we need to work with our managed CARE plans and our commercial plans to ensure that they are also providing services so that the county can focus on the high need, high risk population instead of having to potentially serve people who should be served in a different system.

Thank you. And this is a question for any of you that would CARE to respond. Is it the difference between CARE agreements and CARE plans that—I've been told that there are, the CARE plans are basically being neglected and that CARE agreements and even I think statistics bear out are the sort of the modality most often, almost exclusively, employed.

Do you care to respond to why that is and if we should be doing something different?

I can respond. I would say that it is true that CARE agreements have been the vast majority. As of September 30th, there have been 620 CARE agreements approved and 19 CARE plans. I would also say that that is the way the statute is set up and for a reason.

Because, in kind of our broader mental health system, we always want to go for the least restrictive option and both legally and practically, getting buy in from both parties, including the respondent, that they want the services. And I'm sure the court folk will reiterate this, but those are the ones that are more successful.

This process is, it's about engagement and outreach and getting people to get, to want the services, to get them the services they actually want, and then to follow through. We have other mental health programs that are more, more coercive, more involuntary.

But this, this is that new tool in the toolbox to try to have it be more collaborative and the statute really reiterates that. As much as possible, this should be a collaborative, non-adversarial process. And so, the goal is a CARE agreement, if they can get that.

Senator, may I add, though, that, and this was clarified in your legislation this last year, that the court continues to have oversight of agreements. And so, I think there might have been some misinformation like you're in an agreement and then, you know, you're not part of the process anymore. And that's no further from the truth.

And so, we want to make sure that the judge feels empowered and obviously has the authority to continue to check in on people who are in agreements because things change. As we talked about, this is a highly, this population is complex. Also, we want them to get to a graduation. Right?

We want them to improve and get on their journey of recovery. And I'm sure you will hear from the judges that they want to have those updates as well, even if you're in, obviously, a CARE agreement.

One of the attractive features of this process for me early on was the fact that there was going to be a bench officer holding the institutions as well as the individual accountable. And thus, we built in the opportunity for courts to issue sanctions.

Do you know, Ms. Hadreas, do you know if any sanctions been issued in the last year or even longer since we've, since some of the counties have been going on longer?

To my knowledge, no sanctions have been entered, but sanctions are a couple of steps down the road. I will say there have been, although we're only one year into full implementation, there have been some orders to show cause, which is kind of the first step before that.

And it's the role of the court to, okay, this doesn't seem to be going well—what do we need to do to fix it? And that has been the goal is to hopefully be able to fix it before getting the sanctions.

So, I'd be very interested—not today—but if judicial counsel is keeping track of the orders to show cause, I'd like to know about that, see where they've been issued and for what, what reason? So, if you could do that, that'd be grateful—I'd be grateful.

Senator, in this space, it prompted a question of mine. Then why would the difference—I guess I was having trouble between a CARE agreement and voluntary services from the county outside of CARE, why would then a participant choose the latter?

I think some participants see a benefit of the overall court involvement and part of it is the accountability. This is, I'll say, personally, before I came to the Judicial Council, being in practice as someone representing people with serious mental illness, there could be a frustration in working with counties to get accountability for services.

This does give an extra protection to be able to come in and say, hey, last month we were here and they said I was gonna have interim housing and I haven't gotten it, and that this is a check for that.

And if they go the elective client route, voluntary engagement, then there are no court hearings, so they wouldn't have that advantage.

And Senator.

[Unintelligible]

For your 15—for the, for the 15 people that were in elective service, one of the, again, early findings, but they had less services.

So, why would I choose that route or why wouldn't I be—am I being told of the benefits? Like, why would then at the end of the day, I choose that route?

I mean, it really comes down to the person and what they're looking for. I mean, some folks really don't want to be involved in the court for some very real reasons and may want to get services in a different way. And this, it's really about trying to find—put people into the place that makes the most sense for them in the most, in the most—in the least—restrictive way possible.

You said the CARE plan is more—I forgot what word you use—but least restrictive is the agreement. But isn't the CARE plan the same thing as an agreement? But now it's just, it's the same treatment, right? The same plan, but now it's just not voluntary. But it's the same approach.

It is the same approach, but there are. There is a stricter component to it. In particular, the accountability. If an individual is terminated from a CARE plan, that information can be included if they end up in an LPS hearing in the following six months. That is not true for an agreement, if they were provided the services.

So, kind of like thinking about these additional layers of accountability, since it's dual accountability with CARE, it's kind of like at the point of a CARE plan is where—and you can correct me if I'm wrong, Anne—there is the potential trigger to have sanctions, whereas at the point of a CARE plan and someone's in a CARE plan, there also is that finding. Is that correct?

The sanctions actually can happen for persistent noncompliance with any court order in the CARE Act proceeding. So, it actually is pre a CARE agreement. You could have, potentially could have, sanctions even during the investigation phase.

So, there have been three cleanup bills since the initial CARE court legislation was passed and signed by the Governor. If you had my job, I'm going to ask each of you, what would you do to accomplish the mission of CARE Court.

If I may, I think importantly, it's to wait. It's to let the relationships be built over time. There is no substitute for time and there is no substitute for relationship building. And we know that there is a lot of work to be done. Historically, these disparate systems have not worked together.

They're coming together to work on behalf of these individuals with high needs that are highly complex, that are transient by nature, and it requires a lot of these partners to come together and foster those relationships over what I would argue are a period of years.

And once those relationships are formed and they're really, you know, the concrete has set, I think that's when we'll really see huge uptakes in the numbers of CARE participants.

...Thank you. Ms. Hadreas.

I mean, I would echo the, the patients, but also from a kind of individual timepiece. What we've heard a lot is that these cases take a long time, not just in the investigation and outreach and assessment period, but also people coming into court having the time for a bench officer to really sit and speak with a respondent.

That is something that doesn't happen in a lot of court proceedings. So, preserving that and preserving flexibility for the courts to be able to continue some timelines, reduce, combine hearings when that's more appropriate, but really trying to.

Are there impediments to doing that right now?

There are not, but I have heard interest in potentially changing that. And just to the extent of that, really the courts have been pretty strong on wanting to keep as much flexibility to learn what the person wants and needs and to try to make that happen.

I usually write perfect bills, but I'll acknowledge in this space that there's room for improvement. I have heard that there are challenges with personal service that that's more cumbersome than in other areas. I'm interested in helping to resolve that.

I've also heard, in fact, I was at CARE Court in Los Angeles, that, a follow on to your question, Senator Menjivar, that first responders basically not filed any petitions. If they have, I'm interested, but very, very few.

And one of the reasons, because the form is just so long and so difficult that first responders in particular, unlike family members, aren't responding. And perhaps we should have a different or a shorter form or something like that. So, I'm interested, Ms. Hadreas, as to in both of those areas, what your thoughts are.

Well, first, on personal service, there are exceptions to personal service. One, it can be waived, but it also, if it's impracticable, then it isn't required. But because CARE—so much of this process is around being able to connect with the respondent, if person are not able to actually reach them to give them service, it's kind of hard to believe they'd be able to reach them to give them services.

On the form piece, currently, the statute doesn't have any differences in what's required based on petitioner types. And there are a lot of things that are required in the statute.

So, understanding.

So I should fix my statute.

Understand, well, understanding that people are in different places. I think another question is, is petitioning the best role for that first responder or is there another referral process? We have these other referral processes for folks that maybe don't have the petition information. Is there something that could be done to make sure that those referrals are also going through?

Although, at least in my mind, one of the original purposes was to address so somebody who's having a psychotic episode and is acting out, you know, in, in ways that are not healthy for themselves or for others so that a first responder actually can start the process relatively quickly, but I take your point.

Maybe, maybe that needs to be addressed. So, okay, other thoughts? Other things that we should do? You got a bunch.

I always do. But to, to your point, I know we're going to hear from some of our counties. Counties have actually, in some counties, had really good relationships with first responders and first responders who are actively petitioning.

They've also created a relationship to expedite because to be honest, even in a large county, many of these individuals are individuals that collectively the community is frustrated that they haven't been able to help. And the first responder is seeing the individual on a regular basis.

The local LPS designated acute hospital is seeing this person on the regular basis. And so, I think, too, Ivan mentioned the time to engage the client.

But I do think that these—we are trying to work to tear down barriers in terms of being able to get these system partners to communicate with each other in a faster way, sharing data, et cetera. That's not a specific recommendation, but I do have one.

So, I feel very hopeful that through case-by-case technical assistance and working at the local level that we can ease that a bit and still come with high quality petitions. For me and my passion, getting back to the statistic that I've mentioned twice already, I'm going to mention another one.

When we conceived of CARE and had lots of conversations with you, we wanted people to be diverted from conservatorship, stepped down from conservatorship, diverted from jail, or given a warm handoff from jail into a program that had what we call helpful guardrails for an individual who was struggling and to make sure that when they got into that program, they got the best, most robust care so that they didn't end up in either one of those more restrictive settings.

And so, I'd like us to figure out and make sure that we're hearing from the counties what is not working, because in some places, this is really working as a way to divert people or step people down from conservatorship and in other places, it's not happening at all.

I could say the same for, you know, the relationship between the criminal court and the civil court. So, probate court, civil court, and criminal court, how do we make sure that the right people are getting to the right court proceeding, I guess, and I'm not the court person.

She's like gonna, you know, want to push me off the table. But it's, you know, I'm really, you know, we're all very passionate. We don't want these individuals to be necessarily experiencing this if they can live successfully in the community with the right supports.

And so, anything that we can do to make that an easier process would be fantastic.

And if I may also, just beyond the system partners coming together to work together and tearing down those relationships, as Stephanie mentioned, we have the Administration and the Legislature have partnered on more than $14 billion in investments for the behavioral health population. And there is time needed on that front as well for those investments to come true.

I'll give one example, you know, on the question around, you know, what, what do counties need? There's not enough resources there. One of the investments that, you know, DHCS, along with the Department of Healthcare Access and Information, are making is $1.9 billion in workforce over the next several years.

And so, that includes programs.

And Prop 1 funding, correct?

BH Connect funding. So, yes, and it's in part Prop 1 as well. Yes. And it's, you know, we're working on student loan repayment programs, scholarship programs, recruitment and retention, community-based kind of provider training programs, and residency training programs.

So, in total, five programs that cover, you know, 1.9 million or $1.0 billion in investments. So, that's something that's going to be coming out, you know, over the next few years. We've already got some of the rounds underway. We launched some in July.

Those are, you know, we're, we're on the verge of making some, some awards and we'll be making kind of additional applications will be released in February, more awards coming, and we're trying to get those out as quickly as possible. But those, like I said, will take a few years to bring the workforce up.

That's a major area of shortage historically, and that's why we're making those investments.

I'm going to squeeze in one more question because, Deputy Secretary, you brought up like the needs and so forth. Can you clarify, you or the Chief here, it said that 65% of the participants were housed, but the greatest unmet need was housing.

I'm not as well versed on the report as Ivan is. Was it all—what I can say, though, is that, and we've recognized this, it totally makes sense that the first, in the first and early implementation, that the recommendations were coming or, I'm sorry, that the petitions were coming from family members.

And the reality was that some of those people were housed with their family members. As we move in implementation, we are seeing that the petitions are getting more diverse. And part of that is because, you know, the counties are trying to educate people like first responders.

Hey, you should be submitting a petition, or most notably themselves, frankly, you know, that the county behavioral health can be a petitioner and, in our opinion, should be, in many cases.

And so, I think that's one of the reasons why there's now kind of a little bit of a shift where there's more demand for housing because of the outreach to other petitioners who may be working with a population who's more likely to be unsheltered.

I would agree with that. If only we had reports of the incoming data, right, or incoming participants. Since this report is of only of these participants, I don't think that exactly makes or clarifies the contradicting data point.

Yeah, I would agree. I think importantly, you know, one of the statistics in the report is around how the CARE process does help support permanent supportive housing versus someone that is not necessarily getting those housing supports. So, at petition, 46% had reported housing or a lack of housing or had had some form of housing.

And then, over 50% during participation were able to get housing support services. So, there was about a 10-point increase, which I think speaks to how the CARE process can help kind of structure and provide a list of housing support services that are available to the individual.

Not super satisfied with the response. I think a little bit more digging in this space just to adequately understand and maybe sometimes, you know, just data point numbers don't always paint the whole entire picture. Oftentimes, just because we asked the question, maybe follow up to those data points would be helpful.

Thank you very much. Very helpful. We'll be back in touch. Let's bring up the next panel. Appreciate your help here.

Thank you.

Thank you.

All right, while the next panel's coming up, thank you. I see Mr. Yamasaki here, who, he owns this courthouse. So, thank you very much. The Orange County Superior Court Administrator.

Thank you, David, for your support here. And I also see Dr. Veronica Kelly. Thank you for you being here also. Thank you. All right, next panel, the CARE Act in Practice. Experiences, family practitioners, and supporters, Anita Fisher, Annel Hopper, and Nancy Eldred.

This next panel will talk about the experiences from family petitioners and stakeholders and supporters as the same as the previous panel. Each panelist will have three minutes. We're going to start off with Anita.

Thank you Senators Menjivar and Senator Umberg. I want to start with a quote recently posted on my social media from an advocate named Ellie C. From educate before 8 when someone goes into psychosis, they may not be a danger to themselves or to others, but their brain is still collapsing. They're not violent, they're not choosing it.

We have to change policies around mental health and crisis care so that not dangerous doesn't mean not sick. I am the mother of an adult son who has lived with schizophrenia and substance use disorder co occurring for 25 years.

In 2023, when I stood with Governor Newsom in support of Care Court and shared the reason we needed it In California on 60 Minutes, I did so because I believed it could finally give families like mine a structured way to help our loved ones get the level of care they need when they need it.

However, on Thanksgiving Eve of 2023, I had to file a CARE act petition for my son in San Diego County about six weeks after the program launched. With 25 years experience navigating the local behavioral health services with my son, I anticipated a different outcome this time.

Unfortunately, over the two year period my son was arrested multiple times, evicted from housing, survived an overdose on street drugs and still did not believe he needed care.

There are more details included in my written testimony that I can't be covered in these three minutes, so I'll move on to what I feel can help Care Court be more effective. Provide immediate crisis care, including involuntary treatment without stigma.

Add a mandate for an LPS evaluation if the person fails to engage in the Care Court process or is unable to sustain their engagement leading to the termination of their care plant and remains acutely gravely disabled. A county can detain a person under welfare institution codes 5150 or 5200. While a determination is sought and the evaluation completed.

The CARE judges and courts lack authority to mandate treatment. I've wondered the point of a court with no real power that funding could be better used for supportive housing, increased staffing and other supportive Without a pre designated supportive housing, simply providing shelter often leads to failure as unstabilized individuals struggle with activities of daily living.

If family members or supporters are petitioners, they should stay involved in the process as they are often responsible for supporting loved ones when setbacks occur. I still want to believe that we can make the Care act serve those living with serious thoughts. Final Thoughts yes, this is it.

I'm closing who live who during crisis typically end up on our streets and in our jails. Thank you for allowing me the opportunity to share and I also speak on behalf of many families across the state. Thank you.

Thank you Ms. Hopper.

Thank you. My story is quite similar to Anita's. Thank you Senators, Menjivar and Umberg and other presenters and Members of the public. I appreciate being able to address you. I live in Sacramento County. I'm a mom advocate for 14 years.

My husband, daughter and I were early supporters of the Care Court and she is quoted in San Francisco Chronicle in 2023 saying if care Court had been available, she may not have gone to jail. I'm here today to offer my recent experience as a petitioner. Here's a short version.

My Care Court petition was implemented to the exact letter of the law. After meeting criteria, behavioral health care workers tried three times in a month to meet with my unhoused daughter and offer services, which she rejected. She was just exited from a long incarceration. This sent my petition to the first court hearing level.

I received notice of a second petition being filed by Sacramento County Adult Correctional Health to be addressed at that same hearing. That petition, written by professionals, outlined the four year journey to deliver my daughter through her felony charges and incompetent to stand trial, treatment and training and back to court.

They documented my daughter's diagnosis of schizophrenia, her her constant medication refusals and the symptom of Anosognosia where the person doesn't think they're sick or need help. So even the jail thought my daughter needed high levels of support to survive in the community and avoid recidivism.

To summarize as much as I can, my petition ended with the Behavioral Health Assessment Report that stated my daughter was no longer deteriorating and was engaged in community services. The Correctional Health petition was not heard because no petitioner attended court. That may have changed things with intense family engagement, not Care Court worker engagement.

Our daughter did accept some housing at Salvation Army through the Exodus Project funded by Prop 47 and they deliver help independent of having to say she has mental illness, but she does have to admit to one of the three mental illness, addiction, or both.

This bypassed her issue of Anosognosia that was preventing engagement with behavioral health services and it is strange and unfortunate to feel lucky that my daughter was incarcerated long enough that she still qualified for services despite her lack of insight. So I want to repeat that Care Court process was implemented exactly as it's currently written.

Yet two months later my daughter has lost housing again. No insight, no medication, no supported services and we family are her only support. Her paranoia, untreated, prevents trusting intake workers so she won't answer questions to open the doors to the services she says she wants when she is medicated and has supervised housing. She's a brilliant, wonderful gal.

Thank you.

Thank you. Go ahead Ma'am.

Thank you so much. My name is Nancy Eldred. I'm Vice President of Public Affairs and Advocacy with NAMI California and appreciate the opportunity to represent NAMI today. We were proud to stand with Governor Newsom and the Legislature when the CARE act was first introduced and for decades families have waited for a bridge between crisis and care.

The very idea of Care Court gave families hope, and for years they had been told their loved ones were not sick enough. Yet Care Court promised another door and a chance for engagement before people lost everything.

Hundreds of NAMI families statewide submitted letters in support of CARE act, which was a testament of pent up demand and compassionate system that doesn't give up on people across the state. NAMI California and our affiliates are now helping families navigate the CARE act implementation through practical, accessible and responsive support.

A year into implementation, Care Court's first annual report gives us both encouragement and perspective. Roughly 2,400 petitions have been filed, which is evidence that the model is taking hold, but it remains only a small fraction of those who could benefit.

Families invest enormous energy and emotion in filing petitions, often during moments of crisis and when petitions are dismissed because eligibility wasn't clearly understood. That loss can be devastating. Clear communication of eligibility and documentation requirements at the outset, ideally through NAMI affiliates and county behavioral health outreach teams, would reduce dismissals, make petitions more effective, and preserve families hope.

Clear communication isn't just administrative efficiency, it's compassion in practice. NAMI proudly supported SB27, recognizing Care Court's Room to Grow, and by expanding eligibility and refining the petition process, the program can reach more people whose illness has often fallen through the cracks.

As one family Member shared at a NAMI support group, half the people in the room were trying to get help for their loved ones with bipolar I disorder. For them, this bill wasn't just policy, it was possibility.

Care Court works best when there's a constant threat of communication and when counties, courts and families all hold the same end of the rope. Many of our staff and volunteers have lived experiences themselves and bring empathy and understanding to reach people that traditional systems can't.

Care Court's still young, but its success will depend on sustained partnership between states and counties, and between Clinicians and courts, and between the systems and families who never stop showing up.

For nami, that partnership means continuing to offer technical assistance, educational webinars, surveys, and listening sessions to ensure that the voices of families remain at the heart of the policy's improvement. At its core, Care Court 's a statement of compassion and hope that California will no longer turn away from those too ill to seek help on their own.

And we stand ready to help ensure it continues to grow and reach every family that it needs to.

Thank you so much. Senator Umberg. Want to kick us off?

Sure. Thank you. First of all, thank you. And thank you for sharing your lived experience with us. I'm guessing that many individuals here have lived experience in this space. My own family has lived experience in this space. And it is so frustrating because when your loved one is medicated, they're wonderful human beings.

They're loving, they're responsive, they follow the law. And when they're not medicated, they're not. And they create chaos, havoc, and sometimes even engage in illegal activities. And so years ago, I thought the simple solution is to basically grab our loved one, actually now times two, and forcibly medicate them, because it just seems.

But talking to the person, you say, when you're medicated, you're great. When you're not medicated, you're not great. Can't you understand it? And you know what the answer to that is? The answer to that is they feel better, so they go off medication and then they act out. Right. Is that your experience? Yeah, that's exactly right.

So I'm interested. You talked about basically coercive, involuntary medication. I'm interested in what you think. What do you think we should be doing? I mean, should we. I recognize that this is a challenging question. You know, what should we be doing? Should we be more coercive, should be more carceral in terms of treatment?

What are your collective thoughts here? Yes.

No one wants to see anyone locked away anymore, you know, in those places. That's not what. Oh, that's not what we're asking for. It has been months and months and months and months. By the time we get to this, this. This point where we all need something like this.

So that's where we have things, statutes on the books. There's 5150s, there's 5200s. There are ways to be. For individual to be evaluated for something more restrictive, and that's not happening.

That's what we're saying is that the laws that are already on the books are not being utilized to help these individuals until they end up in jail, until they end up homeless on the streets.

So my families experienced the most extreme form of being locked up for untreated mental illness. And that's the state hospital system. And unfortunately, if we had been able to engage in California's version of LPS, which has very deep medical evaluations and many, many safeguards to make sure that we're not repeating the heinous history.

So if those things had been available, building up to when my daughter was trying to protect herself on the streets, she may not have been criminalized. What she needed was care that was civil care, that would have been a much more humane path.

And if that civil care could have started with 72 to 2 week 5150, the involuntary hold, so the acute illness was knocked down a little bit and then the correct medical assessments, California really supports that, to determine if she was really ready to walk out the door and be fully independent.

And to me, that was a lost opportunity because she didn't have a new pattern yet of what it was to embrace this new health condition that can be for a lifetime. And we don't do that when it's any kind of other visible physical disability. We have stroke victims, they get occupational therapy and physical therapy.

We help the person we walk alongside very supportively for as long as it takes. So they have a pattern and they're ready to be as independent as they can. And we include the setting they're moving into, whether it's a care home or a person's home.

We make sure all the people there know what to watch for with the person when it's. When it's heading back towards needing to go back to the hospital for higher care. Because this is biological. This is not my daughter's behavior being bad. And that deserves a medical response. So especially with stroke victims, cancer, pick a major illness.

We do a much better job about doing this. Extensive aftercare. People come to the home to check on them. And even if my daughter had qualified for a 12 month civil LPS conservatorship, that's a much different concentration. The idea is therapy and learning how to live with it. That did not happen at the state hospital.

The goal is just enough treatment so they can make the person memorize how to behave in court. It's a different goal. A different goal. And this is why.

This is why I'm asking the peer movement organizations that do really wonderful work in many ways, I'm asking them to make room in their advocacy to allow California to keep doing this. Well monitored, safeguarded, lps, conservative consideration for a certain part of the population that has histories like we have, where it's repeated trying, repeated trying.

My daughter had felony incompetent to stand trial community based treatment. And there was. The house was not supervised. They did not have. There was no people who are incompetent to stand trial with felony charges.

They're not bringing in the social skills, they're not bringing in the daily activities of daily living and intellectual activities of daily living to fully take care of themselves. And that house had operators that show up and deliver food. So when the operators would see people becoming dysregulated and they would. One time they got my attention.

Please do an LPS for your daughter. This is our. You know she's here. We know she's in the program. People check on her a couple of times a week. She's supposed to get herself to care. It's not happening. And I said, I can't. She's not. That's not my home. I'm not allowed to do that.

Plus I live in Sacramento county where sheriffs are not responding anymore. And same thing with the operators of this home. They were frustrated. They could see more supervision was needed and more care. So. That's why when we talk about supervised housing, we need to define what that means. And that needs to be also on a sliding scale.

Just that 12 words. We need it to be supervised because this person is truly independent. They are ready. They're making a pattern.

The pattern is visible by everybody around them to take care of that and do have the highest quality they can have in a life, whether that means work or not work, but engaging in purposeful activities meaningful to them. So we.

Let's wrap this response up, if we can. Pardon me if we could wrap this response up.

But that's not gonna be true for everybody. Even when they accept housing, some people are gonna need 24. 7 supervision even if it's not locked. They need transportation assistance, food and laundry assistance, medication assistance, and we need that full.

What county is your daughter in?

Sacramento County.

She's both. You're. You and she are both in Sacramento County.

Yeah.

I'm just wondering if other counties do things differently in. In terms of the handoff, in terms of the aftercare.

I've read that Orange County does. I haven't experienced it, but those are some of my concerns.

Some of the ways that I think the single biggest block right now to being able to make care court its best is coming from the peer movement, organization that has a good heart, compassionate people, but just not making room for this idea that somebody can have that severe of an illness, that this might be a better plan.

Because I think you have a view of the entire state. So what are your thoughts to your.

Point about the county piece? I think every county is doing it differently. And so we are trying to kind of play that bridge, right. To relay that information. Who's doing well?

If you had to pick a county with best practices, what county would you pick, if any?

I have to get back to you, but I do think that that's been a challenge. And I mean, I started this role in January and really just wrapping our arms around that and figuring out who's doing well, who's not, and relaying that effectively has been. It's taken time.

So I think that's a big piece, is making sure that we give it time to work effectively. But I also think it's a challenge to identify who's doing it well and hopefully it'll be a ripple when we have more time.

Let me thank you for taking this very difficult experience and sharing it with us to basically not just help your loved ones, but to help others that are similarly situated. So, Senator Mengjo, I don't want to turn it back to you.

We're going to go back to NAMI here. Eldred, did I say that right? Ms. Eldred, who you mentioned the expansion of who else can benefit from this? Is there demographics or a group that you're thinking about who can also benefit from this?

Well, we were focusing on the individuals with bipolar 1. We've been hearing that in support groups quite a bit. So thankful for that expansion. Center Umberg, I think what we hear a lot from families as well as just the voluntary piece is very challenging.

And then keeping families involved once the petition goes through, I think that's the biggest feedback that we're hearing in terms of, of success. And then also there's challenges with quality of petitions. Right.

So I think we're doing our best to educate family Members and other stakeholders who could be petitioning to really understand that eligibility so that the petitions that were being presented are quality with the.

Involuntary and mandating treatment. Has NAMI had conversations with other stakeholders around this request that you're hearing a lot from family Members?

Yeah, it's a challenge. It's. It's a challenge just to, like I said, the voluntary piece of it, I think it's going to take time. We're hearing that the counties that are successful are reaching out 234 times with the individual. It takes quite a bit of time to build that trust.

And so I think of course the report and everything was very new. But what we're seeing is those that are successful are putting in that time and really taking that time to build the trust with the individual.

You ask for clear communication from who?

I think information sharing, which I think has been effective so far, but just making sure that that continues. Like the CARE act working group, we've got family Member representation on there. That's very helpful. Our representative who sits on the group sits on care countless panels.

But within all of our NAMI programming we just had our annual conference, things like that. Everyone wants to hear about care, how's it going, how's it rolling out. So I think we're still all just information sharing, so giving it time to continue.

My last question to you is the previous panel we talked about the CARE plan versus care agreement. Care plan could potentially be seen as involuntary treatment and so forth. Would then your suggestion, not your suggestion, but would then this be aligned with what family Members are asking for more care plans than stopping at the care agreements?

I think it really varies by individual and what they need. But I would be curious.

I've said so much already. I think the care plan has really good potential to create one more layer before moving to any kind of lps. And also if there was a care plan that might work better for like my daughter's situation, even though in front of that one hearing she had presented well that day.

If they had looked at the 15 year history of difficulty gaining and sustaining those support services, they might have been able to continue following her so that they could document she was still engaging. Still engaging, still engaging. Or unfortunately a very short time later disengaged. Disengage.

She had been offered higher level of housing, moving into that more permanent housing, but she couldn't trust the workers. So. So there are some times that, and I heard that on the earlier panel nuanced, very complex. I heard the judge say these are very complex situations.

And so I would have appreciated more validity given to the objective service of the Correctional Health petition overlaid with our long history.

And if there could have been a care plan or it might have started with an agreement, let's keep following her and make sure that this is actually a really new pattern because that's only two months later and now I'm not even willing to do another care petition because of Anosognosia.

I don't know what the answer is going to be but in my county right now, another care petition wouldn't even work. She's not even going to talk to the behavioral health outreach workers. So I, you know, I'm one of those. It's in a true dilemma. Luckily, it's a small percentage. Some count it as 1%, 3%, 5%.

But these people are also deserving of our care before criminalizing them. So I think finding a way for counties to define it as, okay, this looks good right now. Let's keep following the person.

And then if some, like my daughter dropped off, that would have been a moment to insert a care plan because now she's just floundering around with nothing. Lost her EBT card, lost her phone, lost, you know, all the services that family had worked hard. So that looked great in front of care Court.

There's no way to catch her. Now.

Miss Fisher, as you, I'd love for you to add something, but in your remarks, can you also talk a little bit more? You asked for family petitioners to stay involved in the process. Can you share up to what point? Currently, family petitioners are staying involved.

There is an ROI still, you know, just like when they're in the hospital. And just like during our process, my son, for some reason, they called it, revoked his roi. What's an roi, Sorry, a release of information, you know, like in HIPAA and hospitals.

And I was like, well, I'm the one that brings him the cigarettes every week, you know, So I didn't know why he did it, but he did, he did resign one again. And then I was able to continue communicate and even attend the hearings.

So if they say a family Member can't, even if you're the petitioner, can't attend the hearings. So that's another. And we need to know what's going on because again, like I said at the end, we are the ones that catch them when that net is cut.

We're the ones there at the end that are still going to be walking with them when all of this fails. And I want to add to. I'm sorry, go ahead. Sorry. The previous question about the care plan and the care agreement at this point. Remember, this is stage four. If you want to like cancer.

This, this is when they need to be combined. I don't think it should be two different things with this, with this particular individual that we're working with at this point. This isn't the person that's having mild symptoms.

This is the person who, again, it's been weeks and weeks and months and months and months, and they continue to decompensate. So I think they should just be one plan, whatever works best. And don't try to choose and have to come back and go to court and all of this.

Do what's best for the individual to get them care.

What about when the participant has a volunteer supporter? Do they have the ability to stay within the process?

I don't know. I don't know.

Okay. I'm just wondering if there was a difference between us, actual supporter or a petitioner.

I think I was both. I was the petitioner and the supporter. Just because I was making myself the supporter, I thought, you know, because I'm there to support him all the time anyway. So I didn't, you know, I don't know that.

We had a natural supporter who was from the library. Our library has a social services floor considered a resource floor. And that person walked two blocks to be the natural supporter but was not familiar with any amount of deep medical history. Nor was that person was not made informed of that deep history.

I think that's not how natural supporter is written. I've attended most of the CARE act working groups and ad hoc. I think it's written just to be there to make sure that this person's voice is being heard about what they are doing or what they are wanting to.

So this other family role, I wouldn't have been able to do that very well because I would have wanted to keep adding in the medical history.

Right. Because the volunteer supporters in the report says it's a key feature to ensuring person centered care for care participants and ensuring that at least the supporter goes along with the participant in the process would be key.

That depends on the self report. So when, when behavioral health workers are not double checking self reports from people who have been so dysregulated that entities have done petitions, then what you're doing is it's unrealistic to expect a person with a disordered brain to always give an accurate self report.

There's a desire to want to believe what they're saying. It's not a true lie. But those reports, if those self reports are not.

I don't even—Tribble. Ma'am, please kick us off.

Thank you. My name is Dr. Karyn Tribble. I'm the Alameda County Behavioral Health Director, and it's an honor to be here.

Thank you very much for enabling us to present and due respect to the Senators as well, and as our judicial partners. You have heard, obviously, different perspectives, and I will try to use my three minutes respectfully, given the number of colleagues here. I think what I'll start with is acknowledging that our process began pretty early on.

We did have a very positive relationship with our court partners, with law enforcement, with our city leaders, and as well as our CBO network. So, that really helped Alameda County. We had already implemented assisted outpatient treatment for well over a decade as well. So, for us, we saw it as an additional pathway.

What is slightly different is we made the determination that we would petition on behalf of our clients, knowing that there were still some community members that were not receiving treatment. We have assisted outpatient treatment as well as community conservatorship, again, both active, engaged. To date, we have approximately—we will likely have 200 by the end of this year.

We are a Cohort 2 county. And so, at this point, at least as of last week, we'd add 180 petitions filed. Earlier on, your questions were related to the types of petitioners and the sources. For us, it's about 29% come from our family members.

And so, part of our planning process was to engage initially and to respond and co-create. So, our design actually started in July of the prior year of implementation, and we initially engaged with our family members, with clients certainly, as well as law enforcement, and actually created a formal regular pathway that we all met together.

So, there was an overarching meeting of the minds because again, that is essentially what we all agreed to do is, is to look at outcomes. And so, aside from whether forced or involuntary or not, we just came together with that mindset. And so, actually, for our Department, it's 21% of the petitions were filed by our Department alone.

So, again, 29% represented by family members. About 25% were first responders. So, we were a county that also intentionally engaged with our law enforcement, provided training, understanding the court. Again, I can't say enough about our court and our other legal partners, including Public Defender.

We actually, through their support, not only created a pathway to help our responders create those petitions, but also to be successful to understand what needed to be described. Our courts also created a self help center, a CARE court self help center, which helped individuals including family members and others to really navigate the legal process.

So, again, a lot of effort was placed into the outreach and making the processes easier and barrier free.

So, we think that has to do with a lot of the success we've had in our county. Areas that we're continuing to work through because again, we are learning as we are moving forward to the process is about 20—45—excuse me, of those cases were dismissed and I, I recall your earlier queries as to some of the reasons why.

We've noted that the highest rationale, about 20%, was either that they refused services outright, would not participate in the process.

Three minutes comes and goes really quick.

It does.

But we'll engage in conversation. If you want to throw out those numbers right now and then we'll continue to next panelist.

Absolutely. So that seems to be the highest number in those that didn't meet...so there's a lot of other areas.

Can you say that again? I missed the number.

No, no, no. So, it's 20% that we were unable to locate or that refused service and then another 20% that just did not meet...They did not meet criteria despite the efforts to help people understand them.

Thank you so much. Thank you, Doctor. Moving on to Deputy Director from Public Guardian.

Good morning. Thank you, Senator, and Senators and staff. Marcus Cannon on behalf of Riverside County's Behavioral Health Department. We were a cohort one county and so we were excited to implement early. To date, we have 224 petitions.

We've had eight graduations to date and I think that's certainly the most successful and most exciting part is seeing those graduations and seeing the changes in individuals lives and the changes in where they've come throughout the course course of the program. I think similar to my colleague before me, our dismissal rate is about 31%.

We have 106 individuals currently in the program that we're engaging, 49 who currently have a CARE agreement in place. We are seeing roughly one in four of our individuals who are homeless at the time of petition. Our first responder number is 5% of our petitions are coming from first responders.

But I would want to add some context there. We, like a lot of counties across the state, I think in their behavioral health departments, have built really strong relationships with our first responder departments, with our law enforcement departments. We have ride along clinical therapists who are in police cars with our police and our sheriff.

We have mobile crisis teams that deploy with our first responders. And so, oftentimes, those first responders may say to those behavioral health staff that are right along, "Gosh, don't you think Marcus needs a petition?" And so, the behavioral health staff ends up filing it.

But it's a petition that's at the heart of the desire of the first responder team. So, I think that there is a possibility to undercount some of those first responder petitions. I think in terms of success, in addition to the human success, the behavioral health bridge housing funding has been very crucial in our success.

We've been able to open a new board in care, new adult residential facility, in our county that's helping us have resources for CARE Court participants that outreach and engagement funds are an important part. You've heard here that it takes a long time to do outreach and engagement.

I heard somebody say two or three or four times, I would say 20 or 30 or 40 times that. It takes us—currently, our average time from petition until CARE agreement is 882 days. And that's seeing people almost daily.

I think the timeline is challenging in the public perception from the laws that something's going to happen in 14 days and my loved one is going to be better or on medication in 14 days. So, that continues to be a challenge for us. I think the challenges around housing are real.

Certainly, permanent housing as well as operations funding to grow and expand those types of board and care or adult residential facilities that oftentimes our members need. Independent housing is always the long-term goal. But by very virtue of qualifying for CARE Court, many members initially need supportive housing. So, I think those would be things I would want to highlight.

Those 224 petitions that we've had to date, we've delivered close to 10,000 services to 224 individuals. So, it is a service intensive work to get people engaged, but it certainly works for quite a few individuals and we're proud of the successes we're seeing.

Thank you so much for your part. Dr. Meyer.

Good morning, Senator Menjivar, Senator Umberg. Aaron Meyer, Psychiatrist with University of California San Diego and Behavioral Health Officer with the City of San Diego. So, families and first responders welcomed the CARE act when it was first announced because it was the first major advancement in access to mental health treatment since the implementation of the LPS Act.

Now, two years later, the July 2025 CARE Act annual report offers some positive and concerning statistics. On the positive side, 2/3 of participants who are unhoused at the time of petitioning obtained housing. The proportion of those in permanent housing rose from 46% to 56%. So, that is progress, but the same report leaves troubling gaps.

Of the 160 petitions that did not qualify for CARE Court, there is minimal data about what happened to those individuals after dismissal. More than 90% were deemed ineligible for CARE and aren't subject to outcome reporting. For this vulnerable population, we need to know more than the reason for their petition dismissal.

We can change this if we track outcomes for all care respondents who met a prima facie showing. SB 27 clarified that enrollment alone shall not be considered clinically stabilized in ongoing voluntary treatment. The State Bar reported that about 20% of dismissed petitions were because the individual was enrolled or likely to enroll in behavioral health treatment.

If these individuals were already voluntarily engaging to help, why did someone take the time to file a CARE petition? It's because voluntary willingness to enroll and the ability to engage successfully are two different things. We must build on Senator Umberg's leadership by ensuring that people with inadequate outpatient treatment are included in the CARE process.

For those whose conditions are too severe to participate in CARE Court, the very people this law was created to reach, there remains no path forward. Senator Umberg made sure to reference welfare in institutions code 5200, a process for a court ordered psychiatric evaluation, yet judges cannot initiate this process on their own, and counties rarely, if ever, use it.

In effect, 5200 is a doorway to care that has been locked shut. While a 51-50 hold would not reveal someone's chronic state of grave disability, a 5200 evaluation would. The CARE Act was the first major advancement in access.

However, if individuals who need help are consistently not granted that access and are not treated, then we have not achieved the change that was intended.

It's time to track outcomes for all CARE respondents who met the prima facie showing, use the legal tools we already have, and make the promise of care real, not just for the manageable few, but for those who are seen the most but treated the least. Thank you.

Thank you so much. Appreciate it. And then our last panelist from the Disability Rights of California. Just have to get it closest to you.

Yeah, I just don't want to eat it because I don't—yeah. Okay.

Oh, you had breakfast already. We're good.

I did. So, good morning. Thank you, Senator Menjivar and Senator Umberg. My name is Keris Myrick. I'm with Disability Rights California. I'm also on the CARE Act Workgroup and I'm Co-Chair the Data Ad Hoc Working Group as well.

So, the first thing I want to say is I'm also a person with lived experience, who is a person who was given a diagnosis of schizophrenia as well, and I'm also a family member. So, I have lots of compassion and concern about what's happening to both people with lived experience and their family members.

So, I want to make it clear. I've read through the whole CARE Act Report. I think the CARE Working Group really gets sick of me looking at the reports and looking at the data and making all sorts of notes. But actually, I see, yes, that things are going well, but there are also failures and cracks in the foundation.

So, there are cracks in the foundation of the mental health, substance use, and housing systems that undergird whatever process we want to create for care. The data make it plain that many people in the CARE Court process didn't receive the services they were promised, and even where the court ordered the care, it wasn't available.

So, CARE Court doesn't create new care or new services. It creates a new pathway into an already under resourced system. To put it bluntly, it's like being handed a VIP boarding pass, but the plane is either Larry Air, if you know it's Schitt's Creek, or it's Spirit Airlines—sorry, Spirit.

You get to get in front of the line, but you're still waiting to board the flight that is overcrowded, understaffed, and uncertain to take off. And that pass doesn't mean that you're going to get better service. It just means you're going to be first in line for the same limited seat.

And we need to be honest about what voluntary means in this process. Advocates have been telling us that, oh, this is voluntary, whether it's the plan or the agreement.

But actually, it's a form of psychological coercion that when you bring people before a court, whether it's a civil court or not, you're implying that you're holding them accountable to something through a court process. So, it's a bit—it's coercion. Let's just call it what it is.

But at the end of the day, that's not really what we're concerned about. We're concerned about the financial storm that's ahead—just like the airlines have been under a lot of pressure because of the shutdown that is now over—but counties will face their own reductions under HR 1.

I also work at a mental health policy shop called Inseparable, and according to our Inseparable Medicaid Report, Medicaid is mental health. The proposed federal budget cuts would strip over 1.3 billion in behavioral health funding from California over the next decade, possibly destabilizing the very programs county rely on to deliver treatment, housing, and community support.

We know that Medicaid is the backbone of mental health and substance use care, covering 1 in 4 California's mental health needs. If the funds shrink, the system that CARE Court relies on also will shrink. So—I know I'm getting on to my three minutes. I get it.

So, again, I don't want to get the VIP pass while the plane is grounded. I want to build a better pathway. And I will just say at the end that when we've been talking about the time it takes for engagement, I will say that trust is the biggest way that people participate in treatment.

It accounts for 70% of a person's ability to participate in treatment.

Thank you so much. We've got all the panelists. Senator Umberg, you want to kick us off?

Sure. This is a question for the entire panel. Every governmental entity that's providing services is resource constrained. But in this space, in terms of CARE Court, have you seen a petition denied because of resources?

I'm not talking about qualification, I'm talking about where the court has said, look, we just don't have housing, we don't have behavioral health professionals, whatever it may be. Have any of you seen that? No. I see head shaking no. Anyone want to comment on that?

Go ahead.

You see us correctly, that would say no. We're unable to obviously deny services based on that. It is our responsibility, and I think we all see that, to make sure that the person gets the support that they need.

That being said, I think we're all facing a ceiling in terms of the euphemism of the plane is complex. For example, the outreach and engagement that we're very grateful now that it is supported through reimbursement through CARE Court does allow us to spend a lot of time and have the infrastructure and supportive infrastructure to pay for that.

However, it's a two-edged sword. Once a person either graduates or the petition is dismissed, outreach and engagement is no longer paid in covered benefit. So, it's very complicated. And so, we work with our providers to strategize what funding can we leverage because our goal is to create that safety net.

So, whether or not the person meets prima facie, works through the CARE Court process. Just the structure itself is complex. And the other piece that I'll mention, I think was earlier one of your queries went to, is that we do have individuals who are not just Medicaid, which as you know, the threat to that is pretty striking.

And so, we're concurrently working with our providers to have a very advocacy component to make sure that not only the person receives treatment, but they retain their benefits to enable us to draw down the funds. But we do have individuals who are commercially insured.

And so, once the process discontinues for them, the ability or requirement for a commercially insured person to keep that supportive service going is not there currently. So, if there is an issue, it is beyond county behavioral.

Others wish to respond?

Yeah, and thank you for that because I'm really referring to what is in the report, so I have to go by what's in the report and also maybe what we're hearing from clients and family members that 82% of folks in care plans, or I mean care plans or agreements, they didn't receive at least one ordered social service.

So, I don't know if that is because it's resource, it's not there, it's not available. But that is what I have to read off the data paper. So, I had a whole list of questions myself about the data. And you know, we're just reading a data point.

What does that data point tell us about what's really happening under that data point?

Go ahead.

And then in terms of resources and drawing down funds from Medi-Cal potentially, I saw in the report that 43% of the CARE respondents had unknown health coverage. So, if there's unknown health coverage, counties are then eating that cost that's potentially preventable.

As envisioned originally, there were several either points of failure or points of success. Housing being one, the bench officer being appropriately trained, behavioral health professionals being supportive. Those are different areas where there's challenges.

Dr. Meyer, your point is an excellent point in terms of what do we do for folks who have either been dismissed or were not qualified? And we don't know, and we should know, that's a resource constraint, I think, ultimately. I'm interested in what you think.

I'm going to ask you to tell us too, what you think we should be doing to improve the process. And I get the resource part, but separate, apart from resource, other things we can do to improve the process. Back to housing, though, have you seen that, where someone has not been able to be placed in housing who actually qualified as part of the CARE Court, as a CARE Court participant? You have.

Yes, actually in Los Angeles County, we had a situation with a CARE Court—what are they called—respondent, which I don't think is the right term for them, but I understand why it's the term. But anyway, they were discharged from the hospital. They couldn't find an appropriate placement for the person.

The family contacted DRC. DRC found it was a Latino family, primarily Spanish speaking. So, there was not a lot of information for them in the language where they could really understand what was going on. We determined that, in fact, the person reported to us, oh, he needs a geriatric bed.

I was like, well, wait a minute, he's like 40, he's not geriatric. Why are you saying geriatric? In fact, he'd been told he needed a bariatric placement because he needed that if they need to move him or things like that, they need to have the right staff there.

There are very, very few bariatric places for him to go. So, he did have to go back with the family. That might be considered a placement or that he's housed. But he's not housed. He's, he's placed where he doesn't want to be and he did not have the housing that he wanted.

It's very, very difficult for the family to have him in home. So I would say that is an example of that.

Okay. Others?

Yeah, I would say you can be offered inadequate housing. People go to SROs or potentially sober living housing who need more structured support in a residential treatment setting or they're not able to take medications reliably. And they would be—they would need something like a board and care and that might not be available.

And so, the—I think the CARE Act population deserves prioritization within these scarce queues for the type of appropriate housing that they need.

And I'm obviously mistaken. I thought that they were, I thought that they were prioritized. Maybe that's something else we need to address. All right.

I'll acknowledge I can't comment on the experience of my co-panelists, but they are—the statute does require the prioritization. I would say locally at least, our experience is that the numbers are lower than we anticipated, even with the priority. So, for example, in Alameda, it's about 14% and we're utilizing the behavioral health bridge housing.

So, that's a success. And we're looking at qualitatively what people are wanting is permanent housing. And so, some are electing to remain either stably connected with their family. In some cases, we're just wanting permanent housing.

And that is a very complex barrier for us in terms of obviously respecting the individual's right to participate and is trying to incentivize as much as we can that they consume. But essentially, that has been a, a factor that people have not elected to use that resource.

I'm sorry, go ahead.

If I could add to that, Senator, I would say that we've seen many of the respondents initially benefit from a board and care level of care, but the availability or the lack of ability of availability of permanent supportive housing then affects how quickly people can move out of that board and care setting.

Some of the funds, such as the community supports, benefits that can help us pay for those board and care costs are time limited. And so, that does become a challenge where we have individuals who need that level of care initially, how do we sustain it operationally over the longer term? And then, yes, permanent supportive housing.

I'm sure I'm not sharing anything that the Senators don't know was in short supply already, and then there's concern around potential federal cuts to Section 8 and other permanent supportive housing programs. So, that is a continued challenge.

I don't know about Senator Menjivar, but you should never assume I know anything, basically. All right, anyone else care to respond? Anyone have seen folks who actually have been referred to conservatorship? Have you seen any of that? And anyone basic admitted to conservatorship who's gone through the CARE Court process and not completed it?

I will say no, but I'll qualify that to say is early on in the outreach and engagement process because it exists in our county, we may pursue it initially. We've had some referrals and since we're Cohort 2 county, we're evaluating to see whether we need to pursue a higher level of care in that case.

So, we have not interrupted the CARE Court process to make that pivot quite yet. We're looking to see where people lie. But I think there is a concerning part of remaining stable because it is again, very complex.

And as they're stable to be able to graduate from CARE Court, then for us, we're electing to either make sure that they're county clients so that we can continue to follow them and that is petition or look at conservatorship. But if they are not, that is a concern for us because they may need to be conserved.

They may be privately insured, however, and the resources are much more complex post graduation.

It is the last resort. But we, we don't want folks, I don't think collectively return to basically living under a bridge if need be. We want them conserved, so. Senator Menjivar.

Thank you. Dr. Meyer, I don't know if I heard correctly a potential correlation between no insurance coverage being the reason of lack of service provided because the county would then eat the cost. Are you alluding to that correlation?

So, I'm alluding to the cost to a county budget when potentially someone is eligible for Medi-Cal, and—but—their insurance status is unknown. The counties are not getting that funding for someone who they could potentially get that funding from.

But then, does that—is that one of the reasons why they're not being given the service?

Oh, that wasn't clear to me in the report.

I guess I was just hearing—I was asking you—if is that a correlation? Because that would be upsetting to me, is the fact that 40 or I forgot what statistic you said is unknown of insurance?

Yeah, 43%.

43% unknown insurance. Are those the same percentage of people that are not getting the services, and it's because we can't clarify if they have insurance or not, which is withholding service?

That's a great point. There's some residential treatment centers that only accept commercial insurance. There's some residential treatment centers that accept Medi-Cal. But there's a dearth of places that accept nothing, no insurance.

Doctor, I don't know if you want to add to that.

I would, absolutely. Again, from the county's perspective, that is the safety net. Whether you have insurance or Medi-Cal, that is part of our responsibility to make sure you're stably housed or placed, in that case. Most counties have an ability either to patch or they will cover the cost of an uninsured person.

We will even, quite frankly, work with our county neighbors, brothers, and sisters to see if we can help to change the county's origin. If they have—if they're unknown, we look to find them. We're able to actually query. As long as we know identity, we can find that out.

Wherever their county origin is, whatever their coverage is, we can find that out if it's in a safety net system. But for us, we consider it to be our responsibility and we'll serve them.

And if I could add onto that, I would say, yes, we consider it to be our responsibility. But the longer that there are those delays of someone who's uninsured to the analogy of building a better plane, it decreases the funds available to build a better plane.

Thank you. And then, Dr. Myrick, you brought up something I was going to ask about, the 5200 petition. You don't need a judge approval for 5150, but you do for the 5200. Are counties putting in the petition for that? Alameda, Riverside, are we utilizing this new petition to address the other demographics?

At least for us locally, we've not had to. We have sought higher level of care through 5150, our law enforcement as well. And we've even had hospitals post a person being 5150 work out and we petition and we follow them. So, we've actually not necessarily needed that process. We've been working with our judges.

Our bench, again, is very resource in the terms of their experience in terms of behavioral health. So, we haven't had the necessity as of yet. People receive that level of care through the initial engagement and part of that process, the outreaching teams that we've created or have clinicians as well. So, they can initiate it pretty immediately.

Because one of the anecdotes we're hearing is that first responders, police officers, are hesitant to put someone in a 5150 if the baseline, that is the baseline, so if they won't put them on 5150 since that is their baseline, is—do they know this additional resource is available?

I won't speak for the other counties, but I think the education piece is something that we're continuing to do, so we do reach out to our law enforcement and some other legislation that they had understood some years ago gave them a little bit of hesitance to do that.

But at the end of the day, we're finding, and the opposite of that is actually that they are seeking our assistance, so, much that was mentioned before, the outreach teams, the crisis and mobile crisis, we have EMT as well as clinician ride alongs.

So, in the case for us with law enforcement, if in doubt, we've asked them to just call us so they can call any outreach team, whether it's crisis related or not, and then we can help support them. So, what we have not seen specifically is them not wanting to do it or elect to do it.

Instead, again, that they have actually been the ones to do petition and we will come in in that way, evaluate if they are appropriate.

And then Dr. Tribble, just because you're in Cohort 2, so I'd love to see if you have any of this in your notes. One of the report of Cohort 1 is that we did not collect information for the elective clients and that elective clients received less services than those that participate in the CARE Act.

Throughout the hearing, we've heard that we want to be as least restrictive as possible, so if someone chooses elective, they should be given all the services available to them. In your county, is that the case? That's a good question.

In our case, it is not. So, what we did, we matched the level of service, full-service partnership is what we elect to use, so, for full-service partnership, the person is eligible for housing, they're eligible for 24-hour support. It's a very rich and robust service type.

So, concurrently, before we launched, we actually released and created a program of about 150 active slots, both for outreach and for a person to have services. So essentially, if they have that highest need, it's identical.

So, we don't restrict what is a benefit, of course, of CARE Court is the requirement and the prioritization of housing. That is much more different. So, for example, in our county, we have what is called coordinated entry.

So, because of CARE Court, it does enable us to, I don't want to say bypass the law but really look at the urgency of the situation and have access to it. But it doesn't—CARE Court didn't change the level of service because we're using it based on clinical acuity.

So, what the person needs is truly identified by the assessment. So, we're not having that experience, at least in Cohort 2, and I should acknowledge we did have the benefit of watching implementation of other counties.

We visited them, so we were able to learn what their successes were, what are the challenges, and so we were able to build from that.

And for the other counties, I mean, what are the characteristics? I'm still struggling to understand the elective client, are they taking medication? How are we following their trajectory to see if we've been successful with them choosing that route?

Sure, I could speak to that to some degree. I think that one factor to consider in that report of elective clients receiving fewer services, definitionally, if we go out to see a client and that client is uncertain or unwilling to engage today, we're going to go again tomorrow and go again the next day.

And we're going to record each of those as a case management attempt, an outreach attempt. And so, that person who takes 20, 30, 40 attempts to become successfully engaged in the CARE Court program versus the individual who go out and on the first day they say, those are great services, I'm willing to engage, I'll go today.

So, we take that person to one of our FSP full-service partnership specialty programs. They can receive an appointment with a clinical therapist, with a psychiatrist. The data will show far fewer services because it took far fewer touches to get that person enrolled and engaged in care.

It's not to say that the care that they're receiving is of lesser quality. So, I think that that's one thing we would note in our county that I would want to highlight.

And that's why I think we need to track for the elective clients, and for the people who are deemed ineligible because they refused, how many of them had criminal justice involvement, ED visits, inpatient hospitalizations, or placed on LPS holds?

We had 25% of respondent of CARE participants who had criminal justice involvement, 21% had an ED visit, 20% were inpatient hospitalized, and 20% were placed on a hold. I bet the numbers are higher for the elective clients and for those who are ineligible.

So, I really think that we need to prioritize the people who are most severe who are deemed ineligible for the CARE Act.

Thank you. I lost my train of thought here. Give me one second. Going back to the Social Services and the 83% and over 56% weren't even given one mental health treatment. We heard from the first panel that the plan or agreement is worked between the Judicial Court and the counties and what services are going to be offered, yet still counties report that some of the services being mandated don't exist in your county.

What is your county's—respective county's—relationship or working relationship with judicial courts to ensure that whatever is in that plan or agreement exist in your county?

I could start it. We have a great working relationship with our judge and our judicial partners. We've not experienced them ordering us to provide things that don't exist. I think housing is the one that proves most challenging where it exists, but it may not exist in the quantity, or we may not be able to deliver it as quickly as we wish we could.

Thank you. I'll echo my colleague's statements. I think the additional nuance that I'll add is that one of the things that is unique that, again, CARE Court does allow for is the active participation with multiple stakeholders. So, in the court itself, we will have providers who are even there around their medical needs and their supportive medical care.

They need a follow up appointment with their physician and not just something that's mental health. So, I say that to say it's very upfront, the planning. There are treatment teams that happen. One distinction I think, to your earlier query, I would have added is that it's a double-edged sword.

If an outreach team does a really impeccable job of outreaching and having a person see the value to participate, then they will theoretically elect for treatment, including medications. You asked are folks taking medications? The answer is yes. We have not had to forcibly look at that option at this point.

For most of the individuals, they are mostly agreeing to treatment and participating.

So, the data may not bear out that they've had forced medications or something because again, it really speaks to the effort to engage them because it does take quite a bit of time for a person who may be homeless, living somewhere unhoused, and then bringing them into care.

So, by the time they get there, they're able to see there is benefit to that. And in some cases, it's humorous. They'll say, I want more backpacks. You all gave us backpacks or donuts. In other cases, they said, I need to have my teeth fixed, can you help me?

So, again, I just wanted to acknowledge that when you look at the data, it really is because it is whatever it takes legislation, counties have done that. And in a lot of cases, voluntary is a path forward.

Would you like to add something to me?

Yes. Thank you. Thank you for sharing that because I think it speaks to the research about the difference between engagement and activation. Using the word engagement a lot. Engagement means I showed up and what we're looking for is activation.

To get from engagement to activation, that's where you need to build the relationship and trust. And that takes time, as everybody has said. And I also think that the CARE Act, in and of itself, and I know we're doing more work on that with the CARE Act workgroup, we're not actually measuring what helps people recover.

The definition of recovery in the CARE Act Report is actually a definition for treatment of schizophrenia. It's not about recovery. Recovery encompasses four important components: health, home, purpose, and community. So, we haven't talked about all of those things. And those things become critically important for a person to be activated and engaged in their treatment.

It's not just the meds, it's not just the housing, it's all of those things.

Thank you.

And I would say I think it's important to focus on the elective clients because the majority of people who were in a CARE agreement or CARE plan, in this report, 72% received stabilizing medications, 40% received a long acting injectable. But of the elective clients, almost none were reported to receive stabilizing medications.

And I'm sure the number is even less for those who are ineligible for care.

That's, I think, the point I've been trying to get across. If the whole point is to have people do this in a voluntary manner, then we need to support them to be successful there. Sticking to the social services part, in real life, can you clarify what this means to me?

If a participant is asking for a social service and they're denied it, and one of the reasons why it's denied is because the client declined the service or support, what does that mean in real life? I ask for it and then I just change. I'm pretty sure I probably changed my mind.

Yes. I can give an anecdotal, completely anecdotal example. So, it could be a person who comes, participates in CARE Court, is receiving the treatment, identifies, as I mentioned before, Dental will have it more complex. Their Medi-Cal is set to expire, and they need some care, maybe a preexisting medical condition and surgery.

And so, they are, in the beginning, they appreciate that. Then they realize that is I have to go and participate and talk to a social worker about my status. I have to—I'll be honest, this landscape is complex for people who have diverse backgrounds.

And so, once they hear you'll need my social or someone, they will back out. So, there's a lot of reasons why engaging the system now is becoming a more complicated conversation. Before, it was potentially you have access to benefits that you may not have already had, and you have coverage. Now, it's a little bit—people are frightened what that means.

Will I have to—is it better for me to remain not supported in that way? That is because I'll have to get a job and I know my mental health condition won't allow me to get that.

So, there's a lot of misunderstanding or actual understanding of what it could look like to actually engage in the process. So, for them, the benefits of treatment may not look like reporting to an office, talking to a caseworker, filling out the eligibility forms for them. That feels too much.

So, that's what I mean, that some of the case managers are having to pivot to make sure we support, and again, we have a great relationship with social services. But essentially, folks need to, unless they are conserved, again, which we have, have programs like that, they can opt out.

Thank you. My last question to the counties—what's your one wish list? And we can't say fiscal. I know we always need more money. I know counties always need more money.

Well, under my breath, of course I said fiscal, but I say it now that I'm pulling it closer. I would say, I think you've heard some of the former panelists speak to the need for time. And I don't mean let's slow down because it's, this is, for my 30 years in this field, this is one of the most unprecedented times where you see so much attention to people with behavioral health issues.

So, I hope that the Legislature does not stop. That is incredibly important. And there's so much that has happened in the last year and a half.

It will make it very difficult to isolate what the success of CARE Court is, as opposed to SB 43, as opposed to all the different legislation. BHSA will change the landscape.

And so, you may unfortunately evaluate a county to be unsuccessful, but it may be that some of those prevention programs that helped buttress the safety net are no longer there.

So, I would encourage, if there's ability to actually enable the counties to really drill down on the data to isolate what is working well in a non-punitive way.

And I didn't say money, but I will say incentivizing outcomes because, because that has been a strategy, BH Connect. The state has already moved in that direction but there are concrete outcomes that can actually be paid for when you see those successes, and they can help strengthen the system because, again, we're largely reliant counties are to our local resources, what we can devote.

But that will really help us if we can pause and actually see what is working well. Thank you.

Pardon me. I would second the comments from my colleague, in both directions, to say the fiscal support and housing are indispensable ingredients and so, it can't be done without that, but I recognize the position that you're in as well.

I think, to repeat the comment about time our colleagues from the states mentioned, BH Connect, BCHIP, CalAim, Community Supports, HCAI Workforce Investments. There's so many things moving all at once that I think there's a great deal of promise on the horizon and yet we need some time to allow some of those things to ripen.

Dr. Meyer.

My one wish list item would be prioritization of people who are chronically gravely disabled, who EMS is predominantly the sole providers for people who are cycling through our emergency departments, going before our jails, and are now facing incompetency proceedings.

If we prioritize this population that are predominantly managed by EMS, our cities and counties would be in a much better place.

Close us out.

So, if I, if I, if I had one and I do have a wish list, I would wish that you could hear from people who will be impacted or are currently impacted and are either in or have graduated from CARE Court to hear what they would like.

As a person who's been given a diagnosis of schizophrenia, who's touched every system, every system that we've been talking about, nobody's asked me, well, what worked, what helped you? I can tell you what worked and helped me. My colleagues can tell you what worked and helped me. So, we shouldn't be absent of this process.

So, I'm very glad to be here today. So, one of the things that I can speak to that was, just can't even measure the importance of it, was not just the time that people took with me to build that trust and relationship because I didn't trust people. I wouldn't go in.

I was drug in by police and handcuffs, etc. Was a psychiatrist who just sat with me and was relentless. I don't know how he bailed for it. I really don't. But he did, and here we are.

But the bigger issue was hearing from somebody who looked like me, who also had the same diagnosis as myself and went through the same struggles as myself. I cannot say enough about peer support. I research peer support.

I've implemented it not just in California, but across this nation, because it actually has proven to help people not just go to treatment, but stay in treatment because they learn about activation and being a part of treatment.

Lastly, I would say we don't have enough peer respites, which are other places people can go to get extra support and help when things are not going well. We only have nine in this state or a state that has the most, actually, which is kind of cool.

But nine in a county of, you know, 50—a state of 58 counties—is not enough. And we also need more family support. I listen to our families struggle. I listen to their trauma. I listen to their frustration. And nowhere in this Bill was there anything for families to get the support that they need and deserve.

And we do have the ability to do that because of SB 803. So, we need family support, peer respites, and also, just listening to people who have been impacted to hear what they would like. Thank you.

Make sure Santa gets this wish list for next month. See what he can do. Thank you so much for participating.

Thank you. And we're all beneficiaries of your passion and dedication, really. I'm not just talking about those people you touch. I'm talking about all of California, so thank you. If we could ask the next panel to come to the table. Judge Heron, Mr. Bruce, and Desiree Sanders.

All right, while our next panel is coming up to the tables, let me make a housekeeping announcement. So after this next panel, we're going to turn to public comment, and I suspect there are folks here who are in the audience who wish to participate during public comment.

We're going to limit public comment to one minute, but you should know that each of our respective committees has portals where you can submit written letters, information, comments, concerns, and contrary to conventional wisdom, many of us in the Legislature can actually read. And so we do pay attention to that.

So all right, let's now turn to lived experience by judges and attorneys, and we'll start with Judge Herron.

So I've heard a lot of amazing comments from everyone. My name is Scott Heron. I'm a judge in Los Angeles County.

Judge, if you could just put the mic closer to your I'm used to.

Being told to be quieter. So I'm a judge in Los Angeles County. I handle LPS, conservatorships, aot, and care. I have an opening statement. I don't think you need to hear my opening statement. I'm going to wave my opening statement and let the other guys go first, and then I'll take whatever questions you want.

All right, thank you, Judge.

Let's turn to Mr. Bruce. Good afternoon, Chairs.

Thank you for the opportunity to speak today about San Francisco's experience implementing care. My name is Charles Bruce. I'm a deputy city attorney. San Francisco was among the first cohort of counties to implement care court, launching in October 1, 2023.

As a consolidated city and county, we were uniquely positioned to align departments and partners across behavioral health, housing and the courts. The alignment proved to be a significant asset in both implementation and case coordination. We filed 89 petitions petitions to date with 26 active cases, 18 finalized agreements, and three successful graduations.

A fourth graduation is scheduled for today. CARE Court has shown the most promise when individuals are stepping down from a higher level of care or when they face collateral consequences such as criminal charges or eviction. We transitioned our CARE Court into the probate Department, which has increased accessibility for our target population and streamlined court processes.

However, we have also faced challenges, notably our respondents. Attorneys were delayed in joining due to state bar contracting issues. This slowed early trust building and collaboration. Unlike other counties, San Francisco does not use the Public Defender for Care Court. We support the upcoming amendments under SB27, effective January 1, which expand eligibility.

This change will allow us to reach more people, particularly those who may not meet the current criteria but are still falling through the cracks. These individuals often have stronger family support and may be more likely to engage in services. A key limitation of Care Court is the lack of enforcement mechanisms.

Participation in services in court attendance remains voluntary even when court ordered. Without the ability to require medication or enforced treatment, some respondents remain too symptomatic to engage meaningfully. We recommend that the Legislature Consider a 30 day medication trial requirement or limited involuntary medication authority when clinically indicated.

Statutory inclusion of required services in Care Agreements and plans a presumption for LPS conservatorship when Care Agreements fail due to non engagement or medication refusal Reducing personal service requirements after the initial hearing in favor of mail or email Allowing service of reports on respondents counsel to preserve therapeutic relationships and creating a mechanism to convert Care Agreements into Care plans when respondents disengage without restarting the procedural steps.

Enclosing Care Court holds promise and if we continue to refine the model, address enforcement gaps and ensure adequate resources, the promise can be more effectively achieved. San Francisco remains committed to this work and we appreciate the Legislature's partnership in making sure Court more effective.

Thank you.

Thank you Sanders.

Thank you. Good morning Chairs. My name is Desiree Sanders and I'm the Supervising Deputy Public Defender of our Mental Health Court and Care Court in San Diego. County. My unit represents mental or respondents in Care Court, LPS conservatorships, AOT petitions and other civil commitment procedures.

The reality is Care Court will not work for everyone, but for those that it does, it has made a profound and life changing impact. Coach Pat Summitt once said, success is a matter of perspective. From our perspective, success looks like this. This experience has changed my life.

It's been the first time in a really long time anyone has said anything nice about me and their actions show me they believe in me. That's from our first graduate. The amount of support I received before I went to inpatient treatment gave me so much confidence while I was there.

I knew the team would be there waiting for me when I got out. I've started running 5k races, I have a spot in my church band, I love my house, my mom is healthy and proud of me and I have goals that I know I can achieve. Now that's a pending graduate.

In 110 weeks of care Court in San Diego County we have seen 24 graduates, 34 conservatorship step downs, 4 BH diversions and 158 care agreements. Graduates are connected to long term service providers who continue the individualized support established during their care participation.

Our success stems from collaboration with community partners, flexible systems that adapt to individualized Participant needs and centralized counsel, ensuring consistent coordination across care cases and criminal or mental health cases, probation and parole reporting and much more. Still, challenges remain. Communication gaps persist between criminal, mental health and care courts.

We continue to face a shortage of housing and treatment resources, and it's difficult to continue to provide accurate information about what can truly be achieved in Care Court with the resources that are available. A particularly complex group of individuals involved in both care and criminal courts, often with co occurring substance abuse use disorders.

Yet even here we've seen success in San Diego when participants relapse or face lengthy sentences. Care attorneys have advocated for treatment plans as alternatives to incarceration, keeping individuals connected to recovery rather than returning to a cycle of custody.

With the passage of SB27, we anticipate increased referrals, but clarity is still needed on how those referrals will translate into petitions, translate into petitions and open care files. With looking ahead, sustained funding and housing resources will be critical, especially models that integrate housing and treatment on site, along with transitional aftercare housing to support long term stability.

Care Court's future measure of success will always depend on the lens through which it is viewed. Its continued success relies on a commitment to a voluntary person centered approach and the trust our attorneys and the team build over time with each client as one of our more complex, duly involved.

But now a pending graduate recently told the attorney, thank you for being here for me even when I'm not showing that I want or appreciate the help. You are all my angels. Thank you for your time. Thank you so much.

Thank you.

Great. Judge, I'd like to see if you could respond to something that Mr. Bruce brought up. Mr. Bruce asked for a mechanism to transfer agreements to plants. However, even the report says if an agreement is not reached, the court may then order the creation of a care plan. So what barriers exist for that?

Well, I think the circumstances.

Judge, you're gonna like all of us, we're not speaking close enough to the microphone.