State Mental Health Services

Disability

Sacramento, CA 95811-4114

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California

California’s protection and advocacy system www.disabilityrightsca.org May 17, 2012

Honorable Holly Mitchell

Chair, Assembly Budget Subcommittee#1 Capitol Building, Room 127

Sacramento, CA 95814 Honorable Mark DeSaulnier

Chair, Senate Budget Subcommittee#3 Capitol Building, Room 4203

Sacramento, CA 95814

Re: May Revision - Mental Health Budget Item 4440 Dear Assembly Member Mitchell & Senator DeSaulnier:

Disability Rights California, the federally mandated protection and advocacy system, works to advance the rights of Californians with

disabilities. In addition to our federally required services, we provide the clients’ rights advocates at the 21 regional centers and advocates at each of the five state psychiatric hospitals. What follows are general comments on the state of mental health services, the May Revision and realignment of mental health services, and specific comments on trailer bills (TB) 600, 601, 603 and 614.

General Comments

State support for mental health services has been cut in recent years. In particular, Medi-Cal managed care funding has been reduced substantially. Now that Medi-Cal mental health funding has been realigned to the

counties, there is very little General Fund support for local mental

programs. At the same time, there is less money for county mental health programs overall than there has been in the past. While overall funding has been reduced, there is a higher demand for services, particularly Medi-Cal services. The counties are devoting a higher percentage of their capped

mental health budgets to Medi-Cal beneficiaries. This is reducing the

availability of county mental health services for low-income individuals who do not receive Medi-Cal. The Mental Health Services Act, Proposition 63, is a bright spot in the picture that provides help to thousands of people.

However, we are faced with a two tier mental health system in which a relatively small percentage of people receive intensive services under the Mental Health Services Act while the rest of the system crumbles.

May Revision

The May Revision identifies a $41.7 million shortfall in the Department of State Hospital’s budget. We are concerned that there is no discussion of how that shortfall will be met. Our worry is that it will be met by not filling staff positions and thereby creating staffing shortages. Full staffing is important so that needed services are provided to hospital residents and they are protected from harm.

Realignment

Realignment provides great opportunities for transforming the community mental health system. It will enable greater cooperation and coordination between mental health agencies and public safety agencies. This carries the potential of developing a service system that will end the revolving door between the community and hospitalization, incarceration and

institutionalization.

However, there are challenges. Funding for mental health services must be maintained and should not be diverted to law enforcement functions.

Diverting mental health funding will only make the revolving door worse. There should be a secure firewall in realignment between the mental health and law enforcement funding.

Our primary concern with the Administration’s proposals to reorganize and realign mental health programs is maintaining county accountability so that individuals can obtain needed services. The Legislature should provide for state oversight to insure that mental health funds are used properly.

We are concerned that realignment to the counties may result in quite different services from county to county for individuals with disabilities. While we believe counties should structure services to meet the needs of their communities, we recommend that the Legislature require sufficient

statewide service standards and performance measures to ensure that individuals with disabilities in each county receive equal access to services of equal quality. At a minimum, this would include regulations specifying:

--criteria for obtaining services

--standards for assuring quality and culturally competent services --due process protections

--requirements to provide services in the community in preference to institutions, where appropriate

--requirements to expand the availability of peer support services --requirements for state oversight to ensure county compliance State Mental Health Services Act regulations should be retained and should, at a minimum, provide for

--a community program planning process with strong stakeholder involvement, and

--a state issue resolution process

State Medi-Cal regulations should be retained and should, at a minimum, --define the scope of services available, and

--insure that the types of specialty mental health services provided to each individual beneficiary are adequate to meet the needs of the beneficiary.

Lanterman-Petris-Short Act regulations should be retained and should provide for uniform statewide involuntary detention procedures and uniform statewide facility approval procedures.

Hospital Security

The focus in state hospitals cannot just be on security but also on how to provide effective treatment. Focusing on security alone could lead to lack of treatment and further criminalization of people with mental health

disabilities. At the point that we equate mental health disabilities with criminal behavior - then the focus shifts to punishment and security rather than treatment. Attached are our principles related to secure treatment units.

Penal Code section 1369.1 was a temporary measure to allow

administration of antipsychotic medication for up to 6 months for people determined incompetent to stand trial and in county jails because of a shortage of state hospital beds.

This bill would delete the sunset date of January 1, 2015, would delete the provision limiting treatment to administration of antipsychotic medication, and proposes that Department of State Hospitals (DSH) provide the treatment in county jails, pay for the treatment and pay for the jail bed. Essentially, this bill would allow the DSH to extend the IST treatment program to county jails. However, the bill contains no standards for the county jail "treatment facilities" or standards regarding the required treatment that DSH will provide in county jails. In short, there's no

guarantee that people will not continue to stay in county jails while they wait for a state hospital bed or other appropriate placement. There needs to be adequate standards for the jail facility, as well as for the IST treatment program to insure that inmates in county jail are not locked up in

administrative segregation while they get nothing more than involuntary psychotropic medication.

Comments on TB 601 Transfer of Mental Health Non Medi-Cal Functions

Approval of county-designated 5150 facilities is not a licensing function and should not go to the Department of Social Services (DSS). In fact, county-designated 5150 facilities do not need to be licensed. Approval of

designated facilities requires mental health expertise, which DSS does not have. Approval of designated facilities fits in with the certification functions that will be transferred to Department of Health Care Services (DHCS). It should be transferred there.

Promulgation of the statewide 5150 advisement form should not be

transferred to DSS. Advisement has nothing to do with licensing. It has to do with what a police officer tells a detainee when the detainee is detained for 72-hour evaluation and treatment. It has to do with the rights of the detainee. Advisement should be transferred to DHCS, which has responsibility for patients' rights regulations.

All of the Department of Mental Health (DMH) licensing and certification funding will be transferred to DSS. How will certification functions

transferred to DHCS be funded?

DMH licensing and certification functions and unit, should be transferred to DHCS intact. Splitting up these functions during a major reorganization will result in confusion. Once transferred to DHCS, policy discussions

regarding the most effective way to handle licensing can occur. Another alternative, while not preferred, would be to transfer psychiatric health facilities (PHF) and mental health rehabilitation centers (MHRC) licensing to Department of Public Health (DPH) rather than to DSS. PHFs and

MHRCs are essentially health facilities and are more appropriately licensed by DPH because it licenses health facilities. If MHRCs are licensed by a non-mental-health department, DHCS should add a certification function for MHRCs to insure that mental health expertise is available when MHRCs establish their programs.

Both DHCS and DSH will have responsibility for promulgating patients' rights regulations. However, DSH will have sole responsibility for

promulgating convulsive treatment regulations. This is inappropriate since most convulsive treatment takes place outside of state hospitals. DHCS, in consultation with DSH, should be responsible for convulsive treatment regulations.

Comments on TB 603 Department of State Hospitals

Welfare and Institutions Code section 4027 proposes that DSH may adopt regulations concerning patients' rights and related procedures applicable to inmates of jail psychiatric units. We believe DHCS is in a better position to adopt such regulations because jail psych units are more closely connected with county mental health programs than with state hospitals and should be regulated by the same agency that regulates the county departments.

DPH licenses correctional treatment centers. For correctional treatment centers that provide psychiatric and psychological services provided by county mental health agencies in local detention facilities, the State

Department of Mental Health adopts regulations specifying acute and non-acute levels of 24-hour care. Under Health and Safety Code section 1250.1 this function would be transferred to the DSH. We have the same concerns with this transfer as for Welfare and Institutions Code section 4027 above.

Comments on TB 614 Transfer of Mental Health Medi-Cal Functions

We are concerned that Section 14704 of the Welfare and Institutions Code gives DHCS the authority to administer the specialty mental health program without any regulations. At a minimum, we'd like this section to require DHCS to promulgate regulations defining the scope of benefits and due process protections.

We are concerned about Section 14684(a) (5) of the Welfare and

Institutions Code because we are not convinced there is a need for the amendment. First, services should be provided pursuant to the objectives of the rehabilitation option. Second, the combining of two sentences into one confuses two separate concepts. The first sentence has to do with providing services as close to home as possible. The second sentence has to do with expanding the types of places where services can be provided. At a minimum, these should remain two separate sentences even if the reference to rehabilitation option services is eliminated.

Finally we suggest modernizing the language in the statute by eliminating "the mentally ill." For example in the following section "services rendered to the mentally ill" could be changed to "mental health services."

"Section 5718 of the Welfare and Institutions Code is amended and renumbered as Section 14705:

(a) (1) This section and Sections 5719 to 5724, inclusive, shall apply to specialty mental health services provided by counties to Medi-Cal eligible individuals. Counties shall provide services to Medi-Cal

beneficiaries and seek the maximum federal reimbursement possible for mental health services services rendered to the mentally ill1."

1 _{Bold italics are Disability Rights California additions and bold strikethroughs are Disability Rights} California deletions.

Thank you for the opportunity to provide input on the California Budget items related to mental health.

Very truly yours,

Margaret Johnson, Esq. Advocacy Director

Disability Rights California Attachment

CC: Honorable Members of the California State Assembly CC: Honorable Members of the California State Senate

CC: Honorable Members of the Assembly Budget Subcommittee#1 CC: Andrea Margolis, Consultant, Assembly Budget Subcommittee#1 CC: Honorable Members of the Senate Budget Subcommittee#3 CC: Joe Stephenshaw, Consultant, Senate Budget Subcommitee#3 CC: Nancy Strohl, Legislative Aide, Assembly Member Mitchell’s Office CC: Indira Donald, Legislative Aide, Senator DeSaulnier’s Office